Episodes

5d ago

In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Dry Needling division lead faculty Ellison Melrose shares her extensive experience as a primary faculty member in the dry needling division, discussing both the upper and lower quarter techniques. She emphasizes the transformative potential of the new course for pelvic health practitioners and highlights her background in pelvic health education. Throughout the conversation, Elli candidly addresses the effectiveness of dry needling, noting instances where it significantly enhances patient outcomes. Tune in for valuable insights, tips, and a touch of humor as Elli recounts relatable parenting moments. Watch the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Dec 4

Dr. Britt Lademann // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Total Spine division faculty member Britt Lademann shares her insights on teaching spinal manipulation techniques, particularly highlighting her role as a female instructor in a traditionally male-dominated field. The conversation touches on how her approach makes these techniques more accessible and approachable for a diverse range of practitioners, especially smaller operators and women in the field. Watch the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Total Spine Thrust Manipulation course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 20

Dr. Paul Killoren // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Dry Needling Division Leader Paul Killoren sit down to discuss turf battles in dry needling, patient access issues, lobbying & advocacy for dry needling at the state level, and efforts to increased standards for education. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Nov 6

Dr. Justin Dunaway // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Total Spine division leader Justin Dunaway sit down to discuss the efficacy of thrust manipulation, particular for acute pain, hypermobility, & radiculopathy. Jeff & Justin discuss emerging research in thrust manipulation, acknowledgement of short-term benefits, and the application of manipulation into daily practice. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Persistent Pain Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 15

Dr. Lindsey Hughey // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Extremity Management division leader Lindsey Hughey sit down to discuss incorporating a more holistic approach in healthcare, including mindfulness, the importance of meeting physical activity & nutrition guidelines as it relates to the healing experience, and the role of sleep in health through a "MEDS" framework: Movement, Education, Diet, and Sleep. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 1

Dr. Lindsey Hughey // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Extremity Management division leader Lindsey Hughey discuss the reframing of acute injury from "RICE" into "PEACE" & "LOVE" in order to accelerate healing & improve rehab outcomes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 17

Alan Fredendall // www.ptonice.com In this week's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & COO Alan Fredendall sit down to have a candid conversation about starting & operating a rehab practice through the lens of the "Brick by Brick" course, offering information on foundational legal infrastructure, financials, insurance-based & cash-based practice, and technology. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 3

Dr. Rachel Selina // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Endurance Athlete lead faculty Rachel Selina sit down to discuss rock climbing, endurance athletics, using continuing education to increase confidence & autonomy in practice, and more! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Aug 20

Dr. Paul Killoren // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Dry Needling Division Leader Paul Killoren sit down to discuss a modern approach to dry needling. Paul talks about utilizing dry needling to influence the nervous system for not only pain reduction, but also recovery & performance enhancement. Paul also discusses advanced interventions with dry needling, including peripheral nerve stimulation using electrical stimulation. Take a listen to learn more about how and why ICE's dry needling curriculum is different, and by different, we do mean better. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Aug 13

Dr. Brian Melrose // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Spine Division lead faculty Brian Melrose sit down to discuss house plants, clinical decision making confidence, and mentorship in the clinic & community, Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Aug 6

Dr. Joe Hanisko // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Fitness Athlete lead faculty member Joe Hanisko sit down to discuss the important of human connection in both the patient-facing & back-end aspects of clinical practice. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jul 23

Dr. Ellen Csepe // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Older Adult Division faculty member Ellen Csepe sit down to discuss the topic of obesity, including its psychological impact, physiological challenges, and the role of rehab providers in helping patients manage or overcome their obesity. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jul 9

Dr. April Dominick // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Pelvic Division faculty member April Dominick sit down as April shares her journey from working in a traditional PT setting to opening her own cash pay practice in Denver, where she focuses on pelvic health. She emphasizes the importance of creating a safe space for patients to discuss their concerns. April explains how performing rectal assessments can provide valuable insights into conditions like constipation and tailbone pain, helping patients regain control over their bodies. April highlights the power of active listening and empathy in her practice. She believes that understanding each patient's unique story is essential for effective treatment. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jun 25

Dr. Cody Gingerich // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Extremity Division lead faculty Cody Gingerich sit down as Cody shares insights from his extensive experience in clinic management and education, discussing the importance of adaptability in practice as clinics grow and evolve, including whether to hire new grads or veteran clinicians, the importance of mentorship, as well as discussing the importance of tempo in rehab. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jun 18

Dr. Andrew Bernstetter // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Extremity Division faculty member Andrew Bernstetter sit down to discuss building trust with patients through effective communication & treatments, gradually introducing lifestyle changes, and the importance of leveraging community resources to facilitate behavior changes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jun 11

Dr. Annoushka Ranaraja // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Older Adult faculty member Annoushka Ranaraja discuss basic neurorehabilitation principles and how the application of a fitness-forward treatment mindset can significantly improve outcomes with patients. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jun 4

Dr. Jeff Musgrave // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Older Adult lead faculty Jeff Musgrave discuss setting up an optimal fitness environment for older adults. Jeff & Jeff highlight the need for an inclusive environment that meets older adults where they are at, emphasizes trust & social connections, and that fitness providers & rehab professions need to better understand that for many, it's more about psychological barriers than mental ones. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

May 28

Dr. Mitch Babcock // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Fitness Athlete division leader Mitch Babcock explore the importance of having the right tools for clinical management of the fitness athlete Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

May 21

Dr. Christina Prevett // www.ptonice.com

May 14

Dr. Jordan Berry // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Jordan Berry Spine Division leader discuss improving the physical therapy experience. Jordan emphasizes the importance of contextual factors to care such as emphasizing a premium experience, being intentional with space selection & sensory experiences, and remembering the small details of your patients to create a positive physical therapy experience. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

May 7

Dr. Zac Morgan // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Zac Morgan, Spine Division leader discuss Zac's path from an entry-level student to leading the Spine Division at ICE, including meaning clinical mentorship, prioritizing prevention as a healthcare provider, the importance of balancing delayed gratification, and the need for honest feedback to grow clinically & in business. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 30

Dr. Trisa Hutchinson // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Trisa Hutchinson from our Older Adult Division discuss the unique foci of Physical Therapy and Occupational Therapy, emphasizing the importance of continuing to work to better integrate the two professions to better serve patients. Both fields are essential in promoting overall health and well-being, and their integration can lead to more effective patient outcomes. By understanding and valuing the unique contributions of each discipline, healthcare providers can better support their patients in achieving their goals and enhancing their quality of life. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 23

Alan Fredendall // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & COO, Practice Management Division leader & Fitness Athlete Division lead faculty member Alan Fredendall discuss Alan's unique journey in blending educational pursuits with clinical expertise while balancing family life. Alan shares insights into his current professional and personal landscape, emphasizing the importance of managing these aspects harmoniously. Listeners will gain valuable perspectives on achieving a fulfilling career in healthcare without sacrificing personal commitments. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 16

Dr. Christina Prevett // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Older Adult and Pelvic division leader Christina Prevett sit down to discuss her research in the fields of geriatrics & pelvic health, highlighting key topics such as the safety & efficacy of high-load resistance training for older adults and the postpartum population. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 9

Dr. Mitch Babcock // www.ptonice.com In today's episode of the PT on ICE Podcast, ICE CEO Jeff Moore & Fitness Athlete division leader Mitch Babcock discuss that movement competency and verbal fluency in fitness terminology are essential for physical therapists working with fitness athletes. By improving their ability to perform and coach movements, as well as mastering the language of fitness, PTs can enhance their effectiveness in treatment, build stronger relationships with their patients, and ultimately contribute to better outcomes in rehabilitation and performance. The insights shared in the episode emphasize the importance of these skills in bridging the gap between physical therapy and the fitness world, ensuring that athletes receive the best possible care. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 4

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete lead faculty Rachel Selina discusses the widely studied yet often misused supplement of caffeine. While most humans consume some form of caffeine each day for an energy & mood boost, it can also have significant physical affects. What are they, and how can you better help endurance athletes understanding timing & dosage? Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 4

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division lead faculty member Zach Long delves into the effectiveness of lighter weightlifting for athletes aiming to enhance their Olympic weightlifting skills. Drawing from a recent research study and insights from the Soviet Union's Olympic weightlifting team in the 1980s, Zach offers valuable strategies for CrossFit athletes and Olympic weightlifters. Tune in to learn how these approaches can improve your clinical practice and athletic performance! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 3

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the importance of teachable employees who seek out mentorship. He discusses how many employers express a desire to hire experienced employees, believing that they will require less training and oversight. However, this mindset can be limiting. Experienced individuals may come with established habits and methods that do not align with the organization's culture or practices. Jeff reinforces that as teachable employees grow and develop, they become valuable assets to the organization. They can eventually take on mentorship roles themselves, passing on the knowledge and skills they acquired. This creates a cycle of growth and development within the organization, where experienced employees guide the next generation, further strengthening the team. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 2

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Older Adult Division leader Dustin Jones discusses the topic of stimulating foot orthotics—products designed with protruding knobs aimed at improving balance. With an increasing number of inquiries from older adults about these orthotics, Dustin delves into the evidence surrounding their effectiveness, particularly a recent study on their impact on postural sway. He expresses skepticism about such products, noting the prevalence of misleading marketing targeting older adults and the potential for wasted money on ineffective solutions. Dustin highlights the distinction between traditional foot orthotics, which typically address mechanical issues, and these newer, more questionable options. Tune in for a critical examination of the claims made about stimulating foot orthotics and their actual benefits. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Apr 2

Dr. Rachel Moore // www.ptonice.com In today's episode of the PTonICE Podcast, ICE CEO Jeff Moore & Pelvic Division faculty member Rachel Moore engage in a candid conversation about the unique challenges and rewards of balancing motherhood with athletic pursuits. They explore how Rachel's experiences as a mom over the past five to six years have not only tested her resilience but also enhanced her performance in the gym. The discussion delves into the lessons learned from parenting, the obstacles faced, and how these experiences have shaped her as an athlete. Rachel shares insights that can inspire other parents navigating similar paths, emphasizing the strengths gained through the journey of motherhood. Tune in for an inspiring episode that highlights the intersection of parenting and athleticism. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Apr 2

Dr. Jeff Moore // ICE CEO // www.ptonice.com In this exciting episode of The Daily Show, Dr. Jeff Moore, CEO of ICE, shares significant news about the future of the show and the ICE community. Celebrating a decade of the Daily Show, Dr. Moore expresses gratitude for the support of listeners as the show has grown alongside ICE, which has expanded from just two courses to a thriving fitness forward community. The major announcement reveals that the Daily Show will transition to become an in-app exclusive feature within the Ice Physio app. This move aims to enhance community engagement, learning, and organization away from social media. Tune in to discover the benefits of this shift and what it means for the ICE community moving forward.

Apr 1

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the complexities of the unstable shoulder, focusing specifically on the mobile shoulder presentation. Lindsey outlines the three main categories of shoulder conditions: stiff, weak, and mobile shoulders, while also acknowledging outlier cases such as central sensitization. She delves into the subjective and objective findings associated with mobile shoulders, including key clinical exam indicators like pain at end ranges and excess glenohumeral joint motion. Lindsey emphasizes the importance of correct treatment approaches for mobile shoulders and shares insights on how physical therapists can effectively manage these cases. The episode concludes with a rehab EMOM (Every Minute on the Minute) to consider for patient care. Tune in to enhance your understanding of mobile shoulders and improve your clinical practice! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 31

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick explores the evolution of language and understanding surrounding perinatal conditions such as diastasis recti, pelvic organ prolapse, and perinatal exercise. She highlights the shift from a fear-based approach to a more empowering and neutral language, informed by evidence and clinical experiences. April shares personal insights from her nearly nine years in the field, illustrating how changing terminology can significantly impact individuals' perceptions of their conditions and enhance outcomes. April focuses on practical language shifts, starting with diastasis recti, and aims to empower listeners to communicate more effectively about these important topics. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Mar 28

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division faculty member Guillermo Contreras explores the concept of AMRAP sets (As Many Reps As Possible) and their significance in strength training and rehabilitation. Guillermo begins with the importance of strength improvement for clients in various settings, including athletes and post-operative patients. He emphasizes that nearly 90% of patients aim to enhance their strength as part of their recovery or fitness goals. Guillermo delves into the science behind muscle hypertrophy, highlighting that effective muscle growth can occur even at lower percentages of one-rep max, starting at around 30%. Guillermo lays the groundwork for understanding how AMRAP sets can be utilized to achieve strength and hypertrophy goals effectively. Tune in to learn more about integrating these techniques into your training regimen! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 27

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the methods in which a new practice owner can fund their business including grants, self-contributions, loans, and credit cards. Alan challenges listeners to exhaust federal, state, county, and city grant options which may provide small, but free funding. In addition, he shares insights on how to reap tax benefits for potential owners considering using their own money to fund the start of their practice. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 26

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Older Adult Division leader Christina Prevett discusses the importance of reevaluating post-operative protocols in rehabilitation. She emphasizes the need for evidence-informed practices and questions who establishes these protocols, typically surgeons. While acknowledging that post-operative guidelines are designed to aid recovery and enhance function, Christina challenges the effectiveness of blanket statements and encourages a more individualized approach to patient care. Tune in for insights on how to adapt rehabilitation practices to better respect the unique experiences and needs of each patient. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 25

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich delves into the complexities of movement patterns in extremity management. He discusses the ongoing debate in physical therapy regarding the necessity of specificity in exercise prescriptions. Cody highlights the shift from a focus on nuanced, specific cues for improving movement patterns to a more general approach that encourages overall activity. He aims to find a balanced perspective, acknowledging that while some individuals benefit from detailed attention to their movement mechanics and accessory work, others may thrive with a more straightforward approach to exercise. Tune in as Cody navigates these concepts and encourages listeners to consider the individual needs of clients in their movement practices. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 24

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett discusses a groundbreaking new paper published in the British Journal of Sports Medicine, which addresses the removal of medical clearance requirements for postpartum individuals. Christina highlights her involvement in this important project led by Dr. Margie Davenport, focusing on the Canadian Society for Exercise Physiologists' Postpartum Return to Exercise Guidelines. Christina covers the launch of the Get Active Questionnaire Postpartum, a new screening tool for exercise professionals, along with the publication of several systematic reviews and the International Delphi Statement related to postpartum exercise. Tune in to learn about the significant changes in postpartum exercise practices and the research driving these advancements. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Mar 21

Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division faculty member Kelly Benfey discusses the top three most common faults in weightlifting that CrossFit athletes often exhibit. Aimed at physical therapists and coaches, Kelly emphasizes the importance of recognizing and correcting these faults to enhance athletes' performance and safety. Kelly highlights the complexity of Olympic weightlifting movements and how small adjustments can lead to significant improvements. Kelly encourages clinicians & coaches to keep a checklist of these faults in mind to help their athletes lift more optimally and successfully, ultimately leading to better results in the CrossFit arena. Tune in to gain valuable insights that can positively impact coaching and athlete performance. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 20

Dr. Jim Shepherd // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Jim Shepherd discusses several techniques and strategies to help troubleshoot getting your needle through tough tissue and to the desired target 🎯 Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Mar 19

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Older Adult Division faculty member Jeff Musgrave discusses a recent randomized control trial, comparing aerobic & cognitive outcomes for high intensity interval training (HIIT) compared to moderate intensity interval training (MIIT) for older adult adults with no training history. Aerobic outcomes were similar measured by peak VO2 max, however working memory & peak knee extensor strength was slightly better for HIIT group & they achieved this in 1/2 the training time! Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 18

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Zac Morgan discusses the importance of developing a reflective practice in clinical expertise. He emphasizes that while accumulating repetitions (reps) in your field is important, simply doing tasks repeatedly is not sufficient to achieve expertise. Zac shares insights on how to process these reps reflectively, which can significantly enhance your clinical skills and shorten the path to expertise. He encourages listeners to implement actionable changes in their practice to foster reflective learning and improve their overall clinical performance. Tune in to discover how reflective reps can transform your approach to practice, regardless of your professional setting. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 17

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division faculty member Jess Gingerich discusses the important aspects of c-section births that patients often wish they had known beforehand. She highlights four key points to consider when preparing for childbirth, emphasizing the unpredictability of birth and the need to have open conversations about c-sections, even for those initially planning a vaginal birth. Jess explores the recovery differences between vaginal and c-section births, urging listeners to reframe their understanding of what recovery entails for each. Additionally, Jess suggests incorporating specific c-section preparation into birth prep courses, ensuring expectant parents are well-equipped for any scenario. Tune in for valuable insights on navigating c-section births and enhancing the overall birthing experience. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Mar 14

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division lead faculty Alan Fredendall dives into the topic of triceps tendinopathy, a rare but real condition with a prevalence of just 3.8%. Alan explores what triceps tendinopathy is, the patient presentations clinicians might encounter, and the diagnostic criteria necessary for accurate identification. He highlights the stark contrast in prevalence compared to more commonly known conditions like Achilles tendinopathy, which affects 6-28% of various athletic populations. Tune in as Alan breaks down the context, diagnosis, and treatment options for individuals suffering from this often overlooked tendon injury. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 13

Dr. Rachel Selina // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CAO Rachel Selina explores the concept of effective communication, specifically the importance of not just hearing but truly interpreting what others are saying. Drawing from her personal experience studying abroad in Spain, Rachel emphasizes the distinction between understanding words and grasping their deeper meanings. She shares insights on how this understanding can enhance our interactions, advocating for a shift from mere listening to a more nuanced interpretation of communication. Join Rachel as she delves into the significance of being heard well and the impact it can have on relationships and interactions in both personal and professional settings. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 12

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the concept of "stronger with less," focusing on low dose training for older adults. He highlights a recent publication that challenges traditional biases regarding the dosage needed to elicit a positive response in older adults. Dustin aims to provide hope and practical insights for healthcare professionals, particularly those with limited interaction time with patients. He emphasizes the gap between recommended physical activity guidelines—such as 150 minutes of vigorous activity or 300 minutes of moderate activity weekly, along with resistance training—and the reality that many older adults, as well as healthcare providers, struggle to meet these standards. Dustin addresses the tension that arises when considering effective interventions that may fall short of conventional expectations, particularly in settings like home health and skilled nursing facilities. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 11

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Brian Melrose emphasizes the critical importance of standardization in clinical practice. He discusses how standardizing processes like active range of motion assessments and neural tension tests is essential for obtaining reliable data, which is the foundation for making informed clinical decisions and achieving positive patient outcomes. Brian shares his journey in mastering these techniques, highlighting the necessity of consistency in clinical evaluations to accurately track patient progress and ensure that treatment effects are not mistaken for measurement errors. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 10

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division faculty member Rachel Moore discusses the importance of scaling workouts for pregnant and postpartum women, as well as individuals with pelvic concerns. Rachel highlights a previous episode by Shae Sharbutt, which provided real-world case examples of scaling for different stages of motherhood. Rachel aims to demystify the stigma surrounding scaling workouts, emphasizing its relevance not just for the Open but for everyday classes and boot camps. Tune in for valuable insights on making fitness accessible and safe for all athletes, regardless of their stage in motherhood. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Mar 7

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete lead faculty Megan Peach delves into the complexities of evaluating transverse plane running mechanics. She highlights the challenges of assessing these mechanics due to the limitations of typical running gait analyses, which primarily utilize sagittal and frontal plane views. Megan discusses three specific transverse plane running mechanics that can be assessed without the need for a direct view, offering practical insights for clinicians. Megan emphasizes the significance of understanding these mechanics in relation to running-related injuries, providing listeners with valuable tools to improve their evaluations and interventions. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 6

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore dives into a powerful lesson on leadership that he learned from a respected mentor in the physical therapy field. He reflects on the importance of being accessible and easy to work with, contrasting it with his past pride in having a busy schedule that made him hard to schedule with. Jeff emphasizes that this mindset shift is crucial for effective leadership and urges listeners to consider the impact of their availability on their professional relationships. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 5

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett explores the concept of being "old school" in the medical and rehabilitation fields. She discusses the implications of adhering to outdated practices despite the presence of new evidence and protocols. Christina emphasizes the importance of valuing the experience of veteran clinicians while navigating the challenges of ageism in the workplace. She provides insights into how this mindset can impact patient care and professional development. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 4

Dr. Jeff Moore // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore delves into the crucial topic of mentorship, addressing the common questions surrounding how to secure great mentors. He emphasizes the significant impact a strong mentor can have on one's career trajectory, providing insights on navigating real-world clinical practices and business aspects that aren't always covered in formal education. Jeff aims to clarify the key principles involved in obtaining mentorship, sharing his expertise and experiences to help listeners understand the path to finding someone who can invest in their professional growth. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Mar 3

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division faculty member Heather Salzer discusses essential postpartum resources to help clients thrive during the challenging first year after childbirth. Drawing from her personal experience as well as her professional background, Heather emphasizes the importance of building a supportive community in the postpartum period, especially as traditional family support may be less accessible. She highlights the crucial role of lactation consultants, recommending that new mothers seek follow-up support beyond what is available in the hospital. Heather aims to equip listeners with practical tools and strategies to enhance postpartum care and community support for new parents. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Feb 28

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division lead faculty Alan Fredendall delves into the evolving role of healthcare professionals in addressing health, wellness, and fitness beyond traditional physical therapy. Highlighting a significant study published in JAMA, Alan discusses the alarming statistic that the average American spends only 18 minutes per year with their primary care physician, with marginalized groups receiving even less attention. He emphasizes the importance of extending care to patients beyond standard discharge protocols and the implications of limited physician time on patient outcomes, particularly concerning prescriptions for imaging, steroids, antibiotics, and opioids. Join Alan as he explores how healthcare providers can better serve their patients by embracing a more comprehensive approach to care. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 27

Dr. Brian Melrose // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE faculty member Brian Melrose discusses the vital role of leadership within the physical therapy space. He highlights a powerful quote from management expert Tom Peters: "A true leader creates more leaders, not followers." Brian emphasizes that effective leadership is not about accumulating followers but rather about empowering and developing new leaders. Brian explores the importance of delegation and collaboration in leadership, noting that as leaders achieve success, their responsibilities grow, necessitating the cultivation of future leaders to achieve common goals. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 26

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty delves into the fascinating connection between exercise and the gut microbiome, particularly in older adults. He discusses a systematic review titled "Systematic Review of the Effects of Aging and Physical Activity on the Gut Microbiome of Older Adults." Dr. Musgrave explains the gut microbiome's role, highlighting its composition of trillions of microorganisms that regulate crucial metabolic processes, nutrient absorption, and inflammatory responses. Key metabolites such as short-chain fatty acids, bile acids, and B vitamins are examined for their importance in maintaining healthy glucose levels, aiding fat digestion, and supporting overall health. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 25

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey leads a focused demonstration on conducting a shoulder exam. Lindsey highlights the importance of a thorough subjective exam to determine that the issue is indeed a shoulder condition, ruling out other potential sources of pain. She emphasizes the foundational principle of gathering precise data for effective decision-making in physical therapy. The demonstration begins in standing position to assess functional range of motion and identify any painful arcs, setting the stage for a comprehensive evaluation of the shoulder. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 24

Dr. Shae Sharbutt // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division faculty member Shae Sharbutt discusses the upcoming 2025 CrossFit Open and its significance for athletes, particularly those who are pregnant or postpartum. Shae highlights the excitement surrounding the event, including community activities like in-house competitions and charity fundraisers. Shae addresses the anxiety that some athletes may experience during this time and introduces three types of athletes navigating the Open. The first athlete discussed is the "go-getter," who is eager to participate and aims to perform at their best. Shae emphasizes the importance of setting realistic expectations and having open conversations about current capabilities to ensure a safe and enjoyable experience during the CrossFit Open. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Feb 21

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Fitness Athlete Division lead faculty Guillermo Contreras discusses the concept of remote programming, which encompasses coaching and personal training delivered digitally. Guillermo explains how this method can create additional income for physical therapists and coaches by providing clients with tailored movement and mobility strategies that they can follow independently, while still receiving virtual support and accountability. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 21

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the importance of active listening in leadership and communication. Drawing inspiration from Larry King's approach to interviewing, Dr. Moore emphasizes the value of being fully present in conversations, allowing questions to develop organically rather than pre-planning them. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 19

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he discusses the critical relationship between protein intake and bone health, particularly in older adults. He highlights the growing conversation around protein, often associated with muscle benefits, and emphasizes its significance for bone health, noting that 33% of bone mass is made up of protein. Dustin reviews current evidence on how protein influences bone growth through mechanisms like insulin growth factor IGF-1. Jones underscores the concerning trend of malnutrition in adults, particularly regarding protein intake, and calls attention to studies that examine whether older adults meet the minimum recommended protein guidelines. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 18

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses the powerful connection between beliefs and outcomes in physical therapy. Drawing from his experiences at the recent Spine Summit and his time in PT school under Dr. Craig Wassinger, he emphasizes the importance of confidence in therapeutic interventions. Zac shares insights on how wavering confidence can negatively impact patient trust and outcomes, highlighting the need for therapists to maintain strong beliefs in their practices to foster better recovery for their clients. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 17

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett discusses the theme of vulnerability in obstetrical care. Drawing parallels between the treatment of older adults in healthcare and the experiences of pregnant individuals, Christina emphasizes the importance of empathy and understanding in obstetrical settings. She reflects on her own feelings of vulnerability during labor, delivery, and the postpartum period, encouraging listeners to consider how their patients feel during these critical times. The episode calls for a reframe in how we approach and support individuals in obstetrical care, highlighting the need for compassion and respect for their experiences. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Feb 14

Dr. Jeff Moore // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes the critical importance of effective coaching in fitness classes. He highlights the multifaceted role of a coach, which involves not only explaining workouts and managing logistics but also ensuring the safety and effectiveness of each session. Jeff discusses the challenges coaches face in creating an engaging and productive environment while emphasizing the need to see the bigger picture, particularly regarding injury screens. He calls for listeners to share this episode to enhance community awareness and promote healthier practices in fitness coaching. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 13

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall continues a series on starting your own practice, focusing on the important topic of S-Corp election. Alan clarifies that an S-Corp election is not a different type of incorporation but rather a tax status that provides significant benefits for small business owners. Listeners will learn about the implications of double taxation, where businesses face corporate income tax at both federal and state levels, and how electing S-Corp status can protect owners from this issue. Alan emphasizes the importance of understanding the process and benefits of S-Corp election for anyone who has recently incorporated their business. Tune in for essential insights that can help optimize your practice's financial structure! Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 12

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the critical topic of falls prevention among older adults. She challenges the current frameworks and statistics surrounding falls, highlighting that one in three older adults experience falls each year, which are responsible for 90% of hip and wrist fractures. Christina emphasizes the importance of reevaluating the narrative around falls prevention and its implications for funding and research. Through her experiences in teaching the Older Adult course, Christina engages with clinicians of varying backgrounds to explore the prevalence of falls and the need for a shift in perspective regarding this pressing issue. Tune in for valuable insights on reframing falls prevention strategies to improve outcomes for older adults. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 11

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses the importance of demonstrating client progress in physical therapy. He emphasizes the need to show value to clients by celebrating small wins, which can include decreasing pain, increasing activity levels, and managing patient expectations. Cody outlines three key indicators of progress: the reduction of pain, the enhancement of activity levels, and the significance of maintaining progress even when pain levels remain unchanged. This episode serves as a guide for therapists looking to effectively communicate their clients' achievements and the effectiveness of their treatment plans. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 10

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jess Gingerich discusses the importance of recognizing and addressing pelvic floor health, even for those who do not specialize in this area. Jess emphasizes that while specialties exist, all physical therapists should be screening for pelvic floor issues as part of their practice. She shares insights from her recent conversation with an OBGYN who highlighted the necessity of examining all relevant areas of a patient's health, regardless of the primary concern. Jess encourages therapists to leverage their training in the musculoskeletal system to understand how various symptoms may interconnect and to actively listen to patients' concerns, using tools like body charts to document pain and symptoms effectively. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Feb 7

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester dives into the complexities of lumbar spine flexion in cycling. He sets the stage by discussing the standards and research surrounding lumbar flexion and trunk inclination angle. Matt touches on key concepts of individual tolerance to lumbar flexion, goals & performance expectations of the cyclist, and the role of the bike fitter. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 6

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall dives into 3 key tasks to perform following incorporation of your own rehab practice.. Building on a previous episode, he focuses on three key low-cost or free strategies to enhance the quality of your incorporation. Alan discusses the importance of changing your address to protect personal security, obtaining a Federal Employer ID Number (EIN) for tax purposes, and securing a Type 2 NPI number. These steps are crucial for ensuring your practice is set up correctly and safely. Tune in to learn how these elements can significantly impact your new venture! Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 5

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses a recently published research study comparing the effects of aerobic training versus strength training on hypertension in healthy older adults. The study, titled "Differential Effects of the Type of Physical Exercise on Blood Pressure in Independent Older Adults," was conducted over four years and included two groups: one focused on aerobic exercise and the other on strength training, with both groups participating in two 60-minute sessions per week. While both groups saw reductions in systolic and diastolic blood pressure, the strength training group exhibited superior long-term benefits, showing continued improvements beyond the two-year mark when the aerobic group's progress plateaued. Jeff highlights the importance of strength training in long-term wellness programs for older adults, particularly in managing hypertension. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 4

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Brian Melrose discusses one of the easiest ways to "build the bike" and get solid buy in from our patients when utilizing breath work in the clinic. As much as we focus on our patients pain or dysfunction when they come to see us at PT, we can offer them so much more regarding lifestyle factors. It's our hope that PTs focus on sleep, diet, and even stress within a patients plan of care. When it comes to the utilization of breathing techniques in the clinic one of the greatest challenges can be getting solid patient buy-in. We love using the pulse-Ox to "build the bike" and making these changes VISIBLE. These are easily accessible in the clinic and can be a great objective measure pre and post implementation of a breathing technique to show changes in HR and O2. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Feb 3

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore discusses the topic of planned cesarean deliveries, addressing the emotional and social challenges faced by women who choose this option. She shares a recent patient experience where the patient felt judged for opting for a cesarean, highlighting the complexity of birth and the importance of supporting individual choices. Rachel emphasizes the role of pelvic physical therapists in preparing and assisting patients for cesarean deliveries, aiming to create a supportive environment free from shame. The episode underscores the significance of understanding the diverse factors that influence delivery choices and promotes a compassionate approach to maternal care. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jan 31

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall dives into the upcoming 2025 CrossFit Open and its implications for rehab providers and athletes. With just four weeks until the first workout is released, Alan discusses what can realistically be accomplished in this timeframe. Alan addresses the common feelings of pressure athletes experience as they prepare, especially if they haven't made the progress they anticipated over the past year. He explores key focus areas for rehabilitation and training, and offer strategies for how professionals can support athletes effectively during this critical period. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 30

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore emphasizes the importance of the leadership principle of "giving before they ask." Jeff highlights insights gained from the first quarter of the Vantage program, focusing on effective leadership and business building. He stresses that proactive gestures, such as providing raises—whether financial or in terms of responsibility—are crucial for maintaining good morale among team members. Tune in for valuable leadership lessons and workout inspiration! Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 29

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the crucial yet often overlooked component of care for older adults: psychosocial resources. Despite thorough evaluations and well-crafted intervention plans, many clinicians find that their patients struggle to engage and make progress. Dustin highlights the importance of assessing psychosocial factors that can significantly influence patient outcomes. He shares insights from his experiences, emphasizing the need for healthcare providers to consider these variables to enhance their effectiveness in treatment and improve the lives of their older adult patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 28

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses the order of operations within a clinical session, addressing the common questions therapists have regarding which tools to use first and the best sequence for treatment. She emphasizes the importance of reassessing both subjective and objective signs at the beginning of each session as part of the symptom behavior model. Ellison outlines three key factors to consider when selecting treatment tools: the goal of the treatment, the patient's preference, and the physical therapist's preference. Listeners will gain insights into optimizing their clinical sessions by thoughtfully choosing their approach based on these considerations. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Jan 28

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick reviews a recent qualitative study published last month aimed to identify motivators, facilitators and barriers to participation in physical activity in individuals in the menopause transition and our role as rehab providers in treating these individuals. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jan 27

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete lead faculty Rachel Selina discusses considerations for introducing speedwork into running programming for two groups of runners - injured runners & novice runners. As speed increases load to the tissues, clinicians and coaches should use care and intention when helping runners return to speedwork after injury or when introducing speedwork for the first time. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 27

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the range of motion required in the first metatarsal phalangeal (MTP) joint for endurance running. Megan explains the mechanics of the MTP joint during the stance phase of running, emphasizing that only about 30 degrees of extension is necessary during the initial loading phase (0-20% of stance) to prevent trips and falls. She aims to provide listeners with a clear understanding of the essential range of motion needed for runners recovering from injuries, ensuring they can safely return to the sport. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 23

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall delves into the importance of incorporating your own practice. While you have the option to operate as a sole proprietor without legal incorporation, Alan emphasizes the numerous financial and legal protections that come with forming a corporation. Key benefits include reduced tax rates and the ability to write off more expenses. Alan highlights that even if you plan to remain a solo practitioner, incorporating from the start can prepare you for future growth and provide essential safeguards. Tune in to learn why incorporating is a crucial step in starting your own practice. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 22

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the crucial topic of myocardial infarctions, commonly known as heart attacks. Drawing from a personal experience involving a loved one, he highlights the importance of understanding both the intervention and the long-term care following a heart attack. Dustin points out the seasonal increase in heart attack risks, particularly among older males, as physical activity tends to decline during winter months. He emphasizes the dangers posed by sudden, higher-intensity activities, such as shoveling snow, which can lead to increased heart attack incidents. The episode serves as a call to action for rehab and fitness professionals to support individuals during these challenging times, providing valuable insights into prevention and care strategies. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 22

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren discusses the important considerations when choosing dry needling education. As the founder of iDryNeedle and the division lead at the Institute of Clinical Excellence, Paul shares his extensive experience in the field, having taught dry needling for over a decade. He addresses common questions and concerns about training options, emphasizing the need for unbiased evaluation of different educational programs. Whether you're a student physical therapist or a professional in a newly accepting state, this episode provides valuable insights into navigating the diverse landscape of dry needling education. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Jan 20

Dr. Shae Sharbutt // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Shae Sharbutt discusses the critical issue of racial disparities in healthcare, particularly focusing on African-American women during the pregnancy and postpartum periods. Honoring Martin Luther King Jr. Day, Shae discusses the prevalence of these disparities, which can manifest in unequal access to care, education, and resources. She emphasizes the importance of empowering patients through education, providing appropriate referrals, encouraging healthy lifestyle choices, and recognizing severe symptoms that may require urgent attention. Shae sheds light on the higher risks faced by Black women, including preeclampsia and gestational diabetes, and calls for awareness and action in addressing these disparities in clinical practice. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jan 17

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall breaks down the toes-to-bar, introduces the Tink T2B Tool, and explains how to use the Tink to help athletes progress in their toes-to-bar skill. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 16

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the annual ICE Diversity Leadership event. The focus is on promoting physical therapy (PT), occupational therapy (OT), and rehabilitation sciences to underrepresented communities. Jeff emphasizes the importance of sharing the benefits of these professions with those who may not typically hear about them. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 15

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the relationship between mild cognitive impairment (MCI) and falls in older adults. He explores a study titled "Perturbation-Based Dual-Task Assessment in Older Adults with Mild Cognitive Impairment," highlighting how cognitive decline affects dual-tasking abilities and balance performance. Jeff emphasizes the concept of cognitive reserve, comparing it to physical reserve, and explains how cognitive load during tasks such as walking and conversing can increase fall risk. Jeff aims to shed light on the critical impact of cognitive function on the safety and mobility of older adults. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 14

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey shares insights on conducting an effective elbow exam, particularly focusing on lateral elbow tendinopathy, commonly known as tennis elbow. Lindsey emphasizes the importance of a simple yet focused exam, supported by the latest clinical guidelines from Lucado et al. (2022). The discussion highlights key subjective complaints such as pinpoint tenderness in the lateral elbow and pain associated with gripping and loading activities. Dr. Hughey also addresses the common history of repetitive work in patients, including those in factory roles, baristas, and racket sports. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 13

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett discusses the rising trend of the anti-Kegel movement within pelvic health. She explores the origins of the anti-Kegel sentiment, referencing a study that compared EMG activation from Kegel exercises to that of other core exercises such as planks and leg lifts. This study led some to believe that whole body exercises could replace Kegels, a notion Christina critically examines. She presents both sides of the argument, emphasizing the need for a balanced approach to pelvic health moving forward into 2025. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jan 9

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer explores the surprising connections between the Lord of the Rings and physical therapy, emphasizing themes of community and action. The discussion begins with the character Treebeard, a giant, sentient tree who initially chooses to remain neutral and solitary amidst the chaos of the outside world. As the main characters urge him to take a side in their battle against evil, Treebeard's response highlights the importance of agency and the decision to engage or not engage in the struggles around us. The episode delves into how this metaphor relates to healthcare, encouraging listeners to consider their roles and responsibilities within their communities, especially in challenging times. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 8

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett explores the emotional landscape of exercising, specifically focusing on the feelings experienced during workouts. She discusses the common negative reactions older adults may have towards exercise, particularly high-intensity workouts. Christina emphasizes the importance of intensity and effort in therapeutic exercise, noting the discomfort that often accompanies it. She highlights the emotional journey of exercising, which includes a positive mindset before beginning, the struggle during intense exertion, and the rewarding feelings of accomplishment afterward. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 7

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Management division leader Zac Morgan reflects on the evolution of manual therapy in the field of physical therapy. He shares insights from recent studies and citations. Zac recalls the challenges faced a decade ago regarding the acceptance of manual therapy practices, highlighting the negativity and uncertainty that surrounded its efficacy and safety among early-career clinicians. As he reflects on his experiences treating patients with spine pain, he emphasizes the importance of focusing on patient outcomes rather than solely on the techniques employed. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 6

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer discusses that ultramarathon runners often exhibit a unique level of physical and mental endurance that enables them to tackle extreme distances, sometimes exceeding 100 miles. Heather discusses the concept that this capacity remains intact during the postpartum period as she recounts a personal experience with a woman she met during the Chuckanut 50K ultramarathon, who was five months postpartum and still performing exceptionally well. This runner had trained throughout her pregnancy and was accustomed to longer distances, making the 31-mile race feel relatively short for her. Heather reinforces that healthcare and fitness professionals often harbor preconceived notions about what postpartum athletes can or cannot achieve. Underestimating their capabilities can lead to unnecessary restrictions on their training and performance. Heather encourages practitioners to set aside these biases and act as supportive guides for these athletes. By doing so, they can help ultramarathon runners navigate their training safely and effectively, allowing them to pursue their passion without undue limitations. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Jan 3

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses the critical topic of maintaining aerobic capacity during the off-season for endurance athletes, particularly runners and cyclists. He shares insights on the minimum dose of training necessary to sustain aerobic fitness, referencing a comprehensive review by Spearing and studies conducted by Hopkins. Additionally, Jason addresses the importance of maintaining bone health through impact exercises for runners who may switch to different modes of training during the off-season. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 2

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer kicks off Leadership Thursday with an energetic discussion on the contrasting models of insurance-based versus cash-based practices in the physical therapy world. He shares his enthusiasm for the cash-based model, highlighting its benefits such as autonomy in creating personalized patient experiences, selecting equipment, and managing time effectively. Jeff encourages listeners to rethink their approaches as they head into 2025, advocating for a fresh perspective on how they can shape their practices and the services they offer. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Jan 1

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett reflects on the theme of aging and longevity. Christina encourages listeners to adopt a mindset of being "old people in training." She emphasizes the importance of setting ourselves up for success in our 30s and beyond to ensure a vibrant, active life as we age. This episode is a call to action for personal reflection on health and longevity, steering away from restrictive diets or weight loss goals, and instead focusing on holistic well-being. Join Christina for a thoughtful exploration of how we can prepare ourselves for a healthy future and help others do the same. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 31, 2024

Dr. Jeff Moore // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the concept of Ecosystem Forward Plant Management, a reflective approach to personal growth and planning as we transition into the new year. He emphasizes the importance of surrounding yourself with supportive individuals, echoing his favorite quote: "If you want to go fast, go alone. If you want to go far, go together." Jeff highlights the collective behaviors that come with the New Year, such as setting resolutions and reflecting on personal improvement, and encourages listeners to harness these normalized behaviors to foster their own growth. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 30, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses a crucial topic: "What if birth doesn't go as planned?" This episode is particularly valuable for both pelvic floor physical therapists and non-specialists, emphasizing the importance of understanding the complexities surrounding childbirth experiences. Jess provides insights that can enhance the care provided to patients and clients, ensuring they are supported regardless of their birth outcomes. Tune in for essential information that can help practitioners better assist those navigating unexpected birth scenarios. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Dec 30, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses using the Slingshot to improve bench press & push-up strength, technique, and for offloading the shoulder when in pain. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 26, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall explores the concepts of Parkinson's Law and the Profit First model, discussing their importance in establishing a sustainable business practice. Alan highlights alarming statistics about business failures, with a quarter of new businesses closing within their first year and 65% shutting down by the 15-year mark. Alan delves into why these failures occur, emphasizing that business owners often determine the effort invested is no longer worth the financial return. By understanding Parkinson's Law— which states that work expands to fill the time available for its completion— and applying the Profit First model, aspiring entrepreneurs can create a more efficient and profitable business strategy. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 25, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the significant role of hope in patient recovery. He emphasizes that while hope can be a powerful motivator for patients who may be uncertain about their healing journey, it must be accompanied by a concrete intervention plan to be effective. Without a structured approach to assessment and intervention, hope risks becoming an empty promise. The episode highlights the importance of combining hope with actionable strategies to enhance patient outcomes. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 24, 2024

Dr. Jeff Moore // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses the concepts of impact and friction in relation to growing your clinic as the season comes to a close. Jeff emphasizes the importance of understanding how friction can lead to fatigue, particularly when you're investing significant effort without seeing substantial returns. Jeff shares insights on the challenges faced when starting new ventures, whether it's a hobby or a business, and highlights the need to evaluate what has worked and what hasn't over the past year. He encourages listeners to create actionable steps moving forward, focusing on minimizing friction to maximize impact in their professional lives. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 23, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore unpacks the stigma behind women strength training and gives tips on ways to boost excitement about strength training through education on the benefits and guidance on how to get started. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! https://youtube.com/live/RoTF2fFW4aE

Dec 20, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the importance of mobility & end-range strength in the overhead squat and snatch. Alan demonstrates assessments & techniques to address tight lats, subscaps, and thoracic rotation. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 19, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore underscores the critical role of early intervention in managing acute low back pain, particularly concerning fitness and overall well-being. He argues that while the natural history of recovery may allow for some improvement over time, it often fails to facilitate a timely return to fitness. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 18, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the concept of intentional under dosage, particularly in the context of working with older adults. Dustin shares insights on when and how to effectively implement this strategy across various settings, including clinics, homes, hospitals, and gyms. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 17, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses the importance of technique in manual therapy, specifically focusing on joint mobilizations and manipulations. Cody shares a valuable principle he learned from Jeff Moore, ICE's CEO; the idea of having "iron fists in velvet gloves." He emphasizes the need for clinicians to use a broad contact area with their hands to enhance patient comfort while effectively directing force through body positioning rather than relying solely on hand strength. Cody identifies common faults in techniques and offers simple corrections to improve manual therapy practices. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 16, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick discusses how we as rehab providers sift through the noise of cueing and set someone's pelvic floors up for success when they are loading and lifting? Should we intentionally cue the pelvic floor during loaded activities? If so, which cues are the most effective? OR Do we even NEED to intentionally cue the pelvic floor when someone is lifting and moving weight? Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Dec 13, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall the metabolic pathway mTOR, the role of the amino acid leucine in activating this pathway, and how to provide practical advice to patients & athletes to better understand how the amount, source, and timing of protein consumption can facilitate accelerate healing & performance. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 12, 2024

Dr. Alan Fredendall // #LeadershipTursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall unpacks the 3 pillars of ICE; psychologically informed, manual therapy skilled, and fitness forward care. Alan breaks down each pillar & how it looks to practice it in the clinic with patients as well as combine all three together to maximize the quality of care for patients. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 11, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett continues her series on constipation in older adults. She discusses the significant increase in constipation rates as people age and emphasizes the importance for physical and occupational therapists to address this issue. Christina highlights the implications for rehabilitation professionals and the need for awareness and proactive discussions regarding gastrointestinal health in older patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 10, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey delves into the complexities of femoral acetabular impingement (FAI), exploring its diagnosis and treatment journey. She begins by discussing the historical context of FAI, referencing significant findings from 2003 that linked FAI on imaging to the development of osteoarthritis. Lindsey explains advancements in surgical techniques that allow for safe hip dislocation, enhancing the ability to visualize and address bony abnormalities associated with FAI. She emphasizes the need for improved management strategies within the healthcare system and highlights the role of physical therapy in enhancing care for patients with FAI. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 9, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett opens up about her personal experience with miscarriage and its impact on her understanding of pelvic health practice. She shares insights into how professionals can better support individuals who have faced similar losses, highlighting the often-overlooked aspects of this sensitive topic. Christina emphasizes the importance of empathy and awareness in healthcare, encouraging listeners to reflect on their practices and the support they provide to patients navigating these difficult experiences. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Dec 6, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses knee pain and the transition to fat tire biking as winter approaches. He explains what a fat tire bike is, highlighting its wider tires, which range from 3.5 to 6 inches, making them ideal for snowy conditions. Jason emphasizes the importance of managing knee pain for athletes, especially during this seasonal shift when many are moving to indoor riding or adapting to outdoor fat biking. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 5, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore shares insights on the importance of effective leadership, focusing on cultivating a hybrid democracy within organizations. Jeff highlights the often-overlooked need for leaders to actively seek and value the opinions of their team members, stressing that great employees prefer to invest their time in productive work rather than providing feedback on leadership decisions. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 4, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult faculty member Jeff Musgrave Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 4, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan delves into the topic of imposter syndrome, a common struggle among new clinicians. Drawing from his experience mentoring young professionals, he discusses how overcoming this feeling is crucial for building confidence in one's skills and ultimately helping serve patients. Zac presents an interesting perspective on comparison, suggesting that while it can often be the thief of joy, comparing oneself to realistic standards can actually serve as an antidote to burnout. He emphasizes the importance of setting appropriate benchmarks and recognizing the journey of growth in the clinical field. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Dec 4, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Alexis Morgan discusses that when providing care in male pelvic health, many practitioners may feel apprehensive about initiating the evaluation process, particularly when it involves physical examinations. A highly effective way to alleviate these fears and lower barriers to entry is to begin with a subjective exam. This approach allows practitioners to engage with their clients on a deeper level without the immediate pressure of conducting a physical exam. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Nov 29, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses why the shoulder is the most commonly injured joint in functional fitness, the demands asked of the shoulder during functional movement, and how to help athletes stay in the gym or get back in the gym with movements like bench press, push-ups, muscle-ups, snatching, overhead lifting, and more. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 28, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the concept of "You're not for everyone" - the attempt to create a broad appeal to a wide variety of people that you do not have (and may never have) authentic connections with. Alan discusses in the context of physical therapy practice that it is infinitely more efficient to increase the quality of your offering to current & past patients then constantly be trying to acquire new ones. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 27, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Dustin Jones discusses valuable equipment recommendations specifically designed for older adults in physical therapy (PT) and occupational therapy (OT) settings. The guide categorizes equipment into four key areas: strength, endurance, balance, and mobility. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 26, 2024

Dr. Britt Lademann // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Britt Lademann discusses patients who present with both low back pain and hip pain are a common scenario in outpatient clinics. A significant aspect of managing these patients is understanding the potential outcomes following surgical interventions, particularly hip surgery. Recent studies have shown promising results regarding the resolution of low back pain after total hip arthroplasty (hip replacement surgery). Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Total Spine Thrust Manipulation course , our in-person physical therapy courses , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 25, 2024

Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore delves into a comprehensive and thoughtful gift guide specifically designed for pregnant individuals, postpartum mothers, and those experiencing pelvic pain. Rachel emphasizes the importance of selecting gifts that are not only practical but also considerate of the unique challenges and experiences faced by these individuals. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Nov 22, 2024

Dr. Jeff Moore // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses that effective mentoring is a nuanced process that requires mentors to step back and allow their mentees to take ownership of their roles. This approach is essential for fostering growth and development, even if it means experiencing a temporary drop in performance. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 22, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the importance of scaling a practice. As a business scales, it can reach a larger audience. Jeff highlights that organizational growth enables the service of more people, which directly correlates to a greater positive impact on the community. The more individuals who benefit from the services, the more lives are transformed. This increased visibility allows the organization to fulfill its mission more effectively. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 20, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Christina Prevett shares her experiences as a clinician and highlights the frequency of discussions around digestive health with her older adult patients. She emphasizes the importance of understanding and addressing constipation, a common issue that can significantly impact the quality of life for seniors. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 19, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses the importance of prioritizing "big rocks" over "small rocks" in patient care. He emphasizes that key elements such as load management, appropriate dosing in rehabilitation, and overall capacity building through resistance training, cardiovascular exercise, nutrition, sleep, and stress management are critical for effective injury recovery. In contrast, "small rocks," which include manual therapy, dry needling, cupping, and various self-care techniques like braces and taping, play a lesser role in moving the needle in long-term rehabilitation. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 18, 2024

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer discusses returning to CrossFit activity following a C-section, including progressions back to GHD sit-ups, bar muscle-ups, and the snatch. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Nov 15, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall continues a 2-part series on strength & conditioning and concurrent training. Alan discusses using objective strength & conditioning benchmarks to understand where your athlete lies to better know what to prescribe to improve their performance. He also shares a case study example of a competitive CrossFit workout where both very strong & very fast athletes lost to an athlete with above-average strength and above-average conditioning. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 14, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses that in the realm of physical therapy, one of the most pressing challenges faced by clinic owners is the hiring and retention of exceptional clinicians. He emphasizes that the core issue lies in creating an environment where clinicians feel that their current job is the best option available to them. To achieve this, he proposes that owners must be willing to take two significant risks: investing in a premium physical space and offering competitive pay. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 13, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave shares a case of an older adult having back pain with deadlifting. He covers the process of using: 1. Show, Tell, Touch 2. Progressive Loading 3. Monitoring Symptom Irritability Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 12, 2024

Dr. Britt Lademann // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Britt Lademann shares important updates on concussion management based on recent literature. Britt emphasizes the significance of recognizing and assessing concussion symptoms, particularly in the subacute to chronic phases, which are often seen in adult populations, including those involved in motor vehicle accidents. Britt also discusses the evolution of our understanding of concussions, moving away from the traditional mechanical perspective of the brain being a "bruise" inside the skull to a more nuanced view. She highlights the need for physical therapists in clinical settings to stay informed about the latest research and to implement effective assessment strategies for managing persistent concussion symptoms in their patients. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Total Spine Thrust Manipulation course , our in-person physical therapy courses , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 11, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick reviews a recent publication that interviewed folks with chronic pelvic pain and gathered 4 major concepts the participants found most important from their pain science education learning. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Nov 8, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the concept of concurrent training, research supporting/refuting the principle, and practical applications for your patients & clients Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 7, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore addresses the overwhelming presence of the "10x crowd" making extravagant promises about scaling businesses. He candidly critiques these claims, pointing out that many of the individuals promoting these ideas actually struggle to grow their own businesses. Jeff provides honest insights into navigating the current landscape of business coaching and growth strategies. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 6, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the concept of cognitive fitness. What are the key steps to build cognitive fitness? A recent publication by Harvard Health has outlined 6 steps to maximize cognitive fitness, cognitive reserve, and overall mental health. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 5, 2024

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division faculty member Brian Melrose discusses the role of breath during manipulation techniques in physical therapy. Brian shares his insights on a common question: should therapists cue patients to breathe during manipulation? Brian takes a clear stance against incorporating breath work, explaining that it can hinder the effectiveness of the manipulation and the therapist's ability to identify the barrier. He reflects on his own journey, noting that his views have evolved since his early career when he was taught to use breath to help patients relax. Tune in to learn why excluding breath may lead to better outcomes for both therapists and patients. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 4, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett discusses the important topic of returning to running postpartum. She emphasizes the significance of structured approaches in rehabilitation, highlighting the use of checklists and screening tools to guide the process. The episode provides valuable insights for new mothers looking to safely resume their running routines after childbirth. Tune in for expert advice and practical tips to support postpartum runners on their journey back to fitness. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Nov 1, 2024

Dr. Jeff Moore // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes that poor coaching has significant consequences for those being coached, making it clear that it is far from a victimless crime. Jeff discusses how and why the lack of quality coaching leads to lack of improvement, self-actualization, and trust with patients & athletes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Nov 1, 2024

Dr. Miller Armstrong // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division faculty member Miller Armstrong discusses how to load the cervical spine in a non-daunting manner, including prone sidelying against gravity, loading the shoulders & neck with overhead pressing, and the importance of shrugs. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 30, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett explores the essential aspects of catheter use in geriatric care. She discusses the considerations that clinicians should keep in mind regarding catheter placement, pelvic health implications, and current guidelines surrounding catheterization. Christina also teases an upcoming virtual ICE session that will provide a deeper dive into these topics, emphasizing the importance of understanding catheterization in the context of geriatric pelvic health. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 29, 2024

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway cervical manipulation, risk of stroke, and the path forward in reducing risk for patients. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Persistent Pain Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 28, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic lead faculty Jess Gingerich addresses a common challenge faced by healthcare providers: what to do when a patient is unable to perform a Kegel or pelvic floor contraction despite thorough instruction. Jess discusses the importance of understanding the patient's symptoms, such as leakage, heaviness, or pain, and emphasizes the need for a comprehensive exam to rule out issues in other regions like the back and hip. The episode explores different strategies for teaching Kegel exercises, including tactile and visual cues, and highlights the significance of patient support during the learning process. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Oct 23, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave shares the keys from a newly published article he co-wrote with Dustin Jones. The article focuses being providing tips to for rehab professionals to have a smooth transition of their patients into group fitness. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 22, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses the importance of being a chameleon in your clinical practice. From speaking with patients, to treatment decisions, to rehab programming, being a chameleon will yield better patient outcomes! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 21, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic lead faculty Rachel Moore delves into the topic of pain during labor, challenging the cultural tendency to avoid discomfort. Drawing inspiration from a thought-provoking Instagram post, she discusses how the discomfort experienced during pregnancy and birth prepares individuals for the challenges of motherhood. As a mother of two with experience in both medicated and unmedicated deliveries, Rachel shares her insights on embracing pain as an integral part of the birthing process. Tune in for a thoughtful exploration of the role of pain in labor and its significance in the journey of motherhood. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Oct 17, 2024

Dr. Alan Fredendall // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses handheld dynamometry, including research supporting the reliability & validity as compared to manual muscle testing, when & why to use handheld dynamometry, and also demonstrates the use of the ActivForce2. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 16, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer as she discusses the importance of reframing our perceived value in caring for older adults. She emphasizes focusing on personal growth and transformation throughout the caregiving journey rather than solely on patient outcomes. Julie invites reflection on provider's experiences and how they evolve as caregivers, offering insights that encourage a deeper understanding of the caregiving process. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 15, 2024

Dr. Jessi Witherington // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jessi Witherington dives into the topic of what comes after manipulation in clinical practice. Jessi addresses common questions about dosing and post-manipulation strategies to ensure sustained effects in patients. Emphasizing the importance of individualized care, she introduces the SINs model—severity, irritability, nature, stage, and stability—as a framework for determining the best approach in each unique situation. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Persistent Pain Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 14, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Alexis Morgan discusses diastasis recti, a common issue encountered in clinical practice. Building on previous discussions from earlier this year, she emphasizes the importance of measuring interrectus distance (IRD) versus measuring strength. Alexis highlights new data supporting the idea that ultimately, all roads lead to loading the core for effective treatment. Alexis provides valuable insights for clinicians working with individuals affected by diastasis recti, focusing on practical approaches to loading and strengthening. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Oct 11, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the importance of competition preparation for athletes at all levels, from elite competitors to recreational participants. The conversation focuses on how clinics can better serve these athletes, ensuring they remain active and engaged, whether they're training for their first marathon, a 5K, or a CrossFit competition. Key points include the need for flexibility in appointment scheduling to accommodate athletes who may only seek help when an issue arises, and strategies for increasing athlete visibility and access within the clinic. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 9, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Dustin Jones dives into a recent publication that looks into minimal footwear's impact in older adults and its implications for clinicians. Much of the research on minimal footwear has focused on running. What about older adults at risk of falling? Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 8, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey dives into the topic of carpal tunnel syndrome (CTS). Lindsey explains what CTS is, including its symptoms and the populations it affects. The episode primarily focuses on the various treatment options available for CTS, discussing their efficacy as supported by current literature. Lindsey discusses the heterogeneity of treatment outcomes and presents a "PT first" approach to treatment. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 7, 2024

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer talks about how to combat the barriers of lack of knowledge and skills, lack of motivation/goals, and safety concerns to keep pregnant people exercising for improved mental and physical health. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Oct 3, 2024

Dr. Jessi Witherington // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Spine Division faculty member Jessi Witherington addresses the common issue of imposter syndrome that many new clinicians face after graduating from PT school. Jessie explores the definition of imposter syndrome, highlighting its impact on new professionals in the field and offering insights on how to overcome these feelings of self-doubt. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 2, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Christina Prevett as she dives into the theme of reflection, particularly in the context of career development and ageism in the healthcare field. Christina discusses the importance of acknowledging the value of continuous learning, regardless of a clinician's years of experience. She challenges the notion that being "old school" is simply a function of age, emphasizing that stagnation in professional growth, rather than longevity in practice, is what truly defines outdated approaches. We all get firmer in our beliefs with more experience but it's important to keep an open mind, continue to learn, shape and evolve your practice. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Oct 1, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division Division Leader Zac Morgan dives into the importance of sharpening the subjective exam in clinical practice, particularly in cervical and lumbar spine management. He emphasizes that the subjective exam is crucial for refining the hypothesis list and gaining a deeper understanding of patient issues, often overshadowing the objective exam. Zac shares insights from his experience mentoring students and new clinicians at his practice in Hendersonville, highlighting common gaps in understanding the subjective exam. He encourages listeners to consider attending comprehensive courses on this topic for a more in-depth learning experience. Tune in to enhance your clinical skills and improve patient assessments! Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 30, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick delves into the ongoing debate of whether to isolate the transversus abdominis (TA) during pregnancy and postpartum recovery. A question raised by a student highlights the misconceptions propagated by fitness professionals regarding abdominal exercises, such as claims that certain movements are unsafe for pregnant individuals. April discusses the importance of addressing these misconceptions, which often stem from well-intentioned but misguided advice, and how they can create confusion and fear around movement during crucial periods of recovery. The conversation also touches on similar issues faced post-surgery, such as after abdominoplasty or hernia repairs. Join April as she unpacks the evidence and clinical practices surrounding abdominal engagement during these times. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Sep 27, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses how and why strength provides a buffer against injury and is a great tool for improving quality of life. It is also a great way to improve overall fitness and performance in the gym. Are you or your patients struggling with METCONs that program moderate loads? Get stronger and watch your performance go up! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 27, 2024

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling faculty member Ellison Melrose dives into the topic of abdominal dry needling, focusing specifically on chronic abdominal wall pain. They discuss how this condition often arises from entrapment of the anterior abdominal nerves, frequently seen in postpartum women and individuals experiencing chronic pelvic pain syndromes. The episode covers the techniques for needling the rectus abdominis, including how to orient to the tissue and choose the appropriate needle length. Dr. Melrose introduces the use of electrical stimulation (e-stim) to enhance muscle response during the procedure, explaining the importance of localizing muscle spindle interactions. The episode provides a practical demonstration, including preparation techniques and exercises to visualize the abdominal muscles. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Sep 25, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave breaks downS.M.A.A.R.T. acronym & gives an example of what it would look like to apply this to a patient receiving home health. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 24, 2024

Dr. Miller Armstrong // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division faculty member Miller Armstrong wraps up a mini-series focused on clinical success in physical therapy. The discussion begins with the importance of defining what success means for each individual practitioner and the necessity of making a firm decision to pursue success. Dr. Armstrong emphasizes that once this decision is made, there should be no room for doubt; practitioners must commit to the actions required to achieve their goals. The episode also addresses the challenges therapists face when patients are not improving. Dr. Armstrong highlights the significance of approaching these situations with humility and grace, as acknowledging a patient's lack of progress fosters trust and strengthens the therapeutic alliance. By being honest about patients' conditions, therapists can better support their journey toward recovery. Tune in for valuable insights on cultivating success and navigating difficult conversations in clinical practice. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 23, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses common challenges in addressing stress urinary incontinence in patients. She highlights three key points that can aid practitioners in understanding and treating this condition effectively. The first point focuses on confirming whether the leakage is indeed urine, with tips on how to differentiate it from sweat or discharge. Dr. Gingerch suggests practical methods for patients to verify the source of the fluid, including using an over-the-counter medication that turns urine bright orange. Once established that the leakage is urine, she emphasizes the importance of detailing when these incidents occur to provide better care. Tune in for valuable insights that could transform your approach to treating stress urinary incontinence. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Sep 18, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer provides a comprehensive guide to creating a general workout for hospitalized patients. She emphasizes the importance of incorporating loading strategies and circuit training elements, such as EMOMs, to address the needs of sick patients. The workout focuses on key areas including gait, balance, strength, and power, while ensuring the experience remains enjoyable. Julie highlights the necessity of tailoring exercises to align with each patient's meaningful goals, encouraging listeners to develop activities that mimic the demands of those goals. The episode features a discussion around a specific patient avatar requiring mid to moderate assistance for standing and minimal assistance for walking, demonstrating how to adapt workouts based on individual capabilities. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 17, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses the two essential questions that clinicians must ask during every initial evaluation to set the stage for successful patient interactions. The first question focuses on understanding the patient's expectations of success, which helps establish clear communication and align goals throughout the treatment process. The second question inquires about the patient's perception of their condition, fostering a deeper understanding of their perspective. Cody emphasizes the importance of these questions in enhancing the overall experience for both the clinician and the patient, ensuring that expectations are managed effectively from the outset. Tune in to learn how these foundational questions can improve patient outcomes and satisfaction. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 16, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett delves into the fascinating journey of exploring male pelvic health as a female provider. She shares her personal experiences and how her initial reluctance to engage in pelvic health transformed into a deep passion, leading her to teach and conduct research in the field. Christina discusses key considerations for female providers contemplating a venture into male pelvic health, highlighting the importance of openness and adaptability in their careers. This episode encourages listeners to consider the expanding horizons of pelvic health and to embrace opportunities they may not have expected. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Sep 13, 2024

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete lead faculty Rachel Selina discusses how to modify running programming under three different circumstances: injury, illness & interruptions. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 11, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones delves into the topic of nocebos and their impact on individuals with osteoporosis, particularly concerning the fear of fractures. He addresses a question from listener Lisa Moore about the common advice given to patients with osteoporosis, which often includes avoiding bending, twisting, and lifting. Dr. Jones explores whether this advice is helpful or potentially harmful, emphasizing the need for evidence-based practices in managing osteoporosis. He highlights the fear surrounding flexion-based exercises due to outdated research linking them to increased fracture risk, and encourages a more balanced perspective on movement for those living with osteoporosis. Tune in for valuable insights on how to support clients in overcoming fear and maintaining an active lifestyle. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 10, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren shares research on the efficacy of ultrasound-guided dry needling compared to landmark-based dry needling for safety & clinical efficiency. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling.

Sep 9, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore unpacks a new way to conceptualize coning or doming in our pregnant and postpartum clients, and if we actually even care that it happens at all Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Sep 6, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall covers the subjective & objective factors to assess a patient for a shoulder labrum injury as well as the manual therapy & exercise treatment to crush their plan of care Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 5, 2024

Dr. Brian Melrose // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses removing barriers for patient compliance. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 4, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the efficacy of rehab in hernia prevention, management, and post-surgical care. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 3, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses how your body's regulation can be influenced by various factors such as stress, sleep, and activities of daily life. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Sep 2, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Alexis Morgan discusses passing on the positives of the pregnancy, labor, and delivery process with patients. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

Aug 30, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses ways to identify and treat medial tibial stress syndrome (MTSS), commonly known as shin splints, in the cross-country running athlete population. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Aug 29, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses SHOWING patient progress, SHOWING justification to be paid more, and SHOWING patients how you are different than the competition Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab .

Aug 28, 2024

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

Aug 27, 2024

Dr. Miller Armstrong // #ClinicalTuesday // www.ptonice.com

Aug 26, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com

Aug 23, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com

Aug 22, 2024

Alan Fredendall // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the difference between myofascial decompression & cupping, if myofascial decompression works or not, and how to elevate the use of myofascial decompression in practice Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLMyofascial decompression. What is it? How does it work? Does it work? And how can you elevate what you're currently doing practice if you're already implementing this style of soft tissue treatment? WHAT IS MYOFASCIAL DECOMPRESSION? So let's take it from the top and let's talk about what is myofascial decompression, sometimes abbreviated MFD. and how is it different from cupping? So you may consider these in your mind to be synonymous and that is very very wrong. Why? Calling myofascial decompression cupping is really a misnomer because if we dig deep people have been cupping each other for many many many thousands of years. It comes from eastern medicine and you may have seen it in practice, maybe you do it in practice, maybe you've seen it on social media or the internet, and you see people laying in a static position, sometimes with their whole body covered in plastic or glass cups, right? And so that is cupping, that is sitting in a static position, that is using things like meridian or chi points, the idea that maybe we're removing toxins from the body, and you may even heard of something called wet cupping, where we pull blood to the surface with a cup, and then maybe we puncture it with a needle or a knife and we draw blood out of people. So all of that is kind of in the sphere of the term cupping. And what's very, very, very different about myofascial decompression is that we are using some sort of pump, manual or automatic, to get a decompressive effect through the tissue. And in the context of myofascial decompression, we are always, always, always, always, including movement. We are never having people lay statically with just cups on their body. We are not educating them that we're removing toxins from their body or altering their chi or anything like that. And certainly, hopefully, you are not cutting people open and using the decompressive pressure of the cups to suck blood out of their body, right? And so that is the difference between cupping and myofascial decompression. Both use plastic or glass cups, but they come from very, very different paradigms in why we're using it, what we're doing, and the effect that we're hoping to have. So with myofascial decompression, we know now with MRI studies that when we put these cups on, if we have enough pressure, we know that we can put hundreds of millimeters of mercury of pressure through this cup, and that we can sometimes reach the level of the bone. And so we are decompressing not only just the skin and the fascia beneath the skin, but down to the level of the muscle, fascia between levels of muscle, and even deeper levels of muscle all the way down to the bone. And so thinking about the various levels, when you look at your forearm, for example, what is between you and the outside layer of your skin and the bone? Several layers of tissue. We have our epidermis, we have our dermis, we have super fascial tissue and fascia, we have deep fascia, and then we get into the fascia in and around the muscle. We have the epimysium, we have the paramycium, and we have the endomysium. And that we know with a large enough cup and enough pressure from one of our pressure guns that again we can reach the level of the bone. So we're using higher pressures combined with movement to create this decompressive and sometimes sheer force effect on the tissue, combining the decompression with the movement, that is myofascial decompression. And that is how much different it is from traditional maybe Eastern medicine, quote unquote, just cupping. So the second question that we often get and the second point I want to make is often, does it work? There is a lot of myths on social media and the internet that this is not doing anything, that this could never cause a change in tissue. and that is team Patently Untrue. Certainly, if you do this wrong, you can be very ineffective with this style of treatment, but if you do it right, it can be very, very effective. So I wanna give a shout out to Dr. Chris DiPrato. He's a physical therapist out in the Bay Area of California. You may have heard of him. He owns the company Cup Therapy. He teaches myofascial decompression courses. We had the pleasure of taking one of his courses a couple weeks ago when he was here in Michigan, and we had a great time. In particular, I love to learn all the research he had to share. And some of that research around does this actually work is pretty mind opening. And my point with today's podcast is that when we elevate our techniques, we elevate the efficacy and the efficiency of our techniques as well. And again, certainly, if you do this wrong or sloppy, you will have a minimum effect on the tissue. But if you do it right, you can have a profound effect on the soft tissue of the body. DOES IT ACTUALLY WORK? And Chris shares that in his course when he seeks to answer the question, does it actually work? Chris has used cups with myofascial decompression on embalmed cadavers. He has used them on fresh or what may be called wet cadavers. And he has used them on live living people in an MRI tube and looked at what is happening to the tissue when we have a large cup with a lot of pressure in it. What do we see? And what he has seen over the years doing these studies himself of having people in MRI tubes is that with a large enough cup and enough pressure, again, we can begin to decompress multiple layers of tissue, fascia, muscle all the way down to the level of the bone, which is pretty significant. And that in general, the more hydrated the tissue, the more decompressive effect we have seen. So when he has tested this on embalmed cadavers where all of the body water, liquid blood, everything is removed and the tissue is essentially dried out, we see a minimal effect when we use this technique. But when we use it on a fresh or wet cadaver or a living person that still has blood, all the sorts of fluid that we have inside of our body, that we get a much more profound effect. And more importantly, looking at these MRI studies, we see that not only do we see that effect in the moment, but that we see that effect for at least three to five days after we have done the myofascial decompression. So what is it? It is a technique using high pressure with movement to create a decompressive effect and some sheer force on the body. And does it work? Yes, if you do it right. So that's what I want to spend the rest of this podcast episode discussing. INTERLUDE Before I do that, I just want to introduce myself. My name is Alan. I have the pleasure of surfing as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. This is Technique Thursday. On Thursdays, we either cover leadership topics or we cover technique topics. Today is a technique topic today. And it is Technique Thursday, which also means it is Gut Check Thursday. This week's Gut Check Thursday comes from our own fitness athlete faculty member, Joe Hinesco, who sent me a nice little number for you all to do this week. It is every two minutes, hop on a fan bike, an echo or a salt bike, hammer out 20 calories for the guys or 15 for the ladies. And then any remaining time in that two minute window, you're going to do max repetitions of a barbell thruster. with the prescribed weight of 95 for guys and 65 for ladies. The goal there getting hopefully at least 10 thrusters every round and your workout is finished when you hit 75 thrusters. So the moment you hit that 75th thruster you are done with the workout. So it rewards an aggressive start, it rewards somebody who can be aggressive on the bike but still hop off and pick up that barbell and do big sets of thrusters. So If you try that and you hated it, send all that shade towards Joe. He's the one that came up with this workout, so send that his way. And then I just want to plug again, Chris DePrato cuptherapy.com. He has live and online courses, a level one course, a level two course, both live and online. And if you finish today's episode and you want to learn more about this, maybe you're like me and you kind of just started doing this without any formal training. I promise you, if you take his courses, you will come away with a lot of very actionable stuff that's going to do nothing but elevate these techniques in your own clinical practice. So let's talk about this. PRACTICAL APPLICATION Let's talk about practical application. First things first, if you have done cuffing before, You have probably seen clear cups. What's the difference? We also have cups. These are rock pods. We have these in the clinic as well. What is the main difference? The main difference is that I cannot control the pressure with something like a rock pod. All I can do is essentially stick it on my skin and get whatever pressure comes out of it, right? That might be not enough pressure to do anything and I may have to reset it. And then I basically am just getting lucky maybe with enough pressure for the patient to maybe feel something. But this is not ideal. It does not have a way for us to control the pressure. It does not have a way for us to objectively measure how much pressure we're using. And most importantly, we can't see through this, right? We can't see the tissue. We can't see what's happening underneath the tissue. There is some important stuff that can happen inside of a clear cup that you'll want to see. and I won't steal Chris's thunder, I'll have you take his course to learn that, but it's really important that we have a clear cup, and that we have some sort of control over the pressure, that we have some sort of pump gun, automatic or manual, to pump up the pressure, and really be sure we're just not getting a random application every time we put on a cup like a rock pot. So what does that look like? We have a manual gun, right? It has a trigger here, you connect it to the cup, and you pull pressure out, right? You decompress. And then with this style of cup, you just squeeze to let the air out. Now, what's great about Chris and Cup Therapy that has really made me feel good about this technique is they have solved the problem of how much pressure exactly am I using so that I can be sure if I repeat this treatment in the future, or maybe somebody else has to repeat this treatment for me, they're using the same pressure as me. Lo and behold, the automatic pressure gun, right? So you can see right here, if you're listening on the podcast, you can't see anything. So go over to our YouTube channel, or our Instagram page and watch me on the video. But what you'll see here is we have a pressure gauge, right? And it's measured in millimeters of mercury. It goes from zero up to 760 millimeters of mercury. And as you apply the cup, you will see the pressure gauge change. And that can dial you in more on how much pressure you're putting through the cup. And again, let you hopefully repeat that treatment in the future. And also be sure you're reaching the levels of tissue depth that you want to be working at. So this is a very, very great tool. This is brand new as of this year, I believe. So if you've taken his course before, you'll want to jump on cuptherapy.com and buy one of these. But this is very, very, very, very nice. And so I'm going to put this on myself. I'm going to put some, just some free up, and then I'm going to show you all how great it is with this auto pressure gun. So just putting some lotion over the area where I'm going to apply the cup. I'm going to apply the hose to the cup like so, and then I'm going to squeeze the pressure gun. Doing this one handed is super tough, but I think we can get it. There we go. And so you can hear the gun working a bit. And now as I take the hose off, you can see some pretty darn good pressure, right? A lot of tissue deformation right there, a couple of inches of skin fascia and muscle pulled into the cup. And I can tell you, this is a very different feeling than just having something like a rock pod or otherwise just a squeeze application silicone cup. This is right on the border between discomfort and pain. However, it is enough pressure that I could move those muscles. I could do a bicep curl. I could do pull-ups. I could move my forearm through whatever range of motion I wanted to, and you can see that cup is not going anywhere, and that comes down to making sure that we have enough pressure through the cup that we're reaching not only enough pressure that we can move with the cup on, but again, that we're reaching the levels of tissue depth that we want to achieve. And that is very, very easy to do with the automatic pressure gun. Let's talk about those pressures. What are they? If we really want to reach deep muscle or reach even the levels of intermuscular tissue and fascia, we need to have a lot of pressure through these cups. We need to have 300 to 600 millimeters of mercury. What is the problem with a cup like this? Or what is the problem with the manual gun? I have no idea what pressure I'm at, right? Hence the importance of the pressure gauge on the new automatic gun. Going down in pressures, if I just want to reach the level of the deep fascia, the pressure comes down a bit, 200 to 400 millimeters of mercury. And then if I want to stay superficial, even maybe if I just want to promote some lymph flow, maybe a patient has some swelling or some lymphedema, I can keep the pressure really light, 40 to maybe 150 millimeters of mercury. Again, how can I be sure I'm keeping pressure light enough to only promote lymph flow? Well, with something like a silicone cup or even the manual gun, I have no idea how heavy or how light my pressure is. And so again, it reinforces the need for that automatic pressure gun. And now I would say the key here, and again, the difference between myofascial decompression and cupping is that when we have these cups on, we're doing some sort of movement, right? Chris will take you through a whole protocol in his course of how to get the cups on and how to slowly introduce movement to an area, especially maybe if it's very restricted or very painful, but also different applications using lighter or deeper pressures to inhibit or facilitate different muscles. For example, he's a big fan of putting cups with heavy pressure on the traps for somebody who does a really contrived trap shrug when they lift overhead. And if you want to maybe isolate the deltoids or the upper back, and sort of think about turning the traps off a bit, we can stick some cups on the trap and really put a lot of pressure through those cups. It's going to be really hard to engage and move those traps, and it's going to promote movement through the muscles that we want to target. Again, maybe the deltoids or the upper back. And he has a number of different examples and circuits scenarios for you in his class but the key is the pressure matters and we can't know what pressure we're at if we don't have an objective way to measure it and then track it over time and for me that was a big game-changer what I learned is I was simply not using enough pressure using something like a silicone cup or or using something like a clear cup, but with just the manual gun. Simply not putting enough pressure into the cup to get the treatment effects that I was looking for. And certainly, probably not being light enough on the other end, if I wanted to do something like promote lymph flow, or I just wanted to have some cups on some muscles to facilitate muscle activation, I was probably going too light for deeper structures and too hard for more superficial structures. or movement facilitation. And again, the automatic gun with the pressure gauge changed all of that. SUMMARY So what is myofascial decompression? It is not cupping. It is using pressure, specifically various ranges of pressure depending on the level of tissue that we want to target. always combined with movement to promote movement through that muscle, movement through that tissue. That is very different from cupping where people typically lay in a static position, have a number of different cups applied to them, usually with no idea how much pressure is being put through that cup. Does it work? Yes, if you do it right, it works. As with most things in life, if you do it wrong, it won't work very well. And so understanding that if we have enough pressure through a large enough cup, we can move through several layers of tissue, including all the way down to the level of the bone, which is probably much more of a pronounced effect than maybe we ever thought possible. How can we get better at this? I would recommend if you haven't yet that you take Chris's course. You learn where to put these cups to target different muscles, to target different movement patterns, and that more importantly than anything else, you get yourself that automatic gun either from Chris's website or that you get with the level two course where you have that objective pressure grade knowing that different levels of pressure will target different structures and have different treatment effects. So it's really important we know what those are and what we're trying to achieve with that patient in front of us. us. So I hope this was helpful. Big shout out again to Chris. I reached out to him before doing this episode and just ran this by him and we really appreciate all of his collaboration. You'll notice that ICE does not have a myofascial decompression course. We think Chris is doing it better than anybody else and if it's not broke, don't fix it. So just go see Chris if you want to learn more about this. He runs a fantastic course, very evidence-based, Very movement focused, which you know, anything from us here at ICE, that's what we're all about. So just go see Chris if you want to learn more about this. I hope you all have a wonderful Thursday. Have fun with Gut Check. I don't think you will. Again, if you hate it, just send Joe those nasty messages. Just pass me right on by and go right to Joe. And I hope you have a wonderful weekend and a fantastic Thursday. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 21, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses important tools for acute care PTs: a good attitude, a backpack, a white board, resistance bands, sticky notes, and gait belts. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUER Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. and I am coming to you live from my garage. So this morning what we are going to dive into are fitness forward tools that you can use in acute care and I'm going to do my best to demonstrate some of these tools that you can use to start loading these really sick folks up early. All right so We are going to dive in first by talking about the most important tools that you need to have with you as you go through the hospital and you go visit your patients in their rooms. TOOL #1 - THE RIGHT ATTITUDE So number one, the most important tool that you need is the right attitude. You have to have the right attitude about this. So let me unpack that. Bringing fitness forward care to sick older adults in the hospital. It is not about getting them to do a sexy deadlift with a dumbbell. It's not the sexy thing. It is not, holy crap, I just got this patient, they're in a hospital gown, they're super sick, and they're doing a deadlift with a dumbbell in the hospital. It's not about that. It's not about being able to get the video of that or the picture of that and being able to share that. That is sexy and that is cool and it is badass. However, the meaning is deeper. What the attitude you need to have is, is that you have this beautiful, amazing opportunity to plant a fitness forward seed in this patient who is sick, who has a ton of medical complexity, and you only get to see them potentially one time. You've got one shot to plant that seed and potentially be the catalyst that sets this person up on a better trajectory of health. That's an amazing opportunity. And I would encourage you all to be obsessed with that opportunity. Okay. Every single time I would go into a room, I thought, wow, I have this opportunity. I've got one shot. I could be the catalyst that changes their lives. And the thing about you all who work in acute care, man, you are doing some dirty work, right? You are seeing folks, whether they're young or old, they have multiple types of diagnoses and medical complexities. You are seeing them at their worst and you are seeing them in a very, very vulnerable situation. The fact that you are able to plant that seed yet you don't get to see the sexy outcome and yet you give them your whole heart and whole soul is so important. And it's hard to be in acute care and know that you're not going to get to see a sexy discharge where a patient is lifting a super heavy barbell or they are going all out on an assault bike. You're not going to see that. And that's tough, but you have to reframe it to be, I'm going to be obsessed with having the attitude that I could go into every single one of these rooms, plant the seed, and the patient is able to walk into an outpatient clinic. They want to do fitness-forward care because I planted that seed. And I think that's an incredibly, incredibly important story to tell yourselves so that you can continue to have the motivation to go in and see these folks who are sick day after day. And many times you may not actually get to get them to do the cool fitness board stuff. Okay. So that's the most important thing is having that right attitude. Okay. TOOL #2 - A BACKPACK So the second tool that you're gonna need to bring along with you to every single room is a backpack, all right? You absolutely need a backpack. So this is not the backpack I used in acute care. I used the backpack that they gave us as like a Christmas gift one year. This is a Nomadic. This is my travel backpack. This is a very sturdy, but very expensive and nice backpack. I do not recommend getting something like this to go into hospital rooms, okay? But I do recommend that you get something that's sturdy because you're going to be carrying around a lot of stuff in it. So get yourself the backpack. So what are we putting in the backpack? You're going to put weights in the backpack. No, most acute care therapy offices do not have weights. But you can bring your own. So I would bring a 15 pound dumbbell. and an eight-pound dumbbell, and I would put that in my backpack. Now, some of you are not able to bring a backpack potentially into the patient's room. Cool, then you bring it around and you leave it at the nurse's desk, okay? But the idea here is that you're bringing everything with you so that there is no excuse that you don't have the equipment because you're in the hospital. So you have your weights. Now, I've had people say, well, Julie, isn't that tough to carry around? And I say, yes, it is tough, it's heavy, but who else would want to be able to go rucking through the hospital with weights more than fitness-forward clinicians who are here listening this morning? I thought it was awesome. I felt like I was getting a lot of fitness in by carrying this stuff around throughout the hospital all day. TOOL #3 - THE WHITEBOARD Okay, so after weights, you're gonna have a whiteboard, okay? I'm using a whiteboard right now for my talking notes for this podcast. you all are going to want to use a whiteboard to create workouts with your patient. So have your dry erase markers and as you are digging into their meaningful goals and you're coming up with functional movements that match those meaningful goals, you are writing this stuff down, you are coming up with reps and sets, you are doing this with your patient. Now, I will say, you're not going to buy these and leave these in patient's rooms, right? This stays with you, okay? You can take a picture of this and give it to your patient, or the really cool thing about acute care is that they typically have whiteboards in the patient's rooms, and they're usually filled with some random information many times they are covered up with Call don't fall signs Those become great whiteboards. Okay, so I usually they're not helpful We all can can agree that call don't fall signs are not something that prevents somebody from falling. So I they're great whiteboards so I would take those down turn them around and with my dry erase markers cut right down the whiteboard on those signs then I would leave that in the patient's room maybe I would go find a couple extras and I would put some motivational phrases on there like uh i remember one very specifically i'm trying to kick covid's ass so i can get home in shopwood something like that or something that lets the providers know a little bit more about this patient their name is something that i always put on these signs their name and something about them a goal an interesting fact i want to try and have every provider who walks into the room treat this person a little bit more like a human than a number or a diagnosis and that's a way to do that so whiteboard, slash use the hospital whiteboards, use those signs that are all around the room, turn them over, use those as your whiteboard. TOOL #4 - RESISTANCE BANDS Okay, next, resistance band and TheraBands. Okay, so both. So resistance band is something like this, okay? These offer a lot more resistance than a TheraBand. However, I usually would bring a bag of theravans because i want to be able to leave some with patience right you can do endless things with the TheraBands. I would tie them to the bed rails many times. So even folks who are typically they're just lying supine majority of the day because they're so deconditioned, you can tie those around on the bed rails. They can pull from above, they can pull from the side, there's a lot of stuff you can do with them just tying them to the bed rails. with the resistance bands, this is where I would many times get people up into standing and I would do something like a paloff press. So if they're standing here and this is attached to the bed rail, I can have them do a paloff press to work some core. I can have them do some rotations, you can do rows, you can do a whole bunch of stuff with those resistance bands, but those come with me. I'm not leaving those in the room. TOOL #5 - STICKY NOTES Okay, next are sticky notes. Okay, sticky notes are amazing because they're versatile. So I have sticky notes and then even better than sticky notes, I have a really bright, uh, note card. And then I've also used paint swatches that you can get for free at Lowe's or Home Depot. Okay. So what I do with sticky notes or these things, they become targets, right? So if I'm gonna have folks be reaching for things or stepping to things and maybe I'm calling out colors or I will write on a sticky note a number and then they're not only doing a motor task, they're also doing a cognitive dual task perhaps, These are great tools. They're light, they're easy, they're cheap. The other thing I like with the sticky notes is I'd like to put little notes on them for people. So if I'm using targets with a sticky note, perhaps to show them exactly where I want them to do their deadlift, pick the weight up from and put it down on, I will put a note here that just says like, you're a badass or never give up or something like that. And then that's something that the patient can keep. So they're wonderful for targets. They are wonderful to do some dual tasking. So you can have people reach for yellow or reach for a number that is written on one of the colors. So you can yell out the color or the number. Very versatile tools, very easy to carry around with you. TOOL #6 - GAIT BELTS All right, and then also obviously a gait belt. You need to have a gait belt. obvious reasons for safety but also i have used a gait belt before and i have put it around the bed rail and okay i have never ripped a bed rail off of anything by putting the gait belt around it and tugging on it okay so i'll just say that are they the most sturdy things in the world no i've never ripped one off so that's my preface there. But I have looped this around the bed rail and then perhaps someone is sitting in a wheelchair and they have a really hard time just sitting up tall in their wheelchair, their core is very weak, I will do almost a modified rope climb where the gait belt is around the bed rail and they are pulling themselves up to sit tall, and then going back to the back of their seat, the back of their wheelchair, and then pulling themselves up to sit tall. I've done this in home health, where I looped this to the end of the bed, the bed frame, what am I calling it, footboard. But typically, in acute care, there really isn't a big enough space in those footboards, maybe some of them, but definitely a really cool tool to use to do unmodified rope climb really get that core activated for someone who is so weak that they barely can even sit tall in their wheelchair. TOOL #7 - SNACKS Okay and then lastly You need snacks, okay? Don't forget your snacks. I became so much more efficient and so much more productive when I started bringing food up on the floor with me and putting that in my backpack. So, get you some nuts, get you a bar, a little bit of healthy sugars, maybe some, I always had like clementines or mandarins, those were one of my favorite snacks. Make sure that you have some fuel so you are not having to really put a big stop in the middle of your day. You're not going down to the cafeteria, getting crappy cafeteria food, and it just kind of keeps you focused. When you take that break and go down to get a snack or a coffee, I think it just puts you in that mindset of like, I'm going to just chill and not work as hard. When you just keep hammering throughout your day and you're able to do that because you have fuel, it's really important. Okay, so that is what I put in my backpack. All right, so let's talk about some specific acute care hacks to load up your patients when you don't use the weights. Okay, so let's throw the weights out. My favorite hack, one of them, is to use towels. All right, now this is a towel that I have soaked in water. All right, because a soaked up towel is really heavy compared to a towel that's not soaked in water. So I will roll a towel up and I will put it in the toiletry buckets that are in every single patient's room. So usually these buckets come with soaps and little doodads, things like that. I just get rid of that and I soak up towels and I put them in the basin. Now, you can do a whole bunch of stuff with this. So for someone even in sitting, even having to hold on to this basin, can be very challenging. We can increase the difficulty by going overhead. We can increase the difficulty by doing some marching in sitting. We can do a deadlift from sitting. We can then get up into standing and we can do a deadlift as well. So the great thing about this is it's a great way to introduce the hinge to a patient who is post-op lumbar fusion. Yes, I am loading up someone who is post-op lumbar fusion day one. Why? Because they're going to be discharged. They were probably never taught how to do a hinge in the first place, which contributed to them ending up having surgery. and I want to be the person to break that cycle, right? They're gonna go home, they gotta empty the dishwasher, lift up Fluffy's kitty litter box, whatever it is, why not teach them here and now? So I will put the towel in the basin, and then I will teach them how to properly hinge with an elevated surface in the basin. So I'm teaching them a hinge pattern, loading it up a little bit so that they know how to properly hinge when they go home, okay? And less amounts of things you can do with that basin. The next piece of equipment that I love are your bedside commode buckets. Yes, the things that poop usually goes in. But this is not what we're using them for. We are using clean bedside commode buckets, okay? So the cool thing, buckets, they usually have a handle, okay? So it makes it a lot easier to hold on to than potentially the basin. So what I will do is I will put a bunch of crap in the bucket. So I will put my weights in there or I will go and get a bunch of ankle weights because typically therapy departments and acute care have ankle weights, put them in the bucket and now we got some load. So you can do the same thing. You can deadlift with the bucket, okay? you could do my favorite, which are carries. Okay, so loaded carries. So as you're walking with your patient, they could carry on to the bucket. And the cool thing is that it adds a little bit of a perturbation. Okay, so they're getting an internal perturbation just by holding on to an object. There's a truck coming by, I'm sorry. I am out in my garage. and there is destruction going on in my neighborhood. And it's disruptive. So I'm gonna wait until they go by. Okay, they're hanging out. I'm just gonna talk louder. Okay, so with the bucket, Come on, my friends, keep it moving, keep it moving. Don't say no on a live podcast. Okay, with the bucket, what you can do is if someone is non-ambulatory, they can hold on to the bed rail and they can go like this, back and forth with that bedside commode bucket full of equipment and full of weights, okay? They could hold on to it, hold on to the bed rail and march, just like this. They can swing that bucket forward and backwards. There's a lot of things you can do with the bedside commode buckets to add in a little bit of a perturbation. Okay, lastly, we'll talk a little bit about how to put all this stuff together. So when you are with your whiteboard, right? And you're talking and you're sitting with your patient and you're figuring what movements that you're going to do. This is where you can start introducing what an EMOM is every minute on the minute. You could start introducing what a rounds for time is. So very, very early on, typically patients don't hear about this stuff or feel what intensity is like or load until they're way into their journey and they go into outpatient potentially, right? So the amazing thing is that you get to start introducing them to what a workout is like this early on. Imagine that seed that you've planted, then your patient will understand what it's like to lift heavy and to work hard. They go to home health or they go to inpatient rehab and then they go to outpatient and they're able to advocate for themselves and understand, okay, This is too easy. I don't need that yellow TheraBand or I'm not working hard enough. This isn't challenging enough for me. You are able to give them that opportunity, which is absolutely amazing. And remember, you can be the one that has an impact on them. Farther down the road, you are not going to see that sexy discharge, but you were able to be the catalyst to spark some change. Okay. All right, my friends, that is all. The next time I come on here, I will actually show you an example of like an EMOM or a rounds for time, some examples of what I would actually do with patients in acute care. I will also, on the ice stories, I will post some of my reels I made back when I was in acute care, going back into the archives. I will post on our story my reels that show some of this stuff in action. Lastly, talking about our courses that are coming up. MMOA Live will be in Alabama, we will be in Minnesota, Wyoming, and Oregon for the rest, not the rest of September, we're not in September yet, but in September, so many opportunities to catch us live on the road. Alright everyone, have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 20, 2024

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Justin Dunaway takes a deep dive into a series of three studies tracking the same cohort of patients over 10 years and what they say about the importance of short term changes! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Persistent Pain Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JUSTIN DUNAWAYAll right, team, good morning. I am Justin Dunaway, lead faculty with the Institute of Clinical Excellence, coming at you live from Portland, Oregon. Welcome to another Clinical Tuesday. I am lead faculty for Total Spine Thrust and also our Persistent Pain Comprehensive Management course. 32nd cohort just began yesterday. So if you're thinking about jumping in that will the registration will remain open for another day or so So if you're thinking about it, go ahead and take a look But enough about that. Let's get into today's topic today we're gonna talk about full thickness a traumatic rotator cuff tears and looking at physical therapy or Surgery and what what kind of predicts that stuff? and it's really cool because it's a series of three studies over a decade that looked at the same same kind of cohort of humans and And while I'm going to talk a bunch about these three studies, realize that this really is more than a story about rehab for rotator cuff tears. This is really a story about the importance of our ability to demonstrate within session and between session change, early, often, and frequently. And at Ice, we often hear that we are obsessed with incessant change. We are obsessed with our ability to show short-term changes. And I couldn't agree with that sentence more. Like, totally. I am absolutely obsessed with that. The second half of that, though, which I don't agree with, is that short-term change, within-session change, those things don't matter. What we're really talking about is regression of mean or natural history. And short-term change doesn't predict long-term change. And I couldn't disagree with those sentences more on lots of different levels. But I think that the story I'm about to tell, the three studies that we're about to walk through, give some of the best evidence and support for the need for short-term and within-session change, for at least one of the many reasons why this stuff is so important. So let's dive in. First study, study number one, the effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears, multi-center prospective cohort study by Kuhn and Dunn, 2013. Mouthful. But basically what they did is they took a whole bunch of humans, 452 of them, that had full-thickness chronic degenerative rotator cuff tears, and all of them got six weeks of physical therapy. And then at the end of the six weeks, they were asked, you know, how are you doing? And they got one of three options. They could stay cured, in which case they were done, and we'll just check in at 12 weeks, and then at a couple time points over the next two years, or they're improved, in which case they would get another six weeks of physical therapy, or no better, and then they could opt for surgery. And then at the 12-week mark, the people that were left, that weren't cured in the first six, asked them the same question. If they were cured, awesome. If they were anything but cured, they were offered surgery, and then tracked over the next two years. The physical therapy protocol, I couldn't get my hands on the full version of Appendix A that went into detail about what they actually did, but in the study, in the methodology they just talked about doing the physical therapy was range of motion, was postural control, was scapular training, was mobilizations, was general strength training stuff. And I've got some thoughts on that and we'll dive into here in just a second. But the outcome here is what they found is that less than 25%, okay, full thickness chronic degenerative rotator cuff tears, less than 25% of the 452 people in the trial at the end of the 12 weeks needed surgery. At the six week mark, only 6% of people opted for surgery. At the 12 week mark, that number was up to 15. And then over the next two years, a few more trickled in and that went up to like 24%. So at gut shot, 75% of people with full thickness rotator cuff tears went on to have excellent results in pain, disability, range of motion, strength, functional stuff, and went totally back to life. That's awesome. That's huge, right? The second piece The thing I want to think about here, though, is I think that number could be a bit better, right? I'm going to make an assumption that once we dive into the exercise protocols there, were they really doing strength stuff? Were they really looking at multi-joint movements, overhead presses, rows, pushes, horizontal presses, things like that, and dosing them appropriately for strength? you know, thinking about low or high sets, low reps, two to three minute rest at roughly 80% of their calculated one rep max, or are they doing like three sets of 15 with a band? And call it strength. I have no idea. My assumption is that we probably could be a bit more aggressive with exercise, and I bet that number could get a bit better. But 75% is awesome. So let's run with that. And the conclusion of this first study, which is super important, That if I'm just gonna read the quote if a patient avoids surgery in the first 12 weeks He or she is unlikely to undergo surgery at a later time point up to 12 up to two years So this is the first point here if the patient doesn't opt for surgery in the first 12 weeks They're probably not going to get surgery so our ability to to show them functional improvements in the first six, in the first 12 weeks, is absolutely huge. Because if they don't feel like they need surgery at the end of the 12 weeks, they're not going to get it probably ever. And when we think about conservative management versus surgery, both these things can be effective. But there is massive risk to surgery, right? There's massive financial risk. It's super expensive. And then thinking about the risks of anesthesia, of something going wrong during the surgery, of infection, of interactions, adverse events with the medications, opioid addiction. All of these things are risks of surgery that don't exist in conservative management. Okay, so that's the first study. If you don't opt for surgery in the first 12 weeks, it's unlikely that you're going to. 75% of humans got totally back to life without needing surgery. Study number two, predictors of failure of non-operative treatment of chronic symptomatic full thickness rotator cuff tears. Same research team. This was published in 2016. Again, looking at the same cohort of 452 individuals, This time what they wanted to see is, okay, 25% of you failed conservative management, failed physical therapy. Why? Is there anything in there? Is there anything about you that predicts whether you will or won't do well with physical therapy? And this was really cool. So they looked at all the patient demographics. They looked at age, they looked at sex, they looked at pain, severity of the tear, disability, chronicity, activity levels. They looked at work status and education and handedness and really everything under the sun. And what they found, the first thing they found is that structural factors were not predictive at all. Tear didn't matter, pain didn't matter, disability didn't matter, what your MRI didn't look like. None of that stuff predicted whether you needed surgery or not. The number one most powerful and really only significant predictor of whether you went on to need surgery or not for your full thickness rotator cuff tear was belief that physical therapy wouldn't help you. That was it. If you believe physical therapy would help you, you succeeded, you didn't need surgery. If you didn't believe that, then you opted out and went for surgery. And then smoking status moved the needle just a little bit, which makes sense. If you're smoking, your body is widely inflamed. Things heal slower. Your pain systems are far more sensitive. And then the other thing that was a very small predictor was activity levels. If you had higher activity levels, you were slightly more likely to opt for surgery early. And that makes sense too, right? My shoulder hurts. I can't do all the things I want to do. I'm still trying to do them. Things aren't getting better quick enough. Give me the magic bullet. The important thing here, again, one, structure was not predictive. Two, the only real strong predictor was your belief in physical therapy. Now, this is where it gets interesting, right? If that is the thing that determines whether you get surgery in the first six to 12 weeks, or that's the thing that determines whether you get surgery, and most humans are gonna make that decision within the first six to 12 weeks, you cannot make the argument that within session change and short term changes don't matter and probably aren't the most important thing there is, right? Because I cannot, if the thing that determines whether you need surgery or not, whether you get into that MRI tube, whether you get in the OR suite, whether you're getting those injections, pills, things like that, is your belief that physical therapy can help you, I cannot think of a more powerful way to foster that relief than having some tools in my toolbox that when you walk in the door, very quickly, I can modulate your pain, I can change your pain, your pain pressure threshold, turn on painfully inhibited muscles, gain some access to proprioception, and then get out into the gym and do some things that actually build capacity in humans, and demonstrate that thing within session, and then session after session after session. Short-term change and within-session change are the things that get patients to believe in physical therapy. And belief in physical therapy is the thing that keeps the patient out of the OR. Simple as that. That is the most important tool we have to foster those beliefs. Okay, study number three. This one just came out like last month. The predictors of surgery for symptomatic, atraumatic, full thickness rotator cuff tears change over time. Same research team, again, looking at these same humans that were in this study. Now this is tracking them down 10 years later. The first thing that pops out is that at the 10 year mark, only 27% of these people went on to get surgery. So you think about that, at the two-year mark, it was around 24%. So just a few more people kicked into the surgery over the next two, between two years, year two and year 10. Most of them, over half, opted for surgery before the six-month mark, and then the rest of them slowly trickled in over the next 10 years, with it kind of being less and less each year down the road. At the six-month mark, And everything prior to that, the most predictive thing, again, whether you need surgery or not, was belief in physical therapy and nothing else, right? So those beliefs are gonna be powerful all the way up to the six month mark. Everything we can do in that window to convince patients. that this is the path they need is gonna be the thing that keeps them off the other path. Beyond six months, it doesn't switch to structure, it doesn't switch to pain and disability and any of that stuff. The only two predictors beyond six months were if you were on worker's comp, and again, if you reported high levels of activity. Now this is super important too, right? Because okay, we're six months, we're a year, we're two years, we're five years out. We've done physical therapy, it didn't work, we've kind of forgot about it, that's off the table. And now, the stuff that's really bugging us is the fact that, okay, we're still having trouble at work, we're on workers' comp, we're kind of in that system, we still have all these activities that we want to do that we can't do the way we want to do them, now it's time to do something else. It's important to realize that overall, at the 10-year mark, 70-ish percent of humans, again, didn't need the surgery. And this is an interesting bullet point, too, because one of the things that you'll frequently hear is that, great, people do well with conservative management for rotator cuff tears. But if you don't repair it anyway, you set the patient up for degenerative changes, arthritis, problems down the road. What this study showed us is that the 10-year mark, the 70% of humans that did well with conservative management 10 years ago in that six to 12-week PT window, All of them were successful. And the success that they gained 10 years ago didn't decline over time. They didn't have more disability. They didn't have increased pain or arthritis or things like that. Their gains stuck. And this is one of a few studies that look at conservative management for rotator cuff tears, track them out over long periods of time, and show that there is no negative mechanical effects from not repairing that thing. So, the important stuff here, the key clinical factors here, is that team, at the end of the day, beliefs and expectations are the foundation. They're everything. They're the thing that drive the decisions that patients make, right? And if we don't have the ability to demonstrate change to our patient, if we don't have the ability to show them, not just tell them, But show them time and time again, ruthlessly, within session and between sessions, slowly building up functional outcomes, session after session after session, they're not going to buy this. And if they don't believe in what they're doing, if they don't believe in physical therapy, if they don't think that this is the thing, that's the stuff that determines, OK, am I going to get shots? Am I going to be taking pain medications? Am I going to end up in the OR suite? We need, what this research tells me is that we really need to drill down on our ability to have tools in the toolbox that create quick, transient changes in pain, range of motion, muscle activation. And I get that that's transient, but what we're doing is we're open a window. And then once that window is open, we absolutely have to jump through it, get right into the gym and start doing the large functional movements that build capacity in humans. And then be ruthless about your comparable measures, your functional stuff between sessions and your objective stuff within sessions. and make sure that multiple times every session, you're showing patients change. In every session, when they walk in the door, you can show them change over time. This is where you started. This is where we were after the first week. This is where we were after the second week. The better we get at that, the better we get at demonstrating change in the moment and showing them incremental change over time in the short term, the better our odds of keeping these patients out of the surgical suite. If the only thing that separates these two groups, physical therapy or going under the knife, is their belief in the power of what we're doing in the clinic, then we have to invest everything we have in our ability to demonstrate those changes. All right, team, hope you're half as excited about these three studies as I am. I think it's a really cool thing to look at and then track these patients over the last 10 years. If you got any questions, throw them in the chat. Have an awesome day in the clinic, and I look forward to seeing you out there. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 19, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member April Dominick discusses 4 topics to cover early in rehab for an individual who had a prostatectomy surgery in order to promote optimal physical and mental recovery! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION APRIL DOMINICKPost-op prostatectomy, unique considerations for the PT. Let's talk about them. Today on the podcast, we'll talk about four topics that are unique to post-op appointments when it comes to treating someone with a, or after a prostatectomy. Overall, we address the person who comes in for prostatectomy care with similar basic foundations that we would any other post-op person, like rotator cuff repair, post-op knee replacement. We do this in regards to respecting general tissue healing guidelines and timelines, restoring mobility and function, as well as using those progressive overload principles in order to achieve those goals. Don't let the prostate piece scare you. It's basically the same, except for a few considerations that we'll talk about today. You are the musculoskeletal expert, and you can use what you already know for these general post-op sessions. The post-op PT eval will be, like I said, similar to the pre-prostatectomy eval that I talked about in my previous episode, number 1765. In that episode, I outlined some basic education on prostatectomy, options for surgery. I go into detail about what a rehab session would look like from the subjective to the objective to the treatment and, uh, week over the most common complaints, which are urinary leakage and erectile dysfunction. So the biggest takeaway from that episodes besides how to outline your eval and session is that pelvic floor muscle training prior to a prostatectomy is key for having incredible impacts on improving health-related quality of life post-op. So again, the outline of a prehab evaluation for someone prior to their prostatectomy will be very similar to the post-op. So I just wanted to take out some key pieces or topics to focus on today that are unique to someone who had a prostatectomy. So we'll talk about how to educate, intervene, and I'll give you some tools for four different branches of our post-prostatectomy tree. The first branch we'll talk about is surgery specifics and general pelvic floor knowledge. The second thing we'll talk about is bladder function. Then we'll go into sexual function. And our fourth branch is the psychosocial piece. So let's dive in. SURGICAL CONSIDERATONS Branch number one, surgical considerations to ask the patient. So the patient comes in, they've had their prostatectomy. What do we need to know about their surgery? Well, first off, we need to know which type of surgery did they have. And we're today talking about a full prostatectomy, so removal of the prostate and some seminal vesicles. So which type of surgery was used? Was it open, meaning they had much larger incisions in the abdomen in order to get to the prostate? which is gonna have a huge effect on rehab. Number two, is it a laparoscopy? And that's gonna be a lot smaller incisions on the abdomen, or was it robotic assisted? Generally speaking, those are smaller incisions. They have less trauma and much shorter hospital stays. Another important question to ask is how long was their catheter in? And on average, it's about one to two weeks. If it's longer, there is a big potential to impact short-term bladder function, like urgency, frequency, leakage, and there is a greater risk for UTIs. And then if they know about this, a lot of times they don't really know about this, but if they know about it, any information about how much nerve sparing was achieved during the surgery. We know now the greater the nerve sparing, the likely that there is better function from a bladder side of things, as well as sexual function. So that's just some general surgery considerations. Now we'll dive into pelvic specific education that we can give. In terms of the pelvic floor, most people don't know what the pelvic floor is and don't know how it's related to the surgery they just did. So ensuring that the individual has some visual models or pictures of the pelvic floor itself and how these muscles relate to bladder, bowel, sexual function, supports, and things like that. Then making sure that they know, hey, this is the surgery that you had. Here's what happened, if they're okay with you talking about it. That way they understand why they're experiencing certain side effects. And then asking them, very much understanding what is it that they need in terms of lifting? Do they have a toddler at home? Do they have a grandchild that they're lifting or a caregiver? What are their job duties? Does their work require that they lift? And making sure that we have those in mind so that we can prioritize those with their rehab goals. Still under our pelvic branch, we can also get some objective measurements from them, outcome measures that are really helpful for this population. From a bladder side of things, the International Prostate Symptom Score is helpful. They also ask about nocturia or nighttime leakage. And then the NIH chronic prostatitis symptom index, it talks about impacts of symptoms and their quality of life. From a sexual function standpoint, the erectile hardness scale and then the international index of erectile function, those basically have them rate their erections and the quality of those. And then psychosocially, there is a prostate cancer specific index cancer patients and it measures health-related quality of life, physical function, as well as emotional well-being. So those are some outcome measures that you can track changes of with your patients. And then still on the objective side of things for the pelvic floor, we want to get a general orthopedic assessment and pelvic floor specific assessment. And during that pelvic floor assessment, we are looking at hyper or hypotenicity. We are understanding what their awareness is of their pelvic floor, their connection, coordination, strength, so many different things that we can look at. And you can do an external visual palpation of the pelvic floor. And you can do an internal a digital rectal exam. However, that's only going to be once they are cleared by the physician around six to eight weeks. So that was all the surgery considerations that we want to ask, then the pelvic floor, just kind of like things that we want to go over, objective measures. BLADDER FUNCTION Now we're going to move into the bladder function and talk about education, exercise, and some general tools and resources for that branch. So education wise, we want to be educating these individuals that urinary incontinence is extremely common in this population. It can be significant and very much improve. We usually see most improvements within the year. Clinically, I've seen a lot of improvements in that first three to six months, especially if they're able to come in for PT. And then we want to be telling them about, hey, here's some education on pads, how you can use the weight of the pad to be a specific measurement for whether or not they're improving in their urinary leakage. So weighing the pads is a lot more objective of a measurement than asking, How many paths do you go through? And then teaching them, hey, there's different levels of absorbency of the pads. That could be another measure. If you need one that has a much lighter absorbency, then that can be another sign that you're improving. And then from a daughter's side of things, educating them on taking note of your daytime leakage and nighttime leakage. Reminding them that, hey, if you After the surgery, once you become more and more active, you may notice at first some more urinary leakage and we expect that. for some people. And as they do therapy, we also expect that to get better. So also being mindful for these tracking changes and suggestions. Some individuals may have a lot of anxiety with tracking these changes. So being careful with who it is that you actually recommend being very diligent about tracking. And then from an exercise standpoint to help with bladder leakage, we're always going to start with pelvic floor muscle training. And that can be isolated at the very, very beginning. And then, and we can start that as soon as the catheter is removed. There aren't any solid research-based protocols on how many reps exactly and how often and whatnot, but we generally want to be starting with isolated pelvic floor muscle contractions and then pairing that with functional movements pretty much right off the get-go. I'm gonna say sit-to-stands are one of the biggest and most common ADLs that someone post-op will have leakage with and because think about how many times we stand up to during our day as well. So really harping on mechanics and breathing and bracing strategies to help limit the urinary leakage with that. And then of course lifting, walking, returning to specific sports or job duties is going to be how we also want to pair our functional activities. our pelvic floor muscle training. Then we want to be teaching about breath mechanics and bracing strategies. So really leaning into, hey, there is a spectrum of breath mechanics like using an open glottis versus using a closed glottis. That's going to be a lot more intraabdominal pressure. And really teaching them how to gauge that pressure at the beginning to reduce the strain that they have with activities like standing up. Also ensuring that, hey, when they are lifting, they are not straining. They are not, as we like to say in the pelvic division, going down to the basement. And because that is going to increase unnecessary pressure on the area that is healing. And then progressively building up to increasing intra-abdominal pressures as well as external loads as they return to lifting or impact or return to their sport. From a bladder side of things, the tools that we can use, a penile clamp would be a tool that lightly puts pressure around the mid-shaft and then in doing so it kinks the urethra and that's going to over time increase bladder capacity and help them if they are struggling quite a bit with urinary leakage. All right, so that was the bladder branch. SEXUAL FUNCTION Now we're onto the sexual function branch. The sexual function piece, often the most distressing post-op change. Education-wise, we want to make sure that they understand, hey, there is no longer going to be wet ejaculate post-op due to the removal of the seminal vesicles. You may have a loss of penis length, Expect that. And then also reminding them that, hey, there may be some changes in your erection and orgasm, such as delayed onset or reduced intensity, maybe some increased pain or reduced sensation, but that is why you're working with me. We'll work together on some of those pieces. and then from an exercise or modality perspective for sexual function. Obviously, pelvic floor muscle training is going to be really helpful, making sure that they have an understanding and awareness of which muscles or where they need to be working if there are restrictions to the pelvic floor. So we can teach them some self-mobilization techniques, not only at the pelvic floor, but also globally at the hips and abdominals as well. And this is going to help promote local blood flow, which is what we need for sexual function and for interaction. And then modalities like dry needling plus stim are helpful for local and global blood flow. And then of course, regular aerobic exercise, 150 minutes a week, that is going to 100% improve their blood flow and just overall physical health in general. Other non-musculoskeletal tools that they can use to help with sexual function, penile pumps that can help with erectile function by increasing the local blood flow and maintaining penile length. There are various protocols for using these. And then a lot of folks are also recommended to use medication like phosphodiesterase to help with post-prostatectomy and sexual function. PSYCHOSOCIAL CONSIDERATIONS And then our third branch, the psychosocial branch. While this surgery removes something physically, we cannot forget the ricochet effects it has on the person's mental and emotional well-being. exercise levels pre and post-op, let's use this as an opportunity to create lifestyle change, to increase their aerobic and resistance exercise frequency so that they're not leading that sedentary lifestyle post-op that maybe they did pre-op. This is going to obviously improve mental health and the physical effects post-prostatectomy. While the surgery does affect the client, it also affects their social life. Say leaking or wearing a diaper, going out to happy hour, not a great look. And then also it includes the romantic partners or maybe even caregivers. So ensuring that we are addressing not only the individual who was affected from the surgery, but others in their life. And then tools wise, the Prostate Cancer Foundation, it's a great resource for finding providers, treatment centers, support groups, and there's a space for caregivers. So I really liked that website. Then there's the Mojo app, and that focuses on the psychological side of sexual function for erectile dysfunction. So it's created by a psychotherapist and pelvic floor physical therapist. There's lots of different exercises, little modules that they can go through. A support group is also included. It is not prostatectomy specific, but I think it's a great resource from the psychosocial side of things. And then of course, mental health providers are huge, especially those that are versed in pelvic conditions or even someone who's a sex therapist. SUMMARY Okay, in summary, we know that prehab is vital for these prostatectomy patients in order to improve their outcomes post-op. Post-op prostatectomy, the general guidelines of tissue healing are very similar in how we would use progressive overload principles, very similar as any other kind of operation or post-op. There's just those unique considerations that we talked about. We talked about that tree with some different branches, so making sure that surgically we asked them about specific questions like what was the type of surgery, how long did they have their catheter in from a bladder function branch. We talked about education of the pelvic floor itself and anatomy so that they understand why leakage is happening. We talked about breathing and bracing strategies and using those to up or down ramp the pressure to affect urinary leakage. And then we talked about pairing the isolated pelvic floor muscle contractions and coordination work with whole body strengthening and functional activities. Definitely focusing on sit to stands as they have the greatest urinary leakage. And then we talked about sexual function, ensuring that they know there are changes in their penis, like the erection, orgasm. They can do self-limbalizations to help with restricted areas. They can use the Mojo app, the penile pump, to assist in erectile function. And then from the psychosocial piece or branch, we talked about resources like the Prostate Cancer Foundation, mental health providers for both the client and the caregiver. So our next online cohorts, if you all are interested in pelvic classes through ICE, Our next online level one cohort starts September 9th. Level two starts October 21st, and that's where we really deep dive into post-op considerations. And we also talk more in depth about prostatectomies. Our next live courses are in Hendersonville, September 7th and 8th, Milwaukee, September 14th and 15th, and Galesbury, Connecticut, September 21st and 22nd. Thank y'all so much for listening, and I will catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 17, 2024

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko discusses the concept of maximizing health & fitness. What is the most optimal route for most people? Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JOE HANISKOThis is Fitness Athlete Friday. I want to welcome you to the PT on Ice Daily Show with the Institute of Clinical Excellence. My name is Joe Hanisco. I am one of the Lean faculty alongside Mitch Babcock and Zach Long in the Fitness Athlete Division. In terms of what we have going on in the Fitness Athlete Division, we'll quickly chat on that before we get rolling on the topic of over-optimization today. We are kind of wrapping up our year in 2024. We can see the end of the fall coming in and we have a few more live courses, three or four courses in the state of Colorado coming up here shortly in April. We have Texas coming as well and I know Mitch is going to be ending out the year down in Florida trying to get some sunshine down there. So if you're looking to get on one of our live courses, we have three or four left in those areas kind of spread out nicely across the U.S. I know that we are also about to kick off our Level 2 online course here in September shortly. So beginning of September, if you're looking to get on to Level 2 Clinical Management of Fitness Athlete online, hop onto that. If you're trying to complete your certification or get through that process, We only offer that course twice a year, so it's going to be a few more months before we get back on top of that. But yeah, I'm looking forward to meeting you guys and hopefully catching you on the road here. Over-optimization. I'll have to be clear when I dive into this because I think a lot of us, especially at ICE and our following and all you guys out there in the Army, we love health. We love wellness. We love to optimize and perform. at our best and I think that's great that we're putting our minds into what makes us better humans, better athletes, makes our clients healthier and happier people as well. But lately I've been fielding a lot of questions from my clients on optimization and how to maximize their health. And what I'm starting to see is a trend here in which there's a few things happening and that people are putting so much energy into being perfect that it's kind of coming back to haunt them. and or they're forgetting the basics and I wanted to chat about that. You know you think about optimization from a health metric standpoint you have to think about time investment and sometimes financially investing into this as well but from a time perspective you think I have 24 hours in a day to make the best decisions for myself in terms of my health and well-being And right off the get-go, 30-ish percent of that should be consumed with just proper sleep. If we're getting six, eight, 10 hours of sleep, you're getting a good 30 to 40% of your 24-hour day wrapped up in sleep, which is fantastic, but what I'm getting at there is already a big chunk of time is removed from one thing that should be optimizing your health, which is sleep, and we should be prioritizing that, but that's a chunk of time that you're already devoting to your health and wellness. that leaves you with, you know, 14, 16 hours or so. And most of us are working professionals, and we probably spend six to 10 hours a day working. So you add your eight to hours of sleep to maybe six to 10 hours of work and you quickly are eating up 75% of your time and that leaves maybe 20, 15, 20, 30% of your day left over to make decisions that are kind of not being made for you at this point. And this is where the extra optimization stuff would fall into. But again, what I want to get at here is that in that small chunk of time, you guys are all real humans just like me where we have, uh, after our work day, we have kids that we have to take care of. We might have games that we have to go to. We have grocery shopping, we have meal prepping, we have yard work to do, you name it. We have responsibilities and that 20% that we have left over our day starts to get whittled down to very little time to, uh, to be strategizing what is the best effort to help maximizing my health, my fitness journey outside of the things. that I'm already doing and outside of the time that I'm devoting to work and to sleep, a big chunk of what our 24 hour day gets eaten up into. So what I'm getting at here is when I have clients come in, they're talking about, Hey Joe, do I invest time or money into a cold blanch or maybe a sauna? Which one do I go with? Like which one's going to give me the best benefit? And then they roll into, well, I heard about red light tables and laying in one of those might be helpful for cellular repair and reproduction, which is I think possible, but also, Getting out there a little bit Or do I go and invest time into this laser? Therapy that I've heard is helpful or half possibly, you know during my workouts I'm trying to do some CrossFit stuff stuff and some strength workouts But how many days a week and how much time do I have to invest into? zone two training and then yesterday Joe I listened to a podcast about vo2 max and how Although zone two may help with your VO2 max, high intensity, more interval style training is going to be even more beneficial for my VO2 max. I should certainly do that because that's correlated with mortality. But I can't forget that just building muscle is also correlated with mortality. And then after I do all that, I would like to make sure I have time to breathe and do some meditation and work on some cyclic sighing or some box breathing technique for 15 or 20 minutes a day. But which one should I choose? Should I do nasal breathing stuff? Should I focus on the cyclic sign? And it should leave me some time to then hopefully organize all my supplements because I know that I have inflammation in my body and ashwagandha is gonna be helpful for that. And I'm already trying to take creatine and I heard that magnesium might help me with my sleep so I should probably think about buying some magnesium and figuring out when to put that into my life. And then before I make any decisions, I should certainly go talk to a healthcare professional about getting advanced blood panels and screens done so that I know where all my metrics are so that I can make the best decisions for those supplements and I'll slap on a CGM at the end to make sure that my blood glucose isn't out of control. I hope that was confusing as I ran through that because it is confusing. We have so many freaking things out there now in the last probably, I feel like the popularity has really spurted up here in the last three years maybe now, but certainly every year it seems to be putting more and more energy in. How do I be perfect? How do I make my human body as perfect as can be? Hear me loud and clear. I support people in making good decisions. I try to make good decisions myself. I have been interested in some of these optimization techniques and I have also pursued some of these optimization techniques and theories. What I'm getting at now is that I'm sensing and there's this palpable level of stress that is coming alongside with people trying to be optimized in their health journeys. They are putting so much time and energy into Researching listening and figuring out what is best that they might actually missing the opportunity to do one thing really really good for themselves and therefore not see the benefit or if they are putting energy into optimizing This palpable stress that I'm feeling now, I feel like is actually creating the problem. And the problem is perfection. The stress that comes with being perfect, I feel like could drastically, especially in the everyday human like us, drastically outweigh the benefits of what those optimization tactics are trying to lead to. This is just sort of a paradox now that we're stuck in between how much time and what techniques am I and should I be willing to invest in to see the best outcomes on my overall health and wellness and where do I put them into my daily routine? I think this is the big paradox that we are running into. So my purpose of this talk today was not to necessarily dive into the weeds on cold plunging and red light and supplements I think there's enough research out there, and really the research, like most research, tends to be somewhere in the middle on a lot of these things, that yes, there could be a benefit. Sometimes I believe the benefit is in that upper 1%, meaning that it might make a small change, and so therefore, statistically, there is a benefit. we might be missing a greater opportunity for change focusing on other things. Or it's 50-50 just because some things work for some people and some things don't work for other people or how you execute that in terms of a protocol may not be optimal. So for an example, I know that a lot of people who have invested into red light I'm sorry, to sauna and heat exposure are doing so without really diving into the literature and showing that much of the research, especially the Finnish research that has all the proposed benefits of cardiovascular health with heat exposure. The duration and the heat intensity of these things is insane like most of us don't have a sauna if we're using like a red light Infrared sauna for example that will ever get to the 150 60 70 or higher range like some of these studies are having people who are able to spend 15 to 30 minutes a day or more in a true sauna and that is reaching 180 plus degrees. And then they're reporting results of these cardiovascular benefits. And then people over here in the US are just jumping into the 120, 130 degree infrared sauna and spending 15 minutes there a couple of times a week, uh, and rather than every single day. And then assuming that they're getting that benefit, which I don't know if that is true. I don't know if that will help. I, I can't say that there's been research to show that if you do it halfway that you'll get the same results. Uh, but also it's possible that people are wasting their time with that was what I'm getting at. And so, So this is where it gets like a really slippery slope. So the purpose of this chat today was not to get into the weeds, not to get into the science behind it, but to get into a very clear reminder that the palpable stress that I am feeling as a clinician in terms of conversations is real. I know that it is out there. And I think that what we need to be doing is reminding ourselves and our clients that what they have to be focusing on first is taking their meds. This is an abbreviation that we've used at ICE over the last couple of years now that If we can invest in taking our meds, meaning the M of meds is the mental health side of things. If we can focus on doing something that we enjoy doing for our mental health, putting time and effort into relationships, whether it's with our spouse, our kids, our friends, or all of the above, maximizing our relationships are going to be huge. That is the mental health portion that we certainly cannot deny has a massive contribution to our wellness, our longevity, and our overall well-being. The E is exercise. I think we're all on board that exercise seems to be the most consistent in terms of improving people's health, physical and mental health. And there are a lot of ways to exercise. Find the thing that you love the most and stick to it. If that means that you aren't getting in strength every single day, VO2 max training every single day, Zone 2 training every single day, mobility work every single day, or some combination of that, that is okay. Find something you enjoy doing, help your clients understand that the idea should be that consistent daily movement is the goal and that it doesn't have to be perfect. You don't have to hit every protocol and everybody's understanding what it takes to be maximal, but you need to invest in exercise. That is big. Move daily, find what you love to do and repeat that over and over again. So the M, mental health meditation. the E, exercise, the D, the diet side of things. There are a thousand diets. We know that research on nutrition and dietary information is scattered because humans respond differently to different approaches, but also because there are many different ways to do this well. But we want to remember for most people it's going to come down to maximizing the types of food that they put into their body, the quality of food that they're putting into their body. Choose whole foods. Choose foods that come directly from the earth. Whether you're vegan and you eat nothing but fruits and vegetables and grains or you're a carnivore and you're eating, you know, ribeye steaks every single day. I don't care what that is. If it comes from the earth, you're probably making a better decision than if it comes from a box. Dial that in, maximize your protein intake because we know that the research is very consistent, that the more protein we get in across our lifespan for all different reasons will help with longevity, will help with health, help with performance, and then focus on reducing but also balancing the negatives. Reducing your alcohol intake, reducing your overall sugar intake, possibly the seed oil conversation comes into this as well. But balance that out because when we go zero to 100 on that, a lot of times people are going to slip. They're going to make mistakes and I think that can sometimes lead to frustrations or thinking that they're not getting the best benefit from doing so. And we do know that balance is okay with nutrition. If 80 to 90% of your choices are the right choice, that five, 10, 15% slip here or there that going out with your family and enjoying pizza and maybe a beer with some friends. you're going to be okay. So with the diet, we focus on real foods. We focus on protein intake and we focus on balance, balancing the negatives, reducing them as much as possible, but balancing and enjoying our life because that will tie back into our relationships and the mental health. And last but not least, and we've already touched on this a little bit, is the S, the sleep side of things. Like as much as you can get is clean and clear and the quality as best as you can get. That is what we need to focus on. I think the biggest piece of advice from most literature, that I've read in the time that I've spent looking into sleep is that if you can make your sleep life consistent, if you can go to bed within 30 minutes of a certain time, if you pick 10 p.m. as your goal time and you're in bed by 930 to 1030 or around 10 o'clock every day and you're getting up at the exact same time, give or take 30 minutes or so on either end, you're going to be in a good spot there to help balance out rhythms, circadian rhythms and hormones in the body and you can put as much time into that quality sleep as you can get and you're going to be in a great spot there. So I think we need to not completely disown these optimization tactics. I am not saying that you couldn't and you won't possibly see benefits from cold plunging and sauna. You very well could be or from red light or nasal breathing and just certain meditation tactics or certain supplements. Yes, there's value in those. What I am saying is that if you're trying to maximize everything, you are going to see that. I think that the stress, the palpable stress of being over optimal will outweigh the benefits of the optimization itself. So our resolution, we focus on taking our meds. We would take them every single day, mental health, exercise, diet, and nutrition, and sleep. Take our meds. I hate to break it to you all, but I don't think yet that we're at a spot where you're going to live forever. What I think we need to be focusing on is that we can maximize the time that we do have on earth here. And that comes down to not only doing the right things, the right choices, but balancing them in a way that we can enjoy our life and not feel constantly stressed by the decisions that we're making. You're given your, your panel of genetics when you're born. There's not much that we can do about your genetics, so don't stress too much about your genetics. Your epigenetics, what you can do with your environment and how your genetics might play out is more important. If you have slightly higher cholesterol because it seems to be a genetic component of your body, Don't lose control over that. Maximize your meds. Not literally pharmaceutical meds, but the meds that we talked about and put as much energy into that healthy lifestyle, exercise, diet, everything there. And I think you're going to be better than the average. You're going to turn out okay. Take advantage of your time. Enjoy your time here on earth, guys. Take your meds, do the right things. If you feel like you want to dabble in one or two optimization techniques, that is perfectly okay. But don't let the stress of optimization outweigh the benefits of just living a healthy lifestyle. Hopefully this is a good reminder. Hopefully you can take these conversations to your clients or to yourself. Sometimes for me, even it was a gut check at times. So happy to kick off your Friday here, Fitness Athlete Friday, but this is probably more of a general topic on health and wellness. I'll look to see you guys in the row over the next couple of months. I'll be in Colorado, April 13th, 14th, I think, Long Mountain, Colorado, just north of Denver with my last CMFA course for the year. at least live and hopefully we'll see you on the level two guys. Have a great Friday. We'll talk to you later. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 15, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses using the reMarkable writing tablet to reduce daily documentation burden to 5 minutes per day Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLHow can we make our documentation more remarkable? Often a very boring topic, but a necessary topic as we are required by law to do a treatment note for every single patient that we see. So today we're going to talk about what is that law that requires us to do those notes. And then we're going to talk about new technology and a new way to think about documentation that's probably going to streamline everyone's documentation in a very significant manner. How can we potentially reduce our documentation burden to maybe five minutes per day? DO WE HAVE TO DO DOCUMENTATION? So first things first, what is that law that says we have to do a note for every patient that we treat? That law is actually the HIPAA law. Way back in 1996, the Health Information and Portability Accountability Act, or what we know as HIPAA. And so that has a lot of things in it about not sharing protected health information, about in 1996 the emergence of the internet and what we can and can't do with submitting patient data electronically. But the main thing it establishes is that we do need to do documentation on every single patient that we see, and that that documentation be available to be transmitted electronically via fax or email upon patient request. Prior to this law, we just basically handed over copies of paper documentation, and it could be a lengthy amount of time before patients could get access to their records. In this day and age, patients need our notes sometimes for things like reimbursement. If we're a cash-based practitioner and they're trying to get out-of-network reimbursement, they may need it to submit because they got the day off work or something like that. And so there's a lot of reasons why folks may need their documentation and why they may need access to it very, very quickly. So the HIPAA law of 1996 established that documentation must be available to be transmitted electronically immediately to patients or other providers with patient approval upon request. Some of you may have interacted with a patient who needed documentation because they were involved in an automobile accident or something like that and they need that documentation to then send on forward. HIPAA also mandates that we keep documentation for up to six years and that essentially means the best way to do that is to store it electronically instead of maybe in an old filing cabinet. Now the thing about HIPAA is it says that documentation must be available to be transmitted electronically via email or via fax, but what it does not say is that our documentation must be inherently electronic. Documentation can still be written as long as it is transferred or changed into an electronic format, stored for those six years, and then available upon demand to be sent when requested. And so we're going to talk about how that opens up freedom for us today to do documentation maybe in a very different way that we have not considered before. Before we get into that, what are the penalties for not following this? What if I don't do notes? What if I just never do notes? What if I'm a cash-based practitioner? I don't interact with other healthcare providers on a regular basis. My patients pay me cash. Most of them aren't asking for auto network reimbursement, so they're not trying to see those notes or see super bills or see claim forms or anything like that. You should know the penalties here are quite severe because we are dealing with a federal law and we are dealing with the federal government. So with HIPAA, they have a four-tier system for violations, Tier 1 through Tier 4. Tier 1 is the lightest punishment. Tier 4 is the highest punishment. Tier 1 is considered that you were not aware of what you were supposed to do, and that you could have not avoided what happened. Now, this is kind of in regards to maybe accidentally revealing protected health information, but also if you don't have documentation stored electronically, and you literally can't submit it to someone, and also that you didn't know that you had to do that. That little caveat that you're not aware that you committed a violation is going to be, the burden is going to be on to you to prove that. If you can prove that though, that you literally had no idea what you were supposed to do and you have no way to fix it, the penalty for that is only $100. Very, very light. But realistically, no one lives here, right? Everyone is aware of what they're supposed to do and probably has a way to reasonably fix it. And so we kind of immediately move up to Tier 2. Tier 2 is you're aware of what you were supposed to do, but there's no way that you could have avoided that violation. This is a very common area for us to live in, right? Let's say you finish with patients for the week on Friday afternoon, and then hey, you're catching a plane, you're going on vacation with your family for a couple weeks, but oops, in that couple weeks while you're gone, a patient requests a note from you. You are aware that you needed to comply with that, but you're just not able to do that, right? Your maybe physical note is sitting on your desk next to your computer at the clinic still. There is no way for you to convert that to an electronic format and then transmit it to the patient. that comes with a little bit steeper fine, that's a $1,000 fine each time that happens. And then we kind of move things very, very quickly when we get to tier three. Tier three is the tier where we start to use the term willful neglect, that you are aware you need to do this, you did not do it, but you are willing to catch up on all of the neglect that you have committed in the past. Now when this happens, the fine jumps up to $10,000, right, a tenfold increase. And then tier four is willful neglect, but you're not willing to correct it, right? You know you're supposed to do notes, you know you're supposed to store them electronically, but essentially you show a habit, you show a pattern of just not doing that, even maybe if you've gotten in trouble in the past. And so tier four is the most punishing tier. Tier four comes with a fine of $50,000 every time that happens, so a very severe penalty. And so when we talk about that in the context of our brick by brick class, when we're teaching people to open their practice, the easy rule is just do it, right? Don't try to butt heads and win an argument with the federal government. The fines are very severe. The penalties are very severe. Just do it as annoying as it is. And my second and third part of today's podcast is showing you that we can make it we can't get rid of it completely, but that we can make it quite simple. So let's talk about that right now. USING THE REMARKABLE Let's talk about making your documentation remarkable with the remarkable. So if you're listening on the podcast right now and you're only hearing my voice, go over to our YouTube channel, the Institute of Clinical Excellence YouTube channel, and find the video of this so you can see what I'm doing. So this is a Remarkable. I'll close it up for you. It's got just a little folio and then it opens up and it's essentially just a tablet, right? This does allow finger input, but more importantly, it comes with a very nice stylus that lets you write the same as if you were writing on paper. So what we have been trialing here at our clinic in Michigan is using the Remarkable to replace our electronic documentation. So you can see what I have on here is I have a bunch of body chart templates. And so we have a folder for every day of the week stored on this tablet. And then we have body charts for every patient that has come into the clinic for treatment that day. So let me open up a brand new template for you all to look at. And now you can see here is our body chart template, just like we used to do on physical paper. Now it is on this tablet. We can write all over this thing. We can write eggs and eases. We can shade body charts so we can do our subjective and objective when patients come back into the clinic. And then the nice thing is with remarkable, we can add blank pages so we can itemize our manual therapy. And we can write all over this thing. And whatever we want to itemize, should we choose so can also be included in this template. And so what's nice is as soon as I finish this, it's automatically saved as a PDF, both on this tablet. But more importantly, it is saved back to a laptop or desktop computer. And I'm going to tell you in a second how we can put the tablet together with your EMR and basically have your documentation burden fall off a cliff in a really nice way. INTERLUDE So before we do that, I just want to take a break, introduce myself. My name is Alan. I am the Chief Operating Officer here at ICE. This is Leadership Thursday. We talk all things small business management, practice management ownership, tips and tricks. I am the lead faculty in our fitness athlete division, so you'll see me on Fridays for Fitness Athlete Fridays, and also the lead faculty in our practice management division, where we talk about all things related to practice management in our brick by brick course. It is leadership Thursday, that means it's gut check Thursday. This one, very simple, 30-20-10, toes to bar, paired with single arm devil's press. Rx weight for gentlemen, a 35 pound dumbbell. Ladies, a 20 pound dumbbell. And then just to make it hurt a little bit worse, you're gonna do a 400 meter run after each round. I tested that workout last weekend. I think I came in somewhere around 11 minutes. So not as fast and intense as last week. And then our Brick by Brick course starts up again on October 2nd. That class always sells out. Our current cohort is finishing up week six, talking about Medicare, talking about documentation, doing a deep dive into the stuff that we're gonna talk about. SYNCING NOTES TO YOUR EMR So how do we put our knowledge that we need to do documentation, it needs to be electronically available, with something like the Remarkable tablet. And the nice thing about Remarkable, like we talked about, is that when you finish a document on the tablet, and you close it out, it automatically syncs via the cloud to an app on your laptop or desktop computer, and that document is available immediately. So our previous documentation system, we would still do paper body charts, we would come back to our EMR, and we would hand type our notes. And that was okay. That maybe took three to five minutes for daily note, maybe 10 minutes for initial evaluation. That is all gone now, right? Because we have our body chart on the, on the remarkable and now we're doing electronically and it is updating to our computer in real time. What does that mean? That means we no longer need to come back to the computer and hand type our notes. It also means for maybe some of you that we're doing that and maybe taking a picture of your body chart or scanning it into your printer, that is okay. But again, that is a lot of burden, right? That's a couple more minutes per patient. What's great about Remarkable is that document, that body chart is available immediately as a PDF on your desktop that you can simply upload into the patient's chart on your EMR. And so now our documentation, all of the boxes of our soap note just says see PDF from this date, right? We are no longer typing. That carries over from daily visit to daily visit, see PDF this date, see PDF this date. And in that patient's chart of that date is August 1st, 2024, August 7th, 2024. And it is a PDF copy of the body chart and it is HIPAA compliant, right? It's electronically available and it has all the stuff that documentation needs to be sound and legally compliant, right? It has a subjective, it has objective, it has assessment, it has plan, it has some itemized treatment to justify if we're gonna bill insurance, for example, why we're billing insurance and for how much. And so for us, switching to this system has reduced our total documentation load to about five minutes per day, which is really, really, really incredible when you think about it. We already had given two hours in the workday for admin time, following up with patients, documentation, that sort of thing, and now that administrative burden has reduced down to about five minutes a day. And so that's just extra time that our therapists have that's not spent typing stuff that they have already written down on a paper body chart anyways. What's nice about this, this remarkable system is that you can take it into the treatment room and it looks no different than if you have a body chart on a clipboard or something like that. It's not as intrusive as a laptop. Obviously it's not as annoying as typing, right? just chipping away and typing as somebody's trying to talk to you. It's very, very low maintenance and it's really awesome. Now, what are the cons of this? There are some cons. They are expensive. They're about $500. I have asked for a coupon. I have asked if they do volume discounts. They do not do any of that. They know what they're doing. So there is a con of the price. And then the other con is that this thing is really kind of worthless outside of this specific niche, right? Unless you happen to want to journal on it, unless you happen to hand write a lot of other stuff in your life that you also wish could be available immediately electronically, the remarkable doesn't have a lot of value for you. That being said, We love how nice it writes. It writes the same as paper. We love that because it really can't do anything else, it has a super long battery life as well. So we have transitioned our documentation system to that and we're very, very happy with it. So with documentation, HIPAA law requires that we do documentation for every single patient, that there is a penalty if we don't do that, and that we should probably follow that unless we wanna get in trouble. But there are different ways to think about doing documentation other than just typing forever into those boxes on your EMR. That this might seem like a step backwards, because we're writing now, but because of the technology that powers the Remarkable, because it is available instantly as an electronic PDF, and can significantly speed up your documentation time. So give it a shot. The company's name is literally remarkable. Look it up. There are a lot of other competitors emerging as well. And I'm sure in the next couple of years, we'll see more of these become prevalent. Writing on these has on electronic devices has been around for a while. Many of you may remember the Palm Pilot. However, you know, it had a two inch screen and you couldn't read what you wrote. So this is a significant step forward. The writing is beautiful. We're very happy with it. And if you try it out, let me know how it goes. So make your documentation remarkable. Hope you have an awesome Thursday, a great weekend. Have fun with Gut Check Thursday. See you later, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 15, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses the 3 steps to consider when helping folks with a fragility fracture Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONES Hi, good morning folks. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. We're live on Instagram, we're live on YouTube. Thank you podcast listeners for tuning in. Today, we are going to talk about the three main steps you want to focus on to manage fragility fractures. all about fragility fracture management. This comes from an ICE student question that I really appreciate. I want to take the opportunity to address kind of our whole crew because we're all dealing with individuals that have had that fragility fracture. What in the world do we do after that insult has happened? So I'm going to read this question verbatim and then we're going to get into the goods. So Melissa McNulty, PT out in Oregon. It says, ICE provides some great guidance regarding what to look for, how to screen for vertebral fracture in those with osteoporosis. Can you please tell me, will you still work on strengthening with those with known fragility fractures in the spine? If so, how will you modify? Also, what about the history of a fragility fracture and how far out slash what evidence slash degree of healing do you need to see before you feel comfortable loading that area? I love this question, Melissa. These are all questions I think All of us have asked ourselves, right, when we have gotten that referral, we've evaled that individual with a nice, fresh fracture, maybe it's been a fragility fracture of the vertebra, maybe it's been, you know, femur, maybe it's been, you know, radius or ulna, for example. We all have these things, these doubts. I don't wanna do more harm, but I know this person needs to move. How can I do this in a safe manner? So I wanna start off with defining what a fragility fracture is, right? Because I feel like this gets thrown around a lot, but the definition of a fragility fracture is when you have a fracture that's a result from a fall at a standing height or less. So if someone has a fracture related to a fall, if they were standing high or less, that's considered a fragility fracture. This could be in multiple areas, right? So we often hear fragility fractures associated with fractures of the spine or vertebra, but it could be of the femur as well. So we need to be clear on what that means. So this person has had a fall. more than likely some type of balance deficit, right? They got in some type of dicey scenario, they weren't able to maintain their balance, they weren't able to land in a manner that distributed force and lowered the impact forces, and so they've had a fracture. I think there's three main steps that we want to focus on. What's unfortunate about this is this is a very difficult thing to study. in terms of what are some of the best interventions, what are safe interventions for individuals after they've had a fracture. So, the evidence is very limited compared to before they've had a fracture, right? We've got tons of evidence to support exercise and balance training, functional training and, you know, a lot of kind of that falls prevention. side of things. We have a lot of evidence there, but post fall there's not as much evidence of how to support these people well, which that is growing. There's a lot of people in the kind of osteoporosis fall space that are doing a lot of really good work, but the evidence is relatively limited. One thing we can be confident to say is that we need to get these people moving. I think that is our first step. STEP 1: DEFINE THE ENEMY What I like to think about is in that first step is what we really want to do is we want to define the enemy. As a clinician, it's easy to get someone and to see their chart and see they've, you know, maybe you've may seen some scans, some images you may, you know, have kind of this picture of like, man, they've got this very unstable, unstable situation, unstable fracture, for example, and you focus so much on that particular area. And I think that is where we can go wrong. What is the biggest harm to this person? is not the actual injury, it's the effects of the injury. And especially when we're talking about older adults, when we're talking about working with these individuals, the biggest threat to their independence and their quality of life is their decreased physical activity and their increased sedentary behavior. Their lives completely change after they have a fragility fracture. So we need to be aware of that. And when we have increased sedentary behavior, we're not doing a lot of things maybe out in the community that we once were doing. They give us a lot of purpose. There's a lot of deconditioning that can happen. There's a lot of mental health issues that can happen as well. So we want to combat that. That is the enemy. And so our goal is to try and get that person moving as much as possible so they can continue to do the things that are meaningful to them. It is a very, very delicate scenario. I experienced this, and I don't think I introduced myself. Sorry, my name is Dustin Jones. I'm one of the lead faculty within the older adult division, but I've spent a lot of time in home health, and I would see this in home health where these folks live these vibrant, kind of community-based lives, going out, doing this, yada, yada, yada, and then they had that fracture, and they may have still had some ability to participate in some of those things, but they didn't. And their sedentary behavior went up through the roof, physical activity went down, and over a stretch of weeks, deconditioning really set in that has massive implications for this person in terms of their quality of life and health outcomes. So I want to define the enemy. I don't think it's that particular injury. I think it's the effects of the injury, and we need to be very aware of that and combat that as much as we can. This is where, when we're working with Betty, for example, that we're saying, Betty, I need to get you as fit as possible. Yes, I know you've had that vertebral fracture and it's painful, but we're going to be able to work around that. So you're not going to experience as much pain. We're going to get you as strong and fit as possible in all the areas out around that area, which is ultimately going to help that area heal as well. Betty, how fit will you let me get you? All right. So one, we need to define the enemy. Beth Lee, she's tuned in on Instagram, she asked the question, does it include any environment like a fall on ice? That's a great question. In the literature that I've read that is defining a fragility fracture, it doesn't necessarily say anything about environmental factors. It just says fall, which is an invert and landing in a lower surface. or the ground, right, from a certain height, standing height or less. So, Beth, I'm going to assume that you can go ahead and throw in an environmental factor like ice. It basically indicating that this person likely has, you know, some bone marrow density issues. There's, you know, some type of balance deficit or scenario that led to them losing their balance. So, I think it's safe to say you can throw that in there. Good question, Beth. So one, we define the enemy, it's not the injury, it's the effects of the injury. STEP 2: PLAY OFFENSE Number two, then we play offense. In this scenario, we do want to protect the fracture, right? I don't want you all to walk away and think that we're just doing, you know, 80% 1RM deadlifts, you know, three days out from a vertebral fracture. I don't think that's a good idea. That's probably harmful for that individual. We want to protect that area and give that bone the space to do its job and heal and don't want to continue to pick the hypothetical scab, if you will. But we attack the deficits that are present. So we're often going to find strength deficits in other areas that we know can contribute to someone's risk of falling. We know we're going to more than likely going to find different balance deficits. Maybe they have difficulty with their reactive postural control and their different stepping strategies in different scenarios. We want to be able to attack that. Maybe they have an endurance-based deficit that when they do go on that long walk, relatively long walk to go get their mail, for example, that they start to have a decrease in their balance performance. Or, man, their balance and their stability really crashes when we add maybe a motor dual task component or a cognitive dual task component. We still want to assess them for those deficits and attack them. And so we can have a well-rounded program where we're building up their physical capacity, their balance capacity, their endurance capacity, while we're allowing that particular area to heal. And obviously this is going to look different for different injuries and kind of the level of injury, but we need to think about protecting the area but attacking the deficits that are present. If we can attack the deficits without, you know, causing more harm to the area, man, you're gonna do that person a huge service. And so for me, like in the context of home health, it was a lot of that. Like vertebral fractures, we would avoid kind of the end range, you know, flexion, twisting. We would kind of avoid those scenarios, but man, we would hit it hard on their endurance. I would try and get them as strong as possible in these other areas while respecting, you know, that particular fracture. What's really important I think particularly about this phase when we're kind of trying to attack deficits is that we're able to get accurate feedback on are we doing damage to that area and this is where pain management is really important for a lot of folks that typically they will have some type of pain medication prescribed on board which you know, for many of us, right, that gives us the ability to do a lot of activities because it's lowered their pain levels. But medication timing can be important here because I do want to be able to get some type of feedback that, oh man, that really hurts in that particular area. So I don't want them to take, you know, their meds, you know, an hour before so they're, the meds are in full swing and really masking a lot of that pain signal that can be helpful. I may have them take it 20 minutes before, for example, or if it's a relatively low pain level, let's take it at the end of the session. To get that feedback can be really helpful for your exercise selection and your dosage as well, all right? So step one, we define the enemy. It is not the injury, it's the effects of the injury. Number two, we play offense. Meaning, we're still going to protect the fracture, but we're going to attack deficits. STEP 3: PREPARE FOR THE NEXT FALL And number three, we want to prepare them for the next fall. We often talk about falls prevention, right? And in reality, falls prevention is usually in practice trying to prevent the next fall. I really want you to shift your thought to preparing them for the next fall. A lot of people fall. you've probably fallen within the past year. I don't want to say falling is a normal part of aging per se, but if we can prepare people for the next fall, that may actually prevent a fall or prevent an injurious fall. Now, when we typically talk about falls preparedness on this podcast in our courses, we're talking about fall landing techniques, we're talking about floor transfers, getting up from the ground, so on and so forth. And I think that's very appropriate for fragility fractures once they are healed and stable. So for some, this may be 12, 14, 16 weeks out. For some individuals, it may be a whole year, right? Like it definitely varies, but we can scale and modify fall landing techniques to a very safe and short range of motion to allow them to practice some of these principles to lower the impact forces that they experience if and when they do have a fall. So I think that's important. I'd be very conservative there. Make sure the fracture is very stable, it is healed. That's probably at the end of a plan of care. But along with false preparedness is preparing the bones for the future onset, right? And that is going to be getting those bones as strong as possible. And so, once those bones are healed, then this is anecdotally, right? There is not a lot of evidence really to show the effectiveness of a post-fragility fracture progressive loading, which that's growing. But for now, a very slow progressive loading of those particular areas I think is warranted once that fracture is healed. What can be really helpful for individuals is just showing them how to use their body in a manner, particularly with the vertebral fracture, related to Melissa's question, is like, for example, teaching them a hip hinge versus a rounding of the spine to pick something up. Like, that's something we probably want to be teaching that relatively early on in the rehab process, but I think we can really start to load that later on once that fracture has healed. And so we wanna think about preparing for the next fall. That's fall landing techniques, that's floor transfers, but it's also progressive loading too, that's fine. It's impact training. It's doing some of these things that we'll go over in detail in our MOA live course and then our level two course as well. The dosage is very tricky and the progression is very tricky, right? Because we're dealing with a somewhat delicate situation, so we need to be very respectful, but it can be done. And that's what I think we need to do for these folks that have had this fragility fracture. They've had a fall, a lot of fear on board. It changes their lives in so many ways. I think first we need to define the enemy. It's not the injury, it's the effects of the injury. We're trying to get this person as fit as possible, get them moving as much as they can so they can continue to do the things that they love. As they do that, we want to play offense. We want to protect the fracture but attack some of these other deficits as we're allowing that area to heal. So, it may be a lot of balance training, you know, strength training of other areas, but there's typically a lot that we can work on. And then, as things become more stable, as that fracture is healed, which it may be 12 weeks out, it may be 52 weeks out, right, depending on that individual and their rate of healing. We're starting to, you know, think more about preparing for the next fall. We're preparing the bones by progressive loading. We are showing them how to fall so they can distribute their load, lower their impact force to prevent that injury, showing them how to get up from the ground, so on and so forth. I think if we follow those three things, we can improve someone's confidence and hopefully get them back to where they were before the fracture and maybe even better, right? So, let me know your take on this. Evidence is relatively limited in this post-fracture category. I know Laura Gray and Gorio is doing some really awesome work, really pushing forward on developing some research studies and speaking to building the evidence post-fracture. And so, I'd love your all's take. What's your experience? What have you found? Just go throw comments on the Instagram video for those that are watching YouTube or listening on the podcast. SUMMARY Before I go, I do want to mention some of our Modern Management of the Older Adult courses that are coming up. All three of our courses, we have two online courses and a live course, those three culminate in the ICE Certified Specialist in the Older Adult. So that's a certification for those badass clinicians that are able to handle basically whatever kind of walks in through the doors or whatever they walk into in the home. Our level one online course, the next cohort is starting today, so Wednesday, August 14th at 8 p.m. So we have a few seats left, so hop in there if you've been wanting to do that. The next one won't be until later this year. Our level two is going to be in October, and then our live course, we've got several coming up. This upcoming weekend, if you're in Alaska and want to have a good time, Jeff Musgrave on set up, you're going to be in Anchorage, Alaska, August 17th to 18th. Then September 7th through 8th, we got a doubleheader, one in Mobile, Alabama, and then Minneapolis, Minnesota. And the following weekend, September 14th and 15th, we have another doubleheader in Bend, Oregon, and then Casper, Wyoming. We'd love to see you all. Love to practice some of these techniques, these fall landing techniques, progressive overloading, so we can help serve these folks that have had these fragility fractures. All right, you all have a lovely rest of your Wednesday. I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 13, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty member Cody Gingerich discusses how to know when to challenge or change movement patterns vs. when to be ok with more freedom of movement Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CODY GINGERICHGood morning PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity division and I'm jumping on here today to talk about when to be picky about movement. So, The last several years in PT, there has been kind of this shift in differing opinions on how specific do we need to correct every tiny little movement fault that we see in people, all the way to like, hey, however they move, this is just kind of how this person moves and we can just get strong in whatever positions that they feel comfortable with. And so I want to talk about a little bit of the like, finding that middle ground and there's a time when yes, we need to just let somebody potentially move how their body is going to naturally move versus also, hey, that moving pattern doesn't look good, isn't efficient, could be leading to the injury that they're dealing with and how should we and when should we correct that? So the old adage kind of, uh, that I like to use in that like thought process is it doesn't matter until it does, which is basically saying nothing other than, um, there are gonna be points in time where you have to understand that person moving in front of you and understand where their pain is coming from and then is that movement pattern the problem for their pain, okay? And so the number one thing is that there is no way without any context behind the person in front of you. Like if you just see a video of somebody that you have never met and you watch them move and you say, oh yeah, we need to correct that, that would be not a time where you can fully say that. Okay. And so I would encourage you to, to kind of get rid of that out of your brain of like, if you don't have any context behind that person moving and you just think, well, that movement pattern is incorrect and we would definitely need to fix that. I would argue that that wouldn't be the correct mindset going into that. However, if you have that same person and you see their movement pattern and you understand the sport or the activity that they're doing, and potentially if they are dealing with pain, then all of a sudden we can have that conversation of, is that movement pattern creating some of the issues? Are we putting undue stress on different tissues because of the way that they're moving? Okay, and so a couple examples of this, a lot of times this is going to be if we talk about patient population. If we're dealing with someone who is an older adult and they have a very low movement standard already, like they have not really done much moving and they are generally deconditioned and just need to create any type of strength adaptation as possible. Of course we want to teach them how to hip hinge and teach them how to squat and do some of that, but does it need to be the cleanest, prettiest squat or hinge that you've ever seen? Arguably no. Okay, right now we need to just get all of their muscles moving together in whatever capacity they can in order to just start that strength training process, change their their homeostasis change their overall body structure so that they can move one thing to another. Okay. And so with that population, I would say, go more on the air of how they're moving is not quite as important as what they're doing and what they're moving. Okay. Of course, changing from a squat to a hinge or whatever pattern you're wanting to look at a lunge, a step up those type of things. But if their knee shifts a little bit one way or the other, or they have a bit of like a hip shift when they're squatting, or it's not the prettiest hand you've ever seen, like their chest isn't quite upright, like all of those things, you want to try and work towards them, but you don't want to limit their ability to do that movement because it doesn't look perfect. Additionally, if you're dealing then, if we flip the coin and we talk about more high level athletes, If we talk about high level athletes and you are just watching them move and don't have any context yet, and you see them and they say like, potentially this is like top of the top, right? They have potentially created adaptations and movement standards and movement positions that create the proper adaptation for whatever sport they are doing. So if you think more unilateral sports, I've been watching the Olympics the last couple weeks, right? There are some incredible, incredible athletes. Those people are not going to be symmetrical. So if you think about a shot put thrower, like those people are incredible. Both men and women like throwing those weights incredible distances. They are not doing that on both sides. So they're going to naturally have one of their their push off leg and they're throwing arm is going to be stronger. And so when they do then bilateral movements, there is a chance that that might not look exactly the same every time. But if they are not dealing with any pain or discomfort, then maybe that's not really a big deal at all. And that's actually helpful for them. When we want to start looking at actually diving into some of those, like, hey, we need to really adjust how you're moving and pay really close attention is going to be when A, either that same athlete that I just talked about is dealing with pain and it's more of a unilateral thing, or B, if potentially the way they're moving is inefficient for the sport that they're doing, right? So sometimes when we think about, especially our fitness athletes, When the clock is going, their body just says, hey, I need to get from point A to point B as fast as possible. And a lot of times, as fast as possible does not necessarily mean as efficient as possible, and they end up overloading one joint, one muscle, something, because that is the way their body has just started to adapt, because there is a weakness lying somewhere. Okay, so then in those moments when there is actually pain involved, that's when without that context, you're not going to have any idea. But with context, we can start teasing out, are there weak points? Are there mobility deficits? Are there different reasons why they're moving in these poor movement patterns? Okay. And so a lot of times that's where just a poor movement pattern, but if you end up looking at it and say, well, everything is moving or everything is strength wise, pretty equal. Their mobility is pretty equal. Now we're dealing with something a little bit differently, but if there is a weakness leading to a movement restriction or a mobility leading to a odd movement pattern that ends up overloading those tissues, Now we need to start looking at, well, we need to potentially strengthen that area of weakness or improve that area of mobility. And then that freedom of movement can increase. And now we have a little bit less stress taken off of the tissue that's irritated and the other potential tissues can take up some slack as we build them up. So as opposed, this is kind of going backwards again. So in our heads, when we're watching movement patterns, think more so, is this something where we are creating an overload of a tissue that is unnecessary and creating pain? And what is weak that is trying to make that happen? And sometimes the weakness area can be the thing that's irritated or sometimes you could actually have that stronger side or stronger tissue area be the thing that is just constantly being used repetitively, repetitively, repetitively. So with the example of our fitness athletes, think one of those athletes that does, if they're doing burpees and they do like to do step back or step up burpees and they like one side over the other, okay? A lot of times that is not a problem at all. And they just continue to build some strength there and they might have side to side issues. But then all of a sudden, if that starts to show up in their squat and they have a big shift when they're trying to get out of the hole, that is now their body trying to utilize that stronger side to do a lot of that work. And it's going to start showing up in other areas over time. And then if they develop pain along that whole route, these is the context that you want with movement patterns. Now, all of a sudden, we need to build up that strength at the other side, maybe clue them into, hey, when you're doing burpees, I need you to alternate legs every single time so you're not just repeatedly lunging on one side or the other. Okay. And so at that moment, now we are adjusting movement patterns and then working on their squat patterns. So it might, we might need to say, okay, we need a pause and we need to make sure that when we drive out of that hole, we aren't getting any type of shifting this side to side, and we're not overloading that one hip or that one quad that you feel dominant in. Okay? So that's where, with this, when does it matter versus when does it not? Okay? When we're talking about our lower level athletes, people who have not necessarily moved in a long time, those first six months potentially, of course we're building into, like, we want to still coach good movement patterns, but don't limit their ability to move weight and get stronger just because it isn't exactly perfectly correct. Still allow them, still you're always fighting for good movement patterns, but keep letting them build some strength just as they're naturally growing. And then as that starts to build up, now we can hone in on some of those nuances. As an elite athlete, if they potentially need those differences in movement patterns, but in the absence of any type of pain, or anything like that, don't just automatically assume they need to really change how they're moving or that asymmetry in their squat or their deadlift or something like that is a problem. It might be an adaptation that they literally need. When we need to start changing and looking a little bit more closely and honing in on very specific movement patterns, think more so if pain comes on board, with any of those movement patterns or you notice a big mobility deficit or a big strength deficit that causes that shift or that change in movement pattern and if you can then either coach that out or change their strength or mobility, that's then when we can start teasing out some of these nuances in movement. In the extremity course, we talk a lot about extrinsic versus intrinsic cueing. Our extrinsic meaning not saying, hey, squeeze your lats, squeeze your glutes. Those are more intrinsic things that people think about. But instead, it's like, hey, I want you to drive your head through the ceiling. Okay, so doing something like that, I want you to punch that bar through the ceiling, or I want you to drive, like break a board under your feet when you're standing up out of the squat, something like that, where you're going extrinsic cueing. And that's gonna be more so, can you cue some of these movement patterns out? If we notice more of that weakness or a mobility type of deficit, that's when we need to really hone in on, are we really thinking about moving in the right patterns and using the correct tissues and muscles that we want? And can we get a little bit more specific? If you're noticing, hey, that lateral hip is a little bit weak or their quad is a little bit weak, Now, all of a sudden, if you're doing more specific movement patterns, you can start thinking, hey, I really need your brain at your quad and you can like tap the quad, you can have some kind of stimulus at the quad, I really need your brain focusing in on this quad. And that's where at the out of the bottom of that squat, I need you squeezing that really, really hard. or I really need you thinking like that muscle that we just got burning from a leg lifter or doing the side steps like that's that area in your hip that I really need you honed in on. And that's going to create some of those movement pattern shifts as well. So utilize both our extrinsic coaching and or intrinsic cueing in order to change some of those movement patterns. If you have determined like you have that context with your patient, you understand like there needs to be some nuance to this movement pattern that's going to be more efficient for that person. And they have been working around something for a very long time and their muscles have adapted to that. And now it's getting to a point where it needs to be addressed. Okay, that's what I've got for you today. Hope y'all have a wonderful weekend. We have an extremity course coming to you next weekend. I believe Lindsey's going to be up in Bozeman, Montana. So as far as if you're trying to find a late last minute jump into a course, we'd love to see you out there. Otherwise, hope everybody has a great day. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 12, 2024

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jess Gingerich defines hypertonicity as it relates to the pelvic floor and the role of the pelvic floor in the body as contractile tissue. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION JESSICA GINGERICHGood morning PT on ICE podcast. My name is Dr. Jessica Gingerich, and I am on faculty with the Pelvic Division here at ICE, and I am coming to you today to talk about the hypertonic pelvic floor. We got a great question in our online course about hypertonicity in the pelvic floor around pregnancy. And so before I dive into this, when we talk about hypertonicity in the pelvic floor, we really don't care necessarily if it's prenatal, pregnant, postnatal, really anywhere in the lifespan. We're gonna treat it relatively the same. there may be some factors that we think about at each stage of life but relatively we're treating it the same. DEFINING A HYPERTONIC PELVIC FLOOR So first and foremost the definition of a hypertonic pelvic floor and the reason I put that in air quotes is because we will hear so many different things overactive pelvic floor tight pelvic floor is when the pelvic floor muscles are in a contracted state um or a spasm And so, the symptoms of this can be leakage, heaviness, pressure, a dragging sensation in the vagina, painful insertion, whether that is during intercourse, a tampon insertion, vaginal exam, or anything else. urinary urgency, frequency, constipation, incomplete emptying that could be of the bladder or of the bowels, coccyx pain, pelvic pain, low back pain, and hip pain. So when you have your client that comes in and they say, oh my pelvic floor is so weak because I pee all the time I just can't control it. recognize that that could be their pelvic floor sitting in a contracted state with the inability or I want to say inability or awareness to relax. And so when we think of that contracted state with the inability to drop, recognizing that with that could come weakness as well. So there's a lot of different bubbles that we want to make sure that we are not missing when it comes to a tight pelvic floor. THE ROLE OF THE PELVIC FLOOR The role of the pelvic floor is to contract. So if you can kind of conceptualize my shoulders as the pelvic floor, we want to close the holes and lift and we want to also be able to open the holes and drop. We want to be able to do this during a lot of different tasks and that can be toileting, intercourse, achieving an orgasm, lifting weights during daily tasks, so that's your laundry basket, the kiddos, or even your body weight, lifting your body weight up off the floor or out of a chair. And then as well as just the gym, being able to do things in the gym and having the ability to essentially tension your pelvic floor to the tasks in front of you. When we think of a tight pelvic floor, we kind of have, as a pelvic floor profession as a whole, have kind of gotten into this, the Kegel, you know, not doing the Kegel, it's kind of like lost its meaning in our space, right? If you have a tight pelvic floor, stop doing Kegel, stop, stop, stop, stop, stop. Really, that's not what we want to do. We often hear to not do the Kegel because you're in that contracted state. So if I'm already here and I do a Kegel, I'm not getting much range of motion. I'm not going anywhere. However, we need to know how to do a Kegel for a couple of reasons. A, when you cough or sneeze, the reflexive nature of your pelvic floor should be to squeeze. We want that reflex, we want that ability to be able to do that. We want to train that. But the other thing that we can do is we can utilize the Kegel to improve our proprioceptive awareness, right? So if I am in this contracted state and then I go and do a maximal Kegel, I might be able to then now, okay, here, that's where I'm in that down or relaxed position. It can help improve your proprioceptive awareness. So key goals should absolutely be a part of the plan of care. Teaching the person what a pelvic floor contraction feels like, so what does it feel like when they are closed and up, as well as what does it feel like when they're open and down. So we call that the attic and the basement. We've said this before, it's really nice to use those terms. So if you're out in the gym or out in public, you can ask your client, are you in the attic? Are you in the basement? Rather than asking them whatever cue you gave them during their pelvic floor exam, you're not out there asking if they're squeezing their buttholes. That's really kind. Teaching them how to do this can be done with internal cues or external cues, recognizing that someone may respond better to one or the other. And so you're gonna need to be able to do both. If you are a therapist who does not do internal exams, that's fine. You can refer or you can take our live course and learn how to do the internal exam. and teach this person how to do a Kegel with right there feedback, there's your tactile cue, squeeze my finger. That can be so so helpful and remembering that this is going to create awareness and just teaching them where they are in space. Now, we talked about the kegel. Other passive interventions are gonna be that diaphragmatic breathing. We talk about this all the time. Using that big belly breath as the diaphragm descends, it's gonna take the pelvic floor with it. It is a passive range of motion of the pelvic floor. They can do this in different positions. They can do this in child's pose. They can do this in a happy baby. They can do this in a supported squat. And then also lastly is the functional dry needling. We can use dry needling to help calm down the pelvic floor. Now, the last bits around what we wanna do in the plan of care for a hypertonic pelvic floor is not discharge once this person says, oh my gosh, I know I'm in the basement, I can feel it, I just know I'm there. Or I'm in the attic, my holes are closed, I know that. We want to load them. We want to make sure that when this person comes in symptomatic, that we are teaching them where they are in space, we are changing their symptoms, but now we are loading them. We are getting them back to where they were, ideally beyond where they were. We want them to not have symptoms, but we want them to not need us, really. So getting them stronger, so getting them into a gym, whether you are teaching them about, or I guess really learning what their love language is around exercise, and then leaning into that. And showing them the type of programming that they may want, encouraging them to certain gyms. I know here in Greenville, we have a ton of gyms. I've got a lot of options with a lot of wonderful coaches that I can essentially push these people towards. once they are symptom free and feeling a little more confident in the gym. So that is what I've got for you today. Join us online or on the road. So head over to PTOnIce.com to look at where we are next and we look forward to having you. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 9, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses what creatine is, how we get it, and the concept that not everyone may need to supplement creatine Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLDo we really need creatine? If not, who does? Let's start today by talking about what is creatine? How do we get it? Where does it come from? What does it do from a performance perspective? And then let's finish about talking about potentially who may and who may not need to take creatine. WHAT IS CREATINE? So starting from the top, what is creatine? You've probably heard about it. You've probably taken it at this point and how do we get it? We're going to reference a lot the International Society of Sports Nutrition position papers which come from the International Society of Sports Nutrition. They publish their own journal and more importantly they publish these position papers on a frequent basis that cover a wide variety of of supplement diet and nutrition topics. They are incredibly comprehensive. They cover the thousands and thousands and thousands of supplements that are up there as well as all of the articles, the other thousands and thousands of articles that have research about those supplements that come out on an annual basis. And so these position papers are great because they do such a great job of summarizing all of the research in this area. And so asking the question, what is creatine? Where does it come from? 95% of the chemical known as creatine is found in our skeletal muscles, so our working muscle. And then about 5% is in our brain. We do have a little bit in our liver, but primarily, creatine is stored in our muscle. We have to get it somehow externally. We do not make it on our own. We usually get it between one to five grams a day. is what we're looking for. And that primarily comes from eating red meat such as beef or coming from fish, approximately 16 ounces about a pound per day. And so if you think that you are not eating that much red meat or fish or eating that at all, and you know that for sure, maybe you follow a vegan or vegetarian based diet, then the recommendation for many, many years has been supplementation, typically as five grams of creatine monohydrate per day. If you've ever taken this or you've known somebody who's taken this, it kind of just comes in a big tub like protein powder. It is a tasteless, odorless white powder that you can certainly do what we would call a dry scoop with some water. You can mix it with water or juice. It does not have a taste at all and so it does not really need to be mixed. It can be taken at any time of the day. And over the years, there have been different research papers on the concept of preloading creatine, taking a large dose to kind of bump up levels in our system and then tapering off to the maintenance dose. And what really decades of research at this time point have shown is that just taking five grams a day has the same effect as any sort of preloading, deloading effect. Just taking that five grams every day gets you to the levels where it's found to be optimal. WHAT DOES CREATINE DO? So that's what it is and how we get it. What does it do in our body? Why is it so talked about? Creatine has a number of great effects that have been shown in the research and have been shown and reinforced and validated over again many, many, many years of research. In general, typical results of having enough creatine in your system whether that comes from eating more of the food sources that creatine is found in, or by supplementing, that we can increase our lean muscle mass by approximately five pounds, we can increase our muscular strength, we can reduce our blood glucose levels, we can improve our anaerobic power output, and we can also see improvements in brain function, which is an interesting new area of research for creatine that we'll talk about in a few minutes. Creatine allows for more creation and storage of the chemical known as ATP. We learned about that back in high school. That is the chemical that powers cellular work inside of our body. It also improves muscular hydration and it improves the rate of protein synthesis. So all good things that we would like to have as much of going on as possible, right? With creatine, there's a lot of myths about what it does. What does it not do? It does not increase water retention or bloating, even in some papers having people take four times the dose, taking 20 grams a day. Creatine is not an anabolic steroid. You cannot get in trouble for taking it. It is completely legal to take it. Anabolic steroids, by nature, are some sort of form of testosterone or some chemical, some sort of what we might call a precursor chemical, that results in increased levels of testosterone in the body. Creatine does not do that. It is not an anabolic steroid. Creatine does not cause kidney damage. Again, in studies following folks taking really high volume doses, 20 grams plus a day, no effect on the kidney, and certainly all of the research on five grams a day, no effect on the kidney. Creatine is safe for adolescents and kids. Remember, we primarily get this from our food, and so you can't, if you're somebody that eats red meat, if you're somebody that eats fish, you can't not eat creatine, right? You're getting it every time you have a serving of red meat or a serving of fish. And so no matter what, even if they don't supplement, kids are getting it every day. Kids tend to eat a lot of food, especially teenagers. And so arguably they're probably getting the same amount that an adult might supplement with anyways. And so just know that it's unavoidable and because they're already getting it and they have no adverse reactions. Also, it's naturally found in our muscles that it is completely safe for adolescents and kids to take. When we talk about what types of creatine are out there, what is the most effective? There is zero peer reviewed evidence that creatine sources found in energy drinks, meal replacement bars, you've probably seen them if you've had an energy drink in recent years. It's all over the top. I've got I've got an energy drink can right here. It's four in the morning, what's right across the top. Pure creatine is advertised right on the energy drink can. Meal replacement bars, pre-workout powders, all that sort of thing. Is that as effective or maybe more effective than taking that creatine monohydrate, that five gram scoop from that big jug? Overwhelming evidence would say no. That over time, all of these studies, regardless of dosage, regardless of other creatine type that is not creatine monohydrate, creatine monohydrate consistently outperforms all of the other chemical derivatives that are out there. So, if you are somebody that needs to supplement, just know that just because your energy drink can or your protein bar says it has creatine, it's probably not a biologically available source that's actually going to result in you getting the effective creatine that you want. When in doubt, go with that scoop of creatine monohydrate. Okay, our most important point, who needs it? Looking at research and that sort of thing, who needs it? If it's not everyone, who is it? INTERLUDE And before we get to that point, I just want to take a break and introduce myself. My name is Alan. I'm the chief operating officer here at ice. This is the PT on ice daily show, a daily physical therapy podcast talking about all things related to rehab and fitness across the spectrum. Today is Fitness Athlete Friday. We talk about all things helping the functional fitness athlete, the CrossFitter, the Orange Spheres, the bootcamp. We also talk about supporting our endurance athletes, runners, bikers, swimmers, that sort of thing. So if you are working with that population, you want to get better at working with that population, Fridays on the podcast are for you. I teach a course called Clinical Management Fitness Athlete. We have a three course series here at ICE, two online courses, level one and level two, and a live course. Our level one course just started this past Monday, and our level two course will begin on September 1st in just a couple weeks. You need to have taken the level one online course to take the level two course. And then our live course, where we get you moving barbells, We have you learn how to max out, practice maxing out, a lot of different concepts found in the fitness space that are going to be important for you if you want to work with this population. You can catch us out on the road. Our friend Zach Long will be in Austin, Texas, September 7th and 8th. Joe Hanesko, another one of our instructors, will be in Longmont, Colorado, September 14th to 15th. and Mitch Babcock will be in Houston, Texas, September 28th to 29th. Just want to pause and say congratulations to Mitch. Mitch is my business partner here in Michigan at our clinic. We coach CrossFit together, we teach these courses together. Mitch is a great friend and him and his wife just had a beautiful baby boy on Wednesday night and so they're at the hospital this morning loving on that baby. So if you follow Mitch, go give him a like, go give him a positive comment. I know he'd appreciate that. DO YOU REALLY NEED CREATINE? So do we need creatine supplementation? A really cool article came out towards the end of last year from Moriarty and colleagues in the journal Brain Science, a journal looking at the emerging area of research of creatine supplementation on cognitive performance, specifically in older adults. But what I like about this study is they did a really good job of breaking the population of study subjects into different subgroups, right? And essentially we had four subgroups. Not unlike anything else we are tending to find about the human race as a whole, humans tend to categorize into subpopulations whether involuntarily from things like genetics or voluntarily, right? And so this study did a good job of breaking out younger individuals from older individuals and also those consuming a meat-based diet or a vegetarian or vegan-based diet. And so they essentially found that there are four subgroups here. These subgroups all had the same experimental effect, which was they're taking creatine and they're having some different stuff measured. And what is great about this study is while the aim was to look at cognitive effects, it really kind of let us know, based on what people eat in their age, who might be the person that will benefit the most, and maybe who is a person that, especially if they're hyper fixated on getting their creatine dose in, maybe they don't need to worry as much. And so finding younger individuals aged 11 to 31 that consumed a meat-based diet saw minimal to no improvement in this study with creatine supplementation. Younger individuals, again, aged 11-31, consuming a vegetarian or vegan-based diet saw more improvement, right? And that makes sense given that we talked about you primarily get this from food sources being red meat and fish. And so that if you don't eat those, you have sort of a deficit that you need to shore up. A third subpopulation, now older adults, the other side of the age spectrum, older adults, age 66 to 76, consuming a meat-based diet with no diagnosed cognitive impairment, saw minimal to no improvement. So, young or old, eating meat, no cognitive impairment, minimal effect from creatine supplementation. The final subgroup, older adults age 66 to 76 consuming a vegetarian or vegan-based diet with diagnosed cognitive impairments, saw the largest improvement in the study group. Why? Again, we've talked about it. Folks eating meat on a regular basis are getting that one to five grams of creatine that we need to eat per day. And so for those folks, even regardless of age, it seems like additional supplementation is unnecessary. And so who needs it at the end of the day? Or we should say who needs it the most? It seems to be that older folks who maybe are beginning to show signs of mild cognitive impairment, or definitely who have a diagnosed cognitive impairment, and especially who consume no red meat or no fish or very small amounts, less than 16 ounces per day combined, have the most to benefit from creatine supplementation, especially in regard to improving cognitive performance. But also that in general, the second group right underneath that was even in a younger population, 11 to 31, those folks, again, based on their dietary choices, no red meat or fish or a smaller amount, those folks also saw an improvement from creatine supplementation. So it seems to come down to lifestyle, right? If you are eating red meat, if you're eating fish on a regular basis, especially if you're getting close to 16 ounces, right? Eight ounces of ground beef and rice for lunch, eight ounces of fish and veggies or whatever for dinner, you are checking the box on getting that creatine from your diet. And so that is not to say you should not take creatine and see what happens, but just that if you take it and you're diligent about taking it, and you're consistent with taking it, and you don't see those improvements that we talked about earlier, those improvements in lean body muscle mass, muscular strength, anaerobic power, that is to be totally expected if you don't see those improvements. At the end of the day, should you use it? I would always say with a supplement like creatine, try it. It has almost no risks as we talked about. It is incredibly cheap, literally a couple cents per serving. A giant tub of creatine is like 20 bucks and you get like 500 servings out of it. And so at the end of the day, if you've never supplemented with it, even if you think you're getting enough from your diet, just try a cycle, right? Try taking it for a couple of months, be diligent about it, take it every day like you're supposed to take that five gram dose. But also don't be upset at yourself. If you don't see these massive improvements, likely from your diet, when you begin exercising regularly, possibly many, many years ago, you saw those gains that you would have seen with creatine supplementation. because you were already getting enough creatine from your diet. So you already got the benefit, don't be upset that you're missing out. SUMMARY So creatine, what is it? Where's it come from? Should you take it? creatine is a chemical we have to eat, we use it to power muscular energy functions and other functions throughout our body, and especially our brain. And that new lines of research, especially investigating the effects on the cognitive system, have shown that there seems to be groups of people who benefit the most, and the groups of people who benefit the least. Primarily, those eating a small amount or no red meat or fish who do have a mild cognitive impairment, a diagnosed cognitive impairment, will benefit the most. And even in younger folks with no concerns about cognitive impairment, if they are following that diet with a small or no amount of red meat or fish, they will also benefit. On the opposite side of that, young or old, without any diagnosed cognitive impairment, eating a meat based diet, Those folks seem to have the least to gain from creatine, but again, like we said, all that being equal, try it out if you haven't and see if you like the results or not. So, that's creatine. We hope you have a fantastic Friday. Have an awesome weekend. We'll see you next week. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 8, 2024

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey explains the rationale behind myofascial decompression or "cupping" for patellar tendinopathy and provides a technique demonstration. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION LINDSEY HUGHEYPT on ICE Daily Show, waiting for YouTube and Instagram to catch up. So we are live on both. How's it going? I am joining you again this week on the PT on ICE Daily Show. Welcome. I'm Dr. Lindsey Hughey. I currently serve as one of the division leads at extremity management. And today I want to share with you a myofascial decompression technique for patellar tendinopathy. So today is either Technique Tuesday or Leadership Thursday. So we're bringing Technique Thursday to you all live. My model today is Daniel, my son. So what I want to unpack is a little bit about how do we know someone has patellar tendinopathy and who this might be appropriate for. with patellar tendinopathy, show you the technique, literally just demo it for you live, what you do, and then we'll chat also like how do you know the treatment worked. So we'll talk a little bit about our test retest options for patellar tendinopathy. And then we'll call it a morning technique Thursday, not Tuesday. Great to be with you all again. So first things first, someone with patellar tendinopathy is going to complain of a recent spike in load. Usually it's energy storage and release activities like jumping, sprinting. The other complaint, vice versa, they might have is that a dramatic de-load where they haven't, maybe it's their off season and then they stopped loading completely. this might flare up that patellar tendon. They will complain of pain with energy storage movements, and they'll specifically complain of pain right at the patellar tendon, where that inferior border of the patella sits to the tibial tubercle. When you palpate that as the clinician, that will be tender to palpation. Often when they extend their knees, so you're doing manual muscle testing of quadriceps, that will also cause their symptoms to blip. Having them do a one-legged squat on a slant board is another load test that will often bring on symptoms. The person with moderate to high irritability, patellar tendinopathy, often has coinciding hypertonicity throughout their quadriceps. So when you palpate, it's not just that patellar tendon that is bothering them. Like their quad also is kind of guarded around that knee joint. So myofascial decompression can be a great adjunct to treatment. If you've heard any podcasts that I've done on tendinopathy, you know, that load is our love language, or if you've been at our course, you know that. So ultimately, the teller tendinopathy is going to be healed by high tensile loading that involves loading the local tendon, the local muscle, quadriceps, the chain, and then off eventually gets into energy surge and release. So know this treatment technique that I'm about to show you is just an adjunct to care that creates a modulating window of opportunity to load that person better. So consider it's moderate to high irritability human. And so that's someone that like not just is their activity or sport starting to get interrupted. It's usually our basketball or volleyball players, but also like daily life is starting to get aggravated. They're not sleeping as well. Their performance has dropped. These folks need that treatment that kind of takes that edge off. So without further ado, you kind of understand who the person with teller tendinopathy is, who would be good to execute this treatment on. I want to show it to you. So I'm going to kind of move the camera around just a tiny bit. so that you can really see the quadriceps. So we're going to do one of two things. We'll make sure we've exposed the area. I want to not only get myofascial decompression to the quadriceps and hit each part, but I also want to decompress that patella and the patellar tendon. So to first decompress the patellar tendon and the patella, I'm going to use a silicone cup. So these silicone cups are awesome. The way we'll apply these is we're going to create negative pressure. So you really want to squish this in and then apply firm pressure down with your body, being mindful that this could be an irritating area. The way I would explain it to the patient is we're using this cup to just kind of offload that bone, that patella, and then offload the patellar tendon a bit. So I'm going to create that negative suction and compression. If you have very hairy patients, you're going to want to put some lubricant like a Biotone around that. Just a little bit will go a long way, but again, more hair endowed folks might need a little bit more. So we're going to go here. I'm going to create that negative pressure, I'm going to press down, and then if I've done a good job creating that suction, there'll actually be a little dip or dimple in the silicone cup. The cups I'm using today are from Chris DiPrato and his team. They are amazing cup therapy if you follow them on social media. I love their products. This comes in their kit, this silicone cup, and then their curved cups. These are actually their newest ones are what I'm going to use to hit the vastus lateralis, to hit vastus medialis, and then I really want to get after rectus femoris. I want to make sure I hit all three parts. You can't really get that intermedius without a needle. So we're going to hit those main more superficial areas. So we're going to hit that vastus lateralis first. And then I'm going to place that curved cup and then create suction with our gun. And there's various guns. This is a manual pump that you can use. There's ones with gauges and then electronic gauges. We want about 300 to 600 millimeters of mercury if you do have that pressure gauge that actually gives you a reading. So we'll hit vastus lateralis in two different spots. So one here and then one a little higher. I'll step away so you can see. Then we're going to want to go vastus medialis. So now I'm just on that inner part of the quadriceps. And then we want to hit that rectus femoris and I can hit here and then I can even do one more a little bit higher. I want to show you just there's, these are the newest curve cups. These are awesome as well. So I wanted to show you that. We'll go a little higher and we're really trying to hit that muscle belly here, not tendon. So then this is attached to patient. And I'm not just going to leave him sit here. So I promised him I wouldn't actually make him move. So I'm just going to talk through this. But I'd actually have him do some knee extension with those on. So mod to hired ability, we want to create an analgesic response. So we'll have them do some isometrics, shooting for that 45 second hold, trying to do five reps. So we'd start with just probably doing like a quad set where he'd like push his knee down and then maybe lift a little bit or combine it with a straight leg raise. That would be like level one. As soon as we can get him up and weight-bearing, I want to do like a wall sit or a Spanish squat with these on. So he's in this decompressed, he, they, she, whoever your patient is, decompressed state, and they're still loading. So it's not a static laying there thing or treatment. So once cups are applied, right, I do some kind of active treatment. I've named a few. Lowest level would be that knee extension with a lift and or just doing a nice quad set, then getting to a wall sit or a Spanish squat in a reduced range. We usually start about 60 degrees. And then we take the cups off, right? Reassess the soft tissue. Daniel's probably like, please take these cups off, mom. What we'll do is reassess the soft tissue, but not just the soft tissue. I want to see, is there less hypertonicity? I want to see, is the tendon, after I've palpated it, become a little less tender to palpation? In addition, I want to probably test a load test, like that slant board, if we had just tested that. And you may even see a change in motor response. So if you took your dynamometer, took a quadriceps reading, and then also got an NPRS, did this treatment, Then retested using your dynamometer, you often will see not only a change in pain, but you can even see motor uptick. So an increase in that strength measurement just because pain has now dampened. So this treatment doesn't take a long time, but can be super effective for our patients with that mod to high irritability where life is starting to get interrupted by their patellar pain. SUMMARY Thank you for joining me this morning to learn one of my favorite techniques that I'll use for my folks with patellar tendinopathy. I hope you all have beautiful clinical Thursdays, whatever you do in the clinic, and will consider using this with your patient. If you want to learn more about research concerning patellar tendinopathy and how to load your folks well, join us on a weekend soon in extremity management. So we will be in not only North Dakota, but also in South Carolina, August 24th, 25th. So you have two opportunities coming up, and that'll be our last opportunity of the summer. So really jump in if you haven't yet. And if you want to learn a little bit about some myofascial decompression techniques, our colleague Chris DiPrato, we're a big fan of his courses. We also integrate that in our courses as well. So thanks again for joining me. Cheers. Happy Thursday, everyone. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 7, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave shares shares how by being too quick to limit risk for our patients we can expedite deconditioning, worsen social isolation and mortality of our patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MUSGRAVEWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Jeff Musgrave, doctor of physical therapy. Super excited to be talking to you about everyone dies, not everyone lives. So I am fresh off an epic motorcycle adventure with the CEO Jeff Moore and Matt in the bike fit division of our company. And it was an epic trip. And a great way to summarize this trip is a quote from a motorcycle brand that I've started following recently. We don't promote this brand in any way, I just thought the quote was great, which is, everyone dies, not everyone lives. So just to kind of set the stage a little bit, I'm new to motorcycling, brand new thing, it's something just recently I decided was Important to me a risk that I wanted to take Lots of people in my life very well-meaning that care about me deeply Wanted to just share all the worst case scenarios. They wanted to instill enough fear in me To maybe prevent me from going or to make sure that I'm super safe and and I get that right there is some inherent risk Taking a motorcycle up a cliff face lots of things can happen Some injuries occurred, there were some wrecks, but most importantly, there was the opportunity to really live life. in a very deep, meaningful way to accept some risk, to have a lot of fun, to have some fun stories, to make some fun memories that are gonna last me, I hope, the rest of my life. And I think this is very relevant whether we're talking about older adults or even younger adults. But I think we come in contact with this type of problem with older adults most common. So commonly with older adults, In that same vein, we're trying to help our patients be safe. We want them to make decisions that are going to prevent injuries, prevent falls, and for a lot of our older adults, a fall can be a very serious thing. I'm not making light of that in any way. We know that lots of our older adults are living with low reserve. and low physical resiliency and reserve, so they have very little margin. So if they fall and they have decades of deconditioning, their bones are weak, their body systems are not prepared to help them recover quickly, and this can have a huge impact on their life. So I want to say I recognize that, and we preach this fitness forward approach to try to help build that reserve and build that resiliency, but still what I tend to see when I interact with clinicians, working with older adults, is we treat older adults with kid gloves and we don't want them to be put at any level of risk. But I think the thing that we forget is what they're missing out on. What are the things that they want to do that are risky and how meaningful may they be to their life? So I'd like to give you a few tips just from my clinical experience to help patients live until they die. We want them to live their life as fully as possible, and I think sometimes we don't think about, when we limit our patients, what the downstream effect is for their life. So I've got a few tips here that I think will be helpful, and then we'll go through an example of what this could look like. So, you know, many of our patients, they're maybe not trying to take a motorcycle adventure into the Rocky Mountains. Maybe it's something like walking without an assisted device, or maybe they really need a walker but they're only willing to use a cane. So I think the first thing that we have to do is we have to have an objective assessment here. We can't just make assumptions. We don't want to look at their past medical history, their diagnoses, and decide for them, or heaven forbid, just their age. We know that people age at different rates and have different functional levels. Their age doesn't dictate their treatment. There are clinical findings should, very accurate clinical findings that meet them where they're at. So the first thing I would advocate for is to get an objective assessment of the risk. So how risky is this activity? Say it's some type of walking or balance activity and we're worried that their balance isn't good enough. Well, first thing we should do is say, hold the phone. We need to do a good assessment here, so we need to match up the patient's physical ability to the objective measure and make sure that the activity is represented in our objective measure. One that we really like to use, it's pretty comprehensive, is a mini best test. The mini best test is a great way to look at dynamic balance, looking at reactive components, as well as anticipatory. as well as a vestibular system, and reactive, like how are they gonna react if they do catch their toe? Do they have the ability to react? So if it's a balance activity, we'll wanna make sure that that activity is represented in our assessment. So we can have a very clear picture of how much risk is this. Maybe it sounds really risky, and we have them do the assessment, and it's like, meh, it's maybe not the best, but it doesn't look like it's that serious, On the other hand, it could be that it is very risky. They can't even do the task at all safely in the assessment. So either way, we need to know objectively what's their physical ability to do this task, whether we're doing the task directly or we're trying to replicate it. We need to get an idea of what's required and get an objective measure for that. The second thing we need to know is how meaningful would this activity be to our patients? How risky is this? But how much reward is there for our patient as well? So there's two sides to this. So if we're thinking about, we've got our assessment, then we've got a good idea how much risk is this based on say like their fall risk. It looks like they're having trouble walking and carrying something. So them wanting to carry in their own groceries without their hands would be a pretty risky task. But maybe that task allows them to be independent in their home. Or maybe they don't have the financial resources to pay someone to bring their groceries to them or for some type of grocery delivery service. So that could change their living arrangement. So we don't want to just make these big blanket statements based on risk. So we've got to figure out how much risk is there based on an objective assessment. We also need to know how much reward is there for our patient on the other end of that. Or what are the downstream effects of them not doing that task anymore. Will there be more deconditioning? Will there be lack of social connection? Social isolation, especially if someone is pre-frail, increases their mortality risk by over 25%. So if we, our choices for safety, take away the social reward, and we reduce the value of their life, we may also hasten their death. which is kind of a wild thing to think about, but our trying to play it safe could actually lead to them dying sooner, which is pretty awful, and I know that's not anyone, what anyone wants to happen that's listening to this. And then the final thing is you have to come to some type of agreement that you can work with, that they can work with, that you can work with, right? So that this therapeutic relationship can continue. So I'll give you an example, I'll kind of work through this, and I think this will help make this a little more clear, So an objective assessment of someone's risk. Say we've got a patient who's an independent community-dwelling older adult who has had some deconditioning, they've got some balance deficits on board. They say, I've got a cat, I'm widowed, I live alone, I need to be able to take care of Fluffy, but my balance, I'm really struggling to be able to get the cat food in from my car up the steps into the house, and I've actually had some falls recently, and I'm at the end of the bag of cat food, now what do I do? So the first thing we're gonna do is based on that task, pick an objective measure that's gonna be helpful. So for a community dwelling older adult, we'll probably do some type of quick screen to get an idea of strength and balance, so something like the short physical performance battery. And then based on that, if it looks like there's some serious balance deficits, we may wanna do a deep dive with a mini best test to get an idea of her dynamic balance, her ability to recover if she catches her toe, while she is carrying, it'll also take away her visual field during parts of the test to get an idea of what's her proprioception like, how well is her vestibular system functioning, and then from there, we can get an idea of what is the objective level of risk. So say we run the mini BEST test, and it looks like she is at risk for having a fall. And then the third thing is, we know, based on this patient, maybe she doesn't have a whole lot of social outlets, and this is one of the only times she gets out of the house for a medical appointment. So we need to really go through this filter of, yes, she could fall. If she continues to do this task, she could fall. But if we take away this trip out of the house, we take away a lot of activity from her daily life. So if she's not able to, if she's not lifting, carrying, working on her dynamic balance through this task, even if it's once every couple weeks, that is still a huge reduction in her overall physical outlet in her physical health. I mean it's built into her life so taking that away from her will actually probably expedite her lack of reserve, resiliency, expedite her deconditioning, as well as potentially isolate her from her pets. So if she's trying to take care of Fluffy, she doesn't have a whole lot of social outlets, that may reduce her willingness or desire to even live moving forward if she doesn't have that outlet with her pet. the lack of reward or the loss that that would represent to just say, no, not safe for you to do that. Let's have someone else bring the food, which she loses the physical attributes or the physical activity that is keeping her strong, at least at some level. But then the second piece is, maybe if we went to the extremes like, you know what, you're just gonna continue to get older and more deconditioned, you should probably just give the cat away. which is probably the worst thing we could say if there's any hope of her getting her strength back. She'll have the social isolation, probably some depression, as well as not being able to have that at least low level of physical activity. A way that I would come at this, if this was my patient, is I would describe the risk. Hey Betty, you know what? You are at risk for falling. You do have some deficits on your balance, but I realize this connection with Fluffy is really important for you, and I think we can work together to find some solutions. So some things I would be thinking about is if she needs some upper extremity support, maybe she's not using an assistive device, or she's not using the right one, which also happens pretty often, Maybe we can meet in the middle. Maybe we can say, you know what? I think if you get a smaller bag of cat food, you can put it in a backpack. And if you can get it, if I can teach you how to put this in a backpack and put it on your back, you're gonna have your hands free. And maybe until we get you stronger, just till then, we can use a walker to get you from your car to the steps, and then if you've got enough support or you've got your cane you usually use in the house, maybe we can get you to use the cane for a very short distance. Or maybe even let her set the backpack down and drag the thing into the kitchen. There's so many ways we could get the job done, but we may have to change what it looks like for a short time. And I would almost guarantee you, if that example was your patient, that they would 100% be okay with buying a smaller bag of cat food, which may get them out more often, which may help us reduce their sedentary behavior, improve their activity frequency, how often they're doing that, could be really good, as well as keep the cat, which I think is the ultimate goal. If they get to keep the cat, keep doing the task, maintain their independence, and we can limit their fall risk by giving them some extra support, but the task gets done and it's temporary, I bet they're gonna be on board. So I hope that helps. So I would really advocate before we just give blanket statements for safety for any patient, but especially for older adults. We want to make sure that they have the opportunity to live their life. We need to consider the risk, absolutely. We need to get an objective measure on that, but we need to consider what we're taking away or what their life will look like and the downstream effects of telling them no. With the heart of safety, we may expedite someone's death or reducing the quality of their life. The final phase, after you figure that out, is we've gotta come to an agreement. We've gotta continue that relationship, do what we can to reduce the risk for them, but maybe we have to meet in the middle. And maybe we can make some agreement that it's like, hey, until we get you to this point, would you agree to use this extra support? Or do this task a little bit differently? And almost 99% of the time that I've come at this type of conversation with a client this way, it has always gone well. Team, I hope that you go out there and you help your patients live. I hope that you're careful assessing risk. I would love, if anyone has any examples or stories they'd love to share, please drop it in the comments. If there's a cool story where you've been able to meet in the middle, help someone continue to do something like that, or just have some thoughts. I would love to hear your thoughts on that. If you're interested in learning more from the older adult crew, We've got our level one is kicking off in less than a week. It's crazy. It's time to sharpen those mental muscles, get back into L1. So if you just came off live and you're wanting to get your specialty in older adult, we would love for you to hop in there. If you've already had L1, I'd recommend you hop into L2. The last cohort sold out. The next one of those is gonna be October 17th. As far as live courses, myself and Ellen Sepe, The woman, the myth, the legend is going to be with me in Anchorage, Alaska. We're going to have a great time. That's going to be August 17th and 18th. Great opportunity for some awesome continuing education. Meet us live, work on your skills, and also take in a beautiful state at a great time of the year. We also have live courses on September 7th and 8th in Minnesota and Alabama. Team, that's what I've got for you for today. Go help those patients live. Have a great day. Catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 6, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the role & function of tendons in the body, traditional rehabilitation approaches to treating tendinopathy, as well as a new procedure called TENEX for tendinopathy management. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION LINDSEY HUGHEYMorning PT on ICE Daily Show. How's it going? Welcome to Clinical Tuesday. I am Dr. Lindsey Hugey and I will be your host today and we're going to chat all things TENEX and TENEX care specifically for our tendons. So I'll chat with you a little bit about what it is, what the procedure proposes to do and kind of what we're seeing in regards to its effects So the title officially today is, does TENEX get a 10 for tendinopathy care? So let's dive right in. And I do want to say, spoiler alert, it does not get a 10 for tendinopathy treatment. So first, before we dive into what is TENEX, Let's just chat about in general what tendons need to heal as a little reminder to kind of set the stage. And if you've been to our extremity management course, this will just really be a review. TENDON FUNCTION But our tendons in their most basic function, they connect muscle to bone. They are to act like a spring and they are to be mechanoresponsive, right? To take on load, transmit force up and down and across. they are responsible for speed and acceleration, they need to take on compression and friction. As soon as we spike loads quickly or dramatically deload activity, we will see changes in capacity of not only that tendon, for better or for worse, but also in the structures they're attached to. So consider the muscle, local muscle, and then that bone. So not just the tendon will either gain and be challenged by spikes in load and or will reduce, right, if you dramatically deload. So come to our course if you want to, extremity management, want to learn even more about that, but that's kind of tendon basics. For those that have treated tendinopathy and are in the outpatient space, folks that do a lot of repetitive action or athletes often get tendinopathy at some point in their life. And this results in pain. It can result in sickening and swelling at that tendon, but really it's decreased performance, whether it's in their job that they need to do and or their sport participation. And a lot of folks think this is just going to go away on its own. And they'll try conservative measures, whether it's they've looked it up on Dr. Google or they've consulted their doc. And I want to set the stage of what's really being told for conservative management of our attendants. It's rest, it is NSAIDs, injections, surgery, PRP, stem cell, shockwave therapy, and then physical therapy is on there as well, but we know there's a lot of treatment variation in our profession in regards to building the capacity of that tendon. WHAT IS TENEX? Now on this list for conservative management is TENEX. So I kind of want to set the stage. We now know what kind of tendon function, what will challenge a tendon, and now we know what is really recommended for tendinopathy care. We tend to see, because of this treatment variation as well, right, from rests to anti-inflammatories to surgery and physical therapy, somewhere in between, we see people, and then some folks just not getting care at all, going on to chronicity. telling their docs that, you know, this is hanging on for more than three to six months. I'm not getting better. My performance is lessening. I'm having difficulty at work. And so TENEX was developed. And so we're gonna dive into the treatment. Is this helpful for tendinopathy? So TENEX , T-E-N-E-X, for those listening, is prescribed for those recalcitrant cases that aren't responding from that list we just reviewed. What it was developed in Lake Forest, California by TENEX Health System in collaboration with Mayo Clinic. And what it is, is it's ultrasound guided percutaneous needle tenotomy. It's a mouthful. And what they do is they use a needle, a small incision is made with this specialized device called TENEX, the device is inserted, it delivers ultrasonic energy to the damaged tendon tissue, and it emulsifies that damaged tissue into a soft liquid form, and then that's removed through the same incision. Basically, using oscillations in high frequency to debride and aspirate the diseased tendon, all guided under ultrasound image. The rationale for TENEX, is that it is minimally invasive for those that have been struggling for three to six months to even a year. It's minimally invasive as stated, but they're not going to have a ton of a recovery period. They'll get back to their activities. There is like a very wide variation here, but they'll say anywhere from three weeks to 12 weeks. The goal and kind of the underlying theory of why does TENEX work is that it is stimulating the body's natural healing process. And ultimately that helps restore tendon function. That's what the kind of the proposition is. And then they keep selling that it's minimally invasive and it's shorter recovery than like your typical surgeries that they'll do for tendinopathies. with the cell, they usually will sell the shorter time of two to three weeks back to your sport, back to work without any issue. DOES TENEX WORK? And so what are patients saying about this? So patients, when we look at systematic review level studies, and there's more than a handful of these, we are seeing these patients reporting reduced pain, reporting improved function, returning to their sport, And what's interesting is they're seeing even at a year-end, three-year mark, these patients still reporting improvement in combination with these TENEX procedures. And so we kind of have to take a pause about our biases because here at ICE, you know, and if you've been to our course, we really believe load is our love language for tendon care. And that's really the only way to remodel that tendon is high tensile loads. And so what should we be thinking and advising our patients on, knowing that this procedure exists, it's existed since 2010, knowing that even in the last five years, we've gained some systematic review studies in various areas of rotator cuff, Achilles tendinopathy, gluteal tendinopathy, our lateral elbow tendinopathies, all of these areas are showing evidence of improved pain and function. But there's a lot of unknowns, right? So like, what do we tell our patients? Because they're going to ask, especially if they're kind of looking for that quick fix, and maybe they just started out of care with you as well. Well, I think we have to be honest that we don't actually know a lot of long term data. in combination with physical therapy. So you'll see that often after this procedure, they are recommended physical therapy. So what we don't know is the differentiator yet. Is it physical therapy that is actually helping or is it that TENEX? In addition, that bias that I told you about that I want to share is that you still have to restore capacity to surrounding tissue. So even if you clear out this like dead tissue right this tissue that is specific or excuse me that's been linked to possibly being painful for this patient you still have to lay down new fibers in that tendon, you still have to challenge the local muscle, you still have to help that bone health and so all that doesn't go away. My bias here is going to be that physical therapy when done very well should prevent this TENEX from ever having to happen because we should be able to right away respect that irritability of the patient dampen their pain symptoms right whether they have some degenerative tendon on board or not we might not know but if you respect irritability and then gradually load that person load that local tendon load that local muscle challenge the chain and then as that goes well then start to add in some energy storage where the patient has to take on compression and friction and spring-like movements, we don't have to get to these invasive procedures. But it's that variation in our practice and the things that are just readily recommended on the internet and from docs, which is RESS and NSAIDs and getting stem cells or PRP, these like quick fixes, quick fixes that never really address the underlying problem. So while TENEX, I think there are some promising results and we really have to acknowledge that. I'm going to give it a 5 out of 10 because we do see in those people that are getting TENEX that they have improved pain and function consistently. Only giving it a 5 because We have an opportunity here that TENEX is not the answer, right? We see folks on the other side of that TENEX. It's not TENEX giving the 10 out of 10 pain free, right? Or 10 out of 10 function. It is really in that conjunction of getting the tendon capacity back up. So thank you for kind of going on this little journey with me about TENEX. It's been a question that's been popping up on weekends, you know, what do we think about TENEX and what do we tell our patients? What I'm going to say overall in concluding this is that those suffering from chronic tendinopathy, they may have their mind set that this is what they want to do. Know that you can partner with them. before that and after. Like you are going to be a part of their care no matter what to build up that capacity. You can educate in that way and let them know and I can attach them if you're interested that there are systematic reviews showing promise with this. know that as Dr. Justin Dunaway says, beliefs and expectations are the foundations on which outcomes are built. So if the patient believes TENEX is going to help, it is going to help with pain and function. If they believe physical therapy is going to help, it's going to help. And if in conjunction together, they believe it's going to help, it's going to help. So we really have to have a biopsychosocial approach to this too, not just the facts about the procedure and what TENEX is resulting in on a systematic review level. What really matters is what does the patient believe that's going to help and what's going to get their tendon ultimately more healthy. SUMMARY I appreciate you joining me to chat a little bit about something that's a little outside of the scope of our normal weekend. And if you want to learn more about the tendon continuum, the complex pathophysiology that's happening, we take a deep dive over an hour long lecture on day two of our course that dives into all the latest literature on tendinopathy. our upcoming opportunities to do that and join us. We have two, August 24th and 25th. I'll be in Bismarck, North Dakota, and Cody will be in Greenville, South Carolina. We would love you to join one of us, right opposite ends of the spectrum. And then the next opportunity will be September 14th, 15th in Denver, Colorado. So join us on the road if you can. Thanks for chatting with me a little bit about 10X today. Have a happy Tuesday, everyone. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 5, 2024

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Heather Salzer discusses a case study involving helping a patient increase her calorie & protein intake during postpartum to improve her recovery & performance. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION HEATHER SALZERGood morning, PT on ICE Daily Show. Happy Monday. I'm Dr. Heather Salzer and I'm here with the Pelvic Division at ICE. And this morning we are going to talk about hacks to hit protein and calorie needs to help us stay out of low energy states and avoid RETs. So at the ICE Pelvic Division here, We talk a lot about REDS, also known as relative energy deficiency in sport. It's something that can have widespread effects. It can affect our immunity, sleep, energy across the day, muscle building function, and then a lot of pelvic kind of class specific things like fertility, increase our risk of urinary incontinence. If you want to deep dive into REDS, please join us in one of our pelvic we go into it in great detail, but when we talk about it, we always get the question of, okay, well, if I need to be eating that much, or if my clients need to be eating that much, that feels like a lot. How can we actually get there? So for the podcast today, we're gonna go through a case example, and as we talk about that, discuss overall calorie needs from Red's perspective, and protein needs, because that's something that a lot of people struggle with as well. And as we go through that example, we'll go through hacks of little changes that someone could make in their diet to make these things a little easier. So meet Kristen. She is our client today, and she is 32 years old and around 160 pounds. She's got a three-year-old at home and a 10-month-old that she is breastfeeding. Kristen runs two to three days a week at a pretty moderate, sometimes higher intensity, and she also crossfits around three days a week. She's also pretty busy chasing around her three-year-old and while carrying her 10-month-old with her as well. So how much does Kristen need to be eating a day when you ask her and are getting some feedback from her? So someone with her general demographics would need relatively about 1,500 calories just at absolute baseline doing nothing else. When we add in her activity across the day, we're looking at closer to 2,500 calories. Then we add in breastfeeding on top of that and she's sitting at close to 3,000 calories a day in terms of her caloric need. if we're thinking about how much protein we want her to be getting, likely we're trying to be somewhere in that close to one gram of protein per pound of body weight, just because of her high activity and breastfeeding. So we're looking at like 150, 160 grams of protein. That can be a lot. When we ask this question to our clients, a lot of times, her it's like, whoa, I am not getting anywhere close to 3,000 calories and you want me to eat how much protein? Don't you know that I have kids that I'm chasing after? When am I supposed to meal prep enough to make all of that happen? So let's go through her day, talk about what she might be eating to start with, and then little tweaks we can make to change it along the way. So we ask her, Kristen, what do you eat for breakfast? And she says, well, some days I have got, I do like two eggs, some toast and some fruit. And other days I do some oatmeal with berries and milk. Okay, if we think about that, we're maybe getting 15 grams of protein and probably like 300 calories on top of that. That's not a super strong start to the day. So we ask her, hey Kristen, Do you think you can add another egg or maybe some egg whites to those eggs and a breakfast sausage on top of it? She's like, yeah, that seems reasonable. Or on oatmeal days, can we do overnight oats instead of hot oats and put a scoop of protein powder and maybe a couple tablespoons of chia seeds in there? And then all of a sudden with either of those options, we've upped protein closer to 30 to 40 grams and now we're sitting at like 700 calories. So starting off strong with a good breakfast is a nice way to already help us get those totals earlier in the day. Side note on the oatmeal, I don't know about you but I have tried putting a protein powder in hot oatmeal and it gets chunky. Overnight oats are fantastic and that protein powder scoop is a good way to up the protein on that. So moving on to Kristen's day, we are about mid-morning and she's like, yeah, usually I don't really have time to eat again till breakfast or till lunch. I get going with my day. I'm pretty hungry when I'm breastfeeding, but then I keep going and I really just don't have time to eat again until lunch. So we say, What can we do to make it easier for you to get a snack? Can we have a protein shake that you make with breakfast that's sitting in the fridge ready to go? Can we have some yogurt that can be easily grabbed? Where are you doing your breastfeeding right now? Do you have a station set up? Can we put some protein bars there? Can you grab your yogurt on your way there? Can we stash some protein bars in your car? So finding a way to get her a snack in the morning that can pack an extra 20 grams of protein and maybe another 200 cals on top of that. Breastfeeding, for this specific example, can be a great time to get it. Baby's getting their nutrients in. I promise they won't mind with some crumbs on their head. Fuel yourself while you're fueling baby. That can work great. So, we've already increased by adding in some snacks, packing her breakfast a little bit fuller, now we get to lunch. And we ask her, okay, Kirsten, what are you eating for lunch? And she's like, well, I've been trying really hard to be good about my nutrition and getting in healthy things, so I've been meal prepping turkey and cauliflower bowls. I say, okay, awesome, I'm so excited that you're taking the time to meal prep, that can take a lot of time. And how much are you eating? And she's like, well, I've got this little Tupperware. And you go through it together and you calculate it. And really, she's getting like maybe 400 calories and maybe 20 grams of protein in her little Tupperware. And you ask her, are you full by the time you're done eating lunch? She's like, eh, maybe. You're like, do you think you could eat a little bit more? And she's like, yeah, probably. So you say, girl, you gotta get rid of your tiny Tupperware. The big mixing bowls with a lid, that is where it's at. And we see if we can increase her serving size just a little bit. Can we add especially a little bit more protein into that, up that turkey percentage? Or also she's using cauliflower rice, which great to get some veggies. but maybe we're not getting enough calories overall, so can we add some brown rice and white rice into that mix in addition? Now, we've taken her lunch from 20 grams of protein to maybe closer to 40, and 400 calories closer to 800, just by slight small ups in that serving size. We hit mid-afternoon, we're back to breastfeeding, happens again, And we have some other snacks set up by her station. Maybe she's grabbing a handful of trail mix with some unsweetened dried fruit and some nuts. And so we're getting another 10-ish grams of protein, maybe 400 calories. And we made it back to dinner. We ask her the same thing. Do you feel really full after dinner? And she's like, Eh, not necessarily. And then, so it's like, okay, her family's making tacos for dinner tonight. And she's like, yeah, normally I eat like two-ish tacos. And then I get distracted trying to feed my three-year-old who's thrown their taco meat to the dog on the floor. And then before I know it, all the food's gone and we're on to the next thing. We say, let's prioritize getting you an extra taco. So yet again, without doing more work from a meal prep or food prep standpoint, we're able to increase protein a bit and increase over calories. So say that bumps us up to maybe again, like another 40 grams of protein and 800 calories. So if we look back at our day, Kristen maybe started off with maybe hitting 75 grams of protein and 1500 calories. which will definitely not be enough. That's like baseline function if she were to do nothing else across the day. With a few of our little swaps, we've gotten her really hitting that 2,900 calorie mark that we talked about would be ideal for her and closer to 150 grams of protein. So again, we boosted up her breakfast, adding in a little bit more, made snacks convenient that she could grab, and upped what she was eating just a little bit for lunch and dinner and made a big difference. Now, obviously, you wouldn't want to jump somebody who had been eating very low to a ton all at once. They may feel way more full, so that might be more of a gradual transition. But if you can even start with just, hey, let's really prioritize adding in one more protein-heavy snack. How can we make that easier? Is it making some protein balls over the weekend that you have in the fridge that you can grab? Like I mentioned, is it stashing that protein bar in the car by the breastfeeding station? How can you make that easy to hit those numbers? Now, in an ideal world, when somebody is dealing with, when we're noticing as we ask them questions about their diet, that we're not getting enough calories if we think they need to have a little more protein, it would be wonderful to refer them to a registered dietitian. It is great to have resources in your community of places that you can refer people out to. But the reality is, a lot of the time, they're not going to make time for another appointment. So you are their nutrition resource. The APTA says that it is within our scope of practice to talk about nutrition. So start asking. You will be surprised about the answers you get Especially, our example today was within that postpartum population, but this could be transferred over to any of your clients. Another great group that we really need to be asking about this is our teenage athletes, especially our female teenage athletes. And it is sometimes wild how low of a calorie count those people are getting in a day. Now, if we're wanting realistic Like if we're really wanting to know exact numbers, it is helpful to track for a day or two and see where they're at. Tracking, you can use like MyFitnessPal as a free app that allows you to track across the day. And that's a good idea to be able to see where the calories at versus where we want them to be and where's the protein at versus where we want it to be. I know tracking can be definitely triggering for some people, especially when we're talking about this population I like to recommend, can we do it for a couple days to get a baseline of what you're eating? And then a couple more days on top of that so that you can see, oh, wow, this is where I actually need to be with that. And maybe it doesn't have to be a long-term thing, because it also takes a lot of time in addition. If that's off the table, again, just go back to what are some of those little changes that you can ask them to make and maybe start with just one change at a time. So again, can we add that snack in or can we increase serving size at one meal? SUMMARY If this feels like a topic that you're like, man, I really wish I was a little bit more comfortable talking about nutrition, ICE does have a self-paced nutrition course. If you go to free resources on the app, you can access that. And if you're interested in learning more about REDS and its impact on all things pelvic, such as fertility, urinary incontinence, you should jump into one of our pelvic courses, either live or online. We've got some coming up. Our next online level one cohort is going to start on September 9th. and level two starts on August 19th, and then there's lots of opportunities to join us on the road as well. We'll be in Hendersonville, Tennessee on September 7th, Wisconsin on the 14th of September, and then Connecticut on September 21st. I hope this helps give you some ideas about little changes that we can make to make sure that our clients and you are getting the calories you need to do all of the awesome stuff that you want. Happy Monday, everyone, and go crush some breakfast. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 2, 2024

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses the importance of the need for simultaneously strong & flexible lats to optimize performance & reduce injury risk in CrossFit and other functional fitness athletes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ZACH LONGIt is August 2nd, 2024. I am your host today, Dr. Zach Long, lead faculty inside of our fitness athlete division, teaching our live course and our level two course that we just, uh, just changed the name of that. So excited to talk to you today about the lats specifically in the CrossFit athlete, why this is such an important muscle group for us to appreciate and why I call it the glutes of the upper body because it's just that important of a muscle. We focus so much in the lower body on glute development for athletes, for health, for performance. The lats are the key when it comes to the CrossFit athlete. Why is it key? Two big reasons. Number one, lat inflexibility will drastically impact many skills the CrossFit athlete is trying to develop. But what I want to focus on a little bit more today is lat strength. So let's get rid of the flexibility issue first. So if your lats are tight, what we're going to so commonly see is all overhead lifts affected. But we're really going to see athletes struggle with things like the overhead squat, whereas they're going down into that squat and their hips being flexed, that lat inflexibility is going to really wreck havoc on somebody's overhead squat. And then when we look at so many gymnastic skills as well, If you can't fully open that shoulder up into in-range flexion, you'll struggle with your kipping mechanics. Things like handstand walking will also be drastically impacted if you don't have great lat flexibility. But again, our focus today is going to be a little bit more on the strength of the lats and why that's so important. So obviously we all know that the lats create shoulder extension. So they're going to take our arm from being overhead down towards our side and behind our body. That is a movement pattern that shows up so much in CrossFit, probably more than any other recreational fitness activity. So if the lats aren't strong, movements like your kipping pull-ups, your muscle-ups, your toes-to-bars, are going to be impacted. Even your deadlifts, your cleans, your snatches, the lats are so important in those movements to keep that barbell close to your body and become more mechanically efficient in those movement patterns. So we've got to have really strong lats. I think one great example that I love to do when we're teaching a live course to help people really feel and understand how important the lats are in just barbell-based movements is to have somebody do a hip hinge holding an empty barbell. You slide that barbell down your thigh as you hinge over, and then you stop with that barbell sitting right at the patella. And then you take a second and you let that barbell drift three or four inches out in front of your knees, and then you pull it back to where it's touching your knees. You can do that a few times. And what you'll notice really quickly when you do that is as soon as that bar starts to drift away from your body, you'll feel your back tension really increase as your lumbar paraspinals have to work a lot harder when that barbell gets away from the body. I often explain this to my patients as carrying your groceries into the house. You don't carry your groceries into your house with your arms at 90 degrees of flexion in front of your body. That would not be an efficient position to carry that load. That's what the lats do in your deadlifts, cleans and snatches. So, how do we determine if someone's lats might be weak? That's tough to do. So I have a couple different things that I look at that kind of hones me in on thinking that this might be the case. Number one, does somebody just not have strict pull-up capacity? If somebody can't do that first strict pull-up, then I know that we need to build overall lat strength, then just overall vertical pulling strength. But once somebody has that, then there are a couple other things that I like to look at as well. Number one being, in their strict pull-up, where do I see those elbows at? So where I ideally want to see is when they're pulling themselves up, I want to see that humerus is pretty much staying kind of in the plane of the scapula, about 30-ish degrees forward from being in pure abduction. What I'll really commonly see is individuals that as they do their pull-up, those elbows come really far out in front of their body, almost in like straight flexion or 90 degrees of adduction. And what that usually indicates to me is somebody that's relatively stronger in their arms compared to their lats. So if you jumped on a pull-up bar today and you did a wider elbow angle pull-up and a really narrow angle pull-up, what you'll notice immediately is that as soon as you go more narrow, you will feel your arms working drastically more. So those individuals that go forward elbow position in their strict pull-ups are often weak in their lats. And then there's another great test that I like that's really specific to the CrossFit athlete. We show this in the live course, so this might be a little bit difficult to visualize on the podcast, but I get a very light box or bucket on the floor directly in front of a pull-up bar, three or four inches in front of a pull-up bar on the ground, athletes hanging from the pull-up bar, and I have them go into a hollow body position as if they were doing a kip, but we're doing it really slow. And what I'll usually see is that athletes with strong lats and great kipping form, great hollow body positioning, as they go into that hollow body position, you'll see their toes slide nice and smoothly up and down the box. For individuals that are weaker in their lats and they leverage and utilize their hips too much in their kip, they'll flex their hip, they'll go into a piped position, and you'll see that box actually get pushed forward as they do that motion. So there's three different things that I kinda look at that cue me in to somebody needing lat strength. Now, obviously, that is important for both, for performance, strong lats are gonna make you better at the movements that we see in CrossFit, but I also think that this is really important for us to appreciate as rehab providers, because when somebody has weak lats, we often see their rotator cuff and elbows get beat up as a result of that. So imagine somebody's putting in a high volume of kipping movements, toes to bars, pull-ups, et cetera, on a pull-up rig, but their lats aren't super strong. They're relying a lot on that momentum generated by the kip to get themselves over the bar, but they don't have the lat strength to control that eccentric motion. So they're going to come down a little faster. They're going to be a little less controlled. And when they hit that in range flexion down at the bottom, you're just going to see a little bit more force get thrown at the shoulder than if they had more lat control in those movements. And so very frequently, what you're going to see is those individuals with a little bit of lat weakness are the ones that are showing up to the clinic with rotator cuff tinnitopathy of the shoulder. And they're going to show up with shoulder instability issues. because that shoulder's just getting taxed more because of those weak lats. So, so frequently when I'm treating somebody with gymnastics-based rotator cuff tendinopathy or shoulder instability in the cross-fit population, I'm giving them rotator cuff strength work in an EMOM combined with some lat strength work. And we'll talk about a few drills for that in just a minute. One other thing that you'll very often see, especially in those forward elbow pullers, is that you'll find that they very commonly are those individuals that show up to the clinic with medial elbow pain. They're going to show up with golfer's elbow, medial epicondylogel. that medial elbow is getting overloaded because so much of what we do in CrossFit is already grip intensive. They're dead lifting, they're cleaning, they're snatching, now they're jumping up on the rig. But their rig work is also done in a way that puts a little bit more stress and emphasis on the elbow. And a lot of times that elbow just can't keep up with the load that's being placed on it. So obviously, again, you're loading up the elbow and trying to make those tendons a little bit more robust. but a huge component in those individuals also has to be strengthening those lats so that the elbow's just not getting constantly beat up in those CrossFit workouts. So it is super common for you to see my rotator cuff and elbow rehab programs in the CrossFit population having lat accessory work in it as well. So now I want to talk through my four favorite lat accessory works, excuse me, five. 1. Pull Up Variations Pull up variations are number one. Number two, I really love banded front levers. So especially for athletes trying to learn some higher level gymnastic skills, the toes to bars, the bar muscle up, etc. A banded front lever is a killer exercise to isolate the lats. That one does take a decent amount of strength to do. Number three, racked shins. Man, if you haven't played with racked shins in your own personal fitness journey, I really wanna encourage you to play with this one because it is a killer lat exercise. I mean, the first time you do it, you're gonna spend the next four days unable to raise your hands over your head. So what you do here is you set a barbell up on J-cups to where it's at about chest height, and then in front of you, you either get a tall box or maybe an incline bench, and you place your feet up on the box or incline bench. So your hips are flexed. while your shoulders fully overhead. So it just puts a massive stretch on the lats and then you do essentially a pull up with those feet a little bit elevated. Look up a video of this if it doesn't make sense, but that big lat stretch down the bottom really crushes the lats. And again, you're gonna be sore for days if you do that one. Number four, straight arm pulldowns. So I prefer this with a cable column, but a lot of CrossFit gyms aren't going to have a cable column, so then we just do bands. We get a band attached to the top of the pull-up bar, hold it with both arms, arms straight, and then we keep our arms straight as we go from shoulder flexion down into extension. So what that's going to do is it's going to completely take the arms out of the equation here, and really focus on isolating the lats to extend the shoulder. So this is another one that I really like for that individual that has that really forward elbow pull. I'm just gonna completely take their arms out of it. I might have them a couple days a week doing straight arm pull downs, a couple days a week doing toe assisted pull downs to build up their lat strength. And then number five, the RNT row. So I get a band position tied to like a upright of a squat rack at about knee to hip height. I'm holding the band at the same time that I'm holding a dumbbell or kettlebell. Now I'm doing a rowing motion where the band is resisting shoulder extension and my emphasis here isn't on pulling the weight to my chest. My emphasis is on trying to pull my elbow back towards my hip. When you focus on pulling the elbow back to the hip with that band resisting shoulder extension, you're going to find that the lats just get really, really isolated. For individuals that when they're doing pull ups or we're doing some of the other exercises that we've already talked about, tell me that they just don't feel their lats working as they do that. That's my favorite exercise to just build a little bit of awareness of the lats. It's great for strength. The negative is that we're only training from about 90 degrees of flexion down to zero, so it's a little less specific. But when I need to create that mind-muscle connection to get them to feel and engage their lats, I absolutely love that drill. So there's five different exercises and a couple different ways to test out the lats. SUMMARY So I really hope that you come away from this really appreciating how important that muscle group is for the CrossFit athlete. If you want to dive deeper in this stuff, we focus on lat strength a ton in our Fitness Athlete Live course, again, just because it's so stinking important. And so we've got a number of different live courses coming up that you can check out all across the country. In September, we've got three courses. We're going to be in Austin, Texas, Longmont, Colorado, and Spring, Texas. And then through the rest of the year and early into 2025, we're going to be in New Orleans, Orlando, Florida, St. Petersburg, Florida, Atlanta, Georgia, and Salt Lake City. So you've got a lot of different options across the country to catch fitness athlete live. And I also want to mention that Our Level 2 course, if you've already taken Level 1 online, Level 2 starts up in September as well. And that course always sells out. We have a few more seats available. We're about a month out from the start of that course, but it will sell out in the next two weeks. So if you've taken Level 1, and you wanna move on to Level 2, and you wanna move on to getting your ICE Fitness Athlete Certification, then you need to go sign up for that Level 2 course as soon as possible, because it's gonna sell out really soon. Hope today's episode gave you a few clinical tips and look forward to seeing you next time and at live courses. Have a great one, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 31, 2024

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses the difficulties of working with older adults in practice including medical complexity, being unsure of where a plan of care is headed, and other interactions that patient may have had or is currently having inside of the healthcare system. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CHRISTINA PREVETTHello, everybody, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of our lead faculty within our Modern Management of the Older Adult Division, and we are riding on a high right now. If you've been following us on Instagram, we just had our MMOA Summit where 10 of our geriatric faculty descended on Littleton, Colorado, and we just had an incredible time connecting And when you have these cup-filling weekends where you are just eye-to-eye with other clinicians and you are connecting with your team, I always feel like there is a lot of reflection that happens in those weekends, and I was down to meet him. And I was really thinking about where we have gone in the last seven years since modern management of the older adult has been a thing and where the profession has gone. And I thought today we would talk a little bit about the good, the bad and the ugly that we see right now as truly just realities of being in geriatric practice. And I think about, you know, Christina of 2016 and Christina of 2024 and what Christina of 2024 would tell Christina of 2016 as, you know, you get more experience under your belt. You get more clients that you've dealt with. You get how you've worked through really complex scenarios and how you've dealt maybe with some of the heartbreak that can come with really sad stories in geriatric practice. And so I have four things that I wanted to speak to of realities of working in geriatric rehab as a clinician and kind of our thoughts and feelings on them. IT'S NEVER JUST ONE THING The first one is what I tell a lot of my students or individuals who are just getting into geriatric rehab or just counseling or mentoring on getting into the geriatric space is an acknowledgement that sometimes it can be really intimidating because it is never just one thing in geriatric rehab, right? I work in traditionally outpatient and if I am working with younger folks, it's usually that they're coming in for one specific injury, right? Like they have had something happen and their shoulder hurts or they sprain their ankle and you are working on the ankle. Of course, you're gonna zoom out and you're gonna work on the entire person and we're gonna look upstream and downstream if necessary, depending on what joint it is. But we're kind of working on that one orthopedic thing. That's never the case in geriatric practice. And as we get into higher levels of institutionalization, it becomes even less likely that there is only one thing going on. And that is where clinicians can get in the weeds, right? They can get into these interactions where, yes, they have knee pain or yes, they have hip pain, but they've had surgeries that have gone wrong, or they are a lower or a higher surgical risk, lower likelihood of getting surgery because they have unchecked diabetes, or they're having troubles with sensation now because of diabetes, or they've had heart attacks, or they're on 15 different medications, and they all pop up in the BEARS criteria, and they're all having interactions, and you're unsure if their pain is because of the drugs that they are on, or the things that they are experiencing, or mental health concerns, and there is just a lot. And that can almost give us analysis paralysis. And it can also tend to lead us to really conservative management because you're thinking, oh my gosh, there's so much medical complexity here. I don't know what to do. And my advice in those situations is twofold. Number one is the benefits of doing exercise, especially appropriately dosed exercise, far outweigh in almost all scenarios, outside of the absolute contraindications outlined by the American College of Sports Medicine, the negatives of sedentary behavior. I'm gonna repeat that, that benefits, even in medical complexity, of doing appropriately dosed exercise when possible far outweigh many of the harms or any of the harms, especially when monitored, of doing nothing. And that is always a helpful reframe. EMBRACE THE JOURNEY, NOT THE DESTINATION And the second thing is that you don't have to know everything or exactly where you're going you just need to know the next step. And, you know, a lot of times we beat ourselves up in rehab that we don't know the prognosis or the expected end game or what individuals are going to be able to do after our care. As you get to know individuals and as you see how they respond to rehab, as you see their willingness to do things at home and the support that they have, and you get to know a little bit more about them, that picture will become more clear. But when there is a lot going on, know that exercise trumps no exercise, and just know the next step. Because it can. It can be really intimidating when there's a lot of multi-morbidity going on, but that's why they're coming to you with doctoral level education, right? Like, they need that medical monitoring. If they didn't need that medical monitoring, or if they didn't have real barriers like pain, to being able to engage in a physical activity program, they would be going to a gym. And hopefully the goal is that we can transition them there to exercise program or group therapy or whatever it might be. But they need your help at this moment and they just need you to give them the next step. So that's number one. When it's intimidating, we want to think exercise over no exercise and let's go with the next step. BE AWARE OF THE PATIENT'S PAST INTERACTIONS WITH THE MEDICAL SYSTEM The third thing that is sometimes or oftentimes an unfortunate reality of working with older adults is that they've had a lot of time to interact with the medical system. And we know that when individuals start interacting with the medical system, they oftentimes become afraid, number one. And number two is that they've had lots of chances to have communication with providers and that communication can be the good, the bad, the ugly. You know, I had a client just the other day, she was in her mid-60s, and she had had history of compression fracture with osteoporosis, and she was told by her previous PT that, it's all right, just make sure you don't fall, because if you fall, you're gonna be a paraplegic. And that was just one conversation that probably was like, you know, 15 seconds of that PT's day, but she was talking to me five years later, so that had happened to her when she was in her early 60s. She was now in her late 60s. And she remembered that sentence and it stuck with her. And she was seeing me for hip, low back pain, secondary to a lot of deconditioning. And I freaking wonder why that deconditioning happened. And that was one interaction. And so she's had other interactions with other providers as well. that have been able to tip the scale in the I want to do more category or I'm afraid because of what I have or what is a condition that I am experiencing or that is in my body that is making me afraid to move my body. And When we have those types of thoughts or when they've had some of those negative interactions, we talk about it at MMOA as when helping hurts, as when I have to hope, I have a really hard time with the PT one, but I have to hope that people are trying to be helpful. But when we think about the way that our medical providers and our allied health providers are taught, ourselves included, in PT and OT, We are taught to look for dysfunction. We are taught to look for what is wrong and fix what is wrong. But what that means is that is the frame of reference that we go into our conversations. Here, let me outline all of the things that are wrong with you in our next action steps. And I'm not saying this is something that's bad. I'm just acknowledging that when you have a person in their eighties who have now had 30, 40 years, if not more of interactions where every time they see a medical provider, they're being told all the bad stuff. And it's, we're trying to be concise with our, our appointments. We're really trying to get into the weeds of what's wrong and we're trying to get enough time to, to fix it. And people are coming to see us because something is wrong. I'm not saying that these are, these aren't bad things, but Those can chip away at a person's sense of self, a person's independence, or their confidence in what they can do, and can leave individuals, especially when framed through a really ageist lens of now that you're X years old, I don't expect you to ever be able to do this again. It can make individuals either one, very weary, of your interactions. I'm sure many of you listening to this, and I know I've had it, where you have somebody who's very angsty about the medical profession, and you are that representation of the medical profession, and you sit down and you say, hey, tell me what's going on with your foot. I remember I had a client who was in his mid-70s. I was like, tell me what's going on with your foot. He was coming in for ankle pain, and it was like fire was breathing out of his mouth. He was like, rawr, about everything. it was because he had been tossed around from provider to provider because they weren't going to fix his ankle, but then he had too much arthritis to fix with the procedure they wanted before, and they waited too long, and now they couldn't do the first surgery. And so he had been really tossed around from colleague to colleague, and he was really upset, and I was at representation. And so when you have individuals who've had a lot of experiences with the medical field, the first thing is that we have to tread lightly sometimes because we may be going against or counter message to people that individuals are already seeing. This is probably my biggest issue right now or the hardest thing that I am navigating in my practice is when I'm working with an older adult who has other providers who are telling them different things about the same condition. I have a client right now who is working with an osteopath and a naturopath and her family doctor and me and they're all giving her messages about what's going on with her low back. Many that I personally do not agree with. I'm sure they may not agree with me. And I feel horrible because I feel like she's getting so much mixed signaling and many of it is fear-focused messaging. And then it's really difficult for her to navigate when nobody's on the same page. And so just an example of where, you know, things can go awry really quickly in these really complex situations because they are interacting with more than one person and we oftentimes work in silos. And that is just the reality of working with older adults. And so my next step and something that I don't always get this right is that I try to acknowledge where that provider is coming from and then give my two cents that hopefully is adding to or not in completely the opposite direction of the messaging of the other provider. And that is an art. And it can be very difficult when you get really frustrated. Like I've had situations with some of my clients where I'm very frustrated at the other providers because it's creating difficulties for me to be able to get individuals to load appropriately. And right now our medical system is set up in this hierarchy where my doctoral level education is not the same as the medical provider's doctoral level education, but trying to acknowledge those past experiences. leading with kindness, recognizing that maybe kindness has not been given or time has not been given in other interactions, and taking it one step at a time when we are working with individuals who have had the majority of their interactions with medicine being very negative. And that's just the reality of something that we are going to be dealing with more commonly in geriatric practice. So number one is we are working with complex patients. So it can be intimidating when you aren't working on just one thing. There's a lot going on. Number two is that they have had a lot of experiences with medicine and that can bias them or make them jaded or make them upset. And I don't mean that to cast blame on them. I'm pointing that finger at us around why that has happened. The number three, the reality of working with older adults, and this might be able to be extrapolated out to everybody kind of in rehab, is that we have a lot of burnt out people in our healthcare system. And this particularly impacts our older adults because they are the ones who tend to see more multidisciplinary teams, right? When they're in hospital, they're interacting with social work and nursing and medicine and then us, and then they're coming to home health and they have a caseworker and they have, you know, they have more chances to have individuals who are burnt out in care. And we are, in geriatric practice, most commonly working in multidisciplinary teams, especially when we're in higher levels of institutionalization. In outpatient, PTs and OTs, we tend to be in silos where we work with just each other. Maybe we're in a multidisciplinary team where you're sharing with a chiro, or you're sharing with a massage therapist, or whatever that might be, but it's less, and it's less direct interactions with those individuals. And when people are burnt out in care, especially if it's things outside of the patient care, like a lot of clinicians will say to me, well, Christina, it's not my patients that are burning me out. It's everything else around my patients. It's the percentage of productivity. It's the documentation standard. It's fighting with the insurance companies. It's fighting with other not fighting, but having discussions with other parts of our team who are trying to advocate for care for my person because they have so much going on and it would be so much easier if X profession would be able to help with this or, you know, like, and then they're talking with X professional and they're burnt out too. And this is one where this is probably the ugly where We are not in a position right now where we have too many people who are helping. We are in dire need of mental health providers. The demand on our, not mental health, our medical providers, the demand on those medical providers all across the system, like allied health, nursing, medicine, is becoming higher and higher. We have an aging demographic coming, which means that there is even more demand And it is also a business working in healthcare, whether you're in socialized medicine, like I am in Canada, or if you're in privatized medicine, like in the United States, there is a business model and it is a reimbursement game. And that means that we are unfortunately usually understaffed and the mental health of providers is leading to burnout. And so this means, right, when you have a burnt out clinician, it can be difficult to provide the appropriate dose of care because it requires more effort. It requires more effort in our communication with our providers. It requires more effort on our side. And I think my solution, there is no solution because this is a very complex topic, is more just acknowledging where you're at, right? And acknowledging where you're at is the first step of figuring out how that's reflecting in your caseload. And I do not mean this to have any shame and blame. I mean this as burnt out providers. It influences everything. It doesn't just influence their care. It influences their family life. It influences how they interact. It influences the joy and the pride that they experience in their job. And we are in a time, and I think, you know, it started in COVID. It's still experiencing this backlash of it. where we have individuals who are not happy in their setting because of being burnt out, because of the way that healthcare is set up right now. And the first step is the acknowledgement of that. And the second step is trying to figure out, is there a way for you to get yourself out of it? And that might be going to therapy, that might be having conversations about your workload, that might be talking around the culture in your workplace, if that is somewhere that you are staying. And taking that step to work on you as a provider, because when you do that, then you're more likely to dose your care appropriately. Because if you're exhausted, it is a lot easier for you to do C to Therax than it is to do higher level, more supervision required care. And it is okay to acknowledge that some of that under dosage has come from the fact that mentally you are not in the healthiest space right now. And unfortunately that is a reality right now of being in geriatric practice in a lot of settings. And I guess the last extension of that is that coming in to those interactions, acknowledging that that might be where your colleagues are may give us the opportunity to have really fruitful conversations and maybe come in to those interactions with a bit more patience and understanding and trying to come from a place of kindness to hopefully work to repair fences and amend cultures that just need a dose of patience and kindness in combination with all the logistical and administrative stuff. But some of those things are outside of our control. And so these are things in our interactions that are within our control. So I have talked about the good, the bad, the ugly. And I want to finish with the good. So we talked about how, number one, it can be intimidating being in geriatric practice. There's a lot of complexity there. I always say that my caseload is chronic, complicated, and cranky, like cranky joints, not cranky people. Though I guess sometimes I get cranky people. That two, we have had individuals, the older they are, the more likely they are to have interactions with healthcare or decades of interactions that may have not been the greatest. We have a culture right now that is burnt out. And we need to acknowledge where that burnout is and take the steps in our interactions with our people to try and understand that. And number four is I want to leave you with so much hope, so much hope because the tides are changing, right? We have a team at MMA that is in every setting, right? We have PTs, we got OTs, we got people in acute care, in long-term care, in home health, in mobile Part B, in outpatient that are doing the things that we teach in our course around appropriately dosed care. We have been able to show proof of concept across a variety of different settings. And when we first started MMA and it was just a little bitty idea that Dustin and I had, we had people tell us that we have no idea what we're talking about. that I'm wasting their time, their caseload could never do this. And that has changed. And we are seeing that you are not often the only provider who is putting a weight in somebody's hand and doing a deadlift. You are not the only person who is getting Laverne, like Trisha posted about, who is doing 157 pound sled push in long-term care while her tech or her aide is helping carry her oxygen tank beside her. We are seeing that the spread of the ripples in geriatric practice to give our older adults the best possible care is happening. Gosh, it is slow. We have been at this for eight years, eight years. I started my PhD in geriatric practice in 2016, where we were trying to change the dosing schema for working with our older adults. It is starting to change and it's going to take time. It's going to take a concerted effort. It is going to take all hands on deck. But gosh, I left this weekend with MMA Summit and thought it's changing and we are seeing that change. And I feel so blessed and thankful that we have a team now that is working on that change and that They are kind of going forth and talking to clinicians. And I'm so thankful to the clinicians who spent time listening to our messages. And I'm so thankful to the older adults who have been in my care, who have trusted me with their care and seen some of the changes in my practice over the last 10 years as a practicing clinician. I am just filled with so much hope and so much joy that we are going to leave this profession better than how we got it. And you all are such an integral parts of that experience. So if you want to see us on the road, that's all I got for us today. Alan's going to say that I'm just doing 20 minute episodes now. But if you are looking for our last minute content course this weekend, Julie is in Newark, California, and Dustin is in Salt Lake City, Utah. I'm. Then our next course is August 17th, 18th. Jeff is up in Anchorage, Alaska. If you are looking for the kids to be in school and then go to Con Ed, September 7th and 8th, I'm in Mobile, Alabama. That's the first time we're ever teaching in Alabama, which is kind of neat. So super excited to get out there. If you have any thoughts, questions, concerns about any of the stuff that we were talking about today, or if you want to kind of add your two cents, I would love to hear it. Post it in the comments below. I'm excited to continue this conversation, and I hope you all have a wonderful. week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 30, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses three breathwork strategies: box breathing, physiological sighs, and 4-7-8 breathing and their implications to PT practice. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ZAC MORGANThanks for watching! Good morning, PT on ICE Daily Show. I'm Dr. Zac Morgan, Lead Faculty here with Cervical and Lumbar Spine Management, bringing you this morning our top three strategies for breathwork. So breathwork is one of those things that clinically I've used a lot more the last couple of years than I did the first few years of my career. And part of that is, or a lot of that is, I think my ability to describe it to people. But another big part of it is personal experience with breath work. So I think early on I had a healthy amount of skepticism myself about things like doing nothing or sitting around focusing on nothing but your breath. And it wasn't something that I practiced regularly. So it was something that was harder for me to implement clinically when I would, when I would suggest it to clients. didn't have good uptake rates. They often did not do the breath work or did not do mindfulness meditation. And there often were just barriers in the way. And really personally for me, this journey started a little bit around a year ago, a little bit over a year ago. My dad had open heart surgery and it just was a stressful time of life, a lot of busy things going on. And then on top of that, a big surgery like that with a family member, And I remember during that time having some realizations about stress internally that clinically have helped me a ton. I mean, for instance, my shoulders, I grew up as a swimmer, so my shoulders have always been fairly mobile. And that was never really an issue for me. But I can't tell you how many clients stand in my office and kind of complain about in the front side of their shoulders and it was something I always had a hard time relating to when I would hear people describe it and I always thought of it as muscle tightness and a lot of just issues surrounding the shoulder and then during that week that my dad was in the hospital the same thing happened to me. So like I said I've always had plenty of mobility and then all of a sudden that just went away. I had that same exact feeling of tightness there in the front side of my shoulder. It's very familiar from a lot of subjective exams And that's where I started implementing some breath work. And starting to implement that breath work, I noticed an immediate impact on my shoulder mobility, which was not what I was expecting. I was expecting to just be able to sleep better or unwind a little bit better. But from a musculoskeletal perspective, my shoulder range of motion improved, shoulders felt better. I was able to kind of return to all the activities that I was looking to return to. So it really made me buy in, which has helped me a lot clinically from a being able to leverage that personal experience with the client in front of me. So I would encourage you to start using this some, but within using Breathwork, I think some really actionable strategies surrounding it are what make for more success. So rather than just saying, hey, try some breath work with your clients, which is probably maybe a little simplified version of what I was doing prior to starting it myself. Now what I do is I give it more like a prescription. So rather than just encouraging trying some breath work, I give a very specific prescription of different types of breathwork for people, all to stimulate parasympathetic outflow. So let's go through the top three that I've had success with. And again, I feel like the more prescriptive you are with these things, the more your client will believe that it's important to you as a provider. And then also something about receiving a prescription makes people a little more compliant. So there's three big ones that I want to talk about this morning. The first one's box breathing. The second one's physiological sigh. And then the last one is 4-7-8 breathing. I do feel like I get the best uptake with box breathing, so let's start there. And let's just describe what box breathing is and how to prescribe this with clients. I've had a lot more success by having them on the front end, prior to starting the box breathing, testing their CO2 discard time. So the reason this kind of came into my purview was the Huberman article that came out a couple years ago. I'll put that link in the comments of this video. But essentially they just kind of described how they use some of these protocols with the clients in that study. They were looking at breathwork, mindfulness meditation, and kind of seeing what helped. And it turned out all of it helped. But they gave a little protocol to determine someone's CO2 discard time. And essentially what you do is have the person seated comfortably. They take four normal breaths, breathing in and out of their nose. And then they take a very large breath in their nose. then they exhale as slowly as possible. That exhale can come from nose or mouth or both. The point though is to exhale as slowly as possible. Now you as the therapist are going to time your client doing that prolonged exhale. And if their time lands between zero and 20 seconds, their box breathing time, so how long they breathe, hold, breathe, hold. So inhale, hold, exhale, hold. The time that they do that protocol, if it's 0 to 20 seconds, their prolonged exhale is going to be 3 to 4 seconds. If they can do a prolonged exhale between 25 and 45 seconds, I'm going to have them do their box breathing with 5 to 6 seconds of each chunk of the box. And then lastly, if they're able to do a really long exhale beyond 50 seconds, then I would have them do their box breathing with 8 to 10 seconds. So that specificity of having them test prior to doing the box breathing protocol, for whatever reason, has really increased the compliance rate for a lot of my clients. I think knowing that it's designed for you versus just, hey, here's some breath work, just for whatever reason, builds some compliance. So definitely box breathing is the one that I get the most success with. Again, to quickly describe box breathing, you're going to inhale for a period of time, hold for a period of time, exhale for a period of time, hold for a period of time. That period of time is determined by that CO2 discard test. Secondly is physiological sigh. So probably a little bit of an easier setup here because you don't need to test anything. But the point of a physiological sigh is going to be two inhales through the nose and then a really prolonged exhale that kind of sounds like a sigh, kind of a sigh. type sigh, that can come through the mouth. But those two prolonged inhales, they're going to come through the nose. And the first one is going to be about 80% of your lungs capacity, and then the second one is going to be the top 20%. So you take a really big inhale through the nose, kind of cap things off with a second inhale through the nose, and then as long of an exhale as you can do, making that kind of sigh sound as you do so. So it kind of looks like this. The longer you can make that exhale, the better. So that's physiological sigh. So there's just another option outside of box breathing. And then the last one is 4-7-8. So for 4-7-8, you're going to breathe in for four seconds through the nose. Hold for seven seconds and then exhale however you want to for eight seconds. So that prolonged exhale in both the physiological sigh and in 4-7-8 breathing seems to really stimulate parasympathetic outflow. So with all three of these strategies, the person has to be really compliant to see success. And honestly, it's a more the merrier type of situation. Now, obviously, if you were only sitting around doing breathwork all day, that would be an issue. But for most people, they're not going to do that. So what I usually try to start with is a minimum of once a day. So the person needs to set a three to five minute timer and just perform whatever breathwork strategy we just dictated with that person. and perform it for three to five minutes. Now, I would really prefer that person to do this three to five times a day, especially if they kind of run higher stress, if they're a little higher anxiety, if their blood pressure is up. If they're basically anyone that we interact with in the clinic, most of those people would benefit from doing this a little bit more frequently throughout their day. And so I kind of describe it to them as an acute way of dropping your blood pressure, an acute way of dropping your stress. And if you can kind of titrate that throughout your day, you'll be able to stay a little bit more regulated. And so within that, I would really suggest spending a little bit of time mapping that person's day out with them, like helping them strategize. Here's where this could work, like perhaps before the baby wakes up, but perhaps before the kids wake up, perhaps at lunch, just finding a quick spot that they could do the quick three to five minutes of breathing. The beautiful thing is we're really only asking for five to 15 minutes of this person's day. which is a really small ask, but they won't be successful without your help figuring out where to put that in their day. So I think that's the biggest tip is really regardless of which of these strategies you choose, I think they all work well. Make sure you help that client figure out where they're going to put it throughout their day. and how to fit this into their habits. Once they start doing it, usually compliance is pretty decent because they feel so much better. So it's really just breaking down that first wall of compliance and I think being specific with your prescription and then helping them fit it into their day are the main ways that I've had success with that. So I think this is a really important thing that should be in a lot of our plan of cares, because you think about when people are so stressed, whether that's because they're in pain or just the other demands of being a human on planet Earth, most of our clientele tends to run a little bit higher stress. And so due to that, it's really nice to help them find that release valve in ways other than exercise or sleep. not that I don't want them focusing on that as well. Just another kind of focal strategy for managing these things. Again, personal experience and being prescriptive has been really helpful for me with. So just some actionable things to try in the clinic. So my big suggestion is breach this subject with people. Be willing to talk about it. Be willing to practice some of these yourself so that that way you have some personal experience with them and then help them fit it in their day. If you do those things If you're able to do those things, you'll have a lot more success getting compliance with breathwork with your clientele. SUMMARY That's all I've got for you all this morning, so just some really quick actionable strategies. Try some of these today in the clinic, whether that's on yourself or with a client. If you have anybody that seems really wound up, I would really encourage trying these things. If you're looking for some upcoming courses, I want to kind of just point you in the direction of the next few cervical and lumbar that we have coming up with ice. So if you're looking for cervical, August 24th and 25th will be over in Bend, Oregon, so on the west coast. If you're looking more in the middle of the country, September 7th and 8th, we've got Midwest City, Oklahoma, and then more on the east side of the U.S., October 5th and 6th in Candler, North Carolina, so right outside of Asheville. If you're looking for lumbar this weekend, we'll be right outside of Pittsburgh in Aspen Wall, Pennsylvania. August 10th and 11th, Longmont, Colorado. So right outside of Denver. And then August 17th and 18th, Grass Valley, California. So beautiful northern California there, not too far from Sacramento. So if you're looking for any courses, we'll be kind of all over the place these next few weeks. That's all I have for you all this morning, team. I'll drop that article that I mentioned in the comments of this video and let me know if you have any successes or issues with breathwork as you're implementing this this week. Thanks, team. That's all I got for you. Have a good rest of your Tuesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 29, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Rachel Moore highlights the ways the 2024 Paris Olympics are changing the narrative around motherhood for athletes and providing resources and support along the way Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION RACHEL MOOREGuys, good morning. My name is Dr. Rachel Moore. I am here this morning representing the pelvic crew and I am so excited to talk to you guys about the Olympics and some pretty big stuff that's going on in the Olympics this year. The Olympics is huge in my area. Simone Biles actually lives like five minutes away from me, which is like my claim to fame humble brag. My daughter went to her gymnastics gym. And so if you've seen the Simone Biles documentary that's on Netflix, We were like fangirling and fanboying. We were watching it because we're like, oh, that's where Libby does gymnastics. So Olympics are a pretty big thing in our area, in our neck of the woods. And I think the Olympics this year are really interesting. And I wanted to get on this morning to highlight some of the things, especially when it comes to women in sport. that are really kind of setting apart this Olympics from ones in the past. If you didn't catch it, the opening ceremony was on Friday. It was a really interesting one because they were just kind of doing this parade of river boats down the river. And they incorporated all of these architectural pieces of France architecture into the opening ceremony. So it was pretty interesting to watch. And it just kind of set the tone for how different this year's Olympics are from a lot of the other Olympics in the past. So one of the key things that I think is really interesting, and I didn't even realize this until somebody else on faculty had shared a story about this, is that this is the first Olympics that has been almost equal representation as far as genders go. So the IOC set out to have a goal to have 50-50 participation between male athletes and female athletes. for this year's Olympics. And they actually just barely fell short of that goal. So the way it shook out with the amount of athletes that showed up and qualified and came to the Olympics was 51% male, 49% female. But that's pretty wild to see almost equal representation at this competition on a global level. A lot of us in the ice world are involved in CrossFit. We're kind of used to seeing that 50-50 representation. And that's one thing that really makes CrossFit unique compared to a lot of other sporting organizations. And so it's cool to see this transition or start seeing this change in this shift towards women in sport take this like worldwide platform where it's not a male-dominated thing and we're seeing more females represented and within that we're seeing more women that have children represented so motherhood is really starting to take a front row seat to the Olympics. So Allison Felix, who is the most decorated female track and field athlete, she's a US athlete. She actually made headlines a while ago because she lost her sponsorship with Nike when she told them that she was pregnant. And so that was this huge shakeup as far as women athletes and females in sport of, we are not a liability when we're pregnant. We're not less than because we choose to have children. And a lot of women, we see this a lot where People are delaying having children because of this athletic window and this fertility window kind of overlapping And so when athletes decide to start their families and then there's this response where they get dropped in their sponsorships, that sends us a certain message about what a female's role is and what her worth is in sport when she becomes a mother. And so Alice and Felix really spoke out against this and started this really amazing conversation about this overlap and about maternity leave and about just female in sport and how motherhood fits into that role. She took this to the Olympics this year. Um, so she's at athlete representative for the IOC and she actually started an initiative and it did great. And it's a thing now to open a nursery for mothers with young children at the Olympics. So historically the way it's always shook out in the past is that children are not allowed in the athlete village where athletes and coaches stay for the duration of the competition. So if somebody was breastfeeding a baby and also competing at the Olympics, they either had to choose to be separated from their baby for the duration of that competition, or they would have to kind of foot the cost of lodging for themselves. The problem with that is that Olympics is expensive and not everybody has the funds to even go compete at the Olympics. But then if we're thinking that somebody qualifies for the Olympics and now they have to pay for a caregiver maybe for their child and also they have to pay for lodging for their child or they're not going to be able to To be there that could make somebody not go to the Olympics that had qualified and had earned their spot So it's pretty cool to see this shift start happening. The nursery is actually sponsored by Procter & Gamble So Pampers is like branded all over it it's kind of funny if you look at pictures because they literally put Pampers and like every square inch that they possibly could and But it's a really exciting thing. So it's for children that are diaper age and below and their parents and their caregivers can go and kind of get away from the chaos of everything that's happening at the Olympics and have a quiet space to be together to spend time together. to bond. And then really a big thing is to nurse. The Tokyo Olympics, the last summer Olympics that we had, was right in the kind of height of the pandemic, or I guess kind of the downhill trickling of the pandemic, if you guys remember. And there was a lot of restrictions on the athletes. And so the athletes weren't allowed to bring support people, families, people had to stay behind. They were traveling with this like skeleton crew. And IOC The mothers to spend time with their children and to be able to nurse was Honestly pretty laughable. It was pretty wild if you if you just google like tokyo nursing room olympics Um, there's a picture of one of the athletes like two-year-olds laying on the floor And there's like a folding table with two folding chairs next to it And that's where the athletes would go To spend time with their children in between their events when they weren't training or they weren't preparing for the games again, if we're thinking about the message this sends that really tells people like you're here to be an athlete and everything else doesn't matter like we don't care that you also might be a mom oh it's it's okay you need a space well here's this like folding chair in the corner that message is so different this year the message the ioc is sending this year is that we recognize that the maternal timeline and the athletic timeline might overlap and your worth is not only as an athlete and we recognize that your worth also exists in motherhood. Allison Felix had this really cool quote. She said, I think it really tells women that you can choose motherhood and also be at the top of your game and not have to miss a beat. That's amazing. We preach that all the time in our division. We talk a lot, again, about how the fertility window and the athletic window overlap. And what we're starting to see is this trend of women pushing back and saying, yes, we can still be athletic. Yes, we can still be in the top of our sport. and also show up for our families, and also feed our babies, and us be their primary source of nutrition while we're training for the Olympics. So it's really cool to see this take, again, a worldwide platform to acknowledge that these things can exist at the same time. There's a couple other countries and groups that are showing up for their athletes as well. So the French Olympic Committee is actually paying for hotel rooms for their breastfeeding mothers. to stay in so again before athletes would stay in the athlete village with their coaches partners and babies would stay elsewhere they couldn't go spend the night with them they had to be in the athlete village so the french olympic committee this year has started an initiative where they're paying for hotel rooms for nursing mothers where they can go spend the night with their baby their partner can be there as well so kind of minimizing this interruption between this mother-baby bond and what's really cool is that they made a statement that this isn't just because quote-unquote the Olympics are here in our home ground This is something that we want to see carry over into future Olympics. So they're really again just kind of setting this example that motherhood matters and that we can do both. So really exciting to see when we look at the numbers. The US has 338 women on their team, which is the highest amount of women. on an olympic team france has 293 so these top two countries as far as women and female representation are really just showing up for all uh seasons of females lives um from what i could find i was trying to google like exactly how many moms are on the olympic team and um i even asked chat gpt i was like what percentage of olympic athletes are moms And it was like, we don't have that data. But I did see several articles that said that this year the USA team has 16 moms that are representing the US and five of them are on the basketball team. So kind of astounding that out of 338 athletes, if that number truly is 16, that's pretty wild. But again, it's really cool to see that representation and that acknowledgement as a whole. it's really exciting that we're seeing this culture shift that we have believed in and we have seen again in the crossfit world with annie thora's daughter and now tia and all of these top athletes really embracing their motherhood and talking about how motherhood has affected them as an athlete and watching this happen not just in the crossfit world where we all kind of live and spend time but in athletic world as a whole is so exciting and I just can't get over the fact that the Olympics, which is this massive platform that so many people are tuning into, are really highlighting and bringing attention and awareness to the fact that these athletes are also mothers. These athletes are doing these things simultaneously and it can be done. It's a really exciting message We are all about it here at ICE. We are here for it. We're excited to see it continue. And here's hoping that at future Olympics, we only see these accommodations grow between other Olympic committees, other country delegations, and that this nursery just continues to take off and that the athletes really enjoy it. SUMMARY If you guys want to hop in to our pelvic courses, we have a lot of chances to catch us in September. So we've got Hendersonville, September 7th and 8th, Wisconsin, September 14th and 15th, and Connecticut, September 21st and 22nd. So a lot of ways that you can come hang with us on the road in September. Our next L1 cohort starts September 9th, and our next L2 cohort starts August 19th. So if you're interested in an ice course, especially in that pelvic division, Head on over to PT on Ice and sign up for your course. Otherwise, keep an eye on the Olympics. If you guys have a favorite sport, comment it below. Let me know what it is that you're going to be watching. Obviously, I'm going to be all in on gymnastics because Simone Biles is essentially my neighbor, even though she's really not. But trying to get my daughter into horseback riding, so I keep hyping up all these equestrian things. so that she falls in love with horses. It's not working yet. We'll see. You guys have a great week. I hope you guys crush it. Thanks for tuning in. Bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 26, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how effective the strict press & front squat are in developing maximal performance in the clean & jerk and snatch.​ Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. We hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as a lead faculty in our fitness athlete division. It is Fitness Athlete Friday. It is the best darn day of the week. We talk all things CrossFit, Olympic weightlifting, powerlifting, bodybuilding, running, rowing, biking, swimming, If you are working with an individual who is active recreationally, trying to be competitive, whatever it is, Fitness Athlete Friday is full of tips and tricks for you. Today we're going to be talking about Olympic weightlifting. Olympics start today. Opening ceremony is just a couple hours away, 12 Eastern. And we'll be watching America's Olympic weightlifters take the stage in a couple of weeks on August 7th. And so talking about if we only could do two exercises to have a significant improvement on our Olympic weightlifting, what those exercises might be. We certainly see a lot of interesting suggestions on social media about ways to improve our performance, improve our technique, improve our clean and jerk and snatch. WHAT DOES THE RESEARCH SAY? But if we look to the research, what is actually the most effective? So today, we're going to be referencing a paper from Arthur Zetshin and colleagues back from 2023. In the Journal of strength and conditioning research, the title is associations between foundational strength and weightlifting exercises in highly trained weightlifters support for general strength components. And so we're going to talk about what this paper is, what this paper looked at, what this paper found, analyzing the outcomes of this paper, and then how to take those and apply them in the clinic, in the gym with our patients and athletes. So, with this paper, what was the research question? The research question, is there an argument for doing some specific general strength movements that would translate to higher skill, higher technique barbell movements, specifically in Olympic weightlifting, the clean and jerk and the snatch. And if those movements exist, what are they and how much do they contribute to the performance of the clean and jerk and the snatch? And so this paper, looking at it really quickly, took 19 highly trained Olympic weightlifters. They all had been performing Olympic weightlifting training for at least five years. and had them perform a one rep max of a couple different movements across the two week period in randomized order. So they asked them to max out their clean and jerk, max out their snatch, max out their deadlift, max out their strict press, and max out their front squat, and across 14 days, every couple of days, perform one of those max attempts, and then analyzing the data and trying to observe any sort of relationship in the variance between performance on what we consider the power lifts or the strength movements, which would be the deadlift, the strict press, and the front squat, and then compare that to how does that translate to what that person's max clean and jerk and what that person's max snatch is. And some really interesting data here, finding that 59% of the variance of the contribution to the clean and jerk is associated with maximal strict press and front squat strength. And that 62% of the variance in contribution to performance on a snatch is also associated with maximal performance on a one rep max strict press and front squat. And so finding in this paper that there is really no association at all between how strong someone's deadlift is in their performance on the clean and jerk and snatch. And you might think that's interesting because I might assume somebody who has a heavier deadlift should be able to have a heavier clean and jerk or snatch. But as we've taught in Fitness Athlete in our Level 1 course, our Level 2 course, our live course, for many, many years, when we really dig deep into the research on what's happening with the deadlift, we know it's not a pull off the floor and neither is the clean and neither is the snatch. That when we take somebody, whether they are going to just deadlift to the hip or whether they're going to bring that barbell, to the front rack position with a clean or all the way overhead with a snatch, that first pull off the floor is really kind of a misnomer to call that a pull. That is a press off the floor and we have several studies that look at EMG activation in the body of what is happening with a deadlift, what is happening with the first pull of a clean or snatch. And we know that the quadriceps are the most active muscle during that first pull. And that tells us it's not a pull, right? It is a press off the floor. That's how we instruct athletes in the gym, patients in the clinic, that this is a press off the floor. Imagine you're sitting on a leg press machine. If we took you in your deadlift setup position and rotated you 90 degrees, got rid of the barbell, put the weight on a plate underneath your feet, you would look like you were sitting on a leg press machine. And so it is a press off the floor. And so it makes sense that because it is a partial range of motion press off the floor, that it just does not contribute as much as we might think to our clean and jerk and our snatch performance. But finding that we had moderate to high correlations between strict press and front squat strength with both clean and jerk and snatch performance. So why is that? Why these lifts? How can we interpret that analysis? When we really think about what a clean is and what a snatch is, Try to keep it simple, especially in the CrossFit realm where people may have never been exposed to these movements before. Often our cueing is very simple. Hey, a clean, we're going to jump off the ground and land in a front squat. A snatch, we're going to jump off the ground and we're going to land in an overhead squat. And so Olympic weightlifters already do a lot of front squats, they need a lot of thoracic and shoulder strength, they need to keep their clean as close to the front squat as possible, because that is half of their score in Olympic weightlifting, right? Just two movements clean and jerk and snatch, you got to be got to be good at both of them. Likewise, a snatch is a jump into an overhead squat. And while the study didn't look at performance of overhead squat compared to snatch, It makes sense that a front squat would pair really well with a snatch. When you think about the receiving position of a snatch, a very vertical torso, very strong, stable shoulder position, it requires strength and mobility out of every joint in the body. You need to have excellent shoulder mobility and strength. You need to have excellent thoracic mobility and strength, excellent hip mobility and strength, excellent knee and ankle mobility and strength. a really, really vertical torso position in the bottom of that snatch. And so that front squat really sets us up a strong, tall, vertical torso position. We are training our legs in a squat pattern. We're working on our thoracic and shoulder strength and mobility at the same time. And so it checks a lot of boxes that we see and makes sense that it translates well to the snatch position. What we see, though, in a lot of other research is that we always look at the back squat, and we look at relationships between back squat strength and Olympic weightlifting, and we often find almost no relationship. And that also makes sense. Back squats tend to have more of a forward torso, more of a hinge-dominant position, especially if somebody is a powerlifter, in a way that just does not translate as well to movements like the clean and the snatch. And so understanding that it makes sense that these relatively simple, boring movements, the strict press and the front squat are showing to be really good developers for our clean and our snatch. APPLYING THE RESEARCH So what can we do with this data? What does that help us do in the clinic, in the gym with our patients and athletes? Well first things first, you're probably not going to blow any Olympic weightlifters mind if you tell them they need to get a stronger strict press and they need to get a stronger front squat if they want to be a better Olympic weightlifter, right? Most of them are probably gonna say, yeah, I knew that before I came to this appointment. Do you have anything else for me? When we look at folks who are training specifically Olympic weightlifting, they are already doing a lot of overhead lifting, they're already doing a lot of squatting, often several sessions per week, right? It's not uncommon to find competitive Olympic weightlifters performing some combination of back squats, front squats, overhead squats every other day throughout their week as they're training. Likewise, they're doing a lot of strict press, they're doing a lot of push press, they're doing a lot of jerks, they're doing a lot of accessory work that's going to reinforce overhead lifting. and squat patterns as well. So you're probably not gonna really rock the boat with a true, dedicated, even recreationally competitive Olympic weightlifter and definitely not somebody that is trying to be a professional or is already a professional Olympic weightlifter. They are hopefully already doing all of this stuff in a way that you don't have a lot to intervene on. But outside of that, somebody who maybe wants to get more into Olympic weightlifting, and especially with our functional fitness athletes, our CrossFit athletes who are doing clean and jerk and doing snatch as part of their CrossFit training, they always want to have a heavier clean and jerk and a heavier snatch, right? If they're coming to you and saying, is there anything I could do? I have an extra 30 minutes a week. I have an extra hour a week. I really want to get a stronger clean and jerk and a stronger snatch. For that population, it's tough to recommend to them just do more clean and jerk and snatch. because they're likely already doing it as part of their CrossFit training and they may even be doing it throughout the week in different variations, right? To be doing a high repetition, low load, power snatch and then metabolic conditioning workout and then maybe to maybe later in the week doing a strength piece that looks like higher load, lower volume snatching focused on developing the snatch. So it'd be tough for that person to recommend that they somehow find time in that same week to do more snatching. Instead, what is going to be a really effective and safe recommendation as far as not introducing too much volume to that equation is to recommend to that person, hey, find some time to do more strict press and more front squat. We talked a lot back in episode 1745 back during deltoid week of the importance of the strict press for developing the deltoid, that the deltoid is the powerhouse of the shoulder, but strict press is often neglected or completely ignored in programming. People skip strict press day when it's at the CrossFit gym. They may skip it when it shows up in accessory programming because it's not fun, right? They may do a push press or push jerk or split jerk instead. which doesn't really help improve our clean and jerk as much as it could and our snatch as much as it could because we're not training the shoulder as much as we're now training the legs when we transition to a push press or a jerk motion. Way back, episode 1567 with Midge Babcock, the title of that episode, Don't Be a Jerk with Your Jerks, he covered a lot of research that shows as we transition to that push press, as we transition to that jerk, we're now using 60 to 80% from our legs to get that weight overhead. And so we're not really developing true shoulder strength as much as if we do the strict press. And so just recognizing with that CrossFit that functional fitness population, they're probably skipping or not doing really foundational strength movements like the strict press, And like the front squat, because they are seen as boring, right? They are seen as maybe repetitious. But that is kind of the point that by doing those things more consistently, more frequently, we're going to bump up our front squat strength, our strict press strength, and we'll see a nice translation to improvements in our clean and jerk and snatch. alongside also continuing to do the clean and jerk and the snatch. And so my recommendation for a lot of folks who come to see me for help with maybe performance of what can I do, I have some extra time, is to give them some sort of undulating program that allows them hopefully in the span of the same week to touch a clean, touch a jerk, touch a snatch, a front squat and a strict press maybe even within that same week. And so, teaching those patients, those athletes, of how to optimize their sessions. Of hey, if you're gonna go into the gym, and you wanna introduce more of this stuff, what does it look like? It looks like we should do the Olympic lift first, we should do the power movement first, because those muscle fibers are gonna be the easiest to fatigue, and the longest to recover. So if we're going to clean or snatch that day, we should do that first. We can follow that up with what we might call a power lift, a strength movement. we don't need to be as explosive with those movements, those fibers are not as fatigued. And so we can do something like a clean, and then do a front squat, we could do something like a snatch, and then do a front squat, we could do a clean, and then we could do a strict press. And then at the end of the hour, towards the end of our session, whatever our timeframe might be, we have time for maybe a conditioning piece, if we're a crossfitter, and we want to keep working on our metabolic conditioning, or maybe just some extra accessory work to further develop leg strength, overhead strength, core strength, all the stuff that we need to be a really solid Olympic weightlifter. And so that might look like moving back and forth between power variations of the snatch and clean and adding in extra front squatting, making sure that we're not squatting too much, we're not lifting overhead too much, and just trying to find them a nice blend where they can add in some extra volume without increasing their risk for injury in a way that they're gonna find that time well spent and see those clean and jerk see those snatch numbers go up. And I always love when somebody just wants to do weightlifting, they don't want to do any conditioning that day or anything else. I love my favorite piece for developing overhead strength. Every two minutes for 15 sets, you're going to do five sets of three reps of a strict press somewhere between 70 80% of your max. You're going to transition to five sets of three push press, again, somewhere 70 to 80% of your max push press, and then finish out same rep scheme, same idea with the jerk. And so as our shoulders get fatigued, we bring in more and more of the legs in a way that overloads the shoulders really nice and gets us a nice 30 minute weightlifting session. And so that can always be beneficial for patients as well. SUMMARY What can you do? What can you advise someone when they want to improve their clean and jerk and snatch and they're not already a professional elite Olympic weightlifter, share with them that the most bang for their buck is going to be working in more strict press and more front squat into their training. Ideally, if we can do that every week, increase that consistency, increase that frequency, we know that's going to be a way that's going to productively overload the system. We know the research supports that those two movements have the highest contribution to performance on the clean and jerk and snatch, and that's really where we can help athletes work that into their programming and see them develop the clean and jerk and snatch the way they want so that they can hit new PRs. Team, if you like to learn about this stuff, if you like to hear about this stuff, our next class of clinical management fitness athlete level one online begins this next Monday. We have about eight seats left. Those will definitely be gone by the end of the weekend before the class starts. That literally happens every cohort and has happened for every cohort for many, many, many years. So don't be that person that emails on Tuesday morning. We're going to have to tell you the class is full. And then if you've already taken Fitness Athlete Level 1, Fitness Athlete Level 2, start September 2nd after Labor Day, and that class is already over half full, that'll probably be the last class of Fitness Athlete Level 2 for the year, so don't miss that one if you're on your way to working towards your Clinical Management Fitness Athlete certification. That's all I've got for you this Friday morning. I hope you have an awesome weekend. Enjoy the opening ceremony, the start to the Olympics, and keep an eye out for Team USA lifting on August 7th. Have a great Friday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 25, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of healthcare & rehab as an industry, who the big players are, what (if anything) is being done to change things, and how individual therapists can begin to affect meaningful change Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan, the pleasure of being our Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete and Practice Management Divisions. It is Leadership Thursday. We talk all things practice, ownership, business management. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday comes directly from ICE's CEO, Jeff Moore. sent this to me last week said hey I was just goofing off in the gym trying to get some lifting and cardio in together and so he sent me a workout of 100 bench press with the weights on the barbell 135 for guys 95 for ladies and a hundred calories on a fan bike for guys 80 for ladies with the caveat that you can break up that work however you like you can Do 100 bench press straight through, 100 calories on the bike straight through. You can break it up into 10 rounds of 10 and 10, 20 rounds of 5, 5, 5. Whatever rep scheme suits your fancy, you are allowed to do that as long as you get all of those bench press and all of those calories done. that bench press weight should be light to moderate for you enough that you could potentially do five to ten reps unbroken. If it's so heavy that you could only do maybe singles or doubles or triples it's going to take you a long time to work through a hundred so keep that in mind. Other than that just pace yourself on the bike. There is no use racing that bike to finish a couple seconds maybe faster than normal only to lay on that bench for 30 seconds before you feel like getting some reps in. So just treat it a moderate approach on that bike and hammer out that bench press as able. So that is Gut Check Thursday. Today we're talking about changing the status quo. What does that mean? We're talking about the status quo as it is across healthcare in general, but of course specifically to rehab today on PT on ICE. So we're gonna talk about what is business as usual in rehab, who are the major players, We're going to talk about what is currently being done to address some of the issues across the rehab professions and again in particular physical therapy. And then are there more effective ways to try to change things. WHAT IS BUSINESS AS USUAL IN REHAB? So let's get started first by talking about what is business as usual. And in the rehab industry, the healthcare industry in general, we have what is really going on across pretty much every industry in the country of a slow merger acquisition consolidation of small to moderate companies being bought out by larger companies and slowly paring down the amount of organizations who really offer the same or similar service. A good representation of this is the airline industry. We only have four major airlines left. Southwest, Delta, American, and United. 20 or 30 years ago, there were over a dozen. And in the wake of some of the IT issues we had last week, we may even see that Delta and American could be going away soon if they don't fix their IT infrastructure and get their feet back on board. And so we see that there are just a handful of major players in the industry. And we would label those too big to fail kind of organizations. We have the same phenomenon going on in physical therapy and again in healthcare in general. When we look at healthcare, when we look in particular at rehab, we really have four major players. We have health insurance companies that control the care that patients are able to receive. and the amount of time providers have to spend paperwork wise on providing that care and also the amount of money that providers get. We know that almost every American has health insurance and so that health insurance for the foreseeable future is going to be part of the equation and therefore these health insurance companies are a big player in this industry. We have just a handful of health insurance companies, about 10, that generate $1.3 trillion collectively and employ over half a million people, with an average profit increase every year of about 9% year over year. And these 10 companies insure about three-fourths of Americans. So again, a very consolidated, condensed industry. where if any of those companies were to go out of business or something, it would have a lot of ramifications for the economy, for patients, and for providers. And so health insurance companies stand as one of those too big to fail type of organizations in this equation. Right after health insurance companies are health care companies. Large, national, across state lines, corporate, health care clinics, whether they are primary care clinics, dental clinics, urgent cares, physical therapy clinics, whatever, we see the same issue across all health care professions is that over time we are slowly paring down that the vast majority of clinics are owned by a large corporation and that usually as we get near the top of these organizations, Nobody involved in the leadership or management of the company is actually a healthcare provider. And so these are large, for-profit clinics that provide some sort of healthcare treatment. In the rehab industry and physical therapy in specific, just eight companies are closing in on owning 75% of all outpatient physical therapy clinics. And so that's very similar to health insurance, right? A small amount of companies own the vast majority the organizations and clinics within the industry. We have universities as our third player in the equation. They are responsible for educating entry-level students and getting them prepared to become new clinicians. They certainly have a stake in the equation here. And then finally we have the government itself. That can be kind of vague when we say the United States government. We're kind of really referring to enforcement organizations, Medicare, IRS, who are trying their darndest to try to regulate the other three organizations, big players in the industry. And what we find when we look at the intersection of all these giant, large, too-big-to-fail organizations is that we find that Over time, they have become intertwined. They have developed a symbiotic relationship with each other such that it would be really hard to affect significant change on one piece of the puzzle without it affecting everything else downstream. We see that universities have grown their cohort sizes so much that they are now graduating hundreds. Hybrid programs with multiple cohorts starting per year are getting close to graduating thousands of physical therapists per year. And all of those students need clinical placements. Those large corporate health care clinics are happy to take those students and put them to work for some free labor. I think we've probably all experienced that. at one point or another in our student career. And when those universities grow these cohort sizes, they begin to need those large clinics to have places to send their students to. And those clinics rely on those students, again, as part of their labor force alongside their staff therapists as well. We see that health insurance companies need, at some level, some providers to take their insurance so that they can offer to their customers, our patients, that there are some providers who take your insurance. If we get to a level where no one is taking insurance, health insurance companies are gonna be in a lot of trouble, and so we see that they are trying to hang on and kind of fight back against a shift across healthcare towards cash-based physical therapy and trying to go around the insurance system. And then finally we see that the United States government hasn't necessarily quit trying to enforce curb all the fraud waste and abuse in Rehab in health care in general what we see is they've kind of changed their policy over the years instead of throwing people in jail or busting up companies or that sort of thing that they have shifted their strategy to just collect fines right if they can't and stop it, then they will collect a piece of the revenue that all these different organizations are making. And so you see that fines are becoming much more popular than actual legal action when the government tries to get involved in significant issues with fraud, waste, and abuse in healthcare. So that's business as usual currently. Universities pumping out students, big corporate clinics taking students, offering students a job, health insurance companies playing both sides against the middle and then the government just trying to come in and take a little bit off the top at the end of the day. And really what we see happening is at the end of the day, there's really no impetus to change business as usual, the status quo among those four groups. It is working well enough that there is no significant push to really change things. WHAT IS BEING DONE TO CHANGE THINGS? What is being done to change things? You may have noticed what we did not mention in one of those big players was an organization like the American Physical Therapy Association. Not much is being done here because not much can be done. If we take a second, and please don't hear that this episode is just an episode designed to dump on the American Physical Therapy Association, but structurally it is not designed to hang on and try to enforce or weigh in or make any sort of decisions or affect really a lot of long-term change on any of the issues we see among the big players in our industry. That when we look at what is the APTA, really it is a non-profit member organization. It's not a charity. It's not a church. It's a member organization, it's a non-profit, it doesn't pay taxes, and so at the national level it really can't affect change. Nothing about our profession is regulated on the national level, it is all regulated on the state level. Your scope of practice, whether you can manipulate the spine, dry needle, whether who can prescribe exercise, who can do cupping, who can do blood flow restriction, all those different scope of practice issues are all handled by individual state legislations. And because of that, the APTA cannot really weigh in. They can also not weigh in because they can't legally weigh in. When we look at how the APTA is structured, it's structured as a non-profit corporation. It is forbidden by law, as is every non-profit company, every church, every anything, from engaging in political activities. So what the APTA has is a secondary organization called the PT PAC, the Political Action Committee. That is an entirely different organization. It's an entirely different pool of money. And that is the group that can try to lobby for things like mitigating Medicare reimbursement cuts. But that in general, on the national level, by design, it can't be effective. And just being an APTA member without donating any extra money to the PT PAC itself doesn't really allow us as individual clinicians to help the APTA effect change either. HOW DO THINGS ACTUALLY GET DONE? So, how do things actually get done then? Things really get done in our profession at the state level. State legislation, changing scope of practice, doing things like expanding direct access, opening up the ability to dry needle. We saw Washington just get access to dry needling a couple months ago. That was a state-led initiative from the clinicians in that state, from the state physical therapy chapter, and from the state legislature in Washington. That is how things actually begin to move around in our profession. And the unfortunate thing is you cannot join, just join your state chapter. You have to join the APTA and then also join your state chapter at the same time. So you can't be a part of just your state without being a part of the national organization, which I personally believe is a little bit unfortunate because I'd rather see my time and money go towards the organization that's going to affect the most change, which is going to be my state chapter. A really good example right now, we're close to completely removing direct access restrictions here in Michigan, and that is led on the state level. A guy over on the west side of the state, Dustin Karlich, he is pushing that initiative with the Michigan State Physical Therapy Association through the Michigan State Legislature, and we're hoping that that gets heard in the fall meeting of the state legislature. and that we have direct access restrictions completely removed here in Michigan. And again, that is all done at the state level, not at the national level. So what can we do? What can be done? If that is the status quo, if that is what is currently being done, and most of it is being done at the state level, What can we do to try to change the status quo? We hear a lot here at ICE, you know, what is being done about this issue? What is being done about that issue? And the truth is, not a lot, right? We're not expecting to see reimbursement probably go up ever again. We've talked about why that is. The math just doesn't math with that. And so if we can't meaningfully affect the change that we want to see, especially at the level that we want to see it, what can we do as individuals and what can be done to try to change things in our profession? The first is to recognize, like, hey, we're in a Cold War event, kind of, right? These big organizations that don't really want to change things are pitting themselves against each other, and again, they don't really have an impetus to change. We see a lot of proxy fighting going on, arguing back and forth about who and who cannot dry needle or use cupping or blood flow restriction or whatever. We kind of have these proxy fights across the country. We go back and forth constantly. And the truth is, we need to recognize, hey, how did we actually win the real Cold War? We've significantly changed our strategy, right? How did we do that? We stopped expecting that doing the same thing over and over again would create meaningful change, right? We stopped going into small countries and propping up a government to fight against the Soviet Union. We recognized after 50 years of that, that that wouldn't work. What we did instead was we shifted to focus on our economy, we shifted to focus on being self-sufficient with natural resources, and we went an economy-driven strategy instead of a military-driven strategy, and that's what actually ended the Cold War. We see a very similar recommendation here inside the PT profession. What is the strategy? Literally anything except what we're trying to do, which has not worked in decades. This is one of my favorite books of all time. This is a hefty book. None of you are probably going to read this. That's okay. This is Army FM 7-8, Field Manual 7-8. It is infantry tactics. What I love about this book is probably a thousand pages of how to fight a war. What I love is that almost every section starts with, if what you're currently doing is not working, stop trying to expect a lot of change by doing the same exact thing over and over again. Change your strategy, right? Do the unexpected. There is a whole page in here on how to react to an ambush and the first sentence is, if ambushed, attack back immediately. Why? It is the unexpected thing to do. We have to do the same thing in physical therapy. Do the unexpected strategy because the expected strategy, the thing we've been trying, for the past 50 years or so has not really changed anything and we should not expect that doing the same thing over and over again will affect any sort of meaningful change. If we just stick our head in the sand and say, certainly someone is going to fix all of these issues soon, we should not expect that those issues will be fixed anytime soon. So, what are our recommendations? Support your local state PT association. You can't join it directly, but you can support your state PT PAC, your political action committee, which means that you can give money to your state physical therapy association that they can use to pass meaningful legislation in your state. So if you're in a state and you want access to dry needling, you want access to spinal manipulation, cupping, blood flow restriction, you want better direct access, you want whatever, it's going to change most likely at the state level and so support your state level association. As an industry, as a profession, we need to recognize that slowly over time, we're moving towards a state where it is not going to be possible to accept every single insurance and run a sustainable and profitable practice that lets us pay our therapists what they need to make to make a decent living while working at a reasonable volume, right? We have moved over the years from 40 patients a week to 60 patients a week to 80 to the average now is climbing towards a hundred patients a week that is Unsustainable and the again the idea that we can just do the same thing over and over again and expect change is not going to happen we're not going to to really make any meaningful change by trying to see a hundred patients a week or 120 patients a week and to try to generate more money to be able to pay more people. There are limits to how much you can get, how much you can work, and we need to recognize that over time, if things don't change with insurance, we need to let that ship sail. That is a tough transition, that is a hard transition, but it is a transition that is going to have to happen to some degree at some point in time for almost every physical therapy clinic in the country. unless things meaningfully change. How can those things change? There are systems in place for us to report our outcomes and increase our reimbursement from insurance. Almost nobody does that because it takes time, but it is possible. We're going to see our reimbursement here at our clinic here in Michigan go up 20% in 2025 because we are reporting our outcomes and And we are getting rewarded with more reimbursement. So there are systems in place, but if you don't want to use those systems or do those tasks, you need to recognize that you need to let that insurance ship sail. And it means that you're not going to be on it. And then over time, we'll need to probably pare down our insurances and potentially be cash only across the majority of the profession. And then as individuals, what can we do? Yes, we can support our state physical therapy association and state PT pack, but we can also stick up for ourselves. Every time you go to work for somebody that overworks you and underpays you, you confirm to the leadership of that organization that there is another sucker out there who is willing to accept that, right? And we just perpetuate the cycle that we have been trapped in for many decades. And again, what is the best strategy? Anything different than what we're already doing. So when you are given that quote unquote opportunity from that organization, and it looks terrible, don't take it. There are 34,000 physical therapy clinics across the country. Find a different one. There is a clinic for you that is going to pay you well and respect your time and autonomy. I guarantee it. It just might not be three minutes from your house, right? We sometimes need to choose a little bit of discomfort to make a meaningful bump in our own individual practice and our own individual work inside of the bigger profession. SUMMARY So changing the status quo, recognizing we're kind of stuck in a cold war with several organizations that are too big to fail, that don't really have an impetus to change what they're doing because it's working well enough for all of them. What is being done currently? Not a lot on the national level because it can't. We have to stop expecting that black helicopters with agents in suits from the American Physical Therapy Association are going to drop out of helicopters and just fix things. There are only 160 people that work at the APTA. Almost all of them are administrative roles. There are very few people there that are doing a lot of of groundwork because the groundwork of our profession happens at the state level. So what can we do to support that? Support your state physical therapy association. If you're like me and you don't want to join the American Physical Therapy Association just to support your state association, you can still support your state's physical therapy political action committee PAC PAC by donating money. If you go to that website I think you'll be surprised by how few people donate and in reality how much gets done at the state level with a relatively small amount of manpower and money and that if we all just gave a hundred bucks to those organizations I think we'd be really surprised at how much more change we see affected if only in our individual states, but how effective and how large that change could be across our profession. So, when in doubt, if your courage strategy is not working, literally do anything else, right? Write from the Army Field Manual. If you are being ambushed, attack back because that is the strategy that is least expected. Do something different. Go around insurance companies, support your state political action committee, and stop working for employers who don't respect your autonomy and who don't respect your livelihood, who are trying to overwork you and underpay you. That's all we have for today's episode. I hope you found this helpful. I'd love to hear any discussion you all have about this. You can leave a comment here. I'll be back tomorrow. We're gonna talk about Fitness Athlete Friday, how to develop really brutal strength in a way that translates to improvements in your Olympic weightlifting. So we'll see you again tomorrow morning. Have a great Thursday. Have fun with Gut Check Thursday. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 24, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses the ins & outs of daily life as an acute care physical therapist. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUERWelcome to the PT on ICE Show brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Thank you for spending some time on your Wednesday morning with me. Let's dive right in. So one of the most common questions that I receive from students and clinicians is is asking me about acute care. Should I go into acute care? Should I choose home health over acute care? And I'm having a lot of conversations with folks about pros and cons. and sharing my reflections from having been in acute care and home health and inpatient rehab and outpatient and private and home with older adults. So I figured I would do a podcast and bring all these thoughts that I've been having in these individual discussions to all of you. Okay, so what I'm going to do is I'm gonna go through a list of five to seven things that I believe are the most important characteristics of acute care and will help you decide if acute care is the right setting for you and if you are going to thrive in that setting. Okay, so number one, this is what I believe is the most important characteristic that sets acute care apart and will be the biggest factor in helping you determine if you are going to thrive in this setting. All right, number one is that in acute care you have complete autonomy over your day. You have complete autonomy over your schedule. This ended up being The reason why I feel like I thrived the most in acute care is because I wanted full autonomy over how I structured my day. So let me explain what that means. So when I was working in the hospital, I would walk into work, you clock in, and you are more than likely going to be given a list of patients. It is then up to you to decide which of those patients you're going to see. Are they appropriate to be seen? So you're doing some triaging there and you have autonomy to make that choice. And then you get to decide, most importantly, what your day looks like. When do you go see those patients? And this was so key for me. I don't like to be in a box. I don't like to be back to back all day. I like to create my own day. And so I would look at my list and depending on how intense or complex the patients were, depending on my energy levels for the day, I would decide, like, okay, I'm going to knock out a bunch of my patients in the morning. Back to back to back, get it done, and then go eat lunch, and then in the afternoon when my energy stores are down, that's when I do the majority of my documentation. So my afternoon, I wouldn't really have to see any patients, maybe one, and the majority of it was documenting. Or if sitting around and documenting for a long time is something that fatigues you, you can do a system where you go see a patient, then you document. You see a patient, then you document. So if you are someone who really needs that energy reset after pouring into a human, typically one that's very sick and there's lots of complexities and you need a little bit of a break and a breather, you can set your day up so that you get that break after every single patient or perhaps after two patients. So you really have a lot of flexibility there. I remember I was the type of person who I would love to knock everyone out in the morning. I would go find a quiet room or a room that was near some natural light. I would put my music on and I would just sit there and document. So you have full flexibility there. When you look at other settings like inpatient rehab, you are back to back to back to back. It's one of the things that I liked the least about the setting is that I did not feel like I had autonomy over my day. And I realized that that was professionally a big core value of mine. And then if we think about home health, you do have a lot of flexibility. You schedule all of your patients yourself. However, I learned my experience was that that was a big burden for me and I never really knew what I was walking into. I didn't get the choice of who was on my schedule. Scheduling patients was typically fairly time-consuming and frustrating when you're trying to reach out to all these people and they may not be answering and you're trying to very efficiently, Tetris them into your schedule so that you're not driving all around your region. Trying to schedule patients became just this extra task that really stole a lot of my energy. So after having been in multiple settings, I think that was the biggest plus to acute care. And if you are someone who likes to have that flexibility and you feel you can be efficient and effective and productive by making your own schedule, then acute care may be the setting for you over other settings. Okay, that's the biggest one. Number two, When you work in acute care, you learn how to be a master of scale. You have to learn how to come up with unique and creative loading strategies because you are in an environment where you don't have weights. You are in an environment where maybe you are just stationed to the edge of the bed because your patient is, they have tons of lines and tubes attached to them. So you have to figure out how to do a lot with a little. And that skill right there has become, it became my superpower going forward into every other setting. I never encounter a time where I'm with a challenging patient, they're complex, or we are in a less than ideal setting, for example, someone's home, and I have never felt I'm stumped. I don't know how to bring a fitness forward approach to this person. I can't come up with an idea. I don't have weights, and so I just don't know what to do. That has never happened. And the reason for that is because over several years, I learned how to get incredibly creative. So in the acute care setting, that could be as easy. I carry around dumbbells in my backpack. and I'm like rucking through the hospital, I bring my own equipment. We paused, we paused, we're back. That could also look like the, this is my favorite hack, the toiletry buckets that are typically filled with shampoos and soaps. I dump those out, roll up towels, soak them in water, put them in the toiletry bucket, and now that becomes a little bit of load, I would have folks deadlift that toiletry bucket, press it over their head. That was one of my favorites. I would use the tray table for a sled push. I would turn the hospital bed into a total gym and put it at an incline and have them reach at the bar above their head and they're doing pull-ups or I'm having them basically do a leg press with the hospital bed. I just was able to always find a way to bring that fitness forward approach and the acute care setting really forces you to get creative. And that was just such an amazing skill that has carried me through every single setting with every single patient that I've had throughout my career. So that's number two. Okay, number three. You do not, for the most part, have to take any work home with you. Yes. How nice does that sound? So for a lot of you who are in other settings and you typically at night, you get home from work, you maybe go to the gym, you eat your dinner and then you're like, well, here's my glass of wine and I'm going to sit down and I have one to two hours of documentation to do. That is not something that is typically happening when you are in acute care. Now in the very beginning as a new grad, a hundred percent, I was taking documentation home for me. But the vast majority after that learning curve, you know, after I got through that steep learning curve, I was not taking any work home from me. With me. You actually get to leave work at work. The administrative burden is very, very low. The EMR is very easy. It's a very low, low, low documentation burden. Something that I didn't know and I learned when I went into home health is that my god, documentation burden was enough for me to, was a big reason why I quit home health. I truly was so frustrated and cognitively overloaded by how extensive the documentation was that I could not even be present or enjoy the time with my patients. And for me, that was enough to say this setting is absolutely not for me. So if you are someone who you're really trying to create a barrier of when I'm at work, I do my work and I do a fantastic job. And then when I'm out, I'm off, I'm done. You go home and your energy stores go to your partner, they go to your friends, they go to your family. Acute care is definitely a setting where you can more easily create those boundaries. Okay, documentation burden low, that's number three. Number four, you are gonna do a lot of things in acute care that don't look like traditional therapy. Okay, so what I mean by this is that your role beyond improving someone's mobility and getting those sick patients, those, you know, individuals who need to get out of that bed and trying to start to get them stronger. Beyond that, I would say The majority of my time was actually spent being a fierce patient advocate, a fierce patient advocate. That is truly what my role became. And I actually evolved to loving that part of the role even more sometimes than going in and doing the functional mobility strengthening stuff. I thought it was such a beautiful opportunity to be able to advocate hard for my patients. So in MMOA, we call that significance over sexiness. You're not always going to get this patient doing squats or deadlifts or bringing in weights, but what you can do is you can fight to the end so that your patient can get over to inpatient rehab. I will never forget one of my first patients that I experienced working on the trauma floor was an individual who had a spinal cord injury. He fell down the stairs, ended up in the hospital. He did not have insurance. And he worked hard every single day with us. I worked with him for months. But because he didn't have insurance, acute rehab was saying, no, no, no, we're not going to take him. Even though everything else made him the perfect candidate to go to rehab. And we know that his outcomes were going to be so much better if he was able to go over and get that intensive rehab. So me and my colleagues were able to just hammer on that goal and we brought it up to the physicians and we got them to do an appeal and face-to-face peer review and we worked closely with case management and we were able to get him over to rehab because we went after that so hard. and that was more beneficial than probably anything we could have done in a more traditional therapy sense. So you have this awesome ability to really dictate the outcome of these folks and it doesn't look anything like PT. Another example is if you have an interest in working in the ICU you have an amazing role there to advocate. Meaning you're going around with the physicians and case management and the nurse manager and sometimes higher up execs in the hospital and you're looking at these folks who are on sedation and on the vent and you know that you want to get that sedation down so you can get these people up and start that early mobility. and you get to look at their settings and look at what's going on and say, look, can we get this person off Propofol and put them on Propofol? Or sorry, the opposite, take them off Propofol and put them on Procedix so that we can try and decrease the sedation burden that's going on with our patients and get them mobilizing faster. That is so cool. I thought that was amazing. I loved feeling like I was like this mama bear trying to protect all of my patients and get them to the next best. setting and really improve their outcomes. And much of that did not look like teaching them how to do sit to stands or deadlifts. So if that's something that you feel you would love to do, acute care is a really wonderful setting for that. Conversely, if you are an individual who, you know, I talk to a lot of clinicians and students who love the fitness part, like their core values when it comes to their professional career are that They want to be able to work with someone when they are in the stage of being able to load them up. That's what brings them value. They want to work more from a sports performance perspective. And they want them to be at a level where they're able to do all the exercise. Like that's what you love to treat. And so I give them the, you know, I let them know, acute care may not be the setting for you. You really may belong more in outpatient instead. So something to think about just the how dynamic of the role can be in acute care. Okay next you learn how to communicate and you learn how to be on a team. All right you will hear all the time that in acute care you have to have really solid interprofessional communication. 100%, you've heard that word over and over again. But what does interprofessional collaboration actually mean? You learn very quickly that the world does not revolve around you and your therapy plans. These patients are so complex. They have so much going on with them. You are one small piece of the puzzle that actually helps them move on to the next level of care, or helps them get home and be safe. You learn it really quick. You cannot operate in a silo. You start to learn what the nurse's roles are, what the nurse tech's role are, truly what your OT partners and your speech partners can do. And you learn how to work with case management. You learn how to have conversations with physicians. They're all right there, and you have to figure out You have your patient's health and mobility, and you want them to get stronger. That's the forefront of your mind. But you've got to deal with all of these other individuals who have their own priorities when it comes to the patient. the physicians or the surgeons, like I'm trying to keep the lungs and the heart alive, or I'm just trying to keep that brain alive. Like that's what their focus is. You know, the nurses are, Hey, I got to get these meds into my patients and they're overloaded. And you start to learn to have grace for people when maybe they're not fitting the idea of what you think should be done for the patient because you're thinking about your bias of mobilization and strengthening. So you start to understand, how to create allies with individuals who have various priorities when it comes to your patient case. You learn how to argue, you learn how to be direct, but you learn how to respect everyone else's role and everyone else's time. And that can become a really beautiful collaborative effort where you can work together and move people forward. And you just don't get that opportunity in other settings. When I went into home health, I really missed the fact that I could easily collaborate with my OT partners or my speech partners, or I could easily, you know, talk to a physician. In home health, a lot of the time it feels a lot more siloed and My goodness, if I was able to get even just a PA on the phone to tell them about a concern I had with a patient, that was a big win. So if you are someone who values and loves the fact that you're surrounded by a team constantly, acute care may be the setting for you there. Okay, only a few more, I promise. Let's do two more. Okay, next, the emotional toll slash connection is very high in acute care. Now, every single setting you are going to be emotionally connected to your patients, right? You could be in very vulnerable situations with the patient. However, I do believe acute care has the highest amount of emotional connection and along with that emotional toll because you are with folks that are dying, that have been through catastrophic accidents, that are, you know, I will never forget the day where I was working in trauma and a patient came in, terrible car accident. That individual lived, but her spouse died. And you are pouring into this human, they don't even know that their spouse is dead yet. I mean, you are going to face these situations so often, especially if you work more in the ICUs. You are surrounded by death quite frequently, and you're surrounded by a lot of sadness and loss and grief. And that can take a significant toll on you. I think it's beautiful that you are able to be someone who can support your patient, your patient's family during an incredibly tough time. But that can also be something if you are, um, if you are an empathetic person to a fault, sometimes like I am, that you can take on a lot of that grief and that can end up being incredibly heavy for you. So something to consider if you love to be in those vulnerable positions with your patient and you want to help them through dying and sickness and grief and loss, it may be a great setting for you. And that's not to say you don't experience intense joy as well. You can. see folks who were minimally conscious after a stroke or traumatic brain injury, and you can see them, you know, spontaneously start to recover. And that's absolutely incredible as well. But the emotional roller coaster is incredibly high. So if you are prone to taking on a lot of energy and emotion, and that's something that you know is not necessarily a positive for you, then maybe acute care isn't the place for you. Okay, last one here, last one. you do not get to see the sexy outcome. You do not get to see the sexy outcome. In acute care, you truly have to be okay with being the person who sees this person once, you plant a seed and you hope that that grows and that ends up changing this person's trajectory. But you don't get to see that outcome most of the time. And that's really hard for individuals. Many clinicians, they want to build that relationship and go along that journey with someone and see discharge day, see how far they've come from the amount of effort and work and progress that you've been making together. That longer term relationship is so important. This is one of the, um, this is definitely one thing that I didn't like about acute care as much is that I didn't have the ability to see this see this outcome. On the flip side of that, I definitely adopted the perspective that, hey, I've got maybe one or two chances to work with this patient. I'm going to do everything possible to set them down the right path. I'm going to pour into this human 200% to try and make sure that I can hand off the baton to the next person and it's a fitness forward individual and I can continue to keep them in that lane. And I was okay with that. I loved knowing that as a fitness forward professional, when I walked in those doors of my patients' hospital rooms, I knew, I just felt that their outcome was going to be different because I was coming into their room. And I loved being able, I loved being able to have that impact with them, even if it's for a very short amount of time. If that is something that you feel like you can get on board with and you can really learn to value and you can be okay with planting the seed and not seeing the outcome, acute care could be a really wonderful setting for you. If you are someone who knows that they want to go along the journey over a long period of time, they want to see discharge day and know what those efforts look like at the end and what the outcome was, probably not the setting for you. Okay, all, that's my list. It's not an exhaustive list by any means. I would love for you all to add to this list to kind of let more folks know some pros, some cons, some other considerations. Please add to this. Put it in the comments. Send me a message. I'd love to post other thoughts about all the things that go into acute care and whether it is going to be the right setting for you. Okay. So I will end with talking to you all about what we have coming up in the older adult division. So in August we, Oh, first let's talk about July. My goodness. So this coming weekend, we, uh, the whole team is in Littleton, Colorado. And then once we go into August, we are in California, Salt Lake city. in Alaska, as well as our Level 1 online course, that starts August 14th as well. PTINice.com, that's where you can find all of that info. If you're not on the app already, make sure you get on there and get into our community. We're on the app so much more now, so if you have questions or comments, find us in there. All right, team, have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 23, 2024

Dr. Miller Armstrong // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Miller Armstrong makes his debut on the podcast discussing what separates the top 5% of physical therapist from the rest of the profession. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION MILLER ARMSTRONGGood morning, everyone. My name is Dr. Miller Armstrong. I am a lead faculty for cervical and lumbar spine management, and I'm out of the Nashville, Tennessee area, and super excited to talk about today the topic of clinical success, one choice being required. So what I mean by this, and I'm gonna do a few parts here, so I'm gonna be on over the course of the next couple of months talking about this, but it starts here. What is that one choice? And at ICE, we are quite literally obsessed with thinking about what makes the top 5% of our population and of our profession, what makes them the top 5%. Like what is different about those people that are the best? What do the experts do differently than the rest of us that make them the experts? And so to frame this, I really have to tell you a little bit about my background so that you're able to better understand where I'm coming from. A side note, I couldn't resist hopping on the back porch. It's a rainy day here in Nashville, so it's a beautiful morning. So I couldn't resist jumping on the back porch today. But I was born in this area. I was born and raised in Nashville, Tennessee, actually just south, about 30 minutes, in a town, and now it's a city, called Murfreesboro, Tennessee. And in Murfreesboro, there's a university. And that's where, I mean, throughout my entire life, and throughout my entire childhood, I was in Murfreesboro. Elementary, middle school, and high school. I was down in Murfreesboro, and the college down there is called Middle Tennessee State University. So if you're not familiar with MTSU, they're a mid-major Division I when it comes to sports. So Conference USA, they play schools like Western Kentucky. Conference has switched around a ton since I've been there. When I was there, it was like Marshall, Western Kentucky, Florida Atlantic, Florida International, UAB, things of that nature, kind of in the southeast region of the country. And so I played football throughout my entire childhood and growing up, and then I eventually played football at MTSU. And team, after my second, or after my first year, heading into my second year, we had a coaching switch. And so my first year there, I was playing quarterback and I was on like scout team, practice team quarterback. But going into my second year, we had a defensive coordinator switch. And so the new defense coordinator, of course, brought alongside with him a lot of other staff. So we had a lot of new faces on the other side of the ball. And in that offseason, I got switched over to So I ended up playing linebacker the last few years that I was at MTSU. But you have to imagine that it was not only a new room, like in the college sports world, especially football, I knew a lot of those guys that I was playing linebacker with, but I didn't know them that great. So it was a little bit of a new feel as far as walking into a position room. What was even a newer feel was now we had new staff. And so it was not only a new position, it was a new linebackers coach that I had to get to know. And this guy's name was Siriki Diabate. And Sariki, he's one of my favorite people on the face of the planet. And he was a younger guy. So for the college coaching world, being in your late 20s, early 30s is really young to be a position coach. So Sariki was leading the linebacker room. And Sariki had such a fascinating story. Almost so much so that we couldn't really relate to this guy. So, Sariki was from the Ivory Coast, and he came over to America in his late teens. The dude was like 17 or 18 by the time he showed up in New York, and he experienced a lot of unrest. growing up. Growing up in the Ivory Coast, like, there was a lot of civil wars, there was a lot of unrest in the town that he lived in. So much so that there would be times where, like, militias would come into the town, and he would have to get out of there with his dad for days at a time, just in order to stay safe. So it was a really tumultuous time growing up for Seriki. And so his family saved up some money, and they sent Seriki overseas to America to have a better opportunity. And so Siriki showed up in America, didn't really know any English, didn't really know any direction, but he found American football. And through American football, he found that he had a really nice talent for it. And as he started playing a lot and getting a lot better, he ended up at a juco down in the Bahamas, where he eventually got recruited and ended up playing for Syracuse up in New York. And so as he's playing for Syracuse, Siriki was an undersized guy for the ACC. So the ACC is one of the major conferences across the country. So a lot of big schools, Florida State, Clemson, a lot of these teams. And so those humans are huge. These people are massive. Siriki was about 5'10", 5'11". And at the time he played at Syracuse, He was only about 215, 220 pounds, which is sounds big to the normal American, but for a division one power five conference middle linebacker, that's a small size. Most of those guys these days are walking around 6'1", 6'2 plus and well over 230, 235 pounds. We would watch Siriki's tape. So we would find his highlights basically as a linebackers group and we would watch him when he was playing at Syracuse. Sometimes the GA that was in our room would watch or would bring it up so that we could watch it all together. Because when you watch Sariki run around the field, there was something different about this guy. There was something different about what Sariki looked like on film. So just to give you a little bit of context, in the world of football, especially on the defensive side of the ball, players are graded, a lot of times, individually and as a group, and as a defensive group, they are graded according to how many people are in the frame on film when the play is over. So when the ball carrier is tackled, how many defensive players are in the frame. So if you only have like two guys in the frame that the camera captures, that's not very good. It doesn't show a lot of effort. It's a way to grade effort versus if you have like nine or 10 guys out of the 11 on the field that are in the frame at the end of the play. Coaches, defensive coaches love that. Defensive coaches love that. Individually, they will grade these guys based off of how many times or what percentage of times that an individual is in that frame. So if you're not in the frame at the end of a play, 40, 50% of the time throughout the game, the coach is saying, hey, you're not giving enough effort. Like you're not showing up around the ball when we're watching film. So knowing that, when we would watch Siriki's tape, when we would watch film on our coach, he was literally in the frame every single time. You couldn't find a play where this guy was not in the frame. It was so impressive. He was all over the field making plays in the backfield, making tackles, and if he wasn't making tackles, he was near it. He had the epitome of what good effort looked like. And so it was really interesting to watch, and it was really interesting to hear his mindset. And what he would talk about, team, he would walk into the room, and then he would watch our tape, or we'd be on the practice field, and he'd be all over us as far as trying to get us to make plays. And he would say things like, hey, run through that guy's chest. Like a pulling guard, and if you're not familiar with football, a guard is an offensive lineman. Those guys are usually 315, 320 pounds or more. A pulling guard coming around trying to put hands on you, Siriki would just simply say, run through him. The ball carrier is behind him. So run through that guy. And we would look at him and almost laugh. We were frustrated, but we would almost laugh. We'd be like, Siriki, what does that even mean? Like, what do you mean run through this guy? So much so that throughout that offseason, throughout the first few months that Siriki was there, even through the first few games, like game three, game four, we're watching film, he's still on us, like just decide, just get in there and make a play, run through that pulling guard, whatever it might be. We had such a hard time with this as a linebackers group that eventually we were like, coach, like shoot us straight. What do you actually mean by this? And team, what Sariki was saying next quite literally changed the way I view everything that I do in my career and in my life because of the mindset that he portrayed. What he said was he said, Miller, well, he said, team, crew, he said, guys, what we have to understand is that you really only get one decision. You get one decision. And that decision is whether or not you want to be successful. That decision is only decided by you, and it's really the only decision that you get to make, is whether or not you wanna be successful. Okay, what do you mean by that? And what Seriki said was, if you, and this is in the context of college football, but he said, if you want to be a good college football player, if you wanna be one of the best in the country, you watch film. you learn the playbook. You not only learn the playbook, you show up early. Maybe you get a good stretch in, maybe you get your body warm before the workout, and then you're the first one going as hard as you can in the workout. Even school, you can't get on the field if you have bad grades. So you show up to class, you do your work, you study, you take your tests, you perform well on your tests. But all of that is just what follows making the initial decision that you want to be successful. And that's what he was trying to get across to us. So making that play is just quite literally making the decision that you're going to do what's required. He said that this also comes down to doing everything that the coach says. He said, if you fail, but you're doing every single thing that I'm telling you to do, it's not on you. Your success is determined by your decision. that really started to broaden the way that I viewed a lot of different things because I started to think of, okay, now that I'm in the physical therapy profession, what does that mean? What does being successful look like in physical therapy? And that's what we obsess with here at ICE. In our cervical and lumbar spine management courses, we talk about that. Like, what makes the top 5% the top 5%? And at the end of the weekend, we share a slide. But we talk about a lot of different things throughout the weekend about what makes those experts the experts. Some of those things are like doing the basics really well. not making bad decisions because you don't have bad data. You're not sloppy in your physical exam or your straight leg raise or things like that. You're about it. You lead from the front. You have competency across multiple domains. All of these sorts of things is what attributes a great physical therapist. And so what we have to realize is that that That is preceded by making the decision to be successful, to be the top 5%. It's not like the top 5% or the experts have some magic pill that they take and then they become this great physical therapist. What they've done is they've decided on the front end that I'm gonna be successful. And what that looks like is eradicating all of their weaknesses, making sure they have four asterisk signs that they can chart and that they can track over time. making sure that they, in the first five minutes of every single session, making sure that they never forget to retest their asterisk signs, doing trial treatments, adhering to the test retest model, having a nice hypothesis list because they do their symptom behavior first, like all of these sorts of things that we talk about at ICE, it's all preceded by the experts making the decision on the front end. Because Siriki would argue that if we are not, say you're not rechecking asterisks after a trial treatment on day one, He would argue that that's not getting sloppy, that's deciding to not be successful. Once you make the decision to be successful or be the top 5%, every single thing else, everything else follows. Everything else follows. It's extreme ownership. This guy got to that mindset before the book came out, right? But I love that idea of, Okay, if I don't feel like I'm getting good outcomes, it's probably because I may have woken up that morning and not decided on the front end to do what it took. So whether or not, the fork in the road is whether or not I want to be successful. Once I make that decision, you just do whatever is required of you. And what is required of being a successful PT? All of the things that we preach here at ICE. So if you're not being about it, maybe then you actually didn't decide to be successful. All of those sorts of things. So team, chew on that for a little bit. So excited to be able to jump on here with you all. I love talking about those things. I love sharing a little bit about Sariki, and he had a lot of other sayings throughout three or four years rolling around with that guy, but yeah, it was a lot of fun, a lot of fun. We do have some courses coming up here soon. So, if you want to get into a lumbar or cervical spine management course, August is your month. We're coming in hot all of August. So, August 3rd and 4th, I'm going to be up in Aspen Mall, Pennsylvania, just outside of Pittsburgh, rolling with lumbar spine. The next weekend, August 10th and 11th, in Longmont, Colorado, Brian Melrose is going to be out there in Colorado. And then the following weekend, August 17th, 18th, I am going to be out in Grass Valley, California, over at Body Logic PT with that crew. If you're looking to get into cervical, August 3rd and 4th, if you're in the Cincinnati area, we might only have one spot left or so. It might even be sold out by the time I'm saying this, but cervical management was Zach Morgan. And then the last weekend of August, August 24th and 25th, over in Bend, Oregon with Brian Melrose as well for cervical spine management. So quite literally every single weekend of August, if you want to take a spine course, we're somewhere in the country doing it. Lumbar or spine or lumbar or cervical team. Thank you so much. I can't wait to see you next month talking about the next thing here and have a great day. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 22, 2024

Dr. Jessica Gingerich // #ICEPevic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic faculty member Jessica Gingerich discusses pushing strategy during labor. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION JESSICA GINGERICH Good morning, PT on ICE podcast. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division. Today's Monday, so you know that we are kicking off our week with some pelvic content. So today I'm going to talk about a question that I got from a client. So I wrote this down because I didn't want to get it messed up. And so She asked me, she said, if my uterus contracts to push my baby out during birth, then why do we as women feel or need to push during that second phase of labor? And I love this question because she has, she's done her research, right? She read that the uterus contracts to help push her baby out. And sometimes there are some nuances to our patients that we want to make sure that we clear and explain, and especially around birth, because we can decrease that fear around birth. Or if she wasn't having fear, at least empower her. So the uterus plays a key role during labor. So it expands during pregnancy to accommodate the growth of the fetus. There's also a thick muscle called the myometrium that expands to hold the baby, but it also contracts during labor, um, in this wave like pattern, starting from the top of the uterus down towards the cervix. And it helps to open or dilate the cervix. And it helps to thin or efface the cervix to allow the baby to move towards the birth canal. The contractions become stronger, more regular and more frequent as labor continues. So that is the role of the uterus. The pelvic floor's role is to be in a relaxed position. I like to think holes open, and I even say that to my clients. So it gives this really nice kind of internal cue. Now, while the uterus has a lot of work to do during labor, the role of pushing just helps descend the baby towards the birth canal. So it's just something that helps. And that's all we can that's what we can explain to our patients if they have this question. Now, this is kind of outside of the scope of this podcast, but I want to mention this is Because we do push during labor, we can imagine that the stronger our cores are, and really from an endurance and aerobic capacity, this can be a huge advantage, right? The stronger we go into labor can be a huge advantage to help with this. And so we want to make sure we're encouraging exercise in specifically core work, and even programming that as accessory work for our clients. So let's get into pushing. And there's two specific ways to push, and I'm going to talk about those today. This happens during the second phase of labor. I want to also mention that when we talk about pushing, we've got an open glottis and a closed glottis. The closed glottis is very similar to what athletes do when they are lifting weights. And so we really want them to practice how to push, especially those athletes that when they hold their breath, down below there are holes closed. And so as we talk about these strategies, I want you to be thinking about your clients who would really, really benefit from this. So the first one we're going to talk about is the closed glottis push. This, you think about your canister, so you've got your diaphragm at the top, your abs at the bottom, or excuse me, in the front, you've got your pelvic floor at the bottom and your back muscles in the back. You've got holes in the top and you've got holes in the bottom. And so as we create that intra-abdominal pressure by either tensing our core and holding our breath or tensing our core and exhaling, these are different strategies that create a different amount of force with each. So the first one is closed glottis or closed glottis pushing. This is going to be where we close our mouth, we close our nose and we bear down or strain putting the base or putting the pelvic floor in the basement or in that descended position. This creates a lot of force. This is going to be very helpful if mom is right at the end of that finish line and she can feel maybe she reaches down and she can feel the baby's head. or she, um, someone's telling her that her baby's crowning. She can close her mouth, close her nose and push. The second one is going to be an open glottis push. And so you can imagine we are creating a force through our abdominal muscles as air is coming out of our mouth and our noses. This is typically going to be really noisy and really loud. Maybe mom's screaming, maybe she's, making some really loud mooing faces, maybe noises, or maybe she's cussing because it hurts and that's okay. So this is gonna be a little less powerful, but it can be a really wonderful technique to help control their heart rate and help mom hold on longer, especially if she's got that marathon birth going on. Both of these pushing strategies can be influenced whether mom has an epidural or not. There's going to be less likely them to feel what they're doing. And so they're going to need coached pushing. That's going to be a nurse telling mom when to push. This is important to talk about because they need to practice. Practicing these birthing these pushing strategies for birth prior to birth can help mom come back to that and remember, Oh, this is what I did. This is what I did to prepare for this. I had a client tell me that she was in her second phase of labor. So she was pushing, she was so confused because she could not figure it out. She also had had an epidural. And then she remembered, she was like, wait, I remember that we practiced this, that you, you had me every day practicing how to do this. And so she went back to what she had been doing and she ended up being really, really proud and really, um, happy with how her birth went. But it took her a minute to like, remember, Oh wait, I did this. I knew going into my birth, how to do this. So she came out of that. She was really empowered, felt really good. So that is what I've got for you today. Um, we have our last cohorts coming up. So if you head over to ptonice.com, our last L one is kicking off on September 9th and our last L two of this year is going to be kicking off on September 15th. So head over there, snag your spots. Um, we'd love to have you have a great Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 19, 2024

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the differences between front and rear mount bike trainers, which is preferred for different bike types, as well as budget options. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION MATT KOESTERWhat's up everybody? Good morning and welcome to another episode of the PT on ICE Daily Show. Today I'm going to be your host. I'm Dr. Matthew Koester. I'm one of the lead faculty in the endurance athlete division with a specialty in bike fitting. I am super stoked to hop on here today and talk about probably the most popular question that we get in every live course and one of the most important things when you're getting into fitting for the first time as far as equipment goes. But before we dive into those topics, I want to talk about the opportunities that y'all are going to have to come and find us on the road. with number one being in Denver next weekend. We've only got four seats available for that course, so if you're interested in popping in, it's gonna be in South Denver in the Denver Tech Center area. We are really, really stoked to be heading out there soon, but if that's not gonna work out for you, we have another option, which is gonna be in Bellingham, Washington again, because the last time we were out there, it was completely sold out, the wait list was filling up, and we decided we'd run it back and set up a second course in Bellingham, Washington later this fall. There's gonna be another opportunity as well to see Jason London, who's the original content creator for this course, which is an absolute opportunity in Park City. That's a really cool location. We're gonna be out there in October as well for that course. So if you're looking to get a jump on some of this education and use this stuff in the clinic, the live course is the best way to get through it. So by all means, come find us on the road and check out one of those course options. Now, I said I was gonna talk about probably the biggest question in the course. The biggest one is really the thing that gets you into this. And it's what type of trainer do I need? We have two options in most cases. So to my left and behind me here, we have a front mount trainer, which offers a whole lot of options as far as what bikes can go on. And then we have the tried and true rear mount trainer. And what I want to do today is talk about probably like the biggest pros and cons of each. I want to talk about which one is probably the most appropriate for you and your clinic, depending on what type of bikes you're typically seeing. And then the ones that kind of have, I'd say, more budgetary constraints and or are just limited in availability sometimes. So, to start off first, I want to talk about the rear mount trainer because that is the one that is tried and true. That is going to be, in most cases for us, this green guy here. This is the Curt Kinetic trainer. Now, if I slide that thing forward, You'll see we've got the rear roller, which is basically what compresses the tire and allows you to kind of go through resistance while you're pedaling. You've got this rear cup that basically compresses the back axle of the bike and allows you to keep the bike nice and steady. And then we typically put something underneath the front wheel. Sometimes it's a custom wheel block. Sometimes it's an adjustable wheel block that allows you to lift that thing up and down and change the positions. But with this trainer, one of the things that people really, really love about it is that it's been around forever. They're used to it. When somebody comes into your clinic for a bike fit and they see something like this, they're like, ah, I know what this is. This makes perfect sense to me. I even brought my training skewer, which is typically the axle that they have to replace in the back of the bike if they're going to get on this bike. Because these metal cups here that compress the rear axle when they're tightened up are gonna basically act to lock the bike in place only on the contact points they get to touch. So if those contact points are plastic, which is pretty common as a way to save weight, save money on a bike, you have to replace that either with a training skewer, which just has metal cups on the sides, or in many cases nowadays with how bikes have gotten, these new through axle skewers. So the through axle skewer is typically a lot thicker, it's a lot more robust. It's common on bikes that allows them to put disc brakes on the bikes, which is really more and more ubiquitous these days. So having these options for different through axle skewers allows you to put metal on metal and compress it in the rear end of the trainer. Now depending on what types of bikes or what brands of bikes you're seeing more in the clinic, the skewers that you're going to need are going to change. So they all have various thread types that go on them. Some are very fine, some are medium, some are coarse. Now the Other kicker to this is that even though you might have the thread type dialed in, the distance, so the width of the actual screw itself might change. Last time I checked on the Kirk Kinetic website, which is the name brand for these guys, they had somewhere between, I think, five different options. I think it was like five different ones, three that were the different thread types, and then two more that were XLs for different distances. And each one was running about 50 bucks. So there's a bit of a financial investment to have all the options so that folks can come to see you and have all the options available to them. If you don't have one of these available to you and their bike doesn't have that, you're going to be kind of stuck in a place where you don't have an option with this style of rear mount trainer to throw them on and do the fit appropriately. That could be a bummer. got to have all the pieces. I'll say there's one other option out there, or not one, but two other like styles of these that are completely adjustable. CycleOps makes one, and I'm forgetting the other brand right now, but they basically have plugs and things that you can change in and out to put on. In my experience, they can be a little challenging to work with. They don't always match up exactly the way that I want them to distance wise. I like the tried and true nature of these ones from Kure Kinetic, but if you're in a bind, and you can only afford to grab like one adjustable through axle, I think you can figure it out. You just have to spend more time with it and go through the trials and tribulations of working through it. So, to recap real quick. This guy, tried and true, everybody knows it, everybody's used to it. It's a trainer they spend their entire winter on. The adjustability in terms of having different through axles is definitely a key. You gotta have them, especially nowadays as bikes have gotten more and more modern, going to disc brakes. These through axles are just like almost a non-negotiable So you gotta have all the different types so you can match the different brands and the different bikes that they come in. So, tried and true. Now, we step into one thing that Jason and I have been seeing over probably the last few years that's really become more popular is this front mount trainer. It really started to make its way in probably like a couple years ago in staging areas or like warm up areas for cross country cycling and downhill cycling. Specifically in downhill cycling, you'll see these guys everywhere when it comes to just getting through warmups. What this guy has to offer is two pieces that basically slide together. These two pieces include the front end triangle here, which allows me to remove and add the front fork of the bike. So we take the front wheel off, slide the forks over top of this guy, and snug it up nice and tight. The next piece from there is the rear rollers, where we have to get the tires centered in the rollers so they can smoothly pass back and forth as it's rolling. Cool part about this, they only have one adjustable piece as far as the actual front axle goes. So, and they send it with them. So when you buy this piece, you have everything that you need in order to do the fit. You can put any bike on here, because the front mount options will work for a standard fork, so they'll work for through axles. You can often put their own through axle back into the same bike. When you're talking about the distances here, there's a little track here that allows you to work with different size bikes so that when you overcome that issue, you can even separate them or buy the extenders. It just has to get, you have to make sure they're nice and perfectly aligned. Otherwise the back wheel might want to roll off one side or the other as you get started. So the rear trainer here offers a whole lot of options for being able to just throw a bike on quick. Now, the challenge that comes with that, as you start to get into like, oh, this thing works for everything, is that it kind of has that jack of all trades where it's not quite really any good at one thing. The challenge behind this thing is that it's not near as stable. It kind of sacrifices the stability and the tried and true nature of the rear mount for something that can be a little bit tippy if your patient or client gets on it and you're not paying attention. If they just throw a leg over it, it can kind of pull the weight with it, I'll say I've never had anybody fall off one. I've never had an actual incident, but I can definitely tell you that when I am with a client in the clinic and we're setting up to do a bike fit, I talk to them about getting on and off the bike carefully. I talk to them about how, like, when they're going to transition on, I'm going to grab ahold of the bars just to create that element of stability. But then even once they're up and on, an experienced rider, so I would say a good example of this would be a triathlon athlete. So somebody who's in the Madison area for me, who's doing Ironman Wisconsin and is coming in for a fit, If I throw them on this guy, it will work, and it will be fast to throw it on, but it lacks some of the stability and control that they're used to having when they're on the rear mount trainer that they spend all their time on. So they might hop on this, and they might notice that they just don't feel as confident. They don't feel as great. So they're more thinking about the experience of being on the trainer than they actually are thinking about the fit as they're going through it, which can be a negative. Okay. So there's the negatives to it, and there's the positives to it. From a financial standpoint here, if you were in a clinic where you were going to have to buy things new, and I'm going to kind of make that a subject for a moment, you can't just go on Facebook Marketplace and buy new stuff and throw it in at your organization. This guy's going to run you somewhere between $400 to $500, but it's kind of that jack of all trades. You can put anything on it. There's no bike you need. There's no custom pieces that you have to go through. You can just get any bike on here. The rear mount trainer, gonna be a similar ballpark. In many cases, it'd be like 250 to 450, depending on how nice you go, you can certainly spend more. It's gonna be limited in some ways because you're gonna have to have all of the different through axles to accommodate any different bike that walks in the clinic, but you're gonna have that stability and just steadiness that people really rely on and like when they're riding a trainer at home. So it's familiar, so that's kind of a nice option. If we take a step away from the idea of having to buy new, and you're like, okay, I'm going to budget my way through this in my clinic. And I know that if I buy something used, I can just make sure that it's good quality and it's broken. We started to get changed the tone here a little bit. These are harder to find use, but they are definitely. Hmm. They're harder to find used, you can get a hold of them, but they definitely have deals all the time on new ones. So you can find the ballpark, if you go on Amazon or various websites, you can get anywhere between that $400 to $500 mark. And this is where I would spend the bulk of the money, because you're going to have almost no scenarios in which you can't get the person's bike on the trainer. That is going to get you through more fits, even if it's a little bit less ideal of a setup. On the flip side, if I've invested in this one right here and I've got the money spent, I'm probably going to start looking at Facebook Marketplace because these guys are a dime a dozen. There were so many folks during COVID that were buying up bike trainers and they were going to spend more time on them at home. We saw the same thing with Pelotons and indoor bikes. These things are on Facebook Marketplace, Craigslist if you still go down that rabbit hole. They're everywhere for sometimes like under 100 bucks, maybe 50 bucks sometimes. And then from there, most of your investment on this guy goes towards the actual, through actual skewers that allow you to get all the bikes on. So your investments kind of change a little bit as you go through this. This guy's going to be the most money up front. This guy's definitely going to be cheaper as you go through it. But you got to get more components, more pieces. If I only had one in the clinic, which is kind of the question that people boil it down to, if I only had one, it would be the front mount trainer. and that comes with one more layer to it. I love the ability for a private practice or a clinic to be able to get out in the community and showcase the things that we do on a high level. If I want to go out to our local high schools here and go talk with them about mountain bike fits and making sure they get the best performance, injury rate reduction, all of those things, I can pop out to the local high school on one of their opening practices, which is actually coming up in a few weeks. I can throw up the front mount trainer, and in a very short time, take out their front wheel, put that thing right over top of this guy, pull the back up, and go right through things like seat height, have a quick look at their reach. I can make adjustments to small things on the bike very fast and make quick transitions to the next bike and not have to fiddle around with various components and other changes. So the, not only in the clinic does this kind of become the absolute jack of all trades, getting it on, It also makes some of those like community events that much more approachable and that much easier to go through. So I am always going to lean on this guy, but I will tell you it's nice having both for that occasion when somebody comes in and I'm like, Ooh, I really want the stability of the rear mount trainer for this person to throw it on. But I would say nowadays as I've gotten more and more comfortable with this, those things are few and far between. There are a few more nuances that would definitely go into this. There's more questions that surround them about the live courses. but deciding between which one is right for you. Hopefully this is a helpful conversation, a helpful talk to get you through that decision. Feel free to drop a comment, ask us questions here, send me a DM, but we will be in Denver next weekend. If you're ready to join us, we'll talk this stuff through even more. Thanks, y'all. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 18, 2024

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses reimaging the objective examination for patients presenting with low irritability, especially only in specific positions or under specific loads. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRYWhat is up? PT on ICE Daily Show. This is Dr. Jordan Berry, Lead Faculty for Cervical Spine and Lumbar Spine Management. Today we're chatting about a topic called Low Irritability Equals Function First. Okay, so I hope you're having an awesome Thursday. We're about to break down just a concept that I think matters when you're thinking about the novice versus the expert clinician and how they're efficient during their initial evaluation. This key concept of when you're thinking about going into the objective exam and you know the irritability is low or at least moderately low, we're always gonna test the functional movements first. Okay, so a few concepts that we talk about during our live cervical and lumbar spine management courses, when we're thinking about the objective exam and what the expert clinician does different as opposed to the novice, one of those things is that they have a very long, detailed, subjective exam, and they have a short, clear, and crisp objective exam. and how as you gain more experience and more pattern recognition, typically that will sway even more lopsided towards being a longer subjective while having a shorter and more dialed objective exam. And then another concept we talk about is that when the patient irritability is low, you have to be really aggressive during the physical exam testing in order to recreate the symptoms, right? Because if you under test, then you might not actually recreate those familiar symptoms to know that the treatment that you're about to apply is going to work and that you're moving in the right direction. And so, one way that you can accomplish both of those things, right, with keeping a short, clear and crisp objective exam, and then making sure that you're going to be aggressive during the physical exam testing when the irritability is low, is always thinking about testing the functional movements first. Okay, so let me give you a clinical example with this, and then we'll break it down and talk about why it matters and why it's important. So, Imagine that you're in an initial evaluation and you've done your body chart and you know that the symptoms are somewhere around the area of the lumbar spine, like we'll say low lumbar into the right glute wrapping around towards the right hip, maybe even like anterior lateral right hip as well. But you know there's some vague diffuse symptoms that are somewhere in the lumbar spine and somewhere in the hip as well. And during this objective, you also gather that an aggravating factor is squatting anything over 95 pounds. And so day one, during the initial eval, you know you're gonna be trying to differentially diagnose if the symptoms are coming from the lumbar spine, or if they're coming from the hip, or maybe both. But primarily, again, the initial evaluation, day one, during the objective exam, we're trying to tease out What is the primary symptom generator? We have to nail that down day one. What a novice would do is as they're going into the objective exam, they would likely just hammer through a battery of tests for the lumbar spine and the hip. So they'd probably have that person hop up and you're going through all the basic stuff, right? You're going through active range of motion, your joint exam, your segmental exam, potentially neurodynamics, your test and hit PROM and strength testing and palpation. You're essentially just working down this battery of tests to try to see if anything recreates the familiar symptoms. And so let's say that you go through that 12, 15 minutes of objective exam testing and you figure out that hip passive range of motion, like internal rotation or fader recreates that familiar hip pain. And so now we have an asterisk sign, right? We've got our, um, let's, let's call it internal rotation is what we're going to retest and we've recreated the familiar symptoms. So you've done a good job, right? You haven't done anything wrong, but I would argue that that is not expert level because number one, it took us a fairly long time to get to that answer of what is recreating the symptoms. And honestly, the patient doesn't really care about any of the stuff that you just tested. So, an expert here is going to look at function first. So, we might do some of the same objective testing that we did just a minute ago with the novice, but the first thing that we're going to do if the irritability is low to moderate is look at function. So, if the subjective exam we found out that anything over a 95-pound squat recreates the familiar symptoms, well, I'm going to look at a 95-pound squat. So I get that person out in the gym, maybe we do a warm-up set, and then we load up to 95, and right when they drop down, right when the patient drops down into the bottom of the squat, they get that familiar hip pain. Now, right then, you have one of your asterisk signs, but we could also modify that movement or try to tease out in real time if we can change the symptoms or affect them in any way. So let's say that person drops down into the squat, bottom of the squat, they get their symptoms, and you grab a big mobility band. wrap it around the hip, and give a big lateral distraction, a lateral pull, while they go down into a second rep of the squat, and the symptoms are completely gone. So think about what you've now done. Number one, you have a better asterisk sign, I would argue, because it's something that the patient actually cares about. It's functional, it's very easy to retest, but you've also clued yourself in on your differential diagnosis. Because if I can do something to the hip, right, do a self-mob to the hip or do a lateral distraction for the hip and immediately change the symptoms that we got with squatting, then I know when I go back to the table and I do my more traditional objective exam testing, I'm going straight to the hip. So maybe on day one now, I can leave all of the lumbar spine testing and maybe hold it off until day two. because now I know that I can affect the hip. Now we go back to the table. We do some of the objective testing and I go right towards PROM and I jam that hip up into IR and fader and recreate those familiar symptoms. Boom. Now we've got our two objective asterisk signs. We've got one passive range of motion. We've got one that's functional, the squat. So now when I apply it to some sort of treatment, I've got two ways that I can retest. SUMMARY So number one, why this matters so much of testing function first when irritability is low is differential diagnosis. It's just a fast way to identify oftentimes where the symptoms are coming from or at least cluing you in as to what direction you need to go in instead of just testing all the lumbar spine stuff and all the hip stuff. Now I've clued myself in that I'm probably going to focus on hip day one. So the second thing why it's important is efficiency. We always say during objective exam testing, as little as possible, as much as necessary. So I only want to test the stuff that's absolutely necessary so I'm efficient, but also I don't risk flaring up the patient with doing a bunch of tests and measures that aren't necessary to begin with. And if I can eliminate a few things right off the bat from that functional testing, why not start there? And then lastly, it's way better buy-in. It's way better buy-in. So day one, you're always trying to have the patient walk out thinking, man, I'm finally in the right spot. This person totally gets my issue. And they're definitely going to be walking out saying that if you're first off testing the functional stuff, the stuff that they actually care about that you pick up in the subjective. No patient cares about hip IR, cares about lumbar AROM, cares about palpation. They don't care about that. They care about the thing that they want to get back to that they love. And if you're including that in the physical exam, the buy-in is going to skyrocket. So think about that over the next week or so. About maybe changing the order of your physical exam if this is not typically how you order things. When the irritability is low to moderate and you pick that up during the subjective exam, then when you go into the objective exam, you make sure that you're testing function first. It's gonna help with differential diagnosis, it's gonna help you be efficient, and you're gonna get way better buy-in. All right, so think about that this week. Next week in the clinic, I'd love to hear feedback on that as well. Just to leave you with a few upcoming courses that we have with cervical and lumbar, this coming weekend, we've got cervical management in Oviedo, Florida, few seats left for that. And then also this weekend, we've got lumbar spine management in San Luis Obispo in California. And then coming up August 3rd and 4th, we've got cervical in Cincinnati, Ohio. And then also August 3 through 4, we've got lumbar spine management in Aspinwall, Pennsylvania. All right. Thanks so much for listening. Have an awesome Thursday in the clinic. And if you're going to be a cervical or lumbar spine management course coming up soon, hopefully I will see you there. All right. Have a great day. Thank you. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 17, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he compares & contrasts the different roles of heavy & light lifting in the scope of geriatric rehabilitation. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONESWelcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dr. Dustin Jones with the Older Adult Division and today we're going to be talking about heavy versus light loads, particularly in geriatrics. Which one is better? Is there a certain time, place, person that we may want to use heavy versus light? I want to take a dive into the research and some of the themes that we're seeing in the literature and also just from experience in clinical practice and in fitness. of how we want to think about these different types of load because to be very honest we have a big bias here at at ICE I would say and then definitely in the MMOA division where you will hear us talking about the need to push for higher intensities right especially with our professional pandemic of under dosage where we have individuals that are not being challenged and have the ability to change right like this is a big big issue and something that we really need to speak to and it's very easy to mix that message with that higher amounts of load heavy load is the only way to go and that could not be further from the truth all right so let's kind of get into the pros and cons of you know heavy resistance versus lighter resistance and when we may want to use these because it's really important to be very thoughtful in your approach of applying load to individuals I wanna start with talking about some of the advantages of lighter resistance training. That's the one that we typically associate, oh, that's under dosage, or that's too easy, or that's not gonna be that effective, right? That's not necessarily the case. So when we think about light resistance training, lighter loads, you know, maybe 40, 50% of someone's estimated one rep max, if you're doing those types of calculations, Those loads are really, really great for introducing movement. I think we can all agree that if we have individuals that haven't exercised before, that are relatively new to a movement, have a lot of fear on board, maybe a lot of irritability, that a lighter load is going to be easier to get the party started, if you will, with those individuals. And for some, it may be first set where you're doing a lighter load, check the box, things are looking good, and then we're going to progress to a heavier load. But in some settings, and I'll speak for home health at least, that's where most of my experience is, is that takes weeks and sometimes even months with individuals where we are doing somewhat of a lighter load before we really have a green light to really progress to a relatively heavy load with certain individuals. So introducing movement, I think light resistance training is a great place, a great tool and time to use that. I also mentioned irritability. When we have folks that are highly irritable, A heavy load is not necessarily a great situation, right, for those individuals. They'll often increase irritability and the behavior of those symptoms. They want to be respectful of that irritability and often lighter loads can allow us to introduce movement and helpful movement and activities without causing a big increase in their symptoms or a change in the behavior of their symptoms. So introducing movement, high irritability, those are great places. Another great place to introduce or use lighter resistance training is when we're really focused on movement velocity, of really creating speed with a particular movement, which in geriatrics, oftentimes, it's very helpful when we're working on reaction timing, for example, or performing movements that require a lot of speed, like stepping strategies to regain balance, for example. the lighter loads are gonna allow them to move quicker than if they were bogged down with the super heavy loads. We can use that in our training. Light resistance training also improves strength and hypertrophy as well. There is a lot of kind of mixed literature of showing that, man, heavy resistance training is kind of the gold standard, right? If we're wanting to get people really strong, if we're wanting to improve muscle mass as well, like we gotta lift heavy loads. but particularly in older adults and deconditioned older adults that they can see improvements and significant improvements in strength and hypertrophy with relatively lighter loads, 40, 50, 60% of their 1RM. Now, oftentimes you have to adjust the other variables of dosage, right? Typically higher volume, but we can see an improvement in strength and hypertrophy in older adults, particularly deconditioned older adults with light resistance training. And that's really good news. I think it's really helpful, especially if you're in a more acute setting, you're in home health, acute care, SNF, Those types of settings, the lighter resistance is typically more accessible to these individuals and we can still get benefits from it. So I hope you can see some of the value of lighter resistance training. There are certain times and places and people where we are going to want to use light resistance training over heavy resistance training. Now let's talk about heavy resistance training. What's some of the evidence showing and theme showing of where that really stacks up? What are the benefits? The obvious one is strength and hypertrophy. Most of the literature It's going to be looking at improving strength, improving hypertrophy is with heavier loads, you know, usually that 80-85% of someone's one rep max, you're going to see really good results with a lot of the individuals if you can be able to apply that. One thing that is not often discussed and why you'll often see the MOA faculty use, give a little bit more preference to heavy resistance training is the stimulus it will give to bone mineral density. that heavier loads are going to be a greater stimulus to improve bone mineral density than lighter loads. Most of the research that's showing pretty significant changes or a reduction in decline in bone mineral density are usually doing resistance type activities in higher percentages of someone's one rep max in the 80s, 85% for example. So bone mineral density is a huge one and that's why we'll often use it somewhat preferentially with folks when we can apply it. Another big one, and this is purely anecdotal and from what I've observed working with lots of folks, is the confidence piece. Introducing light resistance training can help build confidence, right? It can get people moving. They can start to do things that they didn't think were possible or what they thought they'd be able to do. initially, but once we get past a certain point, heavy loads are going to be the only tool to really change people's perceptions of themselves. There is nothing like, and this is in my experience so purely anecdotal here, but there is nothing like lifting a relatively heavy barbell off the ground and doing a heavy barbell deadlift with someone that perceived that they are weak, that they're old, that they're fragile, that they're slow, that they can't improve, they can't change. That is such a powerful tool for these people to improve their confidence, but change the perceptions of what they're truly capable of doing. And this has so many ripple effects, right? If I am able to deadlift my body weight, for example, and I'm absolutely shocked and surprised, usually for a lot of members of Stronger Life, a gym for folks over 55 in Lexington, that's where I'm working, it's usually the 100-pound mark. If people can deadlift over 100 pounds, it just blows their mind, and many of us know, like, 100 pounds, that's okay, cool, awesome, but can you do your body weight? Can you do two times your body weight? But for 100 pounds, for some reason, for these individuals, it just, like, kind of, flips the switch, and then they start to think of other activities in a different light. They start to see, well, if I could do that, a hundred pound deadlift, man, going to Lowe's and getting my own bag of mulch is no problem. I don't need help. I can handle that myself. I don't need to go ask Bob across the street to do this for me at my house. I can handle that. Oh, that trip that I wanted to do, I may be strong enough to do that now. I may be able to do X, Y, and Z. Oh, I'm more confident in maybe being able to take care of my grandkids because I know I can pick up 100 pounds off the ground. It has a ripple effect of how they perceive all kinds of different situations. And what I've observed is that behavior often changes, hobbies often change, leisurely activities often change, and overall their life becomes better and more rich and more lively all from an exercise, right? I shouldn't say all, but it's a very profound moment. So heavy resistance training does a great job of achieving that. Another reason heavy resistance training is very, very beneficial, especially in the context of rehabilitation, is it minimizes a detraining effect. So if I'm performing light resistance training over a period of six weeks, eight weeks, for example, I will likely have more of a detraining effect. I will likely lose more of the gains that I've received over that eight week period. I will lose more of that after I'm done, as opposed to if I were lifting heavy weights the whole time. So if you are working with individuals where you're not sure what's going to happen upon discharge, What are they going to do? Are they going to start that exercise class down the road? Are they going to watch that YouTube channel, fitness channel that you recommended? You don't know, right? Are they going to do that home exercise program? It's all up in the air. You're not really sure. We can use heavier loads. to typically get more results, especially related to strength, especially related to functional capacity, related to transfers and independence, we can use heavy resist strain to get more progress over that period of time and they're going to have less of a detraining effect upon discharge and they will maintain their gains for a longer period of time. For me, in the context of home health, this was absolutely crucial, that if I was pretty sure that whenever I discharged Doris, and I was probably gonna see Doris within five, six months, I needed to account for that five to six month period. Doris, I need to get you as fit as possible in this eight week period before we're gonna discharge. So I'm gonna give preference to heavier resistance training as soon as I can apply it with her situation. It'll minimize that detraining effect, all right? So there's lots of different reasons, but I hope you can appreciate the benefits of light resistance training, of when you may want to use it, what situations is it really helpful, but then also for heavy resistance training. There's certain situations where, yeah, we definitely need to avoid light weights and stick with heavier weights. It's very nuanced. There's a right time, there's a right place, there's the right person. We're going to apply these different types of load or amounts of load. We can also appreciate that oftentimes it's overlapped, right? There's going to be times where I'm doing heavy load and lighter load in the same program. They can coexist. And this is why at any ICE course, you're often going to hear us talk about and not or. That we're not here to be dogmatic. We're not here to polarize. We're not here to say, you know, this is absolute garbage. You only need to stick with this particular intervention. That is very rare in our profession of rehabilitation and fitness that oftentimes it's an and not or approach. And that's definitely the case whenever we're talking about the amount of resistance that we're applying to our individuals.SU SUMMARY So let me know your thoughts. Any other scenarios, situations I didn't touch on? I didn't even talk about tendon health, soft tissue, related adaptations to resistance training. Drop some of your thoughts and some of your experiences while using light versus heavy resistance training and geriatrics in the comments. YouTube, hop on Instagram, we'll talk there. But we appreciate you all for watching, for listening. I want to mention a few MMOA or Modern Management of the Older Adult courses that are coming up. We have our certification that is for folks that have taken all three courses. Our Level 1, which is going to be starting August 14th, that's eight weeks online. Then our Level 2 that's starting October 17th, that's eight weeks online as well. And then our live course. So all three of those culminate in the ICE certification for older adults. Our live course is coming up too that I want to mention. This weekend, Victor, New York is going to be going down. Jeff Musgrave is going to be leading that one. It's going to be an awesome crew up there in upstate New York. And then the following weekend is our big MMOA Summit. This is where all the MMOA faculty descend. In Denver, Colorado, we do this one time a year where we all come together, have an absolute blast. We do a lot of activities, hikes, we'll have a big cookout pool party with all the students afterwards. So if you're in the Denver area looking for something to do next weekend, we'd love for you to join that course. All right, y'all have a good rest of your Wednesday and I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 16, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses the benefits of icing prior to exercise for patients dealing with arthrogenic inhibition. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION LINDSEY HUGHEYAll right. Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsey Hughey, one of the division leads of our extremity management here at ICE. Welcome to Clinical Tuesday. It is awesome to be with you all here to share a little clinical tip. I'm going to try to keep it short and sweet this Tuesday. about arthrogenic muscle inhibition, and specifically after surgery like ACL or a total knee replacement, not things we get to usually talk about on our weekend extremity management. So really the big question I want to tackle today is should we ice for this? When you come to our class, we talk a lot about peace and love principles, and this came out of the British Journal of Sports Medicine in 2020 by Dubois and Escular. And they really highlighted that when we're managing soft tissue injuries, we actually don't want to ice or use NSAIDs anymore. And so the question comes up weekend after weekend. Well, what about after surgery? Should we be icing still? Well, because of arthrogenic muscle inhibition, it's kind of a completely different animal. And the evidence would tell us actually, yes, we should be icing for this. And so I'm going to discuss a little bit about that research briefly. But let's just briefly talk about before that, what is arthrogenic muscle inhibition? Well, what happens after surgery, what we see is that the normal activation of the sensory receptors within the joint and its surrounding structures, think ligament, tendon, joint capsule, and even muscle, And these are all responsible for detecting change in joint position, tension, compression. They send signals to the central nervous system. But in response to injury or controlled trauma like a surgery, these processes get disturbed and interrupted. So what happens is after a surgery like that, the central nervous system kind of goes into protective mechanism mode. And so a lot of inhibitory signals get sent to really protect. Big picture, if we step back, this inhibits our quadriceps activation. So after an ACL repair or a knee replacement, we see a lot of the quad swollen, it shuts down, and this leads to sequelae of functional deficits, big ones being like knee extension deficit, which means we miss our terminal knee extension, leads to quadricep atrophy. if we don't quickly regain that knee extension and proper activation, we'll tend to see persistent knee pain if this is not rehabbed appropriately and poor function in our stability as well. So what does ice do? Like what, why is icing potentially beneficial here? Because just to review one more time, that arthrogenics, inhibition that is happening, arthrogenic muscle inhibition, what is happening again is that we see that abnormal joint afferent input, which will decrease excitability of the spinal neurons controlling that quadriceps activity. And so that decreases motor unit recruitment and then even our firing rate. And we see this time and time again in our folks with ACL and it becomes persistent and people after total knee replacement. So what is icing doing? Like why is ice potentially helpful? And then I'll share two articles and point you in the direction to read to share how ice has been beneficial. What icing cryotherapy is thought to do is that it may prevent the activation of those inhibitory synapses that are happen in response to that arthrogenic muscle inhibition or AMI. And By disinhibiting, it actually increases the excitability of the anterior horn cells. We're getting a little nerdy this clinical Tuesday. And so what happens then is that there's less supraspinal control over the reflexive activity of like guarding. And so the icing serves as a strategy to just basically overcome and create disinhibition, right? Prevent that inhibition from happening. two articles specifically in the ACL literature that I want to share. And what's really, I want to give a shout out to Jonathan, because it was actually a course participant that asked this question. And, you know, I said, I actually need to do a lip search because I don't know the answer for sure. And he was so awesome. And he like sent me these two articles. So shout out to him for doing so. So what we see out of the British Journal of Sports Medicine in 2019, there was a scoping review by Sonnery Cotlett et al. And this included 20 RCTs that had moderate quality evidence where they looked at the efficacy of cryotherapy in combination, so let's consider not just alone, but in combination with exercises that activate the quad after ACL. And so what they saw is improvement in activation. These folks tended to do better when cryotherapy was a part of their care and those that had that AMI present. In addition, We see another article I want to point you to, and I'll tag these links for you. We see another article specific to ACL, but that timing might even matter. So there was a study done in the Journal of Orthopedic Surgery in 2019 where they actually compared putting ice on folks before they did quad activation, and they had a sham environment where they It was actually kitty litter that they put on the knee, and then they put ice on the knee. And they did this so that the person measuring output and torque was blinded to know whether they had ice or not. And what they found is the folks that actually had ice prior to had better firing in their quad because what happened is it had disinhibition effects, meaning it stopped that inhibition that usually happens and shuts the quad off. So consider, and that really surprised me, that the timing of our ice in combination with exercise or stim might be the thing we also need to consider doing it before we start a bout of exercise care after surgery. SUMMARY So as promised, keeping it short and sweet today, I wanted to give you all an update that we are, in fact, advocating for cryotherapy for our folks after surgery because it helps with long-term, down the road, better quad activation because of its disinhibitory effects. I'll put those links here for you today. I hope everyone has a wonderful Tuesday and that you'll consider cryotherapy still for your folks post-operatively, which is contrary to our peace and love principles. If you want to learn more just in how we manage knee pain, rehab in general, please join us at an extremity management course. What's coming up is July 20th and 21st. Cody will be in Hendersonville, Tennessee. That course is filling up, so join him there. And then I'll be in Bend, Oregon with Hannah, which is sure to be a blast. We're going to go visit Justin Dunway, our Total Spine Thrust faculty that weekend. It's going to be a blast. That is July 27th, 28th. And then we have two opportunities in August across the country, 24th and 25th. I'll be in Bismarck, North Dakota. Never been there, so join me there. And then Cody, again, will be putting on a course, but this time in Greenville, his home base, the same weekend. So opposite spectrums on August 24th and 25th. I hope you'll consider joining us as you end out your summer. Thanks for your time this morning, everyone. Take care. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 15, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Pelvic division leader Christina Prevett takes a pragmatic approach discussing variations we see in practice and physiology and acknowledges where we still have work to do. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE daily show. My name is Christina Prevett and I am one of our lead faculty in our pelvic health division and I'm coming to you from a cottage on my 35th birthday because I had a Wonderful husband who surprised me but that does not mean that I'm not gonna get excited talking about all things pelvic health so We had a really interesting conversation come up over the last several weeks, and it's funny because it's come up in a variety of different circles around defining normal. What is normal when it comes from a pelvic health perspective? Because when we are trying to make diagnoses of different conditions, urinary incontinence, pelvic organ prolapse, diastasis recti, we have to know what the realm of normal is so that we know when we deviate from it. And so we had a question come up in our app about, what is the amount of normal voiding, the number of normal voiding episodes that an individual should have during the day? Because some of our literature says 5 to 8, and some of it says 8 to 13. And then if you leak a little bit when you're really tired, does that actually consider you to have a condition? Do you have urinary incontinence? If you have a kind of a spasm in your shoulder, you wouldn't say that your shoulder was injured, but you would say that you have urinary incontinence. And it's such an interesting question, and I kinda wanna dive into it a little bit today. So last week, as many of you know, I'm a postdoctoral research fellow at the University of Alberta. And so what I am looking at in my research, I am an interventional researcher, specifically looking at resistance training and its impact on health. And what my studies are looking at specifically right now is on resistance training in pregnancy and its impact with pelvic floor dysfunction. What I was doing was I was learning from physiology researchers. I was looking at individuals who were looking at pelvic floor assessment and measurement. And up in Ottawa, I was at Linda McLean's lab, they are doing data taking on what is normal force production of the pelvic floor and what are things that we can expect to see as differences in the pelvic floor on ultrasound, on EMG force activation, and on dynamometry, which is force production. in a younger cohort of individuals and an older cohort of individuals. And this sparked a lot of conversations because we know that with age, for example, pelvic floor dysfunction goes up, but what are normal wrinkles on the inside of the pelvis? And what are things that we would consider abnormal or needing to seek some intervention for? So I'm gonna try and take you through a couple of different examples in the literature of what we know, what we don't know, and what we have to acknowledge is just areas of gray. So we're gonna talk about the bladder first. So some of our literature is saying, you know, five to eight Ps during the day is normal. Some individuals have pulled that up to eight to 13 as a top end of normal. And then some people will say that you shouldn't ever have to pee at night, or it should be rare, like you shouldn't be getting up consistently to pee at night. And others say that that is true if you're under the age of 65. But if you're over the age of 65, getting up once to pee is considered within the realm of normal. So let's talk about why there is that variability. When we are looking at data sets and we are trying to incur where that normal distribution is. So we think we have an average if it's normally distributed and 95% or 97.5% of our data is going to swing within plus or minus two standard deviations of the mean. And I'm getting kind of in the weeds of statistics here, but that's kind of our normal distribution. And our P of less than 0.05 on a two-tailed test are the ones that are below that two standard deviations on either side. And what that's saying is like when we have this big group of individuals who are kind of distributed across this arc, and we are seeing that this other group of individuals is well below that, then we can say that these are probably different populations or there is something different going on. When we are looking at trying to characterize normal, There is so much that comes into human behavior that creates differences in a person's lived experience. And when we're trying to capture that descriptive data, it depends on a lot of things, right? If we are looking at normative data and we're trying to describe it, it is going to be very specific. to the data set that we are capturing that information from. What do I mean by that? I mean, if we have an individual who's an athletic group of people who are very conscientious of hydration, their normative values for how often they're going to pee is probably in that higher end between eight and 13. If I am working with a sedentary population who doesn't take a lot of care in their hydration, or it's not something that they think about, five is probably on the top end of that. And so we know that this hydration status is largely going to dictate frequency of urination. Similar to things that we know cause liquid to filter through the kidneys a lot faster, things that we call bladder irritants. So if I am working with an individual who has a higher caffeine or alcohol intake, right, that's gonna make it flow through the urine. Caffeine is not a diuretic, it's a mild diuretic. It does make us have to pee, but in the morning, we're oftentimes drinking caffeine that's simulating that the kidneys and the bowels to start functioning. We are peeing more in combination with having caffeine. Alcohol is another one where it increases filtration rate because alcohol is a toxin, our body is trying to get rid of it, and so it can change our frequency of urination. timing of when we drink water can dictate are you a person who gets up every night to go to the bathroom or not. So all of that can be in the realm of normal variation and that makes it extremely difficult then to diagnose things like nocturia or frequency issues where urination is over a threshold where we consider this to be a quote-unquote pathology or a condition. And so what that has done in our bladder consensus statements is that we have added a second part to this. We have said that when you're thinking about healthy bowel and bladder habits, you should be able to defer going to the bathroom as needed. Your urge to go to the bathroom should increase as the amount of bladder filling hits a more critical threshold. We're getting to the top of our bladder fillage. and we should be able to empty our bladder when going to the bathroom and have complete emptying of our bladder. And frequency of urination, we have like, you know, multiple studies that have tried to characterize normal, but the big asterisk sign on this is that frequency should be at a level that feels okay for you. You should not be stressing about your bladder. You shouldn't have anxiety about bathrooms because that's showing that there is issues with being able to defer going to the bathroom, being able to hold going to the bathroom, or you're going to the bathroom so often. that it's disrupting the cadence of your day, right? But that's really difficult because we can't necessarily say there's this cutoff, right? Where if you're going to the bathroom less than five times, you're probably dehydrated. That's pretty consistent. But if you're going to the bathroom six times versus 10 times, It depends on you and on how you are feeling, and if that is okay for you, or if that's something that is all right for your day. And so we don't really have these normative values, and it's why there's inconsistency in the literature about it, and we can't really give you a hard and fast number, and we really don't want to, because you're a human being. It depends on your day. You're not doing the exact same thing every day. So these healthy bladder statements that we have that are in our research and that are in our course are trying to give an idea, right? So if you have a person who's really underneath that or really above that, then it can almost introduce the conversations around frequency and work on things like urge suppression to potentially bring that frequency down or modulate liquid intake to maybe help with some of those concerns. A second example where we're not really sure about normal is when it comes to diastasis recti and pelvic organ prolapse. And this I actually see as almost a bigger problem because it really bottlenecks our research. It actually makes a huge difference in terms of the way that we are educating on normal conditions and normal changes, and how we create a threat response oftentimes when potentially we don't need to. Let me kind of dive into what I mean. When we are looking at our frequency of pelvic organ prolapse, so pelvic organ prolapse is a movement of one or more of the vaginal walls towards the vaginal opening, and it is assessed on a Valsalva Beardown Maneuver, which is done on a relaxed pelvic floor. Okay, that is where we are doing our assessment. We know that our vagina is not a hollow tube, our bits touch, and we do not have our vaginal wall as a cartilaginous ring, right? It is smooth muscle. And therefore, it should be moving, right? We should see some movement, but it is the degree of movement that we have tried to create a cutoff score for in order for us to have clinical care pathways that give us some idea about what is the next step for individuals who are experiencing signs and symptoms of pelvic organ prolapse, right? We can have individuals who have high amounts. So where are some of the issues come up? We can have individuals with high amounts of movement and low symptom burden and vice versa, right? We can have individuals with high symptom burden with low movement. So here comes the first hole in our argument is that there's discordance between subjective complaints and objective symptoms of prolapse. The second concern that we have with using our grading system as it is currently is that depending on, again, the study population that we are pooling data from, and this is gonna be especially true with our individuals who are post-menopause, we can have over 50% of individuals studied in a normal data set where individuals may not even have signs or subjective complaints of prolapse experiencing grade two movement. So not at or past the level of the hymen. And so they can have that movement. And so if greater than 60% or greater than 50% rather of individuals are experiencing grade two movement, can we truly say that this is an abnormal finding? Because that would mean that 50% of our female population or 25% of our population in general is experiencing a condition. and in combination with the fact that they're lacking symptom burden is a concern. The third thing when it comes to prolapse literature, and this is something that I've been thinking about a lot lately, is that so many of my clients who have really high symptom burden are most concerned with their standing and resting position of their pelvic organs. So for some of my clients with higher grades of prolapse, thinking stage three, stage four, it's standing and feeling that bulge around the opening of their vagina in the introitus. And our assessment is on an active bear down, which really is something that other than birth, we should not be doing a max bear down. So the clinical, the jump to this is how we assess pelvic organ prolapse to this is where my symptoms are most prevalent is missing. We're missing a step. And that is why in our pelvic division, we are such huge advocates for the standing assessment, right? We're not doing a max bear down, but I'm seeing where are your tissues resting especially for some of my postmenopausal individuals or those who have a larger vaginal opening, it's very easy for me to appreciate and I get a much clearer picture of the posterior wall at rest in a standing evaluation. And so when we were doing some of our work up in Ottawa, it was really interesting because when we look at individuals who are parous, those who have given birth vaginally, what we see is that our perineum is going to have more up and down movement. We are going to see post-delivery, an increase in range of motion, and it's been most characterized in the anterior wall. And we are going to see a shift in some of our pelvic structures, right? This is normal physiology. And so when we haven't done a great job of characterizing normal variation and then add in individuals who have had multiple vaginal births who have now gone through menopause, some of that shift in structures are wrinkles on the inside that we maybe don't need to pathologize. And so because we have so much of this variation of normal, again, now our definitions for pelvic organ prolapse are an objective sign of descent in combination with subjective symptoms and subjective complaints. And that's wonderful because what it means is, is that people are gonna have different range of motion. Just like some of our individuals from a musculoskeletal perspective are more bendy and can bend over and their elbows can touch the ground. And some people, they can barely get their fingertips to touch because of hamstring length. We're gonna see variations of normal in vaginal wall length. And this is not something that we need to pathologize. It's the combination with subjective complaints that is going to be our important distinguishing factor to potentially modifying or working on the anatomy, whether that's conservatively with pelvic floor muscle training and pest reuse, or that's surgically with a vaginal mesh type of surgery going into prolapse repair. The third where we don't have a very good understanding of normal is with diastasis recti. So two years ago was the first time that we had taken a big representative sample who were not coming in for core complaints and giving them an idea of what is a normal interrectus distance, right? And over 50% of individuals coming in had greater than two centimeters, which is typically our cutoff score for diastasis recti. And what that shows is again, this bell curve of normality is centered around two centimeters. So if our average is two centimeters or 50% of individuals on this normal distribution are experiencing a two centimeter gap, then again, we've had a failure to recognize normal variation when slapping on layers of pathology or conditions. And again, this is alarming because what it does is it halts a lot of our progress. Because until we've been able to characterize what is normal, recognize when subjective complaints come in, and then be able to create care pathways and algorithms that allow for normal changes, but acknowledge and treat the subjective complaints, it makes it difficult for us to take the next step forward. And that was something that I've learned so much from the researchers that I was working with last week who were doing so much work on the basic science level to characterize normal variations and look at anatomical differences between those that have complaints of pelvic issues and those that don't. And what this does is it allows us in pelvic health to understand the physiology and etiology of the conditions that we are treating. And we do a really good job in other areas, like in cardiovascular complaints. But honestly, it's frightening sometimes how little we know about why individuals are leaking. I did a reel where we talk about exhale on exertion, about how that reflexively gets our pelvic floor to work, because our pelvic floor kind of pumps in and out with inhale and exhale. And on EMG, for me, when I was exhaling on exertion and doing an isometric lifting task, my pelvic floor activation was the exact same as when I was balsalving. And this makes a lot of sense, right? Because what the biggest thing the exhale does is it brings down inner abdominal pressure by about half. And so it makes sense that it works for us when we're trying to get people to have a lower threshold before they start leaking, but we have used physiology that is based on anatomical plausibility and we do not have the evidence to back us up, right? So anatomical plausibility is when we take theoretical thoughts about how things work and use them to justify our outcomes. That is where we start. But until we create this bridge where we understand variations of normal and then understand from a physiology perspective what our interventions are doing, we're always going to be a little bit behind in our creation of these care pathways. And so it made me think a lot about my research in resistance training in pregnancy. because we have some acute studies on what the Valsalva Maneuver does, but we have nothing on bracing mechanics when it comes to a female pelvis and heck no on a pregnant female pelvis. And so it really did create so many conversations that were so fruitful and so incredible. And I'll leave you with the final example. So we know that there are some people who are going to experience urinary incontinence a lot more readily or a lot sooner than other individuals. And what we are starting to see is that some individuals have more urethral hypermobility than others do. And it tends to be a non-modifiable anatomical risk factor for incontinence with exercise. What that means is that yes, we can absolutely see improvements with pessary management. It's going to tack up the urethra, prevent some of that hypermobility. We're definitely going to see improvements, right? But we may have a subset of individuals that are not going to have a complete resolution of symptoms because of their genetics, because of the way that their anatomy is. And that to me, like just learning about this physiology research, it makes so much sense for me as an interventional researcher, but also as a clinician, that I have some people where I have hit them with everything and I still can't completely resolve their symptoms. They get a lot better. But it's okay to have those conversations that there is going to be some individuals who have small amounts of leakage. And then the next part of that is when do we actually consider that a problem, right? When is that becoming an issue? And we don't have that answer. Like I can squat and I can have a cranky hip before I warm up, but I'm not injured. I just need to warm up, right? So maybe if I have a drop or two of urine linkage, I don't have incontinence, my body just needs to warm up. And so we just have so much more that we need to understand in terms of normal variation and genetic makeup and anatomical differences between individuals of different parity states, different ages, stages, different disease history, different injury history. And when we do that, it's really going to open up from a research perspective and a clinical perspective to us to get truly a better understanding of what it is we're trying to modify, how we are doing what we're doing, and it's going to get us to gain credibility in a lot of different spaces. All right, that is my rant for today, 20 minutes. Alan's going to be like, yep, this is Christina, she's on the podcast. But I hope that makes a lot of sense to you. I get so passionate talking about this because I think it's so important and it has been a blind spot for me. And so it's very cool to fill up a known blind spot and just work to think about things a little bit differently, which is really neat. If you all are trying to come and see us live on our two-day course, we have two courses left for the summer. I am in Cincinnati this weekend, July 20th and 21st. Alexis is in Wyoming next weekend, the 27th and 28th. And then our live courses start up again in September. If you are looking to get into our online cohorts, September 12th is when our next L1 starts. If you have already taken our L1 online and you wanna jump into our level two cohort, that is starting August 19th and it is filling up very quickly. All right, have a wonderful week, everybody. I'm gonna ring in 35 by the lake and I will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 12, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the different deadlifts variations and who may best benefit from their performance. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONGood morning, everybody. Welcome to the PT on ICE daily show. It is the best day of the week, Fitness Athlete Friday. My name is Guillermo Contreras, here with you today from the Fitness Athlete crew, talking all things deadlift. So this is an exciting topic here. We just finished up our level one course last week and we just had our fitness athlete summit a couple of weekends ago. One thing that we know that throughout the one course as well as the live courses is that deadlift is typically going to be one of the most spicy topics. Should everyone be deadlifting? Why should we, why should we be deadlifting and why should we be deadlifting heavy? One of the questions we most commonly get both in the live course as well as the online course is the question of all the variations we see. The conventional deadlift versus the, you see back here, the trap bar deadlift versus the sumo deadlift. What is the best position? What is the setup? How do we coach it? How do we look at it? And if you want to dive into all that, that nitty gritty, that really deep detail stuff, highly recommend you jump into the L1 course or you join us on the road for a live course. But today, all I'm going to be talking about are the different types of deadlifts. And the topic title is a deadlift for everybody. Right? So not everybody, but everybody. Because there are instances where individuals will be using a different setup or a different variation of the deadlift to be able to move the greatest amount of load in the deadlift movement. So the ones we're going to specifically talk about today are the conventional deadlift, the one we see the most often and the one that we coach typically in the L1 course, you see in CrossFit gyms, you see done all over the place. The sumo deadlift, which we see a lot more in competitive powerlifting where they're trying to lift the heaviest amount of weight humanly possible off the ground. We trap our deadlift because we see it a lot in athletic sports and individuals using it in different ways and we'll talk about the differences there. That'll be more of like an end of the conversation discussion there. And then lastly, some variations known as kind of the hybrid deadlift. And that is just going to be a slightly different for individuals who maybe can't get into position for conventional but don't need to go sumo, we find something in the middle. So first things first, we're going to talk the conventional deadlift. we look at the conventional deadlift we want to ensure that we are set up in such a way where that bar is close to our bodies. So when I coach this out I'm telling athletes that they want to set up hip width apart so their feet are right underneath their hips for this conventional deadlift setup. From there the bar should be lined up closer to my shins. I typically will tell athletes when they look down, they should see that the bar is lined up over their shoelaces and not too far forward, because now that barbell is far away, which makes moving a heavy, heavy load a little bit harder, because it's going to pull you out of position. So we want that bar nice and close. From here, with the conventional setup, what we tend to see is my hips are going to go back. And when I'm set up in this double overhand grip, my hands are outside of my shins. And when I get all that tension on board, my knees are below my hips, my hips are below my shoulders, and I have this really nice stacked set of position in which, again, my shoulders are above my hips, my hips are above my knees, and that bar is nice and close to my body. That is going to be our conventional setup. That is the most common variation you're going to see in the CrossFit gym with any athlete that walks in, someone that's just a recreational weightlifter and is doing deadlifts on a day-to-day basis. The second most common variation we're gonna see is something called a sumo deadlift. With a sumo deadlift, that barbell, and I apologize, if you're listening on the podcast alone, some of this won't make any sense, so I'll try to talk as much as I can, but the video will give you a lot more detail on this. With a sumo deadlift, we set up with a much wider stance. So my feet, if this is hip width apart, This is shoulder width apart. This is just outside of shoulder width apart. With a sumo deadlift, we are going wider than that wide stance. The reason for this, the reason we see this in power lifting is because we are essentially just decreasing the amount of work being done. Meaning that the amount of distance the bar has to travel is less because now, rather than having to go from here to here, the motion turns into here to here. so it's a much shorter distance to travel or a much shorter distance to pull that barbell off the ground. The other big differences we see with that sumo deadlift outside of that much wider setup is gonna be that the torso angle is more vertical. So because I have this wide stance with a slightly more toed out position, or sometimes excessively toed out position, I can now set up with a much more vertical torso, and that bar can stay right underneath me. This means my erectors can be locked in a good position, I can stay nice and tall, and I'm driving through my thighs, boom, to lock that barbell out and overhead. Because I'm so wide with my legs, my grip is now just inside of my hands in this nice narrow position. Because again, I'm trying to decrease the amount of work being done by reducing the distance that bar has to travel. So that is our sumo deadlift. The points of performance still stand when I set up for a sumo deadlift here. my knees are still below my hips, right? It's just a slightly much less difference there, and my shoulders are still way above my hips, but I am much more vertical and I'm driving straight up off the ground. So it's a very different looking movement. The emphasis on load is going to be moved to different muscle groups, but it's a way to do essentially less work because you are moving a shorter distance and you can move much, much greater loads typically if you train it enough. So that is your sumo deadlift. The one here that most people don't know about, that most people don't do, is the hybrid. The hybrid is typically only given for athletes who might struggle to get into position with a conventional deadlift, but want to still be in a more narrow stance position because it's going to translate more into Olympic lifts or other type of lifts from the ground. And what that is, is if this is our conventional stance, this is our sumo stance, we break the difference and we are just slightly wider. So we're no longer just under our hips. We're now maybe just outside of our shoulders and our grip is just inside of our legs there. That setup mimics that conventional deadlift a lot. So I'm still in that hybrid deadlift. I'm sorry, I'm still in that hybrid deadlift stance here. The bar is still lined up nice and close to my shins. I'm sitting back, I'm getting over that bar, my hips are still above my knees, my shoulders are still above my hips, my hands are still nice and close to my body, and I'm pulling there, sitting back and tapping down. That one is most commonly given to athletes who just might not be able to handle that position of hip flexion in a conventional deadlift for one reason or another. or that just slightly wider position, allows them just enough room to sit comfortably into that setup for the deadlift. You'll see athletes, especially longer, taller athletes, when they go to set up in conventional deadlift, they set up here and they can only get there with this kind of nice, kind of rounded position because of how long their femurs might be, or their limbs might be, or if they have a shorter torso. So by just giving that little bit of clearance in that hip, they can sit there in that same deadlift stance, pull, and then get back down. So that would be your hybrid. So again, to recap, we have our conventional deadlift here, slightly wider for our hybrid deadlift, even wider and more upright for our sumo deadlift. That is how we pull heavyweight off the ground. Regardless of how you do your deadlifts, we know that the deadlift is one of the best ways to improve low back pain, to reduce low back pain, to reduce kinesiophobia, to build strength, resilience, and just overall good quality life and function because of the way that you're moving a heavy load off the ground, training every muscle group, strengthening your grip, strengthening your back, strengthening your hips, strengthening your posterior chain. So the deadlift should be something we should have in our arsenal. The one thing I want to give some love to is the trap bar, right? So this behemoth bar over here, we see this a lot. and it's shaped like a, what would that be, a hexagon, I think? Hexagon. We see this a lot in sports, a lot more in like, you'll see it in like football, basketball, because they just want to reduce risk. So they claim that the bar being out in front is just too unsafe. But in reality, what happens a lot of time when you have a lot of athletes, the time it takes for a strength and conditioning coach, if they don't have a large strength and conditioning staff to really coach, cue, and ensure good quality movement with a barbell deadlift, it's hard. So the trap bar takes away a lot of those things that you would normally coach by allowing an athlete to set up with the bar at their sides here and be in a more squatty position. You can get more hingey with it if you'd like, but most people are going to tend to falter back towards that more squatty movement pattern when it comes to a trap bar. There's nothing wrong with using the trap bar. The trap bar is a great way to load up that hinge pattern, that deadlift pattern, get comfortable pulling weights off the ground, even like jumping or heavy farmer scares. You can do a lot of different things with the trap bar, but it's not going to be the same thing as loading up that barbell, having good quality coaching, ensuring that that back is being nice and strong and holding that really stiff, strong position as you hinge forward. And that's where a lot of that magic happens with the barbell deadlift. So again, trap bar, a wonderful tool to use. It also, if you're dealing with crossfitters, it's not going to translate to literally anything else besides maybe some loaded carries, heavy carries, sandbag carries, jerry can carries, things like that. But it's not going to transfer over into strength for Olympic lifts such as the clean and the snatch. So we want to really try and work and improve on that deadlift. So again, one final recap. What do we see? Deadlift, one of the best things we can do for low back pain. Improved kinesiophobia, just get rid of it all together. Improved strength, resilience, quality of life, everything there. This is the health lift, what it was normally known as back in the 20s, I believe. We have a conventional deadlift in which our stance is around hip width. Bars close underneath our shoelaces, hips above our knees, knees, hips above our knees, shoulders above our hips, and that really nice pattern there. We have that hybrid, we'll be slightly wider stance, and now our grip, instead of being outside our knees, goes inside our knees. and we are still driving with that same shoulder above hip, hip above knee position of our body. And then lastly at that sumo deadlift, that really wide stance that again allows us to reduce the distance that bar has to travel so we can do more load typically. the hips are still above the knees, the shoulders are still above the hips, we have a much more vertical torso, and we are driving straight from the ground, standing tall with it. Sumo deadlift, hybrid deadlift, conventional deadlift, and special shout out to the trap bar deadlift as well. So there's a deadlift that anybody can do, we should be deadlifting in the clinic with our athletes, especially if you're dealing with fitness athletes and crossfitters, they're gonna deadlift, so be really good at coaching it, understanding these different variations that they can use to train in different ways. If that's just a little bit, and you're like, oh, I want to learn a little bit more, please, please, please join us on the road. We are not traveling a whole lot in August and July, but starting in September, we are on the road right away. 7th and 8th, we are in Austin, Texas with Fitness Athlete Live. Then the 14th and 15th of September, we are in Longmont, Colorado. And then the 28th and 29th, we are back in Texas, in Springs, Texas, which I believe is down on the coast near Houston, I could be completely wrong, so I apologize for anyone from Springs, Texas if I got that wrong, but please come check us out, we're on the road. If you want to see, learn a lot more, be able to dive into it a lot more, into the science of everything a lot more, the level one, the fitness athlete level one starts back up on July 29th, so that'll be in about three weeks. We're starting up our next cohort of the CMFA L1. And then the CMFA L2, if that's the one course you are waiting to finish up to get your CMFA certification, that starts up on September 3rd. That course is only twice a year. That course always sells out. So please, if you're thinking about getting your CMFA cert and you want to take that L2, dive into all things programming, movement modification, some business aspects, high-level skill, gymnastics, and Olympic weightlifting, Sign up for that one on the PT on ICE website. CMFA L2 starts up September 3rd, CMFA L1 July 29th, and we are on the road in Texas on the 28th and 29th and the 7th and 8th of September, and then out in Colorado on the 14th and 15th. Gang, thanks so much for tuning in this morning. Have a wonderful weekend, and we will catch you Monday on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 11, 2024

Dr. Jeff Musgrave // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Older Adult lead faculty member Jeff Musgrave discusses how choosing pain now can help you avoid pain of regret later in your career. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Welcome to the PT on ICE Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Institute of Clinical Excellence in the Older Adult Division. It is Thursday, so it is Leadership Thursday. Super excited to be bringing to you a message that I think a lot of people are going to relate to. Pain now or pain later? When thinking about this topic, it really came very organically out of a class that I was coaching. So I get to coach people 55 and up, we're all about pushing high intensity, we celebrate sweating, we celebrate heavy weights, and really pushing things in a business called Stronger Life. But we were finishing up class, it was a really tough workout, and I was talking to our members and I said, you know, the reality is, team, you can have a little bit of pain, a little bit at a time, or you can have some uncontrolled pain later in life, maybe years from now, maybe decades from now, but that pain, you're unlikely to get to choose. And we all know this, if you're listening to this podcast, you know that we're all about being fitness forward. We're all about choosing that little incremental consistent pain to avoid greater pain later, right? Whether we're talking about building reserve for not even just older adults, but all people, right? The stronger we are, the fitter we are, the less likely we're going to have those uncontrollable pains through health complications, whether we're thinking about heart attacks, type 2 diabetes and amputation, strokes, Those type of things, for the most part, are very avoidable by choosing a little bit of pain, a little bit at a time. So this really just resonated with me, and as I was reflecting on it, not that I have that many great quotes, but this one, I was like, this one kind of lands. It connects a little bit. And then it made me think about my career. It made me think about people that, in scenarios that I've been through, as a clinician, and my journey in my career. So I think this not only relates to us from a physical standpoint, but thinking about our career, where we're headed, having big dreams, like what do you want out of your life? Who do you want to serve? And how are you going to get there? And the reality is, I truly believe you've got to choose some discomfort. You've got to choose a little bit of pain if you want to reach your goals. Likely, if they're worthwhile at all, they're going to be hard to obtain. They're not going to be easy to get to, and you're going to have to push yourself. And you're going to have to seek some pain. If you're choosing comfort in your career, you're unlikely to reach any big, meaningful goals. That's just the reality of it. So I'm gonna give you some examples, thinking about the perspective if you're an employee and if you're a business owner, if you're an entrepreneur. So for these, really we're just gonna talk about two scenarios. So the first trap that can lead to you not choosing pain is really just seeking comfort, career comfort. And it can be a career comfort as an employee and as an entrepreneur. So the way I see this is if you're early in your career or maybe you're later in your career, it doesn't really matter. But if you were choosing comfort as an employee, it could look like choosing prioritizing a paycheck over growth. right? And I've been there too, right? Student loans, debt, paying the bills, that's a reality. We all have to pay the bills, right? And the more financial margin we have, the easier our life is from that perspective. But that's not always the path to a meaningful career. Those two things can coincide. You can make great money and you can be serving your life's passion, the mission, the thing that you are here as a clinician to do, you can get both. But oftentimes, there are so many more opportunities to choose a paycheck and comfort over growth, over meaningful growth. Some signs, because I've worked at these places before, I've been there, team. Some signs that you are in the wrong place and you're choosing career comfort over growth or that small incremental pain is you're working with a bunch of burned out clinicians. They've been there for a long time. Their interventions are ancient, right? They're not up on the research. They're the ones doing shake and bake with heat and e-stem. They're using the ultrasound machine, whether it's plugged in or not, right? We know it's going to work. Not to say we won't do that to meet a patient's expectations. If they believe that's what they need, we'll do that and then we'll get after it later, right? Another sign you're in a place of just comfort, seeking a paycheck, is all of your clinicians or maybe you have gotten into the habit of using handouts. There's like, here's my older adult knee program. Here's my shoulder program. Here's my hip program. Team, we know if it works for everyone, it works for nobody. Right? Care has got to be individualized. We've got to meet people where they are, do an individualized assessment, and then we can dive in and really bring them the goods. But there's a good chance if you're in a work environment where everyone's super burned out, they're there for the paycheck, it's probably a pretty good one. and the expectations are probably pretty low. No one cares what the quality of care is. All they typically care about is billing units. If billing units is more important than quality, if you're not getting your sword sharpened by the people you're working around, you may be choosing career comfort over growth. I think another area where people can fall into a trap, there are lots of different companies that are gonna offer mentorship. This happened to me. I was switching settings early in my career. I was promised mentorship. What I got? Super full schedule, no help, no supervision. I wasn't even treating during the time my mentor was supposed to be there. No conversations about mentorship happened until I told them I was ready to leave and put in my 30-day notice after I'd been there for five months. No mentoring, didn't execute on the schedule they said they would give me to slowly on-ramp and sharpen my skills. Look around. If your mentor is not available, if your mentor is not someone you want to emulate, that's at the cutting edge, that's constantly growing, that hasn't reached the peak of their career, if you've peaked and stopped, you're done. You're learning or you're growing. So that's another trap that I typically see. So if that is you and that is what your situation is like, you need to run. If you're interested in growth, you're interested in being the best, you can't hang around in a work environment for very long with people that are burned out, that aren't trying, that are doing the minimum, that are there for the paycheck, it will crush you eventually. You can swim upstream for a while, but you need people to go with you. And if you're in that scenario and you can't change your scenario right now, stay connected with us. Listen to the podcast, go to good content courses, and we can help you get through that period. But long-term, if you want solid growth, you've got to find a solid mentor. You need to be surrounded by like-minded clinicians that are going to push you You want people that are gonna point out the things that you're doing poorly. You need a mentor that's gonna say, you know what? I think you can do better. I know what your capacity is. You're smarter than this. You're better than this. Let's get better. Let me show you how. And that person better be someone you're ready to follow. Okay, so that's if you're an employee seeking career comfort. If you're an entrepreneur or a business owner, one of the traps that I see with seeking comfort is you probably busted your tail to get started. I hear Jeff Moore talk about this all the time and it's so true. Getting that boulder, pushing that boulder at the beginning to get some momentum is so hard. It's so challenging to do that. Once you get it going and get some momentum, it's easy to just be like, oh man, I did it, like this is good, I'm making money, I like this, and it's easy to get comfortable there. When really, there's so much more that you could do and I think Sometimes that is not bringing on someone else to help you. You're seeking comfort through just doing it all yourself. Not trusting someone else with things maybe you're not great at. relying completely on yourself. And basically you've turned yourself into an employee for yourself. You don't have time to work on the business. You don't have time to expand. You don't have time to bring on more business or new employees that are smarter than you or better than you in a certain area to really grow your business, to have a big impact. If you're really good, bring more good people with you. Serve your community well. Push yourself, push your business. If you are seeking comfort and you're an entrepreneur, this is my challenge to you, to grow your team. Find something that you suck at and find someone better than you at it. Offload some of those things, a little bit of time if you can. You don't have to go all in. I'm not saying cancel your schedule. What I'm saying is bring someone on that can help take on a little bit of the burden that's better than you in a certain area. That can help shake off the comfort. That'll make you feel a little uncomfortable. It'll be a little harder to teach someone else. It's gonna take some time investment, but it'll pay huge dividends. So that's one of the main ways that I see that happen. But you've got to free up enough time that you can work on the business, not just in the business. That quote I pulled from the EMF Great Book. If you're an entrepreneur, you've never read it. That's a trap that I fall into. I wanna do the work myself, but I've gotta get comfortable giving other people tasks that I'm just not that great at. We can't be good at everything. We can be good at a lot of things, but if we're gonna grow a business, we're gonna have a big impact. We've got to share the load. We've got to share that burden. The other, on that same note with hiring someone, another thing that we see, is if you get too disconnected. So the one extreme that I see with entrepreneurs that you can fall into this trap and I tend to fall into is I want to do too much work and not delegate or let other people do things I'm not good at. The other extreme that I tend to see is we have people that then continue to micromanage really talented people. You give them a job, you give them tasks, but you're upping their grill all the time. You're checking up on everything. You're not giving them the space to be creative. You're not giving them the space to spread their wings and do their thing, to let them fly out of the nest. You're hovering over them, micromanaging everything. You've got to find smart people. You've got to set some clear expectations. You've got to give them good support. Be clear. Just as a side note, when you think you're being clear, you're not being clear. I fall into this trap all the time with not having enough clarity. But the biggest key, once you get someone talented on board, is get out of the way. There's a reason you hired them. Give them the space to do their thing. Okay, so that's part one, career comfort. The second piece, risk little, gain little. If you risk little, you're likely to gain little over time. So if you're interested in growth, being the best in your area, being the go-to in anything, you gotta risk a little bit. You've gotta throw some money at your skills in an efficient way. You've gotta go through the discomfort of getting real feedback. If you're not getting real feedback on your skills, whether you're in the clinical or you're doing some type of mentorship or you're continuing education courses, people should tell you when you do something wrong. They should be bold enough to tell you, hey, that's not great. You can do that better. Here, let me show you and have a trusted source for that. But you're going to have to see some incremental pain and discomfort of being told that's not great. The other thing is if you are one of those people that were like me, you're in a career, you're ready to make a jump, you want to do your own thing, you're gonna have to suffer some pain. You're gonna be on the bubble for a while. You're gonna have to have some revenue streams to help support that jump as you're getting things going, and you gotta be prepared to not make money for a while. For most scenarios, there are very few scenarios where you can just hop straight over, go completely from being an employee into being an entrepreneur. So you need to have a period of time to build an on-ramp for yourself, and this is going to be uncomfortable. You're going to have to have revenue streams that are going to help support you through the period of time that you're working on building a business or building up your referrals so that you can make enough money to sustain things. That period of time will not last forever, but you need to have a solid plan. and you need to have a long runway. The longer the runway you can create financially, the more reserve financially you can create before you start doing a second thing or a third thing. Whatever it takes to be able to build your dream, build your business, you gotta do it. There's no path forward without some pain, without some discomfort, without some extra hours. I've just never seen that happen. If you've been able to do it, please share in the comments. I'd love to know how you pulled that off. So that is the second piece if you're an employee and you're trying to move forward. and you want to start your own thing. If you're an entrepreneur, I think another big mistake through being comfortable and not not risking enough is not risking to make yourself an expert in one area. I see this a lot too where clinicians are well-rounded. They can do a lot of things and that's great. You need to be able to treat all of the things that you want to treat, but eventually, after you become successful, you've got to niche down. You've got to find that specialty area. You want to be the go-to for this. When their friend says, oh, I've got someone that's got pelvic floor dysfunction, you need to go see Amy. Amy is the best at it. No one's going to do a job for you like Amy will. That's who you want to see. That is so clear. The message to your customer is so clear. You need to niche down. And maybe you've got a couple different areas. That's great. Crush it with those. You'll still get word of mouth referrals, but you want your clinic to be known for something in particular. This is great for getting people active. Maybe you're the older adult go-to. If you're over 55, you really want to go see Sally. Sally is the best in the world. She gets it. She understands what's going on. She's going to treat you with respect by challenging you as you're ready. I've got a friend who did X, Y, or Z, or those are the type of stories you want to hear. But you can't be too broad. If you want to grow, eventually you've got to niche down. You've got to be the best at things. Or maybe you're growing your team so that you've got a team of people that are the best at things. The only exceptions I can think of here is if you're in a super rural area, you kind of have to be a jack of all trades, but you want to hit those things that are the most common. And then people are going to trust you by proxy too, right? If you crushed it in this, it's like, well, I'll trust them with that too. And that can be helpful as well. SUMMARY Team, I hope this was helpful. This is something that I'm really passionate about. I found in my own life. personally, professionally, in the gym, seeking some discomfort early is going to help avoid pain later, uncontrollable pain later. So seek that little bit of pain for the growth, for your dreams, the things that you really want to do in life, and you will be much better off for it. Team, if you've got thoughts or questions here, I would love to hear your thoughts. I hope this was helpful. So we want to avoid seeking career comfort and if you risk little, you will gain little. Team, enjoy the rest of your Thursday. We'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 10, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses reframing the conversation around post-operative guidelines for physical therapy treatment. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division. I'm coming to you from the University of Ottawa, so if there's a little bit of background noise, that is exactly why. But today, what I wanted to talk to you about, and the reason why I'm on here a little bit early is because I feel like this is gonna take me a little bit of time to get through, is to start reconceptualizing our post-operative guidelines when we're thinking about not just musculoskeletal injury, but many of our post-operative protocols when we're thinking about early healing and early recovery. in the post-operative window. And so I just posted a reel on our ICE Instagram account that's talking about hip precautions and how we have research going back from as like synthesis of research systematic reviews of research going back as far as 2015 to show that these precautions that were intended to reduce risk of early hip dislocation actually don't do that and what they actually do is they exacerbate post-operative deconditioning and they increase fear of movement. And we see this all the time in clinical practice, right? Individuals go for surgery. They're given these restrictions. These restrictions are not evidence informed. They're never discharged. And what it does is it causes people to disengage with activities of daily living, with sports, with activities that they enjoy. They become more sedentary. And then downstream, we see that the amount of postoperative deconditioning is greater and their capacity to engage back into the things that they enjoy before surgery is less. You know, I've had clients that have said to me, I'm so much worse. Like, my pain is better, but I feel worse than when I went in for surgery. Like, why did I even get this done if I could have dealt with this surgery? And so over the last couple of months, I have really been thinking and noodling on this. I did a podcast on the pelvic section on our Mondays around how our pelvic restrictive guidelines around lifting are not evidence informed at all either. And that when we remove those guidelines, and we have now multiple RCTs that have said, you know, other than don't have penetrative intercourse for six weeks, when we say here are your buoys, and here's how you can progress based on how you feel. not only do you not see an increased risk of postoperative complications in those individuals with liberal restrictions, but they actually have a reduced pelvic floor burden in that postoperative window. And so that early recovery is actually enhanced. And so we have to kind of understand where some of these guidelines come from and how are we as a profession in allied health going to start pushing the narrative and where is our role in that because I think we have a really massive role. So the first thing that needs to be acknowledged that is really front of center when it comes to post-operative guidelines is that when we do research and we take surgeons and we have done cross-sectional surveys, not we other researchers, and asked, you know, where did these lifting restrictions come from? Like, where is your evidence? Or do you believe that your restrictions are evidence-informed? In our pelvic literature, we saw that 75% of urogyne surgeons recognized that the reason for their restrictions is because this is what they have always done. And only 23% of the surgeons surveyed believed that the restrictions that they were giving were evidence-informed. Now that is a massive problem, right? We so often in medicine come through the lens of let's avoid bad outcomes that we don't acknowledge that the lack of doing something by restricting a person's movement can actually lead to adverse outcomes down the road, right? Because yes, they're not saying we did X activity and caused X outcome, but the removal of activity, now what we know in all of our accumulated literature on the effect of deconditioning on trajectory of aging, clinical geriatric syndromes, and post-operative deconditioning that can lead to changes in independence, that deconditioning also needs to be acknowledged in our algorithm of what we are thinking when it comes to our post-operative guidelines. And so what we are acknowledging first is that one, we have evidence that does not support restrictive guidelines in many different examples, right, our arthritis literature, not sitting in bed post cardiac surgery, our lifting restrictions post pelvic surgery, we now have a variety of different areas across different organ systems, musculoskeletal surgery, cardiovascular surgery, urogyne surgeries where we are acknowledging that our restrictions are overly restrictive and that that restriction does not create better outcomes. The step forward that I want to make is that not only are they not leading to better outcomes, but that subsequent deconditioning by overly restricting a person is an adverse outcome in itself in the opposite direction. And what this is highlighting is that we have a big knowledge translation gap problem. We acknowledge in many areas of medicine that this exists, but this is front of center for our allied health clinicians around what we are allowing in our practice or what we are acknowledging in our practice. And so you're gonna say Christina, okay, where are these restrictions coming from and why as a clinician am I hesitant to push back on these guidelines despite the fact that I know that these are not evidence-informed, right? So because there's a hesitancy on the side of the clinician and We want to acknowledge those. Those are the elephants in the room, right? So the first thing is around the fear of an adverse outcome, right? When we don't do anything, we don't have that same feeling of responsibility if something was to go wrong, right? Because I didn't push them. So it wasn't me that caused that adverse outcome, right? And we can't always avoid adverse outcomes, but what we do a lot at MMOA is we try and flip the script of, you know, we think about the harm of loading people, but what's the harm if we don't load them? And that's a slower churn, a slower burn, but it's important to acknowledge that that's relevant too, right? So that fear. But the fear also comes from going against the surgeon and liability and referrals. And so I want to acknowledge that piece and I want to acknowledge it on a couple of different stances. Number one is that our messaging is never to, you know, speak negatively to the surgeon and speak about the person. We speak about the concept. And so the way that if I'm trying to remove restrictions that have been placed on somebody or deviate from a protocol, which I tend to do a lot, when the surgeon has outlined this, I will say where your surgeon was looking at was this is their scope. They're looking for lumps, bumps, infection, early complications. Where my lens is here. based on their assessment of you two weeks ago, they may have felt X from where I am assessing you today. Here's where I think our steps are going forward. So it is not bashing the surgeon. It is not going against the surgeon. It is using my scope as a doctorate level clinician to be able to make further recommendations going forward. And as a newbie clinician, the thought of going against the protocol set out by the surgeon used to terrify me, right? I'm a rule follower and our medical system has placed medicine at the top, which, you know, they have the brunt of the liability. I understand where that is coming from. But as I get into my research degree or when I get into my research career and I acknowledge the level of the evidence when I see the outcomes that are so much better when I ditch these protocols and load people more aggressively earlier and I recognize that a surgeon has never never actually rehabbed a person after their surgeries, it changes my mind, right? I would never go up to the surgeon and say, you know, you are going to go with that anterolateral approach for that hip replacement. I really think you should take a posterior approach. It would be better. Because that's not my scope of practice, right? That's not what I do. That is not where my skill set is. So why are we so shackled by a surgeon telling us what our job is, who has never, never rehabbed a person after their surgery, has not actually seen them for more than 15 minutes in an appointment after their surgery. And so I I would never take continuing education from a PT who has never treated the condition that they are teaching about, right? Like you would never go to see me and teach in geriatrics if I have never rehabbed a person who is over the age of 65. So why is our system created in a way where we are taking rehab advice from someone who has never done rehab, whose medical degree does not actually have an exercise prescription component in a lot of cases. And so that acknowledgement has really shifted my perspective on this is maybe foundational work that they are giving and they are catering also to the lowest common denominator, right? Like when I am working with a person and they are trying to give a blanket statement guideline that has exercises on it, they have to cater to the person with the most amount of deconditioning in order to believe that this protocol is safe for everyone. And we acknowledge as clinicians that that blanket statement never ever works, including blanket protocols, because our people come in with a variety of different chronic diseases, comorbidities, positions, supports, biopsychosocial considerations, motivations and drives, and musculoskeletal reserve around that postoperative joint. And so what we have to acknowledge is the flaws in the system, but I'm not saying that as a bad thing, I'm saying that as this is where I come in. High five me in, this is my job, and I need to advocate for my profession in making an opinion on this, right? And this is where we need to lock shields with medicine and surgery, not blast each other with swords and acknowledge where our scope is and where their scope is. The final thing is around liability, right? And I think the post-operative guidelines around joint replacement are a really good example of where the liability, we have to be acknowledging liability, but we also want to make sure that we are thinking on the other side of the equation, where when we are working with individuals post-operatively, we are worried about post-operative dislocations. And what we see is that those with low musculoskeletal reserve going into surgery and have a fall in the early postoperative window are the ones who are more likely to dislocate or those that have a size fit issue or get a deep infection in the early postoperative window. So what we are doing by deconditioning is we are impacting one of those risk factors in a positive way. If we are creating more deconditioning, if we are lacking reserve around that joint and we are not supervising them, potentially in the early post-operative window, that is where we can have liability on creating an adverse outcome. But we don't have any evidence around pushing individuals too far from an exercise perspective early on, creating adverse outcomes. Now, if that was to change, sure, we're gonna change our strategy, but we want to really be thinking about this from a clinical and critical lens, because it's really important that we acknowledge these things. So, What do I think we actually need to think about with our post-operative guidelines? Or what do I think we are missing with our post-operative guidelines? I feel like we are missing our confounding variables that are going to dictate how quickly we're going to be able to progress individuals. So what do I mean by that? We acknowledge as clinicians, because we do this all the time in our assessments, that there is going to be different things in a person's background that is going to allow us to be more aggressive in rehab or is going to cause us to take a slower approach. Those are not acknowledged in our postoperative guidelines right now. So what are some of those things? One is our level of frailty, burden of clinical geriatric syndromes or complex comorbidities. Secondary is musculoskeletal reserve going into surgery or the amount of deconditioning we are able to stave off with early postoperative mobility. And so what we are acknowledging or what we want to acknowledge is that some individuals, we obviously have that early protective phase around a graft. I'm not saying that we're just going to blast that out of the water, but we know that after two weeks, most of our collagen synthesis is there and now it's remodeling in order to get stronger. And that remodeling requires load. But then we create a brace around an individual for six weeks where we're actually not creating a lot of loading through that joint or we're not actually having pulsing forces from our muscles that are acting and contracting to start creating tensile forces in order for our collagen fibers that are coming down or our healing fibers that are needing that load in order to get stronger. And there's a huge amount of variability in our in vivo studies around the strength of collagen resynthesis and that range is probably related to musculoskeletal reserve. And so, one, we need to acknowledge that yes, we have that early protective phase, but their amount of reserve going into their surgery is going to be a predictive factor of how aggressive we can potentially be post-operatively. Their complexities with respect to comorbidity are going to incur a higher or lower inflammatory load that is going to dictate how fast we're gonna be able to progress exercises, right? When we really step back from all of our comorbidities, a lot of them are related to inflammatory cascades, depending on the organ system that is impacted by the disease. And so when we have individuals with a high comorbidity burden, they are gonna have a higher inflammatory load, and that higher inflammatory load is going to impact how fast we're gonna be able to get individuals working, but on the flip side of that, exercise is anti-inflammatory. but it's going to slow down our progressions. So all of this to say is that one, we need to be confident in our assessment skills that includes early postoperative management. We need to acknowledge that our role is one of critical thinking that allows us to take information medically from the surgeon and some of their early protective phase issues, and then be able to progress them as we see fit, because we're the ones who are seeing individuals that are progressing and we are responsible as well for their wellbeing and their capacity to return to activities of daily living. And that baseline musculoskeletal reserve going into surgery is going to be a big confounding variable or a big protective variable in order to think about their postoperative reserve. And so where I see our postoperative guidelines hopefully going in the next several years is one, blanket statements are gonna go out the window, right? We are going to remove these lifting restrictions. We are gonna give individuals buoys, okay? We're gonna say, hey, you just had surgery on X joint. This is what I want you to think about. I want you to be thinking about gradually returning to movement within your comfort zone, and I want you to look for X, Y, Z. And if you are experiencing X, Y, Z, that is your body telling you that you've probably pushed it a little bit too far today, okay? You're not hurt. sore is safe, but it's your body telling you that you just had surgery and we need to stay within these buoys and those buoys are going to change. And as you get further from surgery, you're going to be able to experience more and more of life and you're going to be able to come back to more and more things and that is going to be okay. And we're going to be able to guide you along that process. In rehab, what we tend to do is think about things very linearly, where we say, okay, we're going to do range of motion passively, range of motion actively, maybe in combination with some isometrics, and then we're going to load through range. I think that's a huge mistake. And you guys can give me your thoughts on this. I feel like, you know, Ice talks a lot about and not or, that we need to be strengthening through the range that individuals have in that moment. And then as they gain more range, we're gonna continue giving them strength in the upper ranges that they are now gaining, right? I think waiting to exercise through range or strengthen through range actually deconditions the joint more, and it ends up being a huge issue. We see this all the time in rotator cuff post-op management, right? There's a protective phase that now, thankfully, a lot of the surgeons in my area are not prescribing to, thankfully. And then we go range of motion first, and then we go strengthening through range, and then getting that strength in those upper ranges, especially over 90 degrees, is a bear in rehab. And where I have seen a shift in my practice, and I've seen better outcomes anecdotally from it, is that I am strengthening through range and with weight bearing earlier, and they're gaining their strength back a lot faster. And so I think this and not or approach to orthopedic post-operative rehab is going to be important. Now, I acknowledge that I'm in an outpatient setting and I'm going to be seeing people who probably have a little bit more musculoskeletal reserve going into surgery than others who are in skilled nursing facilities, et cetera. But that means that your deconditioning effect is going to be that much more detrimental, right? When I have a person who doesn't have a lot of reserve going into surgery and then I see that dip postoperatively, that is going to be very, very impactful for them versus my person who has more reserve going in. And so it makes me not change my stance, but actually be more diligent about my loading principles in that early postoperative period because that deconditioned individual cannot handle more deconditioning. And we see this all the time, right? It's why our hip fracture research is so poor. You know, we have those statistics that if you break your hip and you need a, or if that your 50%, 50% of people who have that surgery end up in a nursing home or don't end up making it over a year or whatever that may be. And that's likely because they have a period of deconditioning on a deconditioned person that creates a lack of reserve around that joint. And then they aren't able to come back from it. So our role in rehab becomes even more urgent where we need to prevent that from happening, right? We, we can't wait. on a lot of those things. Obviously weight-bearing status is going to be one of the things we have to be mindful of, but being able to strengthen a joint around non-weight-bearing status in order to try and reserve as much capacity around the hip and pelvic musculature as we can is going to be really, really important. So I hope all of that made sense, right? We have this gap and I want us to have so much strength in our convictions around how important it is for us to push back against these guidelines. Yes, it's scary, right? We don't like pushing back against medicine because sometimes I think we are not as confident as we should be in our doctoral level education and our evidence is on our side. And so we don't have to be jerks about it, but we have to acknowledge that our outcomes could be so much better. And I want to let you center in on the fact that you are the expert here. The surgeon is the expert in the actual surgery. You are the expert in managing them after. That handoff should be seamless. And it is important for us to advocate. And until we advocate and have respectful conversations that, yes, are scary, yes, your heart rate is going to be up, yes, you're going to feel like you have that adrenaline going through your system, but have the evidence in your back pocket Acknowledge your scope of practice and your skill set and make sure you are there to best serve your older adults. All right, that is my rant for today. If you were trying to see us live in person over the summer, Julie is in Virginia Beach, July 13th, 14th, so this upcoming weekend. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And the entire crew is up for MMA Summit in Littleton, Colorado, July 27th and 28th. So if you were looking to see us on the road in the month of July, you have a couple of opportunities. If you're hoping to get into our online courses, our next MMOA level one starts August 14th. We are just finishing up our last cohort and we have a bit of a break for the summer. And then our advanced concepts level two course is starting October 17th. So I hope you all, I want to know your thoughts around this. Am I going crazy? Am I on the same boat or same page as you all? And what can we do collectively to make this a little bit better? All right, have a wonderful week everyone and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 9, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses details that can be easily missed when treating out tendinopathy! Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Good morning, PT on ICE. My name is Cody Gingerich. I'm one of the lead faculty in our extremity division. And I'm coming on here today to talk about the hidden details of tendinopathies. Um, so in our extremity management course, we cover tendinopathy. We have an entire lecture on day two, as detailed as we can on tendinopathies. But what we know is tendinopathies in general are incredibly difficult to treat. Um, they last a long time. There are a lot, a lot of different variables that you have to constantly be playing with in order to really treat these people out and get them all the way back better and feeling good. And sometimes in an hour, hour and a half long lecture, we still can't cover everything that we, uh, possibly know about tendinopathies. And so I want to cover some today, just some of the hidden details of tendinopathies, things to look out for, and just a couple like additional clinical pearls, um, that may help you next time you're working with someone that has some tendinopathy going on. And there's a couple of different areas that I want to specifically address, and that's going to be more so like elbow tendinopathy. So think medial lateral epicondylalgia or tendinopathy in general. Um, and then patellar tendinopathy as well. Those just tend to be some areas that are pretty common. And so the first thing that I want to really emphasize with tendinopathy is looking at why the additional stress is happening to that tendon. So what we know about tendinopathy up front is that it is a chronic overuse injury, right? It could be acute, but typically it's gonna be in a chronic situation. And that means that that tendon is not doing the capacity or the work that you are asking of it. Okay. If it is an acute situation, a lot of times that is just negligence on that human and saying like, let's say, you know, for an Achilles tendinopathy or a patellar tendinopathy, let's say, you know, they haven't played basketball in 10 years and they decided that over one weekend they wanted to play, you know, two days straight of basketball. And it's pretty reasonable in that situation to be like, well, yeah, your patellar tendon couldn't handle all of that jumping and running that you were doing all at once. And so it's reasonable to think that a tendinopathy could accrue. And that's not necessarily something where you have to really look at like, all right, well, why is this happening? That's just pretty clear on like, well, that person just, you know, blew past their acute to chronic workload ratio. But oftentimes that's not how these things pop up and it's over time and they are long lasting and they are lingering and things like that. And that's the point where we need to really look at, okay, we definitely know that that tenant is not able to keep up with what we're asking of it. But why is it doing so much work that it is getting overused, right? Is there a movement pattern that they are doing that is potentially faulty? Is there a weakness somewhere else that we need to address and that tendon and that those tissues are just taking up more of the slack for a weakness elsewhere? And that's really where I want to hone in today. Because the other thing that we know about tendinopathies is it's pretty much a bullseye when those people come into your clinic and they say, hey, I have pain right here, or they point right to their patellar tendon. That can very quickly tunnel vision us into saying, okay, cool, I need to do wrist extensions, we need to build up that tendon, we need to do isometrics, we need to do eccentrics, we need to do heavy, slow concentrics, we need to really go after that tendon. And that can just pigeonhole us at that spot because it is such a bullseye when those patients tell you, this is where it hurts. And you're like, cool, I know where that is. I know what's happening. We need to get that tendon stronger. And that is true. But there are also other factors involved as to why that thing got pissed off in the first place. So we have those isometrics to help pull pain down and we need to address the tissue that hurts. but additionally addressing why it's doing that, right? And so in the fitness space where there is a lot of like grip heavy things and we see tendinopathies at the elbow, what I see frequently, there's two real things that we need to look out for as far as like those hidden details. One of those is shoulder capacity. How much shoulder capacity do they have? And are they trying to make up their lack of shoulder capacity with hanging on for dear life onto the rig, onto a barbell, onto a dumbbell or whatever, because that is now where they feel like their power is coming from. And that is causing some overuse because their shoulder capacity is not at an ability to really handle all of the things they're doing. And so that leaks down the chain to the elbow, wrist or hand. The other thing that I see very commonly, specifically when dealing with medial elbow tendinopathy, is that a lot of times people with generally weaker grip tend to try and make their grip stronger by doing this like false grip. And that is what is taught and what is appropriate in weightlifting. If you're doing dead lifting, cleaning, snatching, we want knuckles down. And that puts us into a position like this. If we are hanging or doing gymnastics movements, we want knuckles over the bar like this. What that does is every then movement, they then grab a kettlebell for a farmer's carry. They're gonna hook grip it like this. What happens is they're always using this, rarely getting the actual capacity to the other side of their forearm and those gripping muscles. We know the strongest grip is going to be in a little bit of wrist extension as well. And so then we can start pulling out like, well, in your workouts or in your day-to-day life when you're gripping things, I want you to actually start to pay attention to some of your traditional grip and let's see if we can't utilize some of our wrist extensors a little more when you're going to grab a door, when you're going to pick up things like hey let's get our knuckles back a little bit and now all of a sudden instead of just consistently trying to like hammer this tendon and get it stronger, we got to get it stronger, it's like well Yes, we can get it stronger, but we can also help to pull some of that tension and some of that irritation and overall use back to help it calm down. And that's the big thing is like tendinopathy, we want to improve the capacity because that's what overall needs to happen. But if we can improve the capacity while also taking away some of the work that that tendon overall has to do, now we're going both directions at the same time and pushing them forward faster. Right? And so that then leads to like, we're asking less of the tendon and it's getting stronger at the same time. So then that tendon can start that healing process a little bit faster. Okay. A similar thing can happen at the knee. where we have patellar teninopathy. But if you watch that person move, and they are trying to squat, and they are trying to push press, or power clean, or things like that, and they have a bit of a muted hip, where they are not using their hips effectively, and most of that work ends up coming through the quads, that's another situation where Yes, that patellar tendon needs some work and it can improve the overall capacity, but if you don't help that person and coach that person's overall movement pattern, they're going to consistently continue to aggravate that tendon. Whereas their hips should be the most powerful thing that is producing force, right? So get them into a little bit more of that posterior chain, get them using their glutes out of the bottom of the squat, get them using their hips when they're doing it in a power position, when they're doing push press. The examples are numerous where we want people to start using the hips and take away some of the stress from that patellar tendon while you are doing all of the additional isometrics, wall sits, Spanish squats, heavy slow concentric, cyclist squats. These are all great. But sometimes we also want to pull down some of the stress that those tendons are taking on and relearn some movement patterns that could be contributing to this longstanding tendinopathy. Sometimes that might mean adjusting their squat stance a little bit or their deadlift stance, just getting them used to using their hips a little bit more effectively while you're treating out that tendinopathy. So that's going to be one of the really big ways is like, don't get tunnel vision on. We need to strengthen, strengthen, strengthen, strengthen, and don't look elsewhere. Because a lot of times with these chronic tendinopathies, there is a reason there is a weakness in the chain somewhere. There is a weakness in movement pattern where that is causing the overuse of that tendon to happen. So simultaneously, while you're trying to decrease pain at that tendon via some strength training, some isometrics, building that tendon capacity, we also want to be working and trying to figure out, well, what is the underlying cause of why we're overusing this tendon in the first place? So I really want to emphasize that today. The other factor that sometimes gets overlooked in tendinopathy is going to be compression and speed of the tendon and what it is doing and in what space is it operating. So every tendon is going to pass by a bony prominence. That is where the bony attachment is going to be. And anytime we are working through tendinopathies, we want to appreciate that compression that happens in whatever exercise you choose to do. So if we're talking about a patellar tendinopathy, the deeper that person gets into their squat position, the more compression that patellar tendon is going to go under. Same thing when we are doing, if we were doing elbow or wrist exercises, the more that we stretch that tendon, if we straighten our arm, that will, and then extend or flex our wrist, that will put that tendon over more compression around your epicondyles. And that exists for pretty much every tendon in the body. And so Being able to navigate that variable and pull some of those different exercises out or changing exercises, it's not always necessarily that the exercise is wrong, but maybe the range of motion can be adjusted because that tendon can't tolerate the current compression that it is under. Okay. Finally, the speed. The speed is where tendons really hit kind of a fork in the road on what can it tolerate. So we like to live up front with isometrics, concentrics, heavy, slow building blocks of the tendon, but ultimately most tendons get aggravated under speed. So if you think you're runners and you're jumpers and you're throwers If you're crossfitters, where they're pulling a lot under speed on the bar, that's usually where those tendinopathies occur. Quick wrist movements, all of those type of things. And that ends up becoming the aggravating thing. So if we don't end up building in more speed, we aren't going to end up being able to get them all the way through their plan of care. And so that can start with using a metronome, right? So you can track how is this tendon tolerating speed. So you go a 60 beats per minute on whatever exercise you're trying to do. Then you go to 70 beats per minute or 80 or you start, you know, that's where you can very easily track and then you can start getting back into their actual functional movement with speed and knowing that it can tolerate certain levels of that speed. So overall, I saw a question here, stretching the tendon equals compression. Essentially, yes. That is a good way to think about it. If you are stretching the tendon, you are pretty much adding compression around those bony prominences most times. That's gonna be a pretty accurate statement for most of those tendons. Wrapping it around whatever bony prominence is adding compression, and most of the time that's gonna be if you're stretching it. And that becomes typically a more aggravating position for most tendons. SUMMARY So overall, the three really main things that I want to point out as far as additional details to tendinopathies that you don't want to forget about when you're treating tendinopathies. The first one is why specifically is that tendon getting irritated and getting overused in the first point? That is oftentimes going to be a weakness up the chain somewhere or potentially a movement pattern fault that you want to coach out. You want to look at, get your eyes on how they're moving and can we decrease stressors and get change some of that movement pattern while we are treating out the tendinopathy. Number two is going to be really paying attention to the compression around that tendon. Can we change or adjust range of motion of that exercise to help improve some of that compression or potentially add compression if they can tolerate it? finally is going to be speed. If you need to really truly know we are building them out through that full plan of care, getting them back to functional sport activity, you have to get them into speed. And I would track that with a metronome or something like that. So, you know, for a fact that that tendon is able to tolerate more speed, that's going to be more likely to reflect the activity that they are doing. Okay, that's all I've got for you today. Just wanted to touch on a couple different points of tendinopathy. As far as catching extremity management on the road, we've got a couple courses coming up later this month. So we have a course this coming week, looks pretty full out in Kent, Washington. Next weekend, we are in Henderson, Tennessee, couple seats open there. And then in July 27th, 28th, Bend, Oregon. So pretty much all across the country, we've got courses coming to you. from the extremity management. Would love to see you out on the road. Thanks for watching. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 8, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares how YOU can make a huge impact on the quality of life of a client with an upcoming prostatectomy simply through education on pelvic floor muscle retraining, lifestyle changes and physical activity AND learn the ESSENTIAL clinical pearls to include in a pre-operative physical therapy session when working with this population. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION APRIL DOMINICK This is Dr. April Dominick. I am on faculty with the ICE Pelvic Division. Today we are chatting about prehab for a prostatectomy surgery. Why is prehab important and what should be included in your PT session with that pre prostatectomy client? This topic, it is so near and dear to my heart. it's because these humans just don't have the treatment or education that they deserve prior to going into these surgeries and afterwards when they come out. And if I can convince you why it is so important to be able to connect with these humans and to even just educate them on, hey, there is Help for you. There's pelvic floor muscle training that can be done education about behaviors whether that is you actually doing the PT session or you referring them to someone else it can have incredible outcomes for them post-op just because they are aware of pelvic floor physical therapy for their surgery the prostatectomy so Let's dive into what a prostatectomy surgery actually is. It is something to treat prostate cancer, and that's going to be by removing part or the full gland of the prostate. They're also going to remove surrounding tissues and seminal vesicles. The gold standard for surgery is a radical prostatectomy where they remove the entire prostate gland. I didn't have a walnut, so here's what we're working with. This fig represents the prostate. So let's run through some real estate of where everything is situated in someone with a prostate in terms of the pelvic floor and the organs. So we have our bladder here and then we have the bladder neck with the urethra that goes through our prostate. and this is going to be representative of the urethra itself. So the urethra goes from the bladder neck through this fig or the prostate and then down into the penis and that is how everything is set up. With a prostatectomy, after the prostate is removed, that extra support around the urethra is now lost, and the remaining bit of that urethra now needs to be reconnected back to the bladder. This reconnection, we can think about it like a bridge, or a fancy term is the anastomosis, and that anastomosis needs time to heal. So a Foley catheter is placed in for about five to ten days. That means that the bladder is or the urine is emptying passively. The bladder is not doing its job. It's off on vacation. And then once the catheter is removed, the bladder acts like it forgot how to start or how to store urine. It doesn't know what to do with it. And so we have a lot of urinary leakage. So among other things, this is why urinary incontinence or urinary leakage is a major side effect with these prostatectomy surgeries. post-op, the external urethral sphincter is relied on for maintaining continence. So good news for us, the pelvic floor muscles help to close that sphincter and keep pee in until it's appropriate to release it. And that's why pelvic floor muscle training with physical therapy can be so important pre-op and post-op, at least from the bladder side of things. So who does the prostatectomy surgery affect? Well, obviously those diagnosed with prostate cancer. It is the second leading cause of death from cancer in males. It's going to affect our individuals who are older than 50 years old and who are African-American. So if you think about who you are treating currently, if you're treating individuals who have prostates who are older than 50, one in eight of them are probably gonna have some run-in with prostate cancer, whether that's treated with a surgery or not. That's where you come in. You could have such a profound effect with these individuals just by educating them that pelvic floor muscle training exists And whether you're again, whether you're doing the treatment or you're referring out to someone else, you can have such an incredible impact on their post-op outcomes potentially. So, We talked about with a post-prostatectomy, we talked about that surgery can result in urinary incontinence or leakage. It can also affect sexual function. There can be reduced physical function. Think about it. If you're leaking all the time, is that really going to convince or motivate you to go work out? For some, no. And then it'll also affect the overall health-related quality of life. Take 65 year old Phil. You've got a Phil in your clinic. You're already treating him for low back pain, um, with his hikes and his weightlifting, say. And he went in for his annual physical, and then he walked out with a date for a surgery for radical prostatectomy. Besides being in shock that he now has this potentially life threatening diagnosis, Phil comes in and is like, this happened. He's like, am I, am I ever going to be able to hike with my hiking group and not be the person that smells like pee? Am I going to be able to be cool with being in the changing room in the, in the locker room after my weightlifting session, like removing this soggy pair of underwear, or am I going to be able to enjoy sexy times with his partner? Well, since you're here and you intently are listening to this podcast, You, your first line of question is, hey, Phil, did they recommend any sort of physical therapy for you? Um, whether it's pre-op or post-op. And of course, Phil's like, no. So you teach him that pelvic floor muscle training can be so effective and helpful, um, and play a huge role in those side effects that he's worried about. Y'all, what if we could have an incredibly bigger impact, building the foundation, setting the stage for what to expect post-surgery, just with PT sessions? Clinically, I've been treating this population, hopefully you can hear my passion behind it, for about seven years. I've interacted with so many fills that come in, if they even get to me, right? and they are just slapped with that surgery date, and the side effects are kind of breezed through during their appointment, it seems like. And their concerns aren't really heard, their well-being and their questions, they're just kind of like not given a lot of attention. I didn't always do pre-op sessions, but once I started, hoo-wee, I was just blown away by how different the clinical outcomes were in terms of improving, whether that was decreasing the volume of urinary leakage for some or having them return back to their ADLs exercise a little bit sooner. The biggest thing, which was so powerful for me, is these people came in extremely uncertain, having no idea even why, if their doctor did send them to PT, why they were there. And they were just uncertain about these really scary side effects, about how maybe for the first time they were going to experience some sort of losing control of their bodies, from peeing unexpectedly to changes in their erections. And they walked out of that first session feeling a little more confident, a little more certain. And that is the power, I believe, of these pre-op sessions. And then from a research side of things, what's shaking out in the few RCTs that we have for these pre-op sessions and their effects on prostatectomy, some may be helpful in improving quality of life. they may affect a shorter hospital stay. They may reduce post-op urinary leakage in the short term. So some studies find around month one, three, or six, that the individual is leaking less, meaning they're drier faster. Now, when you compare someone who had some pre-op PT to someone who did not around 12 months, they are about the same with their rate. But I would argue that I bet folks are going to be a lot more satisfied if they did that prehab and they are drier sooner, right? So let's go into what a prostatectomy PT session entails before that surgery. We've got these sessions already in place. for folks who are going in for surgery for their ACL repair, for their hip replacement. But just like we're fighting with our pregnant and postpartum population, we are somehow having to fight for someone to have a pre-obsession for something like a prostatectomy, and that impacts so many daily functions. Let's outline what is involved in that pre-op PT session. Again, you can educate someone on what to expect if you're referring them to someone to do this. So we'll go over subjective, objective, and the treatment. From an assessment side of things, from that subjective piece, what you can be talking to your patient about is what are their current bladder and sexual habits? How many voids do they have during the day? How many times do they go pee? Do they have an urge? Do they have urinary leakage or hesitancy? And there are some outcome measures that go over these things. The International Prostate Symptom Score goes over those things. Plus they ask about nocturia or nighttime urination. And then the NIH Chronic Prostatitis Symptom Index is another outcome measure. And I love it because it asks about the impact of these symptoms. How is it affecting your quality of life? Then you want to also ask about their sexual function. How would they rate their erection strength or their satisfaction with their sexual life? From an outcome measure standpoint, you can give them the International Index of Erectile Function. This is something that asks them to rate qualities of their erection from the past four weeks. Then you want to also get a good idea of their current physical activity regimen. What a wonderful time to, if they're already a little physically inactive, hey, let's like plug in for, here's why it would be really great if you could up that physical activity. Not just for that immediate post-op surgical outcome, but also, hey, we can lower all cause mortality. And then from an objective side of things, so we went over the subjective, objectively speaking, we want to get a pelvic assessment. Whether that is over the clothes, external, near that midline, or it is a visual or tactile palpation, or an internal rectal assessment, if that's what you're trained in. So we're looking for, what's their awareness? Do they even know that they have this group of muscles that they can control? called the pelvic floor. We want to be looking at their coordination, timing of the pelvic floor, and then also getting an idea of what is their breathing and bracing strategies for things that increase interabdominal pressure, like fitness activities or functional lifting of the groceries, coughing, running, weightlifting. Typically, this population tends to be a breath holder. So we're gonna spend some time, there's just so much that we can do to help them in this area, to help them have improvements in their methods with that. And then we also wanna be doing some sort of general orthoscreen because what if their hips are cranky? Obviously that's gonna affect pelvic floor, low back, and all those surgical outcomes. From a treatment side of things, so we went over subjective, objective, highlights from the treatment side of things. where we'll talk about education, what to expect post-op, and some homework for them to work on. Education. I cannot stress this enough. The education piece here is vital for affecting their outcomes and well-being. Let's educate them on the pelvic floor. Here's what it is. Here's the anatomy and physiology. Here's how it affects your penis. whether that's for sexual health or for the urethra for urination. Here is what happens during the surgery. Get to know the surgeons in your area and which methods they use. What are their outcomes, right? And then you want to be explaining the risk factors for these side effects like urinary leakage and sexual function. dysfunction. Non-modifiable factors. If you're older, it's not going to help you as much. And if you already have some reductions in urinary function, like you're already leaking, that is not going to help you on the backside. Modifiable factors, tons. So things like smoking, poor nutrition, That is gonna delay healing post-op. Can we identify some current bladder irritants and reduce those immediately post-op? What about poor mental health? Things like low self-efficacy or if they're experiencing anxiety or depression, helping them ID these things and finding them some psychosocial support to have upcoming for the surgery and post-op, so key. and then reduced physical activity. Hard health is heart health. What do I mean by that? Erections, ejaculation, is related to vascular health. Hard health is heart health. So what affects our vascular system? Aerobic and resistance training exercise. If we can have them and talk to them about how it's important and how increasing that physical activity is going to improve their physiologic resilience to the surgery itself and any complications that come up, that is gonna be having such a huge impact on their quality of life. Regarding physical activity, in a 2014 RCT by Mina et al, they found that men who were meeting physical activity guidelines prior to surgery had greater health-related quality of life at six and 26 weeks post-op compared to men who were not meeting those physical activity guidelines. So, from a post-op perspective, we want to tell them what to expect. Urinary incontinence and sexual dysfunction. From the urinary incontinence side of things, they will have a Foley catheter in for five to 10 days. Remember, the bladder doesn't work during this time. Once that catheter is removed, we gotta retrain that neural pathway to help control the bladder so that they know, oh, my bladder is filling, or this is how I'm gonna stop that leakage from coming out, and how to fully empty the bladder. Another huge tip, have them bring a hygiene product, whether that's a pad or a diaper or something, with them to the hospital so that when they are discharged, they have something to help protect them on their way home or on their way to the store to grab their meds. And then urinary incontinence could be present from a couple of months to a year post-op. We see a significant improvement in that three to six month range, but it could be affected by things like, hey, it gets worse at the end of the day because the pelvic floor muscles are tired, or with transitional movements like sitting to stand. So working on these movements with them is gonna be super helpful pre-op. And then maybe talking to them about how, if you're not going to see them for 10 days or so post-op, we may be using the pad weight or the number of pads in a 24-hour period as a marker for our progress. So just having that in the back of their mind. When it comes to what to expect from a sexual function standpoint post-op, it can take up to two years to recover to baseline function from an erection standpoint. We want to set these expectations from an ejaculation standpoint. Dry ejaculate is going to happen now because those seminal vesicles were removed, and that's what helps produce that ejaculate. There may be some changes in their orgasm sensation. Erections, it could be dependent on surgery outcomes. How much nerve sparing was there in that procedure? They have the potential to get better with this, especially with pelvic floor muscle training or things like pumps. And then loss of penile length. This is something that we want to let them know can happen so they don't get a little surprise. Homework wise, we want to address any of those pelvic floor deficits we found from that objective piece, especially that breathing and bracing strategy. We can do that with biofeedback, whether that's with a mirror, with a palpation from the therapist or from them, and just to really improve their awareness and coordination there. And then giving them cues that connect them to the pelvic floor. Evidence supports, hey, pelvic floor contractions with the following cues, like shortening the penis, though I've been told nobody wants to have that. So something like nuts to guts or stopping the flow of urine is great for that. One side of the range of motion, the contraction side of the range of motion of the pelvic floor, and then something for the relaxation side, like let the testicles or base of penis hang loose. I did an Instagram post recently, so you can check that out on the ICE or Revitalize Pelvic Physio page. And then we wanna be, for homework, modifying their poor lifestyle habits. Can we reduce those bladder irritants, process sugar? Can we increase your physical activity and mental health? And then finally, we want to be scheduling their followup visits on the calendar. So whether that's for pre-op, a couple more sessions, or as early as 10 days, once that catheter is removed, they can pop back in to your office. SUMMARY So, I hope you found that information helpful. We reviewed how prevalent prostate cancer is, especially for those who are 50 plus. We know that radical prostatectomy is the gold standard for treatment. Two major things that are affected post-op are urinary incontinence and erectile dysfunction. Pre-op PT sessions are fairly new, but we have some evidence that says, hey, those who partake in pre-op sessions are drier sooner than their counterparts. And then from a PT session standpoint, thinking about asking what their current bladder and sexual function is, asking them about physical activity, mental health, objectively getting a measurement of the pelvic area, and helping them connect with that area a little bit more. Treatment-wise, we want to really harp on that education. about what the pelvic floor is, how it can help with their function, and also what to expect, possible side effects, modifiable risk factors, and then giving them homework to work on those deficits, and then finally scheduling that additional follow-up before surgery and then getting their post-op session on the calendar. My next podcast, I'm going to go into detail on what a post-op session post prostatectomy looks like. So tune in for that. And then if you want to learn more about pelvic floor examination, join us live. We have our next two courses. One is July 20th, 21st in Cincinnati, Ohio. And then July 27th and 28th, we are gonna be in Laramie, Wyoming. If you're wanting more of a virtual option, we have our two different courses that are eight weeks, L1 and L2. And in L2, we go over the male pelvic health conditions as well. Thank y'all so much for tuning in from my prostate slash walnut. Happy Monday, and I'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 8, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses uphill & downhill running, the differences between flat running, and how to progress into vertical running with patients & athletes. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONAll right. Welcome everyone. Happy Friday. Welcome to another episode of PT on ice daily show. Uh, hope everyone had a wonderful 4th of July holiday and have a great weekend ahead. My name is Jason Lunden. I am the lead for the endurance athlete division. Uh, so teach rehabilitation injured runner live and online as well as a professional bike fitting course. And what I'm going to cover today is. what vertical adds to the equation. So talking about uphill and downhill running, both hills and in the mountains, and what the differences are compared to level running, why that matters, and then how to safely progress that training for yourselves and your patients. So uphill and so Adding vertical to one's training obviously means adding some uphill and downhill running, and those are obviously different than running on level ground. So uphill running is characterized by a lot more mechanical work, meaning there's a huge increase in the load on the muscles, as well as changing the biomechanics of running so that one is landing in more of a flexed position at the hip and the knee as well as more dorsiflexion at the ankle and that the amount of hip flexion, knee flexion, and ankle dorsiflexion is much higher in uphill running than level running and or certainly downhill running as well. Stance times are longer, the amount of time in flight is lessened, and impacts are overall less. As far as contrasting that with downhill running, downhill running is characterized by landing with a lot more, the knee in a lot more extension, a lot less hip flexion. And then depending on the experience of the runner for running downhill, If it's more of a novice runner, they're going to be characterized by striking with a rear foot strike pattern or heel strike pattern. If it's a more experienced downhill runner or trail runner, it's going to be characterized by more of a mid-foot strike pattern. Here, downhill running is basically characterized by negative work, so it's all eccentric work. So a lot of more impact to the runner and a lot less load specifically on the muscles, just more of an eccentric load. And so why does this matter? So, you know, thinking about your patients that you might be working with, if you have someone with a high hamstring tendinopathy, that's likely going to be loaded a lot more and potentially irritated more. with uphill running, right? Because that hip is going to be in more flexion. There's going to be more muscle work, particularly on the posterior chain with that uphill running. And that repeated high hip flexion angle is going to also cause some compression at that hamstring insertion. Whereas if someone is dealing with patel femoral pain or maybe medial tibial stress syndrome, Downhill running is going to really increase the stress on those areas with that increased impact and eccentric load and definitely irritate those symptoms. And so you want to be thoughtful when prescribing or getting those runners back into dealing with a vertical that, you know, if it's a high hamstring tendinopathy, you may want that runner to be hiking the uphills and then running the downhills. And then conversely, if it's someone with patel femoral pain, you'll want them to be running the uphills and hiking or walking the downhills. And in addition, If someone is running, whether it be on the road or on the trail, and they have a race that has a vertical profile with some elevation gain and loss, you definitely want them to be implementing hill workouts or running in varied terrain. early on in their training so that they have the time to adapt to those new loads on the muscles and on the joints, as well as, you know, adapt their running mechanics appropriately too. So typically, you know, if it's someone who's new to trail running and, you know, they're going to be running their first trail race and there's, you know, 5,000 vertical elevation gain and loss, they're going to be wanting to implement that training far out in their training. So months ahead of time, again, because of the differences in the mechanics and the loads on the muscles with uphill and downhill running. As far as ways to, you know, implement this safely, there really isn't any scientific evidence on this. It's mainly anecdotal, you know, a lot of kind of looking at a lot of the advice that coaches will give is really based on the 10% rule or the literature that we have on progressing training volume in running. So, you know, no more than 10% increase in vertical per week or certainly no more than 15% over the course of two weeks is a common piece of advice that you'll hear. So what does that look like? You know, if someone is running 10,000, or sorry, 1,000, vertical in the first week, uh, you wouldn't want to increase by more than another, um, a hundred the following week, if you're doing that 10% rule. And that's going to be really more for your novice runners. Um, and generally for your, your novice trail runners or novice runners that are, or novice runners running hills, um, it's going to be looking like, you know, probably being able to add a thousand feet of vertical. in their first week and then progressing from there with that 10% per week or no more than 15% for two weeks. If it's a more experienced trail runner that you're working with who has had a lot of experience of doing a lot of vertical, start at approximately 50% of what their vertical was prior to dealing with their injury. And then the last thing to consider is, okay, so we're talking about vertical, but how are we progressing that in the space of also progressing just running volume as well as intensity? And so a good rule of thumb here is to not, ideally, the safest way is to not progress all three of those elements in the same week, but realistically that's probably going to have to happen. And so the best place to start out is not increasing all of them combined by more than 15% per week. So what that would look like is, you know, I am running, you know, 50 miles a week. I'm doing a thousand foot of vertical a week. And then also within that week, probably, you know, adding in a speed workout as well. And so for the next week, I would want to not increase my weekly volume by more than 10%. So we keep that at, you know, 10% and then not increasing the combined vertical and amount of intensity work by more than 5%. So that would get us our 15% total there. So again, just to recap, you know, adding vertical or dealing with vertical with endurance athletes, uh, is going to be very common. Um, especially if, for those of you living in more mountainous regions, um, where trail racing is, is King. Um, but even for your, your road racers too, if they're going to be running a race with, you know, a vertical profile, so not Chicago marathon, but, um, you know, maybe Boston marathon. where there are some hills, you really need to be thoughtful of how to, one, implement that training, as well as how to progress that training, and how running uphill is going to stress their body differently. how it's going to change your mechanics. So again, uphill running is going to be a lot more load concentric on the muscles, especially on the Achilles, the glute, the hamstrings. And it's going to be characterized by a lot more, a much deeper angle of flexion at the hip, knee and ankle. Whereas downhill running is going to be characterized by a much larger eccentric load with potentially being at a rear foot strike versus a mid foot strike and adding a lot of impact. To progress that, we want to kind of draw on the information and experience we have from both coaching and the literature, which is going to be drawing on just level running. So not increasing vertical by more than 10% per week, or not increasing vertical volume and intensity for a sum of more than 15% per week. And wanting to implement this early on in their training so they have time to adapt to the stresses of training. I'll leave you with just one really cool article that came out more recently, which was looking at downhill running and adaptation to that. And really as little as one bout of 30 minutes of downhill running on a 20% grade results in what they call the bout effect, or it's really a protective effect on eccentric muscle damage and delayed onset muscle soreness. So after that one bout, the next time the runner runs downhill, they're going to have less eccentric muscle damage and therefore less delayed onset muscle soreness. So that's pretty cool. So definitely wanting to implement that downhill running as soon as you can into their training so they start getting those adaptive effects. SUMMARY All right. Well, thank you everyone for listening. We do have some endurance athlete courses coming up. of coming up right around the corner on July 8th is when our next cohort of rehabilitation injured runner online starts. So that is the last one for the summer. So we'd love to see you online for that. Our next professional bike fitting course is going to be in Denver at the end of July. And then our next rehabilitation injured runner live is going to be in Sparks Glencoe, Maryland. in September. So we'd love to see you at those courses. Reach out if you have any questions. Have a great weekend. Get outside. Do something fun. See y'all. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 4, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses how to approach helping patients who don't want help Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONGood morning, everybody. Welcome to the PT on Ice Daily Show. My name is Alan, happy to be your host today. I currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Practice Management in Fitness Athlete Divisions. It is Thursday. We talk all things leadership, business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. It is the 4th of July, so we have a gnarly hero workout planned for you all this week. The workout, I just finished it. It is called Glenn. Glenn is named for former U.S. Navy SEAL and CIA operator Glenn Doherty. He was killed in the attack on the U.S. Embassy in Benghazi back in 2012. And so this is a very long Very kind of moderate intensity piece with a bunch of different stuff thrown together. So the workout starts with 30 clean and jerks Recommended weight there for guys 135 95 for ladies that should be a weight that you can hit for smooth consistent singles getting done somewhere between maybe three to five minutes out the door for a mile run a 2k row for guys 1600 meter row for ladies or a 4k bike for guys 3200 meter bike for ladies After that cardio piece, you're back in the door for 10 rope climbs. That also looking to be done in maybe 3-5 minutes, a rope climb every 15-20 seconds or so. If you can't rope climb, we have some scaled options for 20 pull to stands. or 30 strict pull-ups, whether that's with actual strict pull-ups or with a band, but some sort of challenging vertical pulling motion that's going to get you done in three to five minutes. Back out the door, repeat that mile or that row or that bike, and then come in the door one final time for the coup de grace, 100 burpees. For a lot of folks, this is going to take maybe 45 to 60 minutes. It's going to depend obviously a lot on your mile run time, your ability to cycle that barbell, and your ability to motor through, more importantly, those 100 burpees at the end. Treat this workout just like a run where you're maybe aiming to decrease your split time, start slow, build up speed. The worst thing you can do is race through those clean and jerks in that first run. and then crash into a wall on those rope climbs that second mile and definitely you can hit the wall if you're not careful on those burpees and turn that into a really miserable end to the workout. So just pace yourself, go slow, get faster kind of mindset. So that's Gut Check Thursday. Today is 4th of July. We're kind of talking about a topic related to the 4th of July in the United States of America. The American mindset, the cultural mindset that we can and we should and we have to save everybody, right? We have to be the world's police and the world's diplomat and inside of America as healthcare providers and physical therapists, we have to save every patient. So the title of today's topic is You Can't Save Everyone. I don't want this to be a pessimistic episode where you leave feeling discouraged and like you should give up. I hope you actually leave this episode feeling maybe a little bit more relaxed, a little bit more empowered in your practice. This topic came from a question we had from a student at the Fitness Athlete Live Summit a couple weeks ago. So, on Sunday mornings of Fitness Athlete Live, we take Q&A. We get some really good questions, we get some really good discussion points. And a student named Trevor, Trevor Purcell, who's nearby me here in Clarkston, Michigan, had a question. He said, hey man, you know, you're doing the thing, you're using the symptom behavior model, you're finding out what's wrong with people. you're giving them manual therapy and exercise that's reducing their symptoms, you're trying to get them into loading and higher intensity exercise, you're figuring out what music they like, you're pumping the jams, you're trying to high five, like you're bringing it, right? In every aspect of your practice, the clinical reasoning, the manual therapy, the exercise, the personable skills, the DJ skills, you are bringing the heat And that person is just straight up not feeling it. Like how, what do you do, how do we get those people to get more serious, to get them to maybe transition to doing a maintenance program with us at the clinic, or maybe transitioning to a fitness program out in the community with a resource that you may have associated with your clinic. Like what do we do with those people who seem to, no matter what, no matter what value we're showing them, just really don't seem interested in picking up what we're putting down. And so my answer back to Trevor was be careful, right? Be careful that we don't try to save everybody, even people who don't want to be saved. And so today I want to talk about that. I want to unpack that answer in a little bit more detail. I want to talk about the numbers behind the physical therapy profession and how many people were expected to help. I want to talk about what I call the lie, how we learn to help people in physical therapy school. And then I want to finish and talk a little bit about the reality of what it actually looks like in practice to work with those people and some tips and tricks for that. THE NUMBERS So let's start with the numbers. Numbers are boring. As Jeff Moore, our CEO, would say, data doesn't change behavior, but I'm a firm believer that even though data doesn't directly change behavior, telling somebody they're going to die early if they don't lose weight or stop smoking or sleep better or exercise more, all that stuff, we know That just doesn't flip a switch in people and all of a sudden they change all of their less than optimal health behaviors. But that being said, even if data doesn't change behavior, I'm a big believer that data does inform decisions. And so knowing the data going into any situation can make us better prepared for that situation, even if it doesn't directly influence a decision in that situation. And so stepping back on a macroscopic level and looking at analysis of our profession, there are about 300,000 licensed physical therapists in the United States of America versus a population of 330 million Americans. So if we were to pair up one physical therapist with patients and say, this is your charge, this is your crop of people that you need to help every year, get moving, stay moving, stay with whatever fitness program they've been turned on to, you would need to help 1100 individual people per year. Now, the truth of that 300,000 is that those aren't all full-time practicing physical therapists. We have about 90,000 full-time physical therapists in outpatient. We have about 60,000 in acute care, skilled nursing, inpatient rehab, sort of the hospital side of the equation. and we have about 26,000 folks working in home health for a total of 176,000 full-time licensed practicing physical therapists. People getting up every day, putting on the uniform, and going out to man their post on the trench, right? So automatically that cuts our profession in about half. All the rest of those people are in academia, they are in management or ownership, they're no longer practicing, they are part-time, or even many of them are retired and they just want to keep their license because once you let it lapse, it's a lot harder to get it back than if you just keep it renewing. So that changes the equation a lot. That means every physical therapist now has to help about 1,900 patients, right? Almost double the amount of patients. And if we take a hypothetical scenario where you are an outpatient physical therapist, your productivity is maybe moderate. You see a patient every 45 minutes. You see about 12 patients a day, 60 patients a week. We know those are all highly unlikely to all be unique visits, each with a different patient, that a lot of those folks are coming maybe two to three times a week. And so if we assume that those folks are coming twice a week, then you're probably only interacting with 30 unique people or so per week, and then if the average plan of care is about 10 visits, or about five weeks of care, that we probably only interact with somewhere between 250 to maybe 500 unique patients per year, and that would be a very high volume productivity model. That would be a model where maybe you are seeing a patient every 15 minutes or so, or maybe even more. And so just thinking that statistically already the math doesn't add up, right? That puts us at about 20%. We're helping about 20% of the people we need to if our belief is that we should be helping and saving everybody with getting them moving, helping them stay moving, musculoskeletal rehab, performance, that sort of thing. It's not surprising to me that that number is exactly where physical therapy is at for utilization each year. Only about 20% of Americans seek the help of a physical therapist per year. So all things considered, we're at where we should be for the size of our profession. That if we wanted to reach more patients, we would somehow need to get even busier than we are, which I don't know how that would be possible. If you're only working with 500 people a year, seeing a patient every 15 minutes to see 1,900 people a year you would need to see 6 to 10 patients an hour you would have 3 to 5 minutes with each patient and so obviously that does not seem logistically possible and so the real truth is we either need more physical therapists or we just need to recognize not everybody needs the help of a physical therapist at any given time or wants the help of a physical therapist at any given time and that's okay. THE LIE OF ENTRY-LEVEL EDUCATION So moving away from the numbers and moving into the lie of why doesn't everybody need our help and why do we feel this disconnect between wanting to help everybody but maybe perceiving that not everybody is, again, picking up what we're putting down. We're bringing all the noise in the clinic and they're just not receiving it. In physical therapy school, we were shown a facade, right? We worked with a lot of paper patients, right? A lot of case studies and scenarios on a sheet of paper. We worked with a lot of mock patients who were usually our fellow classmates, our professors, or maybe paid actors who were likely just students in a different program at the college that we took PT school at. And the thing about these folks is that they always got better, right? We did an intervention, a manual therapy, or an exercise intervention, or both, or whatever. and those patients always got better. Not only did they get better, they were completely adherent with their home exercise program, and they miraculously restored their function, sometimes within minutes of care, right? And so the smack in the face is entering those clinical rotations and entering early practice and realizing, That's not how the majority of human beings respond to physical therapy treatment at all. And we get this buzzword that flies around social media as a result, imposter syndrome, right? I feel like I don't belong here. When in reality, I think imposter syndrome is this belief that we're not good enough and we have nothing to offer our patients and that we're not doing enough to save these people, right? If we could just shackle them down and force them to exercise, they would feel so much better And damn it, why don't they just do that? But in reality, what we're probably experiencing is this interaction of higher volume care than we were exposed to in school, right? I remember my mock exams being 90 minutes or two hours. I've never had that long for an eval in practice in my life. And we also had a lack of basic clinical reasoning coming out of school. and a lack of exercise prescription skills. So we're interacting in this high volume model where maybe we're not able to quickly figure out what's going on, correctly dose manual therapy and or exercise for that person to show them a symptom reduction, and also that they just tend to not get 100% symptom relief, even if we do nail it on the head. And so we leave the clinic every day feeling defeated, like we're not helping anybody, like we can't possibly help everybody, and then we come with questions like, What do you do when people just won't accept the treatment that we know is the best choice for them? THE REALITY OF PRACTICE And so that brings me to my final point, the reality, the reality of practice, that not every person needs or wants our services, especially in the span of an entire year. I think often of my own mother, who is a very unhealthy person, has been unhealthy her entire life, who is really a testament to the resilience of the human body, has never exercised, has never picked up a heavy thing, has never got her heart rate above baseline, who I don't think has ever eaten meat or anything that's not packaged or processed in a piece of paper or a piece of plastic, right, lives off Twinkies, and Ho-Ho's, and 7-Up, and lunch meat, and kind of the typical baby boomer diet of nuclear family processed food. Has been healthy her entire life, has done nothing about it, and this past December, having a string of three hospital admittances in about a month of being so sick that it was tough for even the doctors at the hospital to figure out what was wrong, having septic shock, having COVID, just really kind of decaying in a hospital bed. And me going down to that hospital, a two-way drive each way to get her some physical therapy, 10 to 15 minutes of movement, and seeing the kind of miraculous change that she made just doing 10 to 15 minutes of higher intensity exercise a day, right? Function restored, no longer needs a walker, no longer needs oxygen, standing on her own, back to kind of her baseline before she started to get sick and go in the hospital. And thinking that finally, by gosh, this is it. This is the light bulb moment where she's going to connect that the exercise she's doing is related to how much better she's feeling, how much more function she has, the realization that she can probably continue to live independently and she just has to keep doing this stuff. And then again, that lie, right? That getting smacked in the face moment of going back home and hearing, I don't want to keep doing that, I hate that, I'm never gonna do that again in my life unless I have to. And feeling that disappointment, right? Of gosh, why won't you let me save you? And finally, coming after a really bad failed intervention to say hey, you need to turn your life around, you could die, we don't have the time and money to continue to do this with you, I can't keep driving here four hours a day to make you do 15 minutes of exercise. And that moment of, oh, I don't want you to. I don't want to do this exercise stuff. I only did that because I had to. And that's really kind of what we hear a lot from our patients in the clinic, isn't it, right? We hear a lot of the reasons sometimes that they come to see us are extrinsically motivated. They have to come see us in order to get that image they want, in order to get an extension on that pain medication. maybe they're coming to see us so their spouse or their kids or their grandkids or their friends or whoever stops nagging them about going to get their elbow pain seen or their knee pain or figure out why you're falling. So a lot of times Patients can show up without the necessary intrinsic motivation on board that we know we need to see to really have a person make a significant lifestyle change. And understanding that real people don't behave like the fake patients we interacted with in physical therapy school. They don't always 100% get better all the time. They don't miraculously buy into our care. They aren't lifelong proponents of physical therapy just because we treated them once. That's not how real people behave. They have a number of different expectations, a number of different barriers, and a number of different motivation reasons to or to not come to physical therapy. I'm a big fan of the 90-10 rule. This is something I learned from our CEO Jeff Moore. Don't spend 90% of your time helping 10% of people, right? Do the opposite. Spend 10% of your time helping 90% of people because they have the motivation on board that you need to see, that they can make those changes we want to see them make, but they are also voicing and they are showing you and telling you that they want to make those changes. And now that's not to say that we abandon those other people, we abandon the 10%, but rather we reserve ourselves, right? We don't beat ourselves up that we haven't convinced a person who is maybe 85 years old, who has never exercised in their life, who has never eaten something that hasn't been processed, is not probably going to make a miraculous life change after coming to see us for physical therapy for just a couple visits. And so, letting yourself off the hook a little bit. The sooner you learn to recognize who those people are, again, you're not banning those people, you're not going to give them less care, you're not going to say, hey, you can't come here until your attitude turns around, but you're just a little bit more reserved. You're understanding that if you continue to dump a lot of energy and passion into a person who's not reciprocating it, it's unlikely that you're going to see that behavior miraculously change until something else changes in their life and there's no harm in that and there's no reason to feel bad about that because I would argue that you have cemented yourself as a resource in that person's life that if in the future they encounter another injury they're probably going to come see you which is great because it's better to come see PT 2.0 than PT 1.0 or surgery 0.0 or whatever, it's better for you to be the resource in their life for when that pain does pop back up. And if they are ready to make a change, they are ready to lose weight. get fitter, get stronger, stop falling, stop smoking, stop drinking, sleep better. Whatever might change in their life, once they get their own life figured out on their own time, they have you as a resource, and I think that's very, very, very important, and that's very, very, very noble and good work to be doing in your community, while you continue to pour the majority of your energy into the people who are reciprocating the things that you are trying to teach, the things you're trying to show, and the lifestyles we're trying to change and shape. SUMMARY So, you can't save everybody. The numbers support that it's not possible anyways. Recognize that we were kind of set up for failure from the start with school, of never encountering patients who didn't get better, patients who didn't want to come to physical therapy, patients who were soul-sucking sometimes in their physical therapy session. and I think it's a normal and natural reaction the way that entry-level schooling is currently run for us to get that smack in the face feeling when we leave school of, oh boy, this is much different than those fake actor patients and those paper case studies. And the reality, the reality of what can we do We can't dump our energy into those folks and expect them to change on their own. It doesn't mean that we abandon them. It doesn't mean that we discharge them. It means we continue to be a resource for whenever they're ready to change and we pour the majority of our energy into the folks who want and are currently trying to make those changes and need and want our help to do so. That's all I have for you all on this wonderful Thursday. I hope you have a great 4th of July. I hope you have a nice long weekend. Hopefully you have tomorrow off work. Have a great weekend. We'll see you all next week. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 3, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty member Jeff Musgrave discusses how to help older adults understand the value in practicing falling as well as tips for increasing confidence & helping older adults set positive expectations for a meaningful experience. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONWelcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Proudly serving as part of the older adult division and super excited to be bringing you some more conversations, some more topics regarding older adults. In particular, I think a big swing and a miss oftentimes for older adults when we're thinking about balance and falls training. So much of our time is focused on falls prevention, preparing someone for falls prevention and trying to keep someone from having a fall, which is awesome. We need to do that. It's very important. There's a lot at stake for older adults and we want to prevent as many falls as possible. but we really should not stop our falls training there. So there is a lot of great research to show that we can help improve confidence and reduce injury risk if we can actually prepare someone to fall. And there are two big steps there. So if we're going to go beyond this falls prevention into falls preparedness, there's two pieces. One is getting someone up and down from the ground is a key thing for building confidence and something we need to do if we're planning to do any falls landing with anyone. So just so we're clear, I'm not gonna be covering floor transfers today. I am gonna be talking about strategies. If maybe you've learned how to do these things and you're not sure how to create a successful session regarding falls landing. So I did mention that there is some literature showing benefits for falls landing, because maybe that's new for you. You're like, yeah, I'm not so sure about that. There was a study that came out in 2019 by Moon et al, where they took older adults and they taught them a tuck and roll strategy. So the reality is everyone that got exposure to falls landing using a tuck and roll strategy were able to do two things. One, reduce the acceleration speed of their head hitting a cushioned mat, but also the impact force, the ground reaction force is on their hips. So when we're thinking about trying to reduce head injuries, head, neck, spine injuries, as well as reducing fracture risk. We can do that successfully with a tuck and roll strategy. They found that older adults, after only just two sessions of learning a tuck and roll strategy, were able to reduce their head acceleration speed by more than 40%. 40% slower of their head hitting the floor, or in this case, a crash pad. The other thing they were able to do was reduce that hip ground reaction force by 33%. That's huge, and I especially want you to think about, we know that 30% of adults fall each year. We don't wanna say you're older, so we know that you're going to fall, but we do want them to be aware that there are things they can do to reduce their injury risk. We can teach that, and we want to keep in mind that a lot of our older adults, because of deconditioning, have become frail. They've lost muscle mass. They don't bounce back from injuries as quickly as they should because they've lost reserve and don't have that extra beyond what they need to live daily life physically or within their balance, so they are more likely to fall, and they're more likely to get hurt when they fall, causing a catastrophic injury. So we think about the people in our caseload that are the most frail, they probably, in a lot of ways, have the most benefit from these fall landing strategies, because they're the most likely to have a life-altering fall. Because I think most of the time we think, well, this is just for the people who are super healthy, super strong already. But those people are the ones that are more likely to be okay if they have a fall. The people that really probably need this the most and need it most urgently are those who are the most frail, the most weak. They have the most to lose and are the most likely to get injured in a fall. So I really want to advocate that we find the right strategy for the right place to start these strategies for older adults. And I've got a few tips to try to create a successful session for older adults if you're teaching fall landing for the first time. So I'm not going to be going through the mechanics of how to do that. That is something we go through in depth in our in our live course and teaching that, but I do want to help you set the stage for how to make this a successful session, first time teaching fall landing strategies. VALUE IN PRACTICING FALLS So the first thing is value. Your patients are probably gonna need to be sold on the value, like why in the world would we practice falling? Because it sounds risky and you as a provider may be perceiving risk too. And there is some risk involved. We need to have a very calculated mindset of risk versus reward that's also gonna help us dictate at what place do we start these fall landing strategies. So what's the game? We can prevent head, neck, and spine injuries. We can prevent those hip fractures, likely, if we can teach an effective falls landing strategy. So I wanna let them know that they can learn they can reduce their injury risk. They need to know that it's really possible, it's been studied, people have done it, and if you've already been doing this with your clients, you can share success stories of how you've done this with other people, that it went fine, but you also need to keep in mind the individual characteristics of the person in front of you. I'm not saying carte blanche, like take these people, drop it like it's hot, hit the mat, hit the floor with everyone. If you have taken our live course, you know that there are lots of ways to scale this to make it really easy and very non-intimidating, very low risk. And I'll share a couple of those at the end. So first thing you've got to do is you've got, they've got to know the value. Why would I want to learn this? What could be made better? Reducing their injury risk is the biggest sell here. And even if they're not having lots of falls at this point, we do want to keep in mind with populations that have degenerative neurological conditions that we know are progressive in nature, whether it be MS or Parkinson's disease, falls are frequent. They happen very often. And if they've got the motor control and the ability to learn and do those things now, we want to teach them early rather than later. And get those grooves nice and deep. Get those motor patterns. so that they can access them when they need to. So value is the first thing. What's the value to the patient? You're gonna have to sell them on this. Should be a pretty easy sale because our older adults are thinking about falls and the consequences all the time, whether they've had a catastrophic fall or they've had a friend or family member that's had a catastrophic fall. So that should help set the stage. SET POSITIVE EXPECTATIONS FOR A MEANINGFUL EXPERIENCE The second thing is you wanna set positive expectations. They're gonna need to borrow some confidence from you. You have got to come in confident. You've got to know where you're going to start with the person you're planning to teach fall landing. What is going to be a positive experience for them? Where is it reasonable for them to do this? How many reps? How irritable are their symptoms? We gotta think about those things, but we also wanna share the positive experiences we've already had with others. Hey, I've done this with lots of people. I know it sounds scary. Meet them where they are. They probably wanna hear that you know that they're scared. Or they may be a little concerned. Maybe we don't want to say fearful or scared. But, hey, I realize this could sound scary, but I want you to give this a shot. I'm confident you can do this. We can do this without irritating your symptoms. It's not going to be as exciting as you're imagining. I know what you're imagining in your head. We're not going to be just dropping it like it's hot. We're not going to be hitting the floor. We're not going to hit a hard surface. We're going to teach you all the mechanics. We're going to do it nice and slow, and we'll progress as you're ready. So set those positive expectations, let them know kinda how the progression's gonna go, and that you're gonna be starting very simple, very easy, with just learning the positions, and then from there, you can scale it up and make it more challenging. So value first, positive expectations, and then the last piece, which if you've been following the older adult crew for a while, you've probably heard, but is a huge key with older adults for building their confidence, and that is intentional under dosage. You may have someone who's super active. independent, relatively robust, but you still wanna start fall's landing in a scenario that's gonna set them up for success. We want those successful reps early on to build their confidence so we can invite them along on this journey towards more challenge and more challenging options for fall landing. So we can add complexity, we can add more height to these fall landings so that they can really build their confidence, and take this journey with us. So to give you, I think it's gonna make more sense to give you some examples of how to do this. So intentionally underdosing for something like a backwards fall could simply be done from a recliner. You're a home health clinician, you've got a patient who tends towards backwards falling. You can get them at the edge of the recliner and you can have them tuck their chin and then fall back into the recliner. With the recliner up maybe. Maybe it's completely upright, They are seated, chins tucked, and we're gonna have them slowly work on landing from there. From the recliner, you could tilt it back a little bit and do the same thing. You could progress it all the way from an upright position, slowly falling backwards, to 45 degrees, to all the way flat. You could do this in home health in their favorite spot, which for a lot of our clients in the home health setting is in their recliner. Maybe you're in a clinic setting and you want to introduce a backwards fall landing. You can do that from a seated position with a big wedge. So you imagine that 45 degree wedge, their butt is sitting at the edge of it. You're going to have them tuck their chin and then work on landing backwards, sending the arms out. But they're only doing a very small range of motion. They're not in the floor. They're not Worried about being in the floor, you're not having to teach that getting up and getting down, you can do that from a seated position, which is beautiful. I don't know too many of our clients that would not be successful from a seated position, even our older adults who are pretty frail and are medically complex. If they can go from a seated position to a lying position safely, they can work on a backwards fall landing, and they'll be successful. For our clients who are more advanced, say that goes really well. Maybe we have them go from a standing position and just have them sit and then rock back with their chin tucked. That would be a very easy progression. Once again, not getting them in the floor. They may have had a traumatic experience in the floor. They may feel like the floor is lava, just like the game we played as kids. So we wanna keep in mind, we can scale these things and make it very easy, but you should intentionally underdose your fall landing strategy. Give them options that are super easy. I'll give you a couple examples for forward fall landing. So if you're gonna work on forward fall landing, at least the way that we teach it in the older adult division, there are lots of ways to teach fall landings. But a couple of the key things are, dispersing the load across the forearm and turning the head. You can work on just the motor control of tying these two movements together, getting onto the forearms and turning the head, or even just getting in that position from a seated position, just the mechanics. This is what we're gonna do. This is not scary, this is not hard. You can do this with someone who's super fearful, just working on the mechanics. Then from there, you could do it from a standing position to an elevated mat or some type of soft surface. So even just from a standing position, very slowly working on getting the forearms down and turning the head. It's not complicated. It's not scary. There's basically no risk there. And it could be as slow as you're ready for. After that, once you're comfortable with that, you could speed it up a little bit. Let them try to get very, a little faster down to their forearms with a head turn. From there, you could work on a quadruped position. So hands and knees, maybe on a mat table, super soft mat table, firm enough that they're not having difficulty with their wrist being in that fully extended position. But a mat table could be a great spot, or if you're in the home health setting, You could do this onto a countertop. You could put your Airex pad on top of the countertop and work on that forward fall landing. Once they're good there, you could move this to a bed. And we've not even talked about going from standing all the way down to the floor. So just keep in mind, fall landings are very scalable. Our older adults need to know how to fall, especially if they're frail. It's our job to figure out what's a correct scaling option. They need to know we need to do three things. They need to understand the value. They need to also know that this can be done successfully, that you have been successful doing this with others, that you have maybe practiced yourself based on their specific scenario. And then the third thing is you're gonna intentionally underdose this. You're gonna make sure those first reps are very easy, very easily digestible in small steps, going very slow, and you're gonna progress it gradually as they feel comfortable. And it's really that simple, team. You just have to know all the scaling options and start super simple. I hope that was helpful. I hope you didn't hop on here expecting that I was going to show you step-by-step the fall landing piece. That is something we teach in our live course. I would highly recommend if that's new for you to hop in a live course and we'd love to teach you. But that's an idea of how to set up a session for success. First time someone's learning fall landing techniques, those are the steps you want to take. If you've got experience with this, I would love to hear from you. Are there other strategies that you use that have been helpful for that day one fall landing? SUMMARY Team, if you're interested in what's going on in the older adult world, we've got our next cohort of MMOA level one, our eight-week online courses starting August 14th. We still got some seats there. So if you've not taken online level one, that will be happening soon. Level two course, just want to warn you, it does not come around as often in the last cohort sold out. So if you've taken level one, you're preparing to take level two, you're interested in our next spot, that's going to be October 17th, get your spot. They're probably going to sell out again. If you're trying to catch us on the road, maybe this fall landing thing really struck a chord with you, that's something you would like to add to your toolbox. We'd love to teach you how to do this across a continuum of the spectrum of older adults, their functional ability and whatever setting you're in. We can teach this stuff in any setting and we'll show you how to do that. The next live course is gonna be Virginia Beach. That's gonna be the 13th of this month, and then I'm gonna be in Victor, New York on the 20th, and then after that, the entire older adult team is coming together for MMOA Summit. You'll see almost our entire faculty teach this content, be together to ask us questions, pick our brains. You're gonna have tons of value there because you're gonna have so many people to help you answer your questions and go through these different techniques, and that's gonna be on the 27th in Denver, Colorado. Team, I hope this was helpful. I would love to hear your questions, comments, thoughts on this. And other than that, team, have a wonderful Wednesday and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 2, 2024

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling Division faculty member Ellison Melrose discusses the benefits of utilizing dry needling as a treatment for sexual dysfunction in women. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ELLISON MELROSEGood morning PT on ICE Daily Show I am coming to you live from Durango, Colorado this morning in my truck so excuse the background, but we are here to talk about First of all, my name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am coming to you today to talk about dry needling in the pelvic health space, particularly for sexual dysfunction in females or in women. And I wanted to highlight two common diagnoses we have, which is vulvodynia and vaginismus. So let's dive right into that. First, I want to highlight in 2018, there was a joint report done by both the International Urogynecology Association and International Continence Society that overviewed sexual function and dysfunction. They did a deep dive into things like the proper screening, what proper history or physical subjective objective exam would look like. And then they had a huge section on the prevalence of pelvic floor dysfunction in folks that had sexual dysfunction as well. So that's what I wanted to highlight today. We, in the pelvic floor practice or pelvic floor space, we see it often where pelvic floor dysfunction and sexual dysfunction is highly linked and correlated. what I, what this report, um, highlighted is that there's actually 37 different diagnoses of sexual dysfunction that can be attributed to some form of pelvic floor dysfunction. And that's a lot, right? So, um, there granted, I mean, if you look at all of the, the nitty gritty diagnoses, um, we may be thinking maybe we're over medicalizing this, patient population a little bit with specific diagnoses, but it highlights the fact that there's so many people out there that have pelvic floor dysfunction that is contributing to a form of sexual dysfunction. 45% of women that have urinary incontinence will complain of sexual dysfunction at some point in their life. Of that 45%, 34% of that is hyposexual desire disorder. Um, and 44% of those are a brand of sexual pain disorder, which is either dyspareunia or a non-coital, so a genital pain that's not associated with intimacy. And that's what I wanted to highlight. Two most common diagnosis that we see in the clinic that can be challenging for us as pelvic floor PTs often are both vulvodynia and vaginismus. And we'll kind of get into potentially why these can be challenging diagnoses for us. DRY NEEDLING FOR VULVODYNIA Um, but for vulvodynia, the clinical definition of this is anyone that has had pain in or around the vulva region for at least three months without a clear ideology of symptoms. So they don't have, They've had negative cultures, so they don't have either fungal or bacterial infection going on here. And so there's this idiopathic pain presentation in the vulva region. And then vaginismus is a recurrent or a persistent muscle spasm of the pelvic floor, which inhibits any form or enables penetration and there's different forms of vaginismus and different diagnosis underneath that umbrella of vaginismus. And we can kind of dive into that when we talk about vaginismus specifically. I wanted to highlight these two diagnoses particularly because without a proper diagnosis, oftentimes the internal assessment can either be very challenging or it can be very non-therapeutic and actually traumatizing to some of these folks. So if we don't have a particular subjective exam that allows us to understand what is going on with our patients, the whole pelvic floor assessment may be not therapeutic. So for both of these diagnoses, everything starts in the subjective exam. Let's start with vulvodynia. So vulvodynia, oftentimes folks may have symptoms similar to that of a yeast infection or a UTI that then kind of snowballs from there. They may have actually had recurrent yeast infections or UTIs in the past and are familiar with those symptoms, but, and so they do their normal treatment with that, which a lot of times is either over-the-counter medication or they might phone up their OBGYN and say, well, let's get some of these either antifungals or antibiotics on board ahead of time while we wait for the culture. Well, culture comes back negative and the symptoms are still persisting. Sometimes they may get taken away with some of the medication a little bit, but the symptoms overall typically will persist past that. Um, and for folks that have this at this point, it is no longer a, um, you know, bacterial or yeast causing these symptoms. There is a brand of neuropathic pain going So a lot of times they have either had this for quite a long time, at least three months, they've seen other providers that have either provided a medical treatment or something that has been ineffective. And so symptoms have continued. When we think about neuropathic pain and the chronicity and the persistent pain or the chronic pain side of things here, this actually heightened symptoms typically. Um, other subjective things that you might see in these folks is that they may have, um, some sensitivity to, uh, like touch in, in the vulva region, right? So wearing specific type of clothing may be uncomfortable where they may have other brands of, uh, nerve related symptoms like itching or burning. Um, which oftentimes are two symptoms that we think about for either a yeast infection or ATI. And so that's why they get mismanaged in their medical treatment. So it all starts in the subjective exam. And while an internal assessment in these folks isn't out of the question, it can definitely be helpful. It doesn't always, it's not the most efficient way to go about treating this pain presentation. when we think about neuropathic pain, we need to think about, okay, why is this nerve so irritated? And a lot of times in vulvodynia, they see that there is either a irritation of the nerve. Sometimes there can even be, you know, some, some changes in the myelin sheath of these nerves. So there's actual nerve damage associated with it. Depending on maybe what the original cause of the, nerve irritation was. And so when we dive into, we've highlighted their subjective complaints, we know what's going on here, where do we go from there, the internal assessment may be valuable in order to see is this maybe a hypertonicity issue. So if we have tight pelvic floor musculature, can we teach them to relax their pelvic floor and allow for improved blood flow to the pudendal nerve that could be contributing to some of these symptoms. So there is a lot, there is value in that. And I believe that there is, um, oftentimes in the pelvic health space, we are so used to, um, you know, trying to treat, the patient's symptoms ourselves, whereas we can teach our patients to help themselves with learning how to relax their pelvic floor. So there is a benefit in the vulvodynia patient population to utilize the internal assessment. But when we think about efficiency, so how can we treat a neuropathic pain presentation the most efficiently in our in our clinical setting? I am in the dry needling space, and so we use dry needling a ton outside of the pelvic floor world for treating various different brands of pain, one of which is neuropathic pain. So dry needling can be a super efficient tool to improve, to talk to the nervous system and do a nervous system reset to the nerve in question, which oftentimes is the lupudendal nerve. So dry needling is a very efficient tool in order to improve those neuropathic symptoms. With that being said, everything we do physically, manually, we need to highlight that this is a persistent pain diagnosis at this point. And so we need to be utilizing our pain neuroscience education. um, educating these folks about, um, what, what happens to our nervous system when we have had pain for a long period of time. Um, and, and that pain doesn't necessarily equal damage at this point or else everything that we do with our, our manual skills or dry needling, uh, will only get us so far. Right. So, um, vulvodynia again a lot of times these patients come in to us with chronic symptoms so they've been going at this for a very long time they've had typically a medical mismanagement where they've been having some medications on board that weren't helping their symptoms they have a lot of sensitized nervous system and so we want to make sure that we are using the most clinically efficient tool to treat these symptoms. Oftentimes as well, you might actually get some reproduction of symptoms with dry needling when we're approximating the pudendal nerve or getting close to that pudendal nerve, which can be helpful in almost diagnosing, right? So using our tools to help with localizing their symptoms. So that is how we would use dry needling in a case for vulvodynia and in a patient population where we would still likely be able to utilize the internal assessment. DRY NEEDLING FOR VAGINISMUS Now let's pivot to vaginismus. Let's talk a little bit more about different diagnoses under the umbrella of vaginismus and then how we would and why we would use dry needling in this patient population. So, Vaginismus, there's two different diagnoses and underneath that we have two other subdivisions. So we have both primary and secondary vaginismus. So again, a reminder vaginismus is either a persistent muscle spasm of the pelvic floor. It's either persistent or it's associated with something and we'll get into that. Primary means that this has been forever. So this has always been an issue. Um, sometimes there may be a congenital malformation of the genital track on board with this patient population as well. Um, and if that is the case, even things like typically their first, um, like, uh, association with any form of penetration, uh, is oftentimes a, when they get their menstrual cycle. So, um, having a tampon and they're unable to actually insert a tampon into their vagina. Um, from there, then they, they often with this congenital, um, malformation or having it be a primary diagnosis is they, they often are treated fairly medicalized in that state and, and they may require some form of surgical procedure to, widen the vaginal canal. So that's primary vaginismus. Secondary vaginismus is acquired. So it wasn't always an issue, but it could be acquired from a form of trauma. So either an emotional or a physical trauma that then caused muscles in the pelvic floor to spasm. And this can be either global. So what I mean by global is that it's every time anything is enters the vaginal canal, there is a muscle spasm associated with that or it's situational, meaning that things like inserting a tampon may be possible, but physical intimacy with, um, or sexual intimacy is not possible. So there's no, uh, penetration available during, uh, sexual intimacy. Um, so those are the different kind of clinical or, diagnosis we find under the umbrella of vaginismus. Oftentimes in pelvic floor PT, we will see, um, a lot more probably of the secondary vaginismus in that they've, you know, they've never had, they hadn't always had issues, but then something caused or something triggered an issue, which causes the pelvic floor muscles to, um, to spasm, right? And that could be a traumatic birth of vaginal delivery. It could be a sexual trauma. So a, um, yeah, a sexual assault or something of the sort. It could be a, uh, traumatic pelvic exam by their OBGYN, uh, which we've, I see a ton in the clinic and, um, so it could be, a natural physical trauma with that. And then it could also be heightened with a, um, an emotional trauma as well. So a lot of times, I mean, this is a very intimate part of our body. And so there's a lot of times a very, uh, pertinent, uh, or very prevalent emotional, well, um, 70%, I would say probably about 70% of your initial evaluation evaluation, is going to be a subjective exam. Understanding the why behind these patient symptoms is crucial to dictate the course of your treatment or even the course of your assessment in that initial evaluation, right? Like, are we going to be doing an internal assessment on these folks? And a lot of times, probably, probably not, right? So what does day one look like or our initial evaluation look like with folks that have vaginismus? and how and what does our course of treatment look like for them. So typically education goes a long way with folks that have had either a physical or an emotional trauma that has caused muscle spasms here, right? So teaching folks about the anatomy of the pelvic floor musculature uh, why they feel like there's a brick wall when they try to insert a tampon. Right. Um, how, uh, what a Kegel is. Right. So anytime people have any association with the pelvic floor, they are often just think, Oh, I should be doing Kegels. Right. Um, and teaching them what, what a Kegel or what a pelvic floor muscular muscle contraction is and educating like the benefits of relaxing the pelvic floor. And this is just all done through education. So no even physical touch or assessment has been done at this point, but just educating folks around the anatomy of the pelvic floor. Anatomy and physiology of the pelvic floor can go a long way here. We also want to educate about vaginismus itself. So vaginismus is another brand of chronic pain, right? So these folks have typically had pain for an extended period of time, Um, there's not a diagnostic criteria for, for duration of symptoms like there is for vulvodynia. Um, but there is a pain cycle on board here, right? So it all starts in the brain. So it, it either the, the brain perceives an emotional trauma due to either a physical trauma or, or purely emotional that registers discomfort or, or fear associated with, uh, penetration either from a previous, uh, you know, exam with a speculum from a previous sexual encounter, um, from a trauma traumatic birth, right? So the brain remembers those things, which is then going to be causing, it causes muscle guarding. So public for guards, the tight muscles in the public for cause the penetration to be painful. or impossible at sometimes. And then this difficulty in pain reinforces that alarm, the amygdala alarm that's going on up in the brain, right? That reinforces that this is a threat, right? The nervous system then remembers this pain, and so every time our brain is their, their brain is thinking about, you know, either having to go to the OBGYN or having a sexual encounter, anything like that. Um, it is going to remember that and we are going to get the same physical symptoms as the, the tight muscles, um, which is often going to lead to, you know, decrease blood flow to the nervous system, which is going to cause potentially, you know, perceived as pain by these folks. And so they're going to avoid those, uh, you know, avoid whatever is causing this pain cycle, right? And those folks, which ultimately, especially if this is a sexual nature is going to, um, reduce the desire to either have sexual intimacy with their partner or, um, and it's, it's going to reduce that, that overall desire, which is then going to, again, any thought of that intimacy is going to be threatening. So discussing that, that pain cycle with these patients can be very therapeutic and, and helpful in that this isn't their fault, you know? So the nervous system, I like to say it's smart, but dumb, right? It remembers things and not always for the right reasons. And so education about anatomy, physiology, about the vaginismus pain cycle, can take up a majority of your initial assessment with these folks. I also like to do, again, a guided pelvic floor relaxation series with my folks, even if we're not doing an internal assessment. So on day one, these folks, we may not be getting into an internal assessment. We may never get into an internal assessment, but we do want to teach them how to um, feel their pelvic floor muscles and, and learn how to relax them. And so sometimes, um, I will educate them on how to do some self biofeedback either with tactile cueing, um, just medial to their ischial tuberosities sitting on, um, you know, a yoga ball or something like that, where we have some, uh, tactile cueing to the, um, perineal region or the pelvic floor area. Um, and, and teaching them about, again, the anatomy and that when, We're breathing. We're trying to make some of these muscles move. Increasing movement in these tissues is going to increase blood flow to the tissues, which is going to reduce irritation to the nervous system. So teaching them how to relax their pelvic floor without even doing any physical touch yourself can also be helpful. This is a patient population where after we kind of break down and help them understand the why, I like to highlight other tools we have in our toolbox as physical therapists, right? A lot of times when these folks, um, come to pelvic floor PT, they, they've done their research. So they know often that pelvic floor PT equals an internal assessment, which they've had done by their OBGYN and it's maybe been traumatic in the past or Um, they know any form of penetration is, is traumatic. And so, um, right out the gate, I'll say, you know what, that is a tool we have in our toolbox. The internal assessment's a tool. It is gold standard for assessing how the pelvic floor muscles function, but is not everything that we do here at pelvic floor PT. And I introduced dry needling. And I know that seems like for folks that have, don't have vaginismus or don't have trauma associated with penetration, they're like, Isn't dry needling more of a threat than an internal assessment? And for folks that have vaginismus, oftentimes it's not, right? So dry needling the pelvic floor muscles can be an amazing tool as we don't necessarily need to do an internal assessment. on these folks, we know there's likely not going to be anything therapeutic initially with that initial internal assessment. So if we can utilize dry needling in the earlier stages of our pelvic floor PT with these folks, it can be an amazing tool to talk to the nervous system, you know, put a break in that pain cycle associated with the muscle spasms or the tight pelvic floor musculature. It's a beautiful kind of what I like to say control or delete to the nervous system and so it can really help with Retraining that cycle of you know, these muscles Have more control other than just muscle spasm, right? and so if we can take some of the the heightened neuropath or the heightened symptoms down with a tool like dry needling, it may allow us to either ourselves or them do a form of stretching or manual therapy where they can improve the tissue's mobility as well, right? SUMMARY So I could probably talk about this stuff all day. I've already been on here for almost 25 minutes, so I'm going to stop it here, but I want to kind of summarize everything we talked about today. Um, I, we kind of went into a recent report done in 2018 that dove into some pelvic floor dysfunction in, um, sexual function and sexual dysfunction. And we dove into two specific diagnoses today. We looked at vulvodynia and vaginismus clinically and how we can utilize things like dry needling for either treatment or even, um, diving into a little bit of some diagnostic, uh, with, utilize with dry needling as well. Um, and so, uh, while we're, you know, dry needling, the pelvic floor is a fairly unique, um, skill. Uh, there's a lot we can do with dry needling outside of the pelvic floor as well for these folks. And so, um, for those that are in this space, I highly recommend taking our lower body dry needling course if you haven't already, We go into needling for the lumbar spine, the glutes, muscles that surround the sciatic nerve. And so again, taking those principles and utilizing them in the pelvic floor space can be really helpful as well. So we have some courses upcoming this fall. We have, let me pull it up right here. We have a lower body course, I believe in Scottsdale, Arizona, in the beginning of September. We, for those that have taken lower body or upper body, we have two advanced courses coming to you this August. So we have our, our juggling summit up in Seattle and the second weekend in August. And then we have one down in Longmont, Colorado at the second to last weekend in August, um, right before Labor Day. Uh, we have a ton of lower body courses coming to you this fall. So hop onto ptlnice.com and check out what courses we have, um, coming to you. Um, if you guys don't see something in your area, feel free to reach out to us and, um, we can look at getting something booked near you as well. Well, hopefully you guys have a great rest of your Tuesday and enjoy the holiday this week. Bye. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 1, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses three myths in pelvic health surrounding pelvic health demographics, urinary incontinence, and sexual intercourse. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION ALEXS MORGANGood morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan, and I am so happy to be with you all this morning to talk about some myths and bust them. So there are so many myths in pelvic health. I narrowed it down to three. I might sneak a fourth one in. But there are so many myths that need to be dispelled in this area of pelvic health. And so this morning we are going to talk about a couple of misconceptions in the topic of pelvic health and then what the actual facts are. So thank you all for joining me so much this morning. At the end, we'll talk about some courses upcoming in the pelvic health division if you are interested in joining us. So top three myths. Number one, only women need to worry about pelvic health. Number two, urinary incontinence is a normal part of aging. And number three, pain during sex is normal. Three myths that are pervasive in this space. MYTH #1: ONLY WOMEN NEED TO WORRY ABOUT PELVIC HEALTH So let's start with myth number one. Only women need to worry about pelvic health. This is absolutely not true. All people need to be considerate of pelvic health. All people can have pelvic floor issues, no matter what your anatomy is. So whether there is a penis or a vagina, you may have issues that are because of your pelvic floor. So some common issues that we treat are chronic prostatitis, slash chronic pelvic pain. And that is, um, that is what a topic that we discuss in our level two course, as well as erectile dysfunction and so many more. these issues can absolutely be addressed with a pelvic floor physical therapist, a pelvic floor therapist altogether. And it's really important that people understand that these issues can absolutely be addressed And so often, of course, you'll have to take our course to learn a whole lot more about it, but so often these lifestyle things that we discuss like eating well and exercise and getting blood flow, all of those are so incredibly important for all people. And in particular, issues as we just discussed, like chronic pain and even erectile dysfunction. So of course, big solution being when we kind of shift the gears and talk about how all people may benefit from pelvic health, then all people have an equal opportunity to seek that care. that's a big part of why in the ice certification for pelvic health we go over all anatomy and all diagnoses surrounding any and every pelvic floor issue that can arise here because We want to provide health for all. And if you are ICE certified in pelvic, then you know exactly what I'm talking about. You have the abilities to provide that care to all people. Speaking of, congratulations to our individuals, our very first individuals who are ICE certified in pelvic. We just completed our first level two course and we have several who are now ICE certified in pelvic. So congratulations to you all. MYTH #2 - URINARY CONTINENCE IS A NORMAL PART OF AGING Moving on to myth number two, urinary incontinence is a normal part of aging. It is absolutely not the case that incontinence is inevitable with age. And again, this kind of goes back to myth number one, this occurs in all can occur in all people. So incontinence might occur with, um, males and females, and it does not have to happen just because someone is aging or just because someone had their prostate removed. There's a lot of different types of urinary incontinence, but these can all be addressed. A big one that we talk about a lot in sport and kind of in function is stress urinary incontinence. and this is where there's an increase in intra-abdominal pressure and the pelvic floor musculature either doesn't know how to, can't coordinate enough, or is not strong enough to withstand that pressure up above and the leaking occurs. There could also be urge incontinence where you have the urge to go pee and then it's really difficult to hold it in because of that urge. And we even have functional incontinence as well where it is difficult for an individual to get to the bathroom in time because of some type of physical impairment or cognitive impairment. And because of that, there is incontinence. So for all of these individuals, there are absolutely solutions for them. And because of that, we don't accept the myth, we don't accept the statement that it's normal to Pee your pants as you age. It is absolutely something that can and really should be addressed to improve the quality of life for all people. MYTH #3 - PAIN DURING SEX IS NORMAL Myth number three. Pain during sex is normal. That is a very pervasive and difficult myth that we hear quite a bit. Maybe that is surrounding menopause, maybe that is surrounding postpartum, or just in general. But pain during sex should not be expected. Sex should be pleasurable, should be enjoyable, and should be enjoyed by both or all parties involved. And unwanted pain during sex is something that can and should be addressed to improve pleasure in a very important aspect of life that is sexual health. There's so many reasons why someone might be experiencing pain, and just like in all areas of the musculoskeletal system, when we experience pain, it's not always straightforward. Wouldn't it be nice if it were? But with pain with sex, we talk about in all of our courses, we layer in all of the different aspects of pain with sex and begin to separate these issues out. It is our job, it is our duty, it is our honor to help individuals decrease pain and increase pleasure with sex to improve their quality of life. And we do this from some simple ways like lubrication maybe more complicated ways like can referring someone to counseling to mental health therapy to assist in maybe some prior traumas and we also can do some manual work as well as exercises in order to fully address the full person and address the full picture of the reason why someone is having pain with sex. So again, if you want to learn more about that, we do talk about it in all three of our courses, our live, our online, and level one and level two, but we really take a deep dive in level two. So if this is something that you're interested in, yay, join me. This is one of my more recent more recent interest in pelvic health, and we would love for you to join us in any of our courses. SUMMARY So to recap, pelvic health is absolutely important for all people. Incontinence is treatable. Let's help these individuals get treatment. And lastly, pain with sex should be addressed. Let's have Our job is to get individuals to understand that we are available for them to help them address their pelvic concerns. And let's reduce those barriers as much as we can for them, talking about them, letting people understand that you are a resource for them. And by all means, take this information, create some reels about it, create some posts, but get those myths out there, and most importantly, get the truth out there. Thank you all for joining me this morning. Before I close up, I just wanna let you all know, our Level 1 course, it's about to sell out. There are still a few spots. We have one week left before we officially start, so that's July 8th, if you're listening on the recording. And so sign up for that if you are trying to get that in soon. It will sell out. Same with level two, but that one starts in August. So August 19th. And then our next three courses that we have live are in Ohio, July 20th and 21st. in Wyoming, July 27th and 28th. And then Tennessee, right here in my hometown, Hendersonville, Tennessee, September 7th and 8th. So we hope that you will join us. If you're already signed up, can't wait to see you in person. And thank you all for tuning in this morning. Have a great day, have a great week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 28, 2024

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty member Mitch Babcock recaps the annual Fitness Athlete Summit, discussing how students become leaders in loading, confident in their strength & coaching, and the importance of walking the walk. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. MITCH BABCOCK Good morning PT on ICE Daily Show. It is a wonderful Friday morning here in June. I hope you're doing well. Thank you for tuning in. Whether you're tuning live on Instagram, YouTube, or if you're streaming this and downloading this, after the fact. We are glad you're here and thank you so much for making PT on Ice the daily show your downloadable PT daily podcast. Today's topic is Summit Recap. So we had a Fitness Athlete Summit this past weekend here at CrossFit Fenton and I want to talk to you about some main principles so just some main themes that kind of stand out to me as faculty after observing and watching kind of the things that went down this weekend. It was a wonderful weekend and thanks to all of those that attended the course this weekend. You guys knocked it out of the park and we're going to get into that shortly. I do want to draw your attention to the fact that there are three online courses starting up in July. So if you are sitting there looking to get involved into an eight-week interactive online course, there are three that are kicking off just this first week of July. So I want to draw your attention to them before the holiday weekend kicks up and you lose track of what's starting. You've got Brick by Brick where you can work through with Alan about all the details around getting your clinic actually going. Like what are the steps involved to getting NPI number, business bank account, tax ID, all of those things that are necessary and legal to get your clinic up and running. Alan will walk you through all those steps in a brick-by-brick online course. We also have a Rehab of the Injured Runner. Jump in on that course. It's a phenomenal resource for a lot of very actionable stuff. If you are a CrossFit coach like I am, there is nothing better than being able to come to your CrossFit athletes with a lot of running related tips, and strategies towards increasing their mileage, increasing their cadence, and decreasing pain that they have with running, because we all know us CrossFitters are pretty bad runners. So that's my little shout out to the Injured Runner course. That online course kicks off in July as well. And then the last one is our Fitness Athlete Pelvic course online. Jump into that one as well for all things pelvic floor, bracing, strengthening, modifications related. That's your resource for all things pelvic. Online only, those are some eight week options for you. It was a wonderful summit. We spent all day Saturday, Sunday going through our traditional fitness athlete content. But in addition to that, we had a number of folks, we had probably 15 or 20 PTs come early and jump into a Friday afternoon class here at CrossFit Fenton. We went out to a local restaurant, kind of had some drinks and socialized a little bit Friday night. My introduction to the weekend said, we're looking to make this the most fitness heavy course, Con Ed course, you've ever went to in your life. Taking the fitness athlete course and literally ramping it up in intensity and load, and the participants answered that call all weekend long. From the first moment we broke out in back squat, we had plates on the bar, we had people getting into a heavy back squat, breaking down technique, and that theme carried on all the way through the weekend. I was stoked to see it. I love the fact that the participants leaned into the challenge that the weekend presented. And so I walk away with a couple common themes. Before I get into those, I do want to shout out our wonderful team. We had eight faculty from the Fitness Athlete Squad here this weekend, all did a phenomenal job with the lectures that they led, and it was really an honor to sit back and just kind of watch the team do their stuff. So Zach, Guillermo, Joe, Kelly, Jenna, Tucker, Alan, myself, it was a wonderful job. Team, I just want to give you guys a shout out real quick before we get into this. LEADERS IN LOADING The first thing that comes to mind after the weekend is the fact that these individuals, anyone that participated in the course, are now leaders in loading. in their respective communities and clinics. They're going to take all the confidence that came from the weekend, all the principles, all the learning, and they are going to be the resource in their relative clinics for helping people get stronger. And that is such an important role and a big responsibility. And you could almost see it and feel it in how attentive everyone was to the lectures and how detailed they were in the coaching and how they dove into the nuance of the barbell lifts and didn't just skim through them. You could tell that the participants at this course wanted to soak every ounce that they could from it because they knew that they were taking it back to their clinics. And maybe they had an uphill fight ahead of them. Maybe they knew that the clinicians that they're surrounded with and they're 9-5 aren't on board with deadlifts or barbells or dumbbells or heavy loading or EMOMs. And they know that when they roll back in that their sword better be sharp because they're going to be up against some resistance and kind of swimming upstream, if you will. But I appreciate the fact that they kind of knew that challenge, that they were ready for it. And I feel really confident that those folks are going to make that change. It's not an easy change. Anyone that's out there in their clinic right now listening to this being like, that was me. I was the crazy person in my clinic with the timer on the wall and the barbells banging in the clinic and everyone thought I was nuts. But hopefully you guys can share some of the stories that it works. Meaning, not only with your patients, but with your colleagues. That over time, these principles start to rub off on your colleagues that maybe were, you know, detractors at first. They weren't really on board with the mission and the vision, but they started to see your outcomes. They started to see how much fun your patients were having, and that they started to adopt those things as well. And over the series of maybe some weeks, months, or years, you now have a clinic staff that kinda operates very similarly. Everyone is now on board with the loading. Maybe it took a few in-services. If there are any tips, tricks that you guys have encountered, this would be a great podcast to comment, share, or just leave something in the comments below this of little things that have helped you and your clinic get those folks on board. You're now the leaders in loading in your respective communities. I hope you don't back off of that line. I hope, if anything, you keep pushing that line forward, saying, no, not only do we need this, we need more of it. We need heavier, more intense loading in the clinic. And if it takes me being the person to start this in my community, then I'm going to do that. THE CONFIDENCE OF STRENGTH That leads me on the second point that I saw over the weekend is the confidence of strength. Strength confidence, right? And that can be defined in a couple different ways. One, personally, seeing a PT relatively scared of the deadlift, relatively fearful of their low back. lean into that deadlift section from the principles and the lessons that we teach prior to to the technique breakdown to the coaching and then eventually the max out deadlift lab and watching the confidence change in just that one hour lecture is huge. Seeing that they're like, man, I didn't realize I was that strong. I didn't realize I could do that. I didn't realize my colleague could do that much weight as well. We have this newfound sense of confidence around our own strength and our own low back. But what comes secondary to that is the confidence of the strength movements themselves. I now have confidence of instructing this deadlift. I know what I'm looking for. I know what a good start position is. I know what a bad one is. I know how to cue and correct this thing. I feel much more confident with the movement itself, not just with my own strength because I feel confident with that too, but with instructing and teaching the movement. We know that physical therapists' beliefs around their low back impact the treatments that they select and the outcomes that they get with their patients. Your fearfulness of your low back strength or your back pain is wearing off on your patients in a bad way. And seeing clinicians really overcome that this weekend is one of the best parts of the entire course and not just the summit itself. But there definitely was an aura. Having the entire fitness athlete team. Having all of these participants that were really down with the mission. Really leaning into this. You could palpate the change in confidence with just that one lecture itself. It was a great moment. It was a great breakout. And I hope that that confidence that you have. After going through a course like this, where you get stronger, where you feel more confident with the strength, with the barbell movements, that you maintain that confidence by way of staying involved with the barbell, staying in the gym, continuing to practice what you preach, continuing to lean into the movements that you're not the greatest with. But get more coaching, get more refinement, and develop your skill set. Because that confidence will go a long way, not only in your personal health and development, but in your treatment, health and development, right? So it's really bifactorial, and I'm really excited to see the change in that. THE CONFIDENCE OF COACHING The other component, and I just have two left, the other component was watching the development of the coaching confidence, right? Seeing clinicians go from the first breakout of the weekend, telling people to activate muscles, don't do that, into the later part of day one and into day two, where you're starting to see a much more engaged, effective coaching. We come in as a profession looking to change movement with our hands or our mobilizations or our manipulations and techniques. And we leave the weekend realizing how much more effective we can be just by coaching, using our words, using tactile feedback, using tempo, using targets, using visual things. That component, that change will really carry with you in your treatments. being able to walk up to somebody and get into an effective coaching position that you can break down the static position, refine that position, break down the dynamic component of the movement, have them pause in a position where they're losing shape, correct that shape using a slow tempo to allow yourself time to make the changes you want to do. Refining your coaching ability goes so far in your your ability to refine movement in the clinic. Seeing that coaching confidence develop, seeing your ability to change movement with your words and not just your hands is really, really helpful and something that as a profession we really need to wrap our heads around more and spend more time refining. Maybe the mobilization technique doesn't need more reps. Maybe just your coaching does. Get a few more reps in there. It was a really wonderful weekend, team. From seeing the confidence of the strength movement to knowing that you guys are going back to your clinics to be the leaders of loading in your relative communities and watching how much you leaned into that coaching development side of the weekend was really, really powerful. I hope you take all of that stuff. I hope you take all the lessons, all the lectures, all the research articles. You compile that with all of your in-person experiences that you had over the weekend, watching people get after it. WALK THE WALK And most importantly, walking the walk, right? From Friday's optional workout that a number of clinicians jumped in on, to Saturday night's WOD at the end of day one, which you guys are accustomed to from taking ice courses. What you don't know is that we really ramped up the heat with this being the Fitness Athlete Summit. We had teams of three, we had heavy power cleans, we had bar muscle-ups, chest-to-bar pull-ups. Like we had a really spicy piece for 18 or 20 minutes there Saturday night, and all the clinicians didn't back away from the heat at all. And we even had an optional cardio piece on Sunday day two during lunch that we had more than 50% of the participants jump in on. break a sweat before we grab a little bite to eat on Sunday. Walking the walk, living this lifestyle, showing your patients in your in your relative communities that you can get strong, you can get confident with this, you can get fitter, you can get more shape and what that's going to do for your lifestyle. If all of that spurred from this weekend, it was the best weekend I could have dreamed of. In every single weekend we hit the road, we hope to do something similar. So hats off to everyone that was a participant this weekend. Hats off to the entire fitness athlete team for conveying the message loudly and with intent. I appreciate that very much. I look forward to the next Fitness Athlete Summit. We're going to do another one next year. We'll get the entire team together. I don't know where it'll be yet, and I don't know what things we'll have in store for it. But I know that we had a ton of fun this year, and there's no reason to stop that anytime soon. So be looking for the entire team to come together next year at a destination we haven't determined yet, with some coursework built into the weekend that maybe you don't find everywhere else. Be looking for that. Team, I wish you a wonderful weekend. If you are heading into a 4th of July vacation and you're stepping away from the clinic a little bit, I hope you recharge the batteries. I hope you spend time with family and friends, enjoy the moments of life, and then get back into the clinic where you make a difference. And don't forget that you do. So, with that, have a wonderful rest of your Friday and a wonderful weekend. Take care, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 27, 2024

Dr. Brian Melrose // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses the details surrounding maintaining your secondary levers on set up for more success with cervical spine manipulation techniques. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. BRIAN MELROSE I'm one of the lead faculty in the spine division, teaching both cervical and lumbar courses. And I'm here and stoked to be here on a Thursday, a clinical Thursday to talk about the number one thing that I think could dramatically improve your success utilizing cervical manipulation in the clinic. And really what that boils down to is going to be maintaining your secondary levers. And so we'll get into all the details of what I mean with the verbiage there, as well as talking about a particular technique that I think this will help with. But I got to zoom out first and kind of allude to where this comes from. And to be honest, man, it's just from being out on the road for the last couple of years, teaching about 15 to 20 courses a year and getting the opportunity to work with a lot of different physical therapists, from around the country. And those folks, you know, they have a lot of different backgrounds. They have different opinions about manipulation. Some folks have been trying cervical spine manipulation for years, whereas other folks are relatively novice with things. And so I think if you can understand how to maintain your secondary levers, it's going to help everybody. If you are more of a novice practitioner or novice with utilizing cervical manipulation in the clinic, this is the one time where I'm going to plug our courses and say, if you want everything, like if you want to know how to keep things safe, if you're wondering about if the pot matters, How hard do I thrust? The answers to all of those questions will always live in our weekend course. And I truly believe that it takes a full two days of kind of immersing yourself in that space to really understand stuff. You're not going to learn cervical spine manipulation techniques well by just cruising YouTube or Instagram. If you're a novice, make it out to one of our courses sometime this year for one of those details. But if you can absorb the concept that I kind of talked through today, that is significantly gonna help your kind of hands during the weekend and therefore your success in the clinic. So listen up, tune in and see if you can grab this one. Again, I think it'll help you dramatically when you make it out to a cervical spine ice course later this year. For those of you that are more in the middle, the folks that probably did a manipulation course at some point in their career, and you use it very occasionally in the clinic, maybe once or twice, week in and week out, but you just don't feel confident with your hands. Every time you go to set up someone's neck, maybe it feels just a little bit different. If that feels like you fall in that category, then this podcast is for you. If there's one thing that I see very often on the weekends, it's folks kind of missing or losing some of their secondary levers. And if you can understand what we talk about today with a person's neck and kind of what I show with the foam roller, again, I think that will dramatically increase your success with cervical spine manipulation and therefore your outcomes in the clinic. And so to kind of dive into things, then we really have to start with describing what a secondary lever is. And so when you set up a manipulation technique, you put on your secondary levers first. That's part of your setup for the thrust or primary lever. And so secondary levers are really designed to put tension into the system. and help lock out or isolate a particular level of the spine that we are trying to, again, isolate to thrust through. And so those secondary levers take up tension and then set us up well for our primary lever, which is in the direction with which you thrust. And so the primary lever is the last lever that you put on. It's what you explore and you kind of lean in and you're eventually going to feel a barrier. you're gonna feel something crispy. And again, if you have cracked someone's neck before, you are gonna say, ooh, like there it is. Like I'm gonna come back and I'm gonna smack right through that thing. And so that's kind of the setup that we're talking about. Now let's take this a step further and go into a very specific manipulation technique so that we're all on the same page. And I want to talk today about like a mid cervical kind of cradle hold. So again contact and non contact and you're going to put your levers on first to put some tension into the neck. And so it really depends on who you learn this from. That's one factor is what secondary levers you put on first. You may also change your secondary levers, either number one, which levers you put on, and especially how much of each lever you put on based on the patient in the clinic. Like if you have someone that's very stiff and lacks side bend, you may need less of that to get their neck in a locked out position. You have somebody that has, you know, a lot of movement in their neck, you're going to need to put on a different degree of those secondary levers so that by the time you get into rotation, you say, Ooh, there it is. And I feel confident with that. And so for the mid cervical cradle hold, typically the head's on a pillow, so the patient's a little bit flexed, and then I'm gonna introduce some degree of side bend, some degree of lateral translation, and then last, start exploring rotation. And what you're hoping for on that setup is that if you put the right amount of secondary levers on board first, i.e. side bend and lateral translation, that as you begin to rotate, you're going to feel that barrier come in relatively early in rotation. You're going to feel things crisp up there. And again, you're going to have that ooh moment where you say, there it is. So I think that's the kind of setup that we're talking about, but the problem that I end up seeing all the time on the weekends is that as folks go in, they get it set up, they find that barrier the first time they say, Ooh, there it is. And then again, we can't stick at the barrier and just thrust through it. We have to back off a little bit. And there's a technique called priming where you're going to get to that barrier a couple of times before you thrust. Now the issue is, and the moment of truth that I see happen a lot on the weekends, is folks go in, they find that barrier the first time, and then they back off. And they come in, and they check that barrier again. They back off, they check it a third time, a fourth time, a fifth time, a sixth, like it keeps going. And that's again, because they're learning the technique. There's two big problems with that though. Number one is, is when you get into the clinic, think about your patient, like they're laying there, right? They're trying to trust your hands. They're trying to relax. And if you check something three, four, five, six times, they are feeling like a sitting duck. They're going to start kind of tensing up and anticipating it. And that's the last thing that we want. And so one of the jokes that I love to make is like, you get two primes. If you've got to take a third, take a third. But after that, you've got to go for it. So that's part of the problem. The other issue though is, is that each time folks tend to kind of prime or reassess that barrier, they begin to lose some of their secondary levers. What happens then is they begin to leak some of the force, or excuse me, some of the tension that they've created in the neck. And so they'll, again, side bend, side glide, they'll begin to rotate, they feel that barrier, they say, ooh, there it is. They'll back off a bit, they'll lose some of their secondary levers, and then they go back in to check with rotation again, and they have to rotate a little bit further because they lost tension in the rest of the system. And they feel that, and they go, ah, dang, it doesn't feel right. So then they want to go check it again. They check it again, they lose their levers a little bit more, and then they have to rotate a little bit further. And so by the second, third, fourth, fifth try, they've really unbuckled a lot of the tension that they put on beforehand. The thrust that they have to keep chasing the barrier, they lose confidence with their hands. And we all know that if you don't feel confident with your hands, your patient won't relax as much. And so we really have to maintain those levers as we get going. And the best way to visualize this concept is with a foam roller. So I've already posted something to the Ice Physio Instagram account to help visualize this. But I'm going to demonstrate it with a foam roller now so that you can see it. And then I'll have my wife, Ellie, step in here. We'll show it with an actual neck. So what we're looking at here is Setting things up in this position. So let's imagine this is someone's neck. There's a cervical spine, again, is oriented down towards the foot of the table. I'm going to introduce my hands here, and I'm going to begin with a little bit of side bend. And so now what I need to imagine is that I have to maintain this axis or direction of side bend in the foam roller. When I get in and do lateral translation, the foam roller needs to stay oriented in that same plane. If I unbuckle them a little bit, again, I've already lost my levers. So side bend, side glide, and then as I begin to explore rotation, I can't lose, again, the angulation of the foam roller. If I wanna keep all of the tension I've built into the neck, it needs to stay crisp, it needs to stay clean, and I need to, again, be able to set things up for the thrust technique. And so if you can visualize that with a foam roller, then it should make sense when we do it with a patient's head. So Ellie's gonna come on in here, She's gonna lay down for us. And so the same technique kind of applies, right? The pillow is introducing a little bit of flexion, just like where the foam roller was. I get my hands in here on the neck, just like this. And then I'm going to explore, again, side bend, lateral glide, and then rotation. And what I'm doing in this forehead and her chin, maintaining that orientation, then as I spin, we're going here. But I can't unbuckle some of those other levers as I re-explore that rotation. They need to be maintained so that as I get over and I thrust, I can maintain the position and maintain the tension in the system. And so I think if you can visualize this concept in terms of putting good secondary levers on first, creating a lot of tension in the system, you have to maintain that as you prep the thrust. And again, you're just not gonna get the impulse in the right area that you want. So, in conclusion, guys, whether you're novice or whether you're a little bit more advanced in trying to kind of master techniques, the whole purpose of today is to really hammer in the point that you have to maintain those secondary levers with any manipulation technique. That's what's building kind of, again, the tension in the system. And if each time you go to kind of prime the barrier, you lose some of that, you're gonna have to go further into your primary lever, in this case, rotation, to research for that barrier. It's gonna make you feel less confident, like you don't really have it. SUMMARY So make sure you're maintaining your secondary levers on your setups. And again, this will dramatically increase your success in the clinic, the confidence in your hands, and again, the results for your patients. Awesome. Thank you so much for having me here this morning, guys. It was great to talk about this on clinical Thursday. The last thing I want to do is just plug a couple of courses that we have coming up. Our next cervical spine courses, I'm teaching out in Kent, Washington this weekend, but we're all sold out for that. So your next chances are probably the weekend of July 13th and 14th. Jordan Berry is on his home turf out in Charlotte, North Carolina. And Miller is going to be out in Oviedo, Florida on July 20th and 21st for cervical spine. Next two lumbar courses will be in Amarillo again on that July 12th and 14th weekend. You'll be stuck with me down in Texas. And then after that, we're doing a course in San Luis Obispo out in California. Love the central coast in CA. And that will also be on July 20th and 21st. So hope to see you guys at some courses later this year. I hope you're having a great Thursday and have a great end to the week. Thanks so much. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 26, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty member Julie Brauer discusses how fitness equipment is not necessary for older adults to reach fitness goals, how fitness equipment is not feasible for older adults to obtain or use, and that older adults likely do not want to use this fitness equipment because they can't correlate how using it translates to functional activity Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor, Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Jane. JULIE BRAUER Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. Excited to be hanging out with you all this morning. Our discussion this morning I am hoping to offer you all an expanded perspective and even maybe a perspective shift when it comes to how you approach loading older adults. The shift is this. The barbell is a tool to help get our older adults brutally strong and stave off functional decline, but it is not a rule. The barbell is a tool, not a rule. So this perspective shift has occurred for me over the last nine plus years of my career, working with the sickest of the sick in the ICU, all the way to higher level athletes in a CrossFit gym. So across that entire spectrum, I've had to be incredibly creative and unique when it comes to introducing loading. I have worked with folks where loading them up is the last of their priorities. What's more important is the fact that they don't have the money to keep their lights on or they are having to use clothes to fill holes in the ceiling. I have worked with folks who have meaningful goals that have absolutely nothing to do with floating. And I have definitely had to shift my own perspective of what is success as a therapist. So let's unpack this. I've learned a lot over the past nine years of working with such a wide spectrum of folks. These are the things that I've learned. I want to share them with you. Number one, the barbell or a kettlebell or a dumbbell, insert any fitness forward tool, is not 100% necessary for older adults to reach their meaningful goals, okay? Number two, it's not feasible. The barbell and fitness forward tools, they're not feasible in many settings and in many populations that we serve. Number three, in many cases, older adults may not want anything to do with weights. Number four, final one here, is that in many cases no matter how hard we try older adults are not able to make the correlation of how lifting a weight is going to translate to their meaningful activity. So these are some themes. This is what I've learned over my nine plus years. And what I have also learned from my own experience and also being out across the country, meeting and connecting with you all, is that when we get really excited about fitness forward care, and this was me to a T, sometimes we can have blinders on and we become so laser focused on having our older adults lift weights. I mean, it makes sense. It's badass. Many times they feel like it's badass. It's sexy. It's cool. However, we can start to equate our success as a therapist with our ability to get our older adult to lift weights. And that can be a really limited perspective here. And what it can do is it can make us forget about the fact that the majority of the older adults that we're serving are not lifting barbells or kettlebells in their homes. They are lifting, pushing, pulling functional objects like laundry baskets or bags of mulch, kitty litter, dog food, pots and pans, Amazon boxes, buckets of tools. I could go on and on and on. The problem though is that many of us will develop an entire plan of care and we will never actually use these items that older adults are lifting at home. So this is where I want you to start to get a little curious and think, huh, why wouldn't I use the actual objects that my patients are using at home in my plan of care? Like that makes so much sense, right? Now, I know what you're thinking. You're thinking, well, Julie, there's so much carryover. If I can get an older adult brutally strong in their deadlift, then lifting that laundry basket is going to be successful, and it's going to be easier. And the answer is, yes, I 1000% agree with you. And that's the most beautiful thing about fitness forward tools, is that we can use them to help our older adults become brutally strong. And then the meaningful activity is easier right that deadlift we get them loaded up really heavy that laundry basket is going to feel lighter they're going to have less fear when they go to lift it their rpe is going to be a lot lower That's the beautiful thing about fitness forward tools. I think about that with my own training. So I have a bias towards a barbell. If any of you are thinking, man, this girl must hate a barbell. I love a damn barbell. I use it in my training. I'm a trail runner and I do strict strength training with a barbell to get my legs as strong as possible so that when I am running uphill or scrambling up rocks during my races, it feels a lot easier, okay? But here is where we have to really think about this. I want you to open up your mind. Here is where a perspective shift can come in. I want you guys to start thinking about this as an and, not, or scenario. So while you are working on moving your older adults towards brutally strong, building their reserve and their resiliency, I also want you guys to be thinking, only always, in tandem, use the functional objects that your folks are using at home. It's, I'm going to have Betty in the clinic today, lift a heavy barbell, and I'm going to have her lift a bag of mulch that she is wanting to lift at home. And not or, do these things in tandem. Why? Well, think about it. If we're using the objects that folks are actually using at home, let's say Betty walks into your clinic, she's scared, she's never deadlifted before, she doesn't even know what a kettlebell is, she's gonna call it a kettleball, but she sees over on a shelf that there's familiar objects that she's used at home. So subliminally, she's walking into your clinic and she's like, There's a bag of mulch in here. There's kitty litter in here. There's a bucket of tools. There's a laundry basket. Huh, I use all that stuff at home. Immediately, your environment becomes less intimidating. So imagine having those objects at your disposal when you are going to introduce the deadlift to your patient. They're familiar. Many times, they're much more approachable than a weight, especially if there's fear on board. And most of all, they are incredibly specific. We know how important task specificity is when we are teaching someone a new skill. You cannot get more specific than having your patients actually use the objects that they are lifting at home. I had a wonderful discussion with another one of our members, Trissa Hutchinson. She's on our older adult team. She's an OT. She's absolutely brilliant. She really opened my mind to this perspective as well. And she was telling me a story of how her patients, who many of them, they reside in memory care. So a lot of her folks have cognitive impairment on board. And she was telling me, Julie, it is such a high level cognitive skill to be able to correlate that kettlebell on the ground to the groceries that I have to lift from the ground. That sometimes can be too high level of a cognitive skill for many of our individuals. So she really has to put her folks in the exact scenario. She gave me a very specific example of she's working with her folks and she gives them the FES. So she's evaluating how fearful some of her folks are doing certain activities. So she does everything she can to create an obstacle course in her clinic that mimics what she is fearful of in her environment so she can build her confidence with her patient. That FES score did not go up at all. The FES scores, typically when she sees with her folks, do not improve until she puts her patient in exactly the scenario. And perhaps that means actually taking her patient outside to do a nature walk. And she actually sees herself in that scenario in the clinic because it is the exact same as what she is encountering at home. So my call to action for you all is this. I want you to think about lift with the barbell, but also lift the grocery bags. What could that look like? If you were in an outpatient clinic, I would love to hear some people start to bring in functional objects into the clinic. Many folks that we talk to across the country are telling us that they have spent so much time trying to convince their managers to put a squat rack in the clinic. Keep going after that. Keep being the squeaky wheel because it's so beneficial to have a squat rack and a barbell. However, the barrier a lot of the time, our managers are saying it's too expensive and why do we actually need that? Okay, so while you're working on that goal, what if you brought in stuff from your garage, right? Stuff that is readily available and it's not very expensive. If you're like me, I would go in my garage, my husband has a lot of stuff in there that I would want to just get rid of. Maybe I would go and try and do a little clean sweep of stuff in my garage, bring it in with some buckets, bring in some functional objects. Maybe I go and I buy a bag of mulch, right? Maybe I go and I bring in a laundry basket. Start filling your clinics with this stuff. They're readily available to most of us, and it's offering the opportunity for older adults to start lifting in a different way, a way that could be more approachable. And you could start to get further with them right out the gate. SUMMARY All right, y'all, that's all I have for you this morning. I love if I could hear any of you start to talk about how maybe you're starting to use some actual meaningful functional objects in the clinic. If you have any questions, comments, I'd love to talk further about this. Have a wonderful rest of your Wednesday. I will leave you with what is coming up within the older adult division. So the rest of July, is it? It's not even July yet. For the month of July, we're almost there. We have several courses, so we will be in Virginia Beach, we will be in Victor, New York, and then our whole team will be in Littleton, Colorado, for our MMOA Summit, which is gonna be awesome. And then our next L1 course, our eight-week online course, starts in August, August 14th. PTNIS.com is where you find all that info. Have an awesome rest of your day. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 24, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of our lead faculty within our pelvic health division. Sorry for coming on here a little bit early. We are in the throes of young kids finishing school and trying to work around new schedules. So apologies for being a little bit early. But today what I wanted to talk to you all about was what do we really know about resistance training in pregnancy. And as many of you who have kind of followed the podcast in the past know, I'm a postdoctoral research fellow at the University of Alberta looking specifically at resistance training in pregnancy, which means that a big part of my job in my postdoctoral fellowship is to be very aware of the state of the literature and then where my role is as a person trying to build a program of research to be able to add to the existing body of literature. And I'm going to start this episode talking a little bit about my story getting into this because I think that it's relevant. So my PhD research was in high load resistance training in a geriatric population. I love my older adults. You know that I'm part of the older adult division. And I had two children while I was going through my doctoral studies. I was going part time. And then I was also a national level weightlifter before I got pregnant with my daughter. So I was doing a lot of heavy resistance training during my pregnancy. And I had a committee meeting during my pregnancy talking about, you know, obviously that I was going to go off on that leave, et cetera. And one of my committee members, whose name is Stu Phillips, many of you know him from the protein metabolism and resistance training literature. He said, you know, Christina, if you think that there isn't any research in loading the older adult appropriately, wolf when it comes to what we know in pregnancy. And I thought that was super fascinating and of course being the nerdy researcher that I am, I looked into the research and I recognized that he was right. And So I kind of want to talk today about what we truly do know, what the state of the literature is, a little bit about me trying to change that, I'm going to talk a little bit about some of my research studies, and then where we can go going forward. So we know in a general population that resistance training is one of the best things that we can do for our overall health. I don't tend to try and put people into specific buckets that you have to exercise in a specific way because the best exercise is the one that you do. But in terms of longevity and maintaining independence into older age, supporting whatever exercise you like to do with resistance training is definitely a recommendation that I'm gonna make with a lot of passion. Whether you choose to prescribe to that exercise program or not, Resistance training is one of these exercise modalities that is going to allow us to have independence. It's going to stave off a lot of chronic disease and musculoskeletal injury. And we know that, you know, the best exercise program is the one that we start as early in our life as possible and go into older adulthood. I'm going to try and put on as much muscle mass as I can before the age of 40 and then hold onto it for dear life into hopefully 100. And so we have a lot of really positive evidence for resistance training in a general, like reproductive age population, but then also into older adulthood. We've talked a lot about it in the Jerry segment. But when we don't have evidence, right, around exercise, or we don't have any evidence in any type of intervention in pregnancy, we freeze, right? And I say this all the time. If we don't know, the answer is no. and when we aren't sure we freeze, which is where bed rest and pelvic rest recommendations have come in when complications can creep up in pregnancy because we don't really know what we can do, right? We're not really sure what we can do. So we want to give a recommendation that we're doing something. And so we pull people back from activities of daily living, sport, exercise and we say like, let's not do anything because you know, there's this complication happening. And where evidence is starting to show now is that many of our complications have pro-inflammatory cascades and therefore exercise might be a really important mitigating factor or modifiable influence on a person's experience of complications during pregnancy. But the baseline is that if we don't know that the answer is no. And so that knee jerk reaction has trickled into a lot of our recommendations around exercise in pregnancy and specifically around resistance training. So when we look at public perception of resistance training or exercise in pregnancy in general, it's really interesting because aerobic training is generally seen as more positive as something that you're doing to benefit the health of mom and baby. But there's a lot of fear-focused messages that are put into the resistance training space. And gosh, we've seen this all the time, right? Like we see when a person lifts a heavy deadlift and they're pregnant, like go into the comment sections and you just are gonna heave because you see everybody telling you that your baby's gonna die and that you're being reckless and all this type of thing. And so if we're going to combat these messages, and we know that the perception is generally more negative because of a lot of fear and thoughts of danger around resistance training and pregnancy, we have to one, know where the state of the research is. And then two, we have to build levels of evidence that are going to gradually gain us more confidence and being able to remove some of those fears around resistance training. I've done podcast episodes before where I talk about risk tolerance of providers to allow individuals to flex their own decision making during pregnancy and how in low to moderate intensity exercise, we tend to feel very good in that risk tolerance zone, but where we get a little squeamish is in these higher intensity zones. Part of the reason for that is the state of the literature currently. So right now I can't speak specifically to my results because I haven't published this yet, but I am working on a systematic review on resistance training during pregnancy. And we have pulled about 50 studies on resistance training during pregnancy, which sounds like a lot, which it is. And it's been a lot of work to get the systematic review under control. But what we have noticed and what I have seen over and over and over again is a couple of things about the resistance training literature. Number one is that we have very few studies that look at resistance training in isolation. And you may not think that's necessarily a bad thing, because a lot of people are exercising in multiple modalities. Think about functional fitness, they're doing aerobic training and resistance training. But when we know that there's a lot of incurred benefit of aerobic training, especially when it's dosed appropriately, there's an interference effect that we see in the literature. So what I mean by that is that we know that there is benefits of aerobic training on rates of gestational hypertension and preeclampsia. We know that individuals who respond and continue to do aerobic training have less rates of gestational diabetes. We know all of these things already. So when we put in a known benefit and then kind of add in resistance training, we can't say with confidence that resistance training reduces our risk of gestational diabetes because we know that aerobic training does and aerobic training is in that multi-component program. So it's a big issue right now that we don't have a ton of research that's on resistance training in isolation, because then we can't isolate and say resistance training benefits X, Y, Z outcome, and aerobic training, there may be overlap, and they also do X, Y, and A, B, C, but without studies done in isolation, interventional studies done in isolation, we can't really say that this is incurring some sort of benefit. The second thing about our current state of the literature is that the resistance training research is unbelievably underdosed. So I'm gonna make a comparison for you. So the evidence that we have right now around resistance training in those with congestive heart failure in their 70s and 80s is higher dosed than a lot of the resistance training literature in pregnancy. Let me say that again. A lot of our dosing for resistance training is higher in our older adults with frailty, multi-morbidity, and complexity than it is for our uncomplicated pregnancies. When I am looking at that research, that makes me sad, and it just shows how much we need to do. When there is a randomized control trial that comes out in 2024, and the aerobic dosing is 70 to 80% of heart rate reserve, which is a great intensity for the aerobic training, and the resistance training part of the exercise program is using a yellow Theraband, I see red and I start to rage. And so the dosing here is unbelievably poor, especially for somebody, right, who we are not thinking has low musculoskeletal reserve going into their pregnancy, right? In general, individuals are not having trouble with activities of daily living as soon as they find out they're pregnant. And so we are going in almost with this assumption that individuals who are pregnant cannot have higher loading on their skeleton. And we're worried about strain, but a strain is not happening on the body with a yellow TheraBand for a person who's of reproductive age who is pregnant. Like that is not an appropriate dose. And so it's concerning that there is not an appropriate dosage for our resistance training interventions, especially when it is dosed appropriately. the aerobic side. So this brings me to our next problem. is if resistance training isn't dosed appropriately, if I am getting an individual who is pregnant with no complications to do a 16-week exercise program where the max amount that they are allowed to lift is two kilos or 4.4 pounds, and I wish I was lying about that prescription, can I realistically, as a provider and as a researcher in that space, say resistance training was the part of that exercise program that incurred the positive benefit? Right, going back to my first point about how when we have multi-component programs and there's a known benefit for aerobic training, it's hard to see the additive effect of resistance training. In combination with the fact that the resistance training prescription is not sufficient, what I would deem sufficient, to drive musculoskeletal adaptation or maintenance to prevent deconditioning in a pregnant individual. That creates a problem. It creates a problem and it creates all the downstream issues that we're seeing where pregnant individuals are restricted, right? Like when our max is a yellow fare ban on a 2024 randomized control trial, that don't lift more than 20, don't lift more than 30 pounds. that's gonna hold, you know, that's not gonna get better because we don't have any evidence to back us up, right? And so this is like a call to action around how we need to change some of our thought processes around the way that we are prescribing exercise for pregnant individuals, but we also need to push back on academia and be like, hey, like, this is not okay for this to be the state of our literature because I hate that I have to say this and my postdoctoral supervisor and I were having this conversation. Do we even have enough evidence in resistance training in pregnancy to truly be able to include it in our guidelines? And the answer is we don't. Not really. We're extrapolating from our general population literature and we're saying, well, based on some of the preliminary literature we have right now, light toning exercises seem to be okay. Literally the term in a big conglomerate of our RCTs was saying that they did aerobic training and light toning for our resistance training interventions. That drives me. It drives me with just unbelievable amounts of passion about why it is so important for this clinician science bridge to happen. It is why I will not step away from literature and doing research because we just need to demand so much better. And so what does that mean going forward? we need more research in this area. And so that is where my postdoctoral work has really taken off. So when we are thinking about our literature base, when the state of the literature is a two pound dumbbell, and I'm saying, I want to do an RCT where women are deadlifting over a hundred pounds, you can imagine that that amount of gap can create issues with an IRB board or an ethics board saying, whoa, whoa, whoa, whoa, whoa. We don't want to put mom and baby at risk. here's what we need to do. And so because of that, we need to build layers of evidence. So if you guys remember from your schooling, right, we have our levels of evidence from level five, which kind of our clinical commentaries, our professionals who are doing this in practice, that when the evidence isn't there to back us up, and then we go retrospective, prospective, RCT, and then systematic reviews and meta-analyses are kind of at the top of this evidence pyramid. And so when we are trying to build an area that does not have a ton of research to back us up, we need to start building levels of evidence. And that's what I'm trying to do. And so this started with our cross-sectional survey. You've heard us talk about this on our podcast, this podcast in the past, where the first thing that we have to do is show that there are individuals who are heavy lifting during their pregnancy. And so the cross-sectional survey that was published last year was the first step in that process. say, hey, look, we put out a survey for a couple of weeks online. We got almost 700 women who had lifted heavy during their pregnancies to tell us about their experiences. Great. Look, there's this need. They are very confused about what they're allowed to do and what they're not allowed to do. Like they're getting advice, like don't lift more than 20 pounds. Two, if you were doing it before, you can continue doing it now. Just don't strain your body. And even the strain on the body is a little bit question marks because, you know, there's so much that goes into it, et cetera. Right? It creates a situation where we recognize that there is a need because there is an absence of literature and there are people who need the answers to that. The next part is that we're going to start doing retrospective data taking and so right now I have two research studies that are open for enrollment and I am going to beg all the clinicians who are listening to this if you have a person who fits these bills if you could please please please send them our studies because I hope that the first part of this podcast tells you that there is just so much we need to do. There is so much that we need to do in this area, and I need your help in order to do it. So our retrospective study is taking individuals who have given birth within the last year and tracked their exercise through a training app. So if that was Wattify, if that was an Excel spreadsheet, if that was, you know, pen and paper, whatever it may be. If you tracked your exercise during pregnancy, specifically your resistance training, and you gave birth in the last year, we want you in our research study. So what we're going to do is we're going to ask you a whole bunch of questions about your pregnancy, your labor and delivery, how you felt about it, all those types of things, and then we're going to ask you to upload your training logs. And so what we're gonna try and do is descriptively see how did people modify? Are there any issues with resistance training that are popping up as patterns that clinicians or providers or obstetricians need to be aware of? And then how can we use that information to start help counseling individuals on strength training during pregnancy? And so that's a retrospective study. We also have a prospective study that is open for analysis. This is gonna take me about three and a half years to get out, but that is okay. So we are taking individuals who are less than 20 weeks pregnant, so in that first trimester, first half of their pregnancy, and we are following them forward over time. So every trimester, we are asking individuals questions about exercise during pregnancy, and we are asking you to upload your training logs. And so what that's going to do is it's going to build on our level of evidence, right? So now we have cross-sectional snapshots in time. There are recall biases that happen with that. We have our retrospective study that because we were using the training log, that recall bias is worked around because we have evidence of what they did over time. And then the prospective study, we are getting their thoughts in real time going forward. And so now we've gone from a level five of evidence and we're going to be pushing up to level With that evidence, my next goal is something interventional. Right now, we're going to have this building of evidence that we're seeing that is going to allow me to apply for funding for a randomized control trial that looks at different dosing schemas for individuals who are deciding that they want a resistance train during their pregnancy. SUMMARY And so if you have any individuals or if you are listening and you are in one of these two camps, I would love for you to join our army to try and build the level of evidence on resistance training in pregnancy. It is so necessary. It is so needed. And we are going to be leading the way in our pelvic division. We are very actively involved in research. Obviously, I'm a postdoctoral research fellow, so I'm there in the weeds of it, but also our other faculty are involved in the trenches as well. And it's just so, so, so important that we do this the right way and that we gradually build a level of evidence. And I am not okay with where we are right now. We need to do better. I will be part of the trying to make this better. And I'm recruiting you all to my cause to try and help me out. So I will post these research links in the captions, or you can head over to my Instagram at drchristina underscore private, and you can hopefully sign up for some of our studies. All right, if you are wanting to hear me get all fired up about other stuff or you wanna hear some of our faculty on the road, we have two courses in July that are still open for participation if individuals wanna sign up. I am in Cincinnati, Ohio. That is a smaller course. So if you are interested, July 2021, I'm in Cincinnati, Ohio. If you are interested and you are closer to Wyoming, we have a course July 27th, 28th in Wyoming. If you cannot get on the road because of kiddos like me who is coming early because kiddos are home for the summer, we have our next online cohort starting July 6th. So we are past 90% sold out for that course. So if you are looking to get in, please don't wait because there may not be the opportunity and then you'll have to wait until the fall. All right, that's all I got. 19 minutes. I'm sorry, I just get so passionate talking about resistance training in pregnancy. I hope you all have a wonderful week, and we'll talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 21, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the importance of incorporation, the difference between various corporate structures, and secondary benefits to incorporation Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Practice Management and Fitness Athlete Divisions. It's Leadership Thursday. We talk all things small business ownership, practice management, tips and tricks, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. So Gut Check Thursday this week comes courtesy of street parking. If you don't know street parking, It is an at-home functional fitness crossfit style program designed for people who are primarily working out in the basement, the garage, the barn, whatever. A bunch of different options, at-home programming designed to do by yourself or maybe with your spouse or your kids or something like that. So this workout was sent to me by our very own Dustin Jones, division leader over in our older adult division. 12 rounds for time, 5 double dumbbell hang power cleans right into 7 double dumbbell front squats and then drop the dumbbells and do 9 box jump overs. Recommended weights, 50's for guys in the hands, 35's for ladies. and then a 24 inch box for guys and a 20 inch box for ladies. So go there, you're trying your best to hold on to a minute per round, maybe faster if you can really cycle those dumbbells really fast and you're light on your feet and springy on that box and definitely trying to get done under the 15 minute mark. So remember, you are rewarded for participating in Gut Check Thursday. Post your time lapse on Instagram. tag us at ice physio hashtag gut check Thursday you'll be entered into a weekly drawing to win a free ice t-shirt that will mail out to you so that is gut check Thursday today we're talking about incorporation do's and don'ts so we start our brick by brick course with this topic. This is a very important topic. I believe this is a very overlooked topic. I think this is an area of practice management where we can think it really doesn't matter. We can get really sloppy with how we incorporate and our incorporation type, if we incorporate at all, and I think it's really fundamental to understand why we incorporate, how we incorporate, and one of those benefits that you may not know that will result in you hopefully paying less tax money each year as a benefit of incorporation. WHY INCORPORATE? Let's start with why do we incorporate? Who cares, Alan? I'm seeing patients at my CrossFit gym or I see a couple people from my run club or whatever. I see them on nights and weekends. What does it really matter? Is it worth paying the $50 to my state to form a corporation? Short answer, yes. We talk a lot in Brick by Brick that becoming a business owner, even if it's not a full-time thing, even if you never plan to grow your practice beyond yourself, the whole idea behind being a business owner is to really look at and evaluate where are those areas that have maybe even a small degree of risk but that has a really simple, easy, low cost, time and or money solution to eliminate that risk. And owning a business, running a practice is really about minimizing that risk as much as possible because why not? Why carry a bunch of risk even if it's a hundred different amounts of really small types of risk? if you don't have to. And incorporation is one of those risks. The cost of forming a corporation is something that you can do in every state on your own. You don't need to hire a lawyer. You don't need to pay $1,000 to LegalZoom. We show you in Brick by Brick that it's a form usually on your state website. It's something you can fill out yourself. It's something that might even be free, especially if you're a small business owner, you're a first-time business owner. Something that you can knock out as simple as a couple minutes. In some cases, have your incorporation documents back instantaneously. So you're thinking, in some states, five minutes and zero dollars to form a company that is going to go a long way to limit your risk. Let's talk about that risk. What is that risk? When you are running a business, if you are not incorporated in the eyes of the law, both the legal law as well as tax law, you and your company are not separate entities. You are what is considered a disregarded entity. You are somebody who has not formed a corporation. You and your company are the same person, the same entity, and that carries a lot of that risk that we were just talking about. If you were to be sued for whatever reason, your business assets can be held liable to cover whatever you might be sued for personally, and vice versa. If someone falls in your parking lot, if a robber tries to break into your clinic and falls through the window and cuts their arm on your window glass and sues you, Your personal assets can be used and seized to pay for the outcome of that lawsuit should you lose. And that is because you have not legally separated yourself, the individual American taxpayer, from your company, your business. And again, that process is very, very, very simple, often quick, often very cheap to do. And so we always, always, always encourage people Even if you are seeing one patient a week, one patient a month, you are just a side hustle, seeing patients five to 10 hours a week, even if you never plan to grow beyond yourself, you plan to just essentially be self-employed, spend the 50 bucks, spend the 100 bucks, spend the 10 minutes, spend the hour, and incorporate so that you create that legal division between yourself and your business. Your personal assets are protected when the business gets in trouble, your business assets are protected when something may happen in your personal life. The last thing you want to do is have your house seized because maybe somebody slipped on the ice in your parking lot which you have no control or responsibility over and yet here you are having your personal assets seized because you have not incorporated. DIFFERENCES IN CORPORATE STRUCTURE So looking at a corporation, what are the two major types that we see with physical therapists? These are going to be state dependent, but you are going to form some type of limited liability corporation. The reason, again, we do this is right in the name of those companies. We are limiting our liability. So we can either form a limited liability company, LLC, or in some states, Physical therapists may be required to form a Professional Limited Liability Corporation, PLLC, or sometimes called Professional Corporation, or PC. What are the differences? They're important and it's important to know them. I'll start with this, you should always form an LLC and not a PLLC if you do not need to form a PLLC. The major difference between these two corporation types is that in an LLC you are protected from malpractice and fraud claims against anybody else in the business including yourself as a personal practicing physical therapist working in your own business. Now in a PLLC, a professional limited liability corporation, what some states have done is said, hey, professional level folks, folks who are licensed professionals, whether they're healthcare professionals, mental health therapists, attorneys, dentists, whoever, anybody that is required to have a professional license in this state must form a professional limited liability corporation or professional corporation. Why? These states are saying, hang on a second, you should not be safe from committing male practice or fraud as an individual licensed provider, even if you are acting within the scope of a corporation. And so the difference between an LLC and a PLLC, primarily, is that you do not have built-in mail practice and fraud protection with that PLLC. At the end of the day, you have to form whatever your state requires, so if you have to form a PLLC or PC, you have to do that. But if you don't, you want to form that LLC. The second difference in a PLLC is there is a big con, and it is that everybody in the company, anybody who will ever have ownership stake in that company, has to be from the exact same profession. So for a while, ICE was a PLLC. We are now a corporation, an inc, if you will, but we were a PLLC, which means that Jeff Moore was our owner. He's a physical therapist and because he formed the PLLC and he was a physical therapist, no one else could have ownership stake in the company that wasn't also a physical therapist. So that's something to keep in mind, especially if you're going into business with a partner, that partner must be a physical therapist. If you are also a physical therapist, if you were to sell the company, you would have to sell it to another physical therapist. If you were to pass it on to your children, or your spouse, or any of those things, everybody would have to be from the same company, or you would have to dissolve and reform the company. If you're dealing at all with any sort of contract insurance or whatever, you want to avoid obviously dissolving your company, losing your business, losing your business name, losing your tax ID, all that sort of thing. So we want to avoid dissolving our company if the company is changing hands under good terms. And so that is the second con of a PLLC. But again, if you have to form it by your state law, you have to form it. So LLC versus PLLC, if you're able to, always choose LLC, but recognize you might have to choose PLLC. TAXATION BENEFITS TO INCORPORATION And now the final benefit, a benefit that's not talked about a lot, is one of the reasons, aside from protecting yourself from legal liability, is that there are a lot of taxation benefits to forming a corporation. This is really hard to understand, but if you have been alive for a while, you recognize that this is naturally true. America is built to service companies. There are a lot of legal benefits. There are a lot of tax benefits to owning a company. Even if you don't own a giant company like Amazon or Tesla or something like that. Even if you own your own small business and you're your own employee. there are a lot of taxation benefits to incorporating as an LLC or a PLLC. The primary benefit is that you can elect something called S-corp taxation. This is a form you fill out with the IRS, form 2553, and this is not a different type of corporation. What this is doing, back in 2016 under President Trump, a law was passed where we can elect to be taxed as an S-corporation. What does that mean? It means we are eligible for pass-through taxation. Instead of paying a 21% flat corporate tax on all of the revenue that our business makes, and then paying it to ourself, paying it to others, and having those folks pay income tax on that money, avoiding that double tax is the result of something called S-corp taxation. And so, your company does not pay tax, it does not report anything to the government, you pass through your revenue and expenses to your personal income tax. What does that do? That provides us with two main avenues for benefits. The first is it lets us enroll 20% of all of the business expenses over to our personal income tax as a deduction. Now that's pretty huge. As you're starting, you may not spend a lot in your business, but if your business grows to multiple people, you will find yourself spending tens of thousands and hundreds of thousands of dollars in expenses. What's nice is that 20% of that can get pulled through to your personal income tax as a tax deduction. And so you get to stack that on top of all the other stuff you write off. As a business owner, you have a lot more leeway now of other stuff you can write off. You can write off anything that you may have spent money on that's a reasonable business expense. And so by having a business, by being incorporated, you're able to write off a lot more things and overall pay a lot less income tax than when you were an unincorporated personal citizen just paying taxes. That is one of the primary benefits of spending the time and money to get yourself incorporated. SUMMARY So incorporation, do's and don'ts. Do please incorporate. If I haven't stressed it enough, it is a relatively cheap, quick process that gives you a lot of legal protection. It also gives you a lot of taxation benefits that should see your tax bill be lower once you own a business and are incorporated than before when you were not incorporated and you were just a private citizen paying taxes normally. So if you have Deeper questions about this, our Brick by Brick course starts again July 2nd. We go really deep into the weeds on topics all like this. We talk about incorporation, we talk about whether or not you should work with insurance, we talk about how to work with Medicare either in network or taking cash. and we get into the nitty gritty about a lot of business topics so that at the end of the eight weeks, you feel really good about starting your practice or at least understanding the steps you need to take to start your practice. So if you're interested, we'd love to have you. Again, the next class starts July 2nd. I hope this was helpful. Have a wonderful Thursday. Good luck with that Gut Check Thursday workout. If you're coming to Michigan this weekend for the Fitness Athlete Live Summit, we'll see you tomorrow. Have a good weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 21, 2024

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses programming and starting to fill more of a coaching role that can be an excellent way to continue to help runners beyond formal clinical care. It can also be a fun way to diversify your revenue streams and supplement your clinic income. Start thinking in 3 tiers for offering either endurance or strength programming (or both!) 1. Generic 2. Semi-custom 3. Fully custom/interactive Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. RACHEL SELINA All right. Good morning, everyone. Welcome back to the PT on ICE Daily Show. My name is Rachel Selina, and I'm happy to be your host this morning. We're here for Fitness Athlete Friday. And with that, we're going to jump into the topic of programming, but not looking at it from like what the programming actually consists of. but more so kind of how do we, how do we market that programming and what is it as a service that we're actually offering? Okay. So we, we talked about this at the sampler this year, um, about starting to find ways to diversify our revenue streams. Um, mostly from the standpoint of like avoiding burnout, but also like it brings you more income, hopefully doing something that you enjoy. Doing that's kind of a change from your normal. I always think it's kind of funny. I'm definitely someone who likes diversification So I end up having like I have like six different Roles or six different jobs and so trying to explain to someone like hey, I thought you were a physical therapist It's like what I am but I also I also do this or I also do this I also offer this and to me that That helps me. I like being able to work with people in lots of different capacities. So as we're talking about our endurance athletes, we're going to look at how do we use programming, kind of both the endurance programming, like our aerobic training and strength training and offer that as a service. And one of them that we'll dive into is like, yes, it can be an additional revenue stream. But I think from a performance standpoint, it's also really helpful for our patients because if we think they're ending formal care and we can send them out and still have a way of being in contact with them, like if we have designed their next training program, right, they're done in the clinic, we're not seeing them on like a regular basis anymore, but they're following a program that we wrote, they're more likely, if something comes up like, hey, my Achilles started bothering me, instead of waiting for it to be like a big deal, Um, I think it's more front of mind if they're following something you designed for them to think like, Oh yeah, I could reach back out to Rachel. Like I could ask her about this. Um, or just being in that more constant contact, but in a non nonclinical standpoint. So I think it, it helps our patients as they're going back into their training, um, to just have that kind of touch point or remembrance, um, that we're here, um, and we can help them with that. So from a performance standpoint, they're going to, be involved with us and be in that more constant communication so things don't go unchecked for such a long time. So that I think is helpful from the performance standpoint, but then there's also lots of ways that we can offer programming and kind of our particular take on it and what good programming could look like. because we have that background, we have that knowledge instead of someone just going, not that there's, you know, not good plans on the internet, but someone just going and getting programming from a random other person or from, you know, someone who's not familiar as much with how to kind of work around injuries or prevent injuries through what our programming is doing. So if we, if we think of that, like our aerobic programming first, okay, like what's the, How many days a week are they running? Are they training for a half marathon or a marathon? I think there's really three levels of programming we can offer and I kind of think of it tiered as how much input it takes on my end. So the first tier would be I write a program and I keep it very general. Like it's not for a specific person. It's I have written a marathon training program and I have available whether it's on my website or Instagram or whatever, however you want to sell it. Like I have available a half marathon and marathon training program that anyone can just buy. Um, or maybe I offer it for free. That's an option too. Um, but someone just buys it and there's no other input from me beyond that. I wrote it. Um, and I think with that, like it's very hands off. Um, here, this is what you're getting. This is what it is. Go do it. Um, I think with that though, like we're in a good spot to be able to do that because we can design a program with all of those good like principles of progression, kind of making sure we're not progressing too much, too fast, keeping pace under control, all of that, but it's not specific, right? This is a very general. I think if you're going to, even if you offer it for free, right? You could still have on that program, right? At the header or something like that. Like you can still have your name, your clinic info, something. to that nature, where again, every time that person looks at that program, they're seeing your name, they're seeing your clinic, and just being that point where you're front of mind, right? They can't get away from you, in a good sense. So that's kind of our first tier, something very general that's just put out there, anyone can buy, there's no other input to it. If we take it a step up, okay, that next step, that next tier, I think is semi-customizable. There's now a person in front of me who has a goal. So this now is Sarah, who's going to run a half marathon. And Sarah wants to run it at whatever pace. She wants to run an eight-minute pace. I can take that program, that general program, and adapt it to what Sarah needs. So I can put specific pace goals in there. I can put… you know, Sarah works late on Tuesday, Wednesday, Thursday, so she needs shorter workouts on those days. Like I can, I can change some aspects of that program so that it is specific to the client or the patient. But then beyond that, it's not, there's not anything else beyond that. I'm not, you know, I'm not in weekly check ins or anything like that. It's here's a program that's Tailored now for you. So semi customizable I think is that mid mid range and then if we were to go one more step Okay, like someone who wants everything I think of fully custom training programs And this is where they're bringing you on a more of like a coaching role. So I've written their programming But I'm also now having regular checkpoints, right? It takes a lot more on my end because I can't just do it and be done. It requires a constant kind of back and forth and checking in on how the training is going. Are they progressing appropriately? How are they tolerating it? And making those kind of week by week changes. And this, I'll think of using this if someone has very specific goals, like it's not just here's the race and here's the pace I want. But if there's a lot of elevation involved, or altitude involved, or multiple disciplines, or just something very, very specific. Or if someone really wants that more constant touch point, this is where we'll start thinking of fully custom programming. And then in terms of, like, you're obviously going to charge different. Like I said, that first tier, if you're just putting a general program out there, you might choose to have that be a free resource for people. because you know they're going to keep seeing your name, and that might be all you get from that, which is perfect. For a semi-customizable one, I usually think of charging per the time it takes me. So if I usually have a set cash rate in my clinic for an hour, and writing a custom training plan takes me an hour and a half, I'm gonna charge an hour and a half of what my usual clinic rate is. So I'm making sure that I'm compensated for it, and it's not taking away from my other my other revenue generation. And then fully custom, I think you have a lot more flexibility here for what what you want to charge, because it's going to depend on how much of your time it's going to take. So that can be I think you can either do it on a month to month basis or think of it as like a training block, which is usually helpful with our endurance athletes because they're usually training in those blocks of like, I have four months of you know, training for this one particular event. So maybe you do a particular like four month payment for whatever you think your time will be for that, that given goal. So that's kind of our that's our aerobic training. I think we can also look at this for strength training. And in a similar sense, like I'm not going to break it down quite as much, but you can have different levels, like you can have just a general program of know two days a week of strength training that someone's going to do and they're going to do the same thing each week as kind of your lowest tier non-customized. But then you can take it up a step or and think of like I'm going to write specific workouts every week for again for Sarah. Sarah is going to get two workouts from me each week that are you know taking into account her strength level her progression and that would be a different a different cost, a different level than just that generic. Or you can also think of doing like a class. Like if you have the space to do a class, maybe you start to offer a strength training for runners class that meets either once a week or twice a week. And you have people commit to that timeframe, right? Because then you can block out that time in your schedule. You have maybe one or two hours during the week that you know are dedicated to that and getting people to sign up for that bigger block of time. But again, they're just they're all different ways to offer something that we have the skill set to do and probably do better than a number of people that are out there doing it just because we can take into account proper progression and loading principles. And if we're doing some version of the custom programming, we know how to monitor tolerance to training load and whether that adaptation is occurring how we want it to. We know how to modify Or work around injury and then if we're constantly involved with that person, right? How much more likely are they to to come to us earlier? Which is the goal like most people don't seek out care for an injury until it really stops them from running So if we can get to people earlier, right? We can hopefully keep them going just like we say we we don't want to like leave the gym when we're injured we we want to use the gym to help us with our injury and We can think of it the same way for running, like we don't want our runners to have to stop running. We want them to be able to work through that and keep running so they're not losing that capacity. And like I said, just determining your cost, like you have to decide what your time is worth and how much time each type of programming is going to take you. But I think it can be a really good way just to be able to think differently, to kind of activate a different part of our brain. Um, and it's really rewarding to be able to help someone meet their specific goal, um, and kind of see them from that whole, that whole longer term process. So just some food for thought, um, different ways you can start to diversify your income working with endurance athletes in a way that benefits you, but also really benefits your patients. Sweet. Um, we have some injured runner courses coming up. So if you are interested in our online course, that one, our next cohort starts July 9th. OK, that's our eight week online course. We meet every Tuesday. And then we have now several options coming up for Injured Runner Live. Our last two for this year will have the beginning of September in Maryland. And then we just added a beginning of November course here in Michigan in Grand Rapids. So we'd love to have you out at one of those if you're looking to dive deeper. into working with your endurance athletes. So that's all I have. I hope you have an excellent Friday. Hey, enjoy your weekend and hopefully get out there and go for a run. All right, bye everyone. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 19, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones shares tips to make HIIT more objective, being diligent with monitoring vital signs, and underdosing high-intensity with medically complex patients when needed. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. DUSTIN JONES Alright folks, welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the older adult faculty within the MMOA division. Today we are talking about the top tips to apply high-intensity interval training amongst medical complexity. So I think many of us have been there, right? We're working with that individual that has a whole laundry list of different diagnoses, different medications on board, maybe in a more acute setting. And we know that high intensity interval training is helpful for people. We've seen some literature, we've read some of the research, but what does it actually mean to apply this amongst a very complex situation? All right. So we're going to cover, some key takeaways from a super helpful article that was published last year in 2023 in the Cardiopulmonary Physical Therapy Journal titled, Putting It All Together, An Evidence-Based Guide to High-Intensity Interval Exercise Prescription for Patients with Complex Comorbidities. And I really appreciated the team that wrote this article because it is difficult to navigate, right? Like, we will see some of these headlines of high-intensity interval training proven to be effective in the ICU, for example, or HIT being effective with folks that have recently suffered from a stroke. Some of these things we typically wouldn't associate high-intensity interval training with, but it's been shown to be effective. Now, when we go to apply that, it can be rather intimidating, right? I can speak to this mainly from the home health setting where The trend in home health is that people are getting discharged from more acute settings like the hospital a little too soon, right? So you have these very medically complex individuals in their home with very limited monitoring, medical support if something goes awry, and all the negative thoughts and what coulds, right? What could happen starts to creep into your head, and that can dramatically influence our intervention. Let's talk about three, I've got three main tips for y'all, things that I have learned through mainly mistakes in my career, but then also what this article talks about. One is objectify, two is monitor, three is, I'm gonna save that one for last. BE OBJECTIVE WITH HIGH-INTENSITY TRAINING All right, so the first one, we go to apply high intensity interval training. We need to be objective. Here's what can typically happen. You read an article, you maybe hear a PT on Ice daily show podcast, see a social media post like, all right, I'm going to use this with Betty tomorrow. All right, Betty, we're going to do high intensity interval training. And you're already working on gait training, for example. with Betty and so you're going to be like all right Betty I want you to go fast for 30 seconds and then I want you to walk slow for 30 seconds we're going to do that for a total of 10 minutes right great start I love what you're doing there you got a one-to-one work rest ratio it's already a goal that Betty has to improve her ambulation ability, maybe even distance endurance. Awesome. But what typically happens, right? She goes to do her fast walk. What does that actually look like? Is it fast? Or is it just slightly faster than her normal or a slower walking speed? All that I'm saying here is when, say ambulation, when we aren't objectifying it, when we aren't giving people a number to hit, to look to, to get that real-time feedback loop, they will often undershoot their intensity. This is where the ergometers that many of us have access to can be very, very helpful. A lot of these things are, they're collecting a lot of dust in a lot of clinics, to be honest, right? Like the new step. It's either collecting dust or we're throwing people on there for 20 minutes while you finish your notes or they take a nap, right? We got our recumbent bike. Maybe you have a rower, maybe you have an echo bike, maybe you have a ski in your clinic, but these are functionally all ergometers that are measuring work, they're measuring speed, they're measuring distance traveled. Those are objective metrics that we can use for dosage, that we can use to give people that target to try and hit to make sure you're reaching an intensity. Right, RJ, outpatient, has an Echobike. Echobike, you look at that screen, you've got calories, you've got watts, you've got your revolutions, right? You've got your distance. These are all things that we can use to set a goal to achieve appropriate intensity while we're performing our intervals. So RJ, for example, with the Echobike, it may be watts, right? You may say, pick a number of watts that you're trying to hit. during that 30-second interval and then it's going to be 30 seconds easier, 30 seconds rest for maybe like a total of 10 minutes with someone. Giving them that objective thing to look at is going to be so much more effective than just quote-unquote saying go faster, all right? NuSTEP has the same thing, right? Many of you all have already, I shouldn't say wasted the money, the NuSTEP can be helpful with certain patient populations But my gosh, the price per square foot of a NuStep is absolutely ridiculous. But if you already sunk the money and have one, freaking use it, man. That thing has all kinds of data and information that we can use to really redeem the NuStep, redeem that piece of equipment and achieve a higher intensity. All right? That's the first one. We need to objectify what that high intensity actually looks like. Use ergometers. If you don't have the ergometer, maybe use something like a percentage of a heart rate, for example, some other metrics that we can use to objectify. MONITOR VITALS Speaking of heart rate, number two is going to be monitor. Now, this is what really allows us to apply higher intensity intervals with medically complex individuals, is when we are monitoring Vital signs and signs or symptoms. Vital signs are absolutely huge especially in so many acute settings. Hopefully many of you all are getting them at rest initially, hopefully at least bare minimum at the initial evaluation, right? But when you're working with more acute individuals, you have these complex comorbidities. We need to be checking vitals every visit, but then when we're applying these high intensity intervals, it can be very helpful and advantageous for you to check vitals before, during exercise, and then after to gauge their response. Now I'm not saying check every single vital sign, right? But there's gonna be some pertinent ones based on who you're working with, right? So like if I have someone that is constantly cruising, you know, in the 150s over 90s blood pressure, they're pretty hypertensive. It's not managed terribly well. They sometimes have some symptoms, but a lot of times it's asymptomatic. I'm going to be checking blood pressure pretty regularly. I'll also be checking their heart rate as well. And I can do that during, and before, during, and after an interval. That's where these ergometers can be really helpful. Like a new step, for example, when I program that interval, they're working hard, but then they have that rest. That rest is when we check our vitals. I'll support their arm, get a manual blood pressure reading, and you're going to be able to gauge their response and make sure that you're in a safe zone, right? And the way we like to think about these zones is we like to think about them as traffic lights. So there's a red light in terms of things that you may see where we're going to stop exercise and a yellow light where we're going to be cautious but proceed and then green is just full send. We go into those in our Level 2 course, related to resting vitals, exercise vitals, signs and symptoms as well, related to high-intensity interval training. But for our purposes here, we want to monitor during, so you'll have a good idea of how they're responding. Another one is if someone has some type of cardiopulmonary issue, then a pulse ox can be really helpful, looking at oxygen saturation. We can see their response, make sure we're good to go, and we can adjust our dosage based on that. when we're able to monitor those vital signs it's going to give you an objective view of what's actually happening and I don't know about y'all but here's what typically happens with me is I may throw someone on a new step for example a recumbent bike and we're doing high intensity interval training and I know they've got some cardiopulmonary issues on board, some things that I'm somewhat concerned about, and I literally tell them to go hard. I may give them, you know, hit this number of watts during these hard intervals, and I literally am closing my eyes, crossing my fingers, praying to the rehabilitation gods that something bad doesn't happen. But if we're able to monitor and get that objective information, you can rest assured that you're giving that person exactly what they need, and it is safe. UNDERDOSE THE HIGH-INTENSITY FOR MEDICALLY COMPLEX PATIENTS Alright, so first we need to objectify it, second we need to be able to monitor it, and then third and the counterintuitive one, but it's the reality when we're going to apply high-intensity interval training amongst medical complexity, is that we need to underdose. I hate to say it y'all, but we need to underdose. Oftentimes, I'm not gonna say always, but oftentimes these folks are have a lot on board, right? And from the medical side, but then also from the psychological side, you take someone that has been given the diagnosis of heart failure and imagine what that feels like, right? You may have some perspective of what that actually means, a prognosis of that and what people can continue to do with a diagnosis like that. But there's so many individuals that will get these seven syllable medical diagnoses and they literally view it as a death sentence and they're actively falling apart right in front of your eyes. And that is not necessarily the case. There's a lot of psychological damage as well as physical damage along with these medical complexities. And it can be very advantageous when you introduce something novel and new like high intensity interval training to do it in a very approachable manner. This is where I am typically when I'm introducing I may use something like a subjective report, like an RPE, a rating of perceived exertion. That goes against the first thing I said, right? I told you you need to objectify it, but maybe initially, we want them to be a little bit more in the driver's seat and give them that RPE. You may say, I want you to go hard, I want you to go fast, I want you to go at a seven out of 10, RPE of 10 is your all-out effort, right? Initially, I think that is helpful. But we don't want to stay there because most of the time, people's true high intensity doesn't necessarily match up with their perception of high intensity. And that's where we need to be objective to calibrate that. But initially, I think under dosage, self-report can be very, very helpful. We also need to consider what these high-intensity intervals can do to people outside of our session, right? I learned this the hard way way too many times in home health, where we'd have this epic session. We'd be gone for about 20, 25 minutes, high-intensity intervals, you know, doing steps or ambulation, and then we do some transfer training. I'd take them, walk them out to their mailbox and back. They haven't seen the sunshine in weeks. Man, it was an epic session. And then I come back in a few days. What has that person done since that session? Nothing, right? They weren't able to do their laundry. They weren't able to do any tasks around their home. they were laid up because I absolutely gas them. And so we want to be able to leave gas in the tank for many of these individuals to be able to do things that are really important to them like ADLs, like IADLs, maybe a certain social function, right? And so when we start with that under dosage, you will be able to tweak and progress without impacting the rest of their life too much. which is really important. Many of you all may not have experienced that, right? I think many of you all probably did MRF, right? Memorial Day, high volume, you're working real hard for, you know, 40, 50, 60 minutes, maybe more if you're me, right? How'd you feel after that, right? Many of you all, myself included, were absolutely wiped and that's what a 10-minute session can do for some of these individuals. SUMMARY So, We may want to introduce it in an underdosed manner, see how they respond, make it approachable, and then gradually progress it from there. Then we start to objectify it, give them that target for, I want you to hit this many watts, for example, or this many revolutions per minute. And then we continue to monitor their vitals before, during and after those intervals, and you've got a potent cocktail that can really influence people's functional capacity, but then also the disease process that they are suffering from, and most importantly, it can be safe. All right, let me know your thoughts. Let me know any tips that you have from applying high-intensity interval training amongst medical complexity. I would love to hear from the folks in the ICU, in acute care, in skilled nursing facilities, in acute rehab, where you're dealing with a lot of medical complexity. Love to hear from you all. Drop in the chat on this Instagram video, or if you're watching on YouTube, if you're listening on the podcast, we're grateful for you listening. Hop on social media, and I'd love to hear your take as well. Hope this was helpful. I'll also put the citation for the article, the really helpful article, in the comments on Instagram as well. All right, hope you all have a lovely rest of your Wednesday. Go crush it, and I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 18, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses addressing shoulder mobility in wrist pain patients. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. CODY GINGERICH Good morning everybody. My name is Cody Gingrich. I'm one of the lead faculty with the extremity division and I am coming with you today on a clinical Tuesday and we're going to be talking about treating wrist pain at the shoulder. All right we're going to be tackling shoulder but treating the wrist. Okay. So wrist pain going after the shoulder to deal with wrist pain. This is a big deal when we're talking specifically about, um, a fitness athletes. Okay. So The reason being, the fitness athletes, people who are lifting in the front rack position, so think our Olympic weightlifters, our crossfitters, people who are just really working a lot of front rack position or overhead movements in general, are going to really benefit from these type of things, okay? So, couple things that I wanna start with and why it is important to look at the shoulder when someone is coming in with wrist pain. In the extremity division we talk about wrist pain a lot of times and most most of the time a lot of different presentations of wrist pain are going to be due to or need more wrist extension. It is going to be a wrist extension intolerance and that is largely going to be the case when we're talking about what we are today as well. With these barbell athletes or overhead athletes that need a good amount of wrist extension to get into good front rack position, or if we were thinking about handstand walking or handstand push-ups or pressing weight overhead, we also need a good amount of wrist extension tolerance to support our body weight overhead. Okay. And a lot of times when these people can come in, we can get pigeonholed into just looking at the wrist and be like, okay, well we're lacking some wrist extension and we need to treat that and we need to calm that down. And we, we stay in our lane right there at the wrist. But what I want to talk about today specifically is going to be really addressing shoulder mobility. in order to free up some space at the wrist. So I have a couple of, uh, I have a PVC that hopefully y'all can see, and we're going to try to show you, um, why in a non-adequate shoulder mobility can end up putting way more stress at the wrist with these athletes, even if they have a pretty good amount of wrist extension. Okay. So when we're talking specifically about the front rack position, I've got a PVC pipe here. So one thing is going to be where we're starting with is going to be if we have a lack of lap mobility, a lack of lap mobility is going to not allow our elbows to come forward and up as much. Okay. And so what that leads to is that barbell then sits way more on our wrist and hand than it does on our shoulders. PVC, I got to kind of tuck my chin down and get it there. But the more that we can drive our elbows up, the more that weight then is supported by our shoulders in that good front rack position. If we don't have the ability to really turn our elbows up high and we keep them low because we don't have that mobility, then most of that weight then comes through our wrists. And even if we have good wrist mobility, that is still a ton of pressure there coming through the wrist joint. The other side of things is we also need shoulder external rotation in that front rack position to distribute the weight that's going through our wrist more evenly. So the other front rack position that I see where if we can't get our wrists and our hands out here, we end up with our wrists right over our shoulders and maybe our elbows even just outside, just like this. And what that does is it forces extension and rotation at the wrist and ends up putting a ton, a ton of stress through that radial side at the wrist. Whereas if we can then open up that shoulder external rotation, that then can distribute the weight more evenly. We can have a flat palm. and a flat wrist into extension. So the other thing when we're talking about getting overhead, I mentioned handstand walking. If we don't have adequate shoulder flexion and we are overhead, that leads us to be here and we still are trying to get our feet up and over our body to walk forward. And that then requires a significantly amount more wrist extension if we don't have all of that shoulder flexion. If we can gain more shoulder flexion then at the top we don't need to roll over our wrist extension quite as much. So a couple different ways and that could also be a lat mobility problem as well. So what I want to encourage you is we have several tests If someone comes in and they're saying they've got pain with these particular movements, right? First, make sure that they have that adequate wrist extension. And the best test we've got for that is really going to be have them place their hand on a table and then see if they can get their elbow beyond 90 degrees at the wrist. Even right at 90, they probably have enough wrist extension to be able to calm those symptoms down, even without gaining wrist extension. So you can still make gains in their pain and treat their wrist pain, even if that wrist extension is a little slower to come. It is typically easier to treat soft tissue mobility restrictions than it is joint restrictions, typically. So a lot of times in our athletes in this population, those shoulder mobility limitations are oftentimes going to be soft tissue related. So we want to then check shoulder mobility. The best test for that, to check lat mobility, is going to be the seated wall test. So if you have the person sit up against the wall, back as flat as they possibly can, PVC pipe then in their hands, palms down, and reach up can they get their knuckles to the wall? If they can, have them then turn those palms up and reach again. And if they come up short of the wall, we can be confident that there is some lap mobility restrictions on board. Okay, that is going to be a situation where treating the shoulder and the lats are going to be a really great way to address the wrist pain, because that will then allow those elbows to come up higher, take stress off of what the wrist is going to have to take on. So if we can decrease stress at the wrist by increasing shoulder mobility, we are doing a good job bumping that wrist pain forward. That's going to address both the elbows high in the front rack position and oftentimes the stacked overhead position when people are going handstand pushups, handstand walking. So we can kind of knock out two birds with one stone by really looking at the lat mobility. Secondarily, we can also look at shoulder external rotation. Okay. Now this could be a mobility issue. This could also be an external rotator strength issue. Okay. But to check the rotation can have them in supine, bring them to this position and then passively rotate and see if they have that mobility to get into that external rotation. If they don't, if they can't access that external rotation in that 90-90 position, we are going to want to start working into that external rotation. That can be with some contract relax. We can do the classic PVC stretch where we work this way and try to warm that up ahead of time before they get into that front rack position. we can also work some like band work in this position working out again contract relax or have the band pulling here stretching out some of those internal rotators and then we can go x internal rotation and then we do eccentrics into external rotation with a band moving that direction that will help to open up some of that external rotation specifically in that front rack position. Okay, so what that will do then is again in that front rack, get us from instead of this position, it will get us more that position and more evenly distribute that weight across the wrist as opposed to it digging into one side or the other. SUMMARY So overall, If someone comes in with wrist pain, and specifically that wrist pain is happening when they're in a front rack position, when they're putting a bunch of weight on their hands from doing handstand walking, handstand pushups, go after and look at the wrist absolutely, but absolutely don't neglect looking up the chain and looking at shoulder mobility, shoulder strength. If they don't have adequate lat mobility to get their elbows through in a front rack position or full shoulder flexion in that position, look first at the lats. See if we can't gain some shoulder mobility from that soft tissue, really be able to get in and through that elbow, take off some of the stress from the wrist. If they have a hard time getting their hands outside of their shoulders and big chest there, start looking at do they have adequate shoulder external rotation, either mobility or strength to be able to maintain that position and again, decrease the stress from the wrist. If you don't hit that and they don't have that ability, you can treat the wrist all day long, but they are going to continue to just keep pissing that off because they don't have any way to overall decrease the stress that that wrist is taking on. Once we can find that root cause of why that wrist is taking on so much weight, then we can start increasing the tolerance to that wrist extension. So we can start mobilizing there, we can start adding back like a plate carry where we're working here, we can spin that in different ways, all of that, and we can then start working at the wrist. But if we don't clear the shoulder first, you're going to be fighting a losing battle overall, because we haven't addressed why that wrist is taking on so much weight and getting irritated in the first place. Okay, so I just want to keep keep y'all's heads involved as far as don't always get tunnel vision onto one joint, right? We always want to look up the chain and seeing if there is something going on that we might be missing. That's all I got for you for today. So again, just as a quick recap, someone coming in with wrist pain, specifically our barbell athletes going overhead, we really want to clear lap mobility and external rotation mobility at the shoulder and make sure that those things are clean so that we can decrease the stress being put on the wrist. If you want to catch extremity man My last minute plans that you can make it to there. Otherwise, we will be in Kent, Washington on July 13th and 14th or Hendersonville, Tennessee on July 20th and 21st. We hope to catch you out there. We have a ton of different, all of those exercises and techniques that I just talked about are in that extremity course and we go into them in much more depth. So we'd love to catch you out on the road. All right. Hope everyone had a great day. Thanks for listening. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 17, 2024

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Heather Salzer discusses tips for designing home exercise programs for newly postpartum moms, including removing barriers to movement, being smart with the structure of the HEP, and encouraging habit stacking. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. HEATHER SALZER Good morning, PT on ICE Daily Show. I'm Dr. Heather Salzer and I'm here with the pelvic team at ICE. And today we are going to be talking all things home exercise plan for the new mom. I think this is an area where we can do better as clinicians. Oftentimes I hear, man, my postpartum population just really doesn't do a good job doing the exercises I give them. This is a group where they have a lot going on, right? So oftentimes we just assume, okay, well, they don't have time to add in these extra things. And that's where we're wrong. I think if we meet them where they're at and set them up for success, not only will they have small wins of being able to accomplish, that part of their rehab plan, but also we're going to see better results with our care plan from there. This is a topic that's very near and dear to my heart. In clinic, I treat about 70% pregnant and postpartum individuals, so I've had a lot of time to help these people figure out how can we best increase compliance and set them up for success with their exercises. Additionally, I am about four months postpartum with an adorable little daughter at home, but she certainly takes up a lot of my time. And so in the last few months, I've had some experience using some of these same tips and tricks that I use with my clients for myself to be able to get in some of my rehab as well. So this is a topic that's fresh on the mind for me. We're gonna divide this up into about four different sections of tips today. So we'll be talking about workout structure, removing barriers, habit stacking, and managing expectations and how you can use these areas to help set your clients up for success. Let's dive in. WORKOUT STRUCTURE So first of all, workout structure. I am a huge fan of using time-based workouts or home exercise plans for this group. And the reason is then they know, man, I only have five minutes, but I can sneak that in right now. And so within that, I like to keep it 10 minutes or less. And if it's somebody who's wanting more, you can give them several segments of five minute or 10 minute things, but that way you at least know like, okay, let's at least try to get these five minutes in. So what does that look like? I will use a lot of remands, so rehab every minute on the minute, and set them up with maybe three exercises, and we'll do that two times through, or three times through, and so that gives them either a six minute or nine minute workout. Another thing in this postpartum population that I'm a big fan of is the Tabata, so 20 seconds on, 10 seconds off. One specific example of something I give people a lot is some variation of that hollow hold and Superman hold. I'll set this up, what this looks like is eight rounds, so four rounds of hollow hold, four rounds of Superman hold, and we'll do that for 20 seconds on, 10 seconds off, and you can scale it up or down. So maybe that hollow hold in the beginning is just lifting one leg and focusing on kind of finding that core tension. Maybe we're progressing it all the way to a hollow rock. Similarly with the Superman, we can lift just the arms, lift just the legs, and then talk them through what are the progressions across this. And then four rounds of each, flip-flop back and forth or do all four hollow, all four Superman, and in less than four minutes, like three minutes and 50 seconds, right, they'll get a really effective both core workout and some blood flow to that posterior chain, which can be both important areas with this group. If you're like, man, I don't know, Heather, I don't know if that's really enough of a workout, I challenge you to try it today and choose a level that feels difficult for you, wherever that may be along that spectrum, I bet by the end of four minutes, you're gonna be like, oh, yeah, okay, I can see how that could work. So using those time-based intervals can be huge in this group to help set them up for success when we're thinking about workout structure. REMOVE BARRIERS TO MOVEMENT Second, we're gonna be worrying about removing any barriers to set them up for success for getting their workout done. A big piece of this can be equipment or space. So if all of their equipment is in their garage and they have a garage gym set up, but it's hard for them to hear their baby from the garage, they may be avoiding going in and using that space. So can they bring their dumbbells in, maybe just one set of them, program everything with one weight to start, and put them by the couch? Make that more accessible. Maybe we're using baby for weight instead. Little one doesn't want me to put her down. So instead, let's hold her. Let's see what we can do with that baby, using the baby for our weight instead. Another thing, if you're a new parent or have been around new parents at all, I'm sure you've heard the words tummy time. So I love utilizing this time that mom is going to be on the ground with her new baby as a way to get in some of our exercises as well. So we're kind of removing that barrier of like, all right, you're already going to be there. Let's set this up. So what this could look like is maybe we're working on some C-section scar tightness. So while baby's on the ground, working on baby's tummy time, mom can do the same. She can be down there doing some gentle Cobra stretching. Maybe we're taking that opportunity to slow down, take some deep breaths, get into happy baby, child's pose, do some side planks, get creative with it. What does your patient need? But tack it onto that time. And yeah, tummy time is a great opportunity to sneak that in. So really think about what's their setup at home? How can, like ask them, where do you envision yourself getting these things done? what will make space or what will make sense with your space and then work with them with that. HABIT STACKING Number three is going to be habit stacking. So this ties a little bit into what we were just talking about tummy time, doing their exercises while they're already doing something that they're doing that day. I first kind of heard the term habit stack from James Clear's book, Atomic Habits. And I love this concept where we take something that we are already doing across the day, and then we add our new thing that we want to do on top of that, and it's gonna help increase our ability to get that new thing done because we already have established that other habit. So in the postpartum population, there is a lot of things that happen routinely across the day, and so let's take advantage of that, right? Tummy time was one example. Another example of something that I give a lot in clinic is when we're dealing with like shoulder tension, maybe we're spending a lot of time breast bottle feeding, holding baby, coming forwards, and I want just more blood flow to kind of open things up and get them moving across the day just to get them out of that position. We always say your next posture is your best posture, right? So Can we figure out where they're spending the most of their time nursing or bottle feeding or whatever that looks like? And can we set a heavy resistance band by that? And every time they do that, which is probably gonna be every one to three hours in the beginning, that's a lot of times, can we do some banded pull-aparts just to get increased blood flow to their shoulders, neck? with that. Maybe we're not doing this in the midnight feedings. Maybe we're just encouraging like 50% of them, but that's one example of how we can get that in. Some other things that I like are adding things on with diaper changes, another thing that's going to happen routinely. If you're wanting that person to work on kind of establishing connection with pelvic floor and you think that doing some pelvic floor contraction Kegel work is appropriate, you could time that with a diaper change. So every time you change a diaper, give me 10 to 20 pelvic floor lifts. Another example I'll use is every time you make coffee or go to heat up your coffee in the microwave because it's gotten cold and you are now heating it up for the third time to hopefully drink it, can you do a set of lunges or squats in the kitchen while you're making that coffee or heating it back up? Get creative, ask your clients what are you doing across the day And if I give you this to try to do on top of it, do you think you'll have the time and space for that? Use habit stacking to your advantage. Lastly, and I think most importantly, is managing expectations. These people need wins. They need to feel successful. And they need to know that it's okay if they're not hitting this every day. So I talk a lot with these people in this group about consistency over time. That if you miss a day, if you miss a week, if life gets in the way, let's talk about what happened where we weren't able to get to it, but also let's not worry about it too much. Let's jump back on it. Because in the longterm, over the next few months, if we can be doing this a couple times a week, even for five minutes, three to four times a week, we will see change. So first of all, just setting them up for success, knowing that they do not have to be perfect with it, but then also kind of managing how fast they expect to progress with how much time they're able to put in. Because in reality, if we are doing five minutes a day, four days a week, can we expect really quick progress? Maybe not. Again, I would argue the exercise that we're getting done is always better than the one that's not happening. However, let's talk about what our realistic expectations of what we're kind of what we expect out of it based on what we're putting in. And let's really help these people have these small wins, feel confident with it. And oftentimes what's going to happen is you give them like four or five minutes of something to do. They're able to be consistent with that. They come back feeling great because they were able to do what you asked them to. And maybe they're already starting to notice a little change in their ability to contract the core again or connect with those muscles. And they're gonna come back and they'll be like, okay, I want more. How can we carve out more time? How can we make this maybe a little bit longer? Okay, now I think I'm ready to add a little bit more weight. So get that win, and then you can stack on. Always meet them where they're at. If they want more from the beginning, great, go for it, give it to them. But also, have a conversation, figure out what that looks like, and then from there, really kind of help work with them to figure out what the best plan is. Awesome. SUMMARY So in summary, we're thinking about our workout structure We are removing barriers to help them get it done. We're gonna give them opportunities to habit stack so that we can take advantage of the things that these moms are doing across their day already. And we're going to help them manage expectations, talking about consistency over time, and really setting them up for success. If you would like to learn more about working with this population, we would love for you to join us in one of our pelvic courses We have our next online cohort for level one starting July 8th. That's filling fast, so if you would like to get in on that, make sure you get grabbed your spot soon. And then we have two opportunities to join us on the road before long here. July 20th we will be in the Cincinnati area in Loveland, so jump on that course. And then we also have an L1 pelvic course or sorry, a live course July 27th in Laramie, Wyoming as well. So would love to see you online or on the road soon. And thank you for joining me here this morning. And I hope you have a lovely rest of your day. Happy Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 14, 2024

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses femoral neck bone stress injuries, including referral for diagnosis, potential treatment options, and rehabilitation & return to running. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Jaina. MEGAN PEACH This is your PT on ICE, the daily show. brought to you by the Institute of Clinical Excellence. My name is Megan Peach. I am one of the lead faculty for Rehabilitation of the Injured Runner online and live. And today I'm gonna talk to you about, no surprises here, bone stress injuries. But specifically I wanna talk to you about femoral neck bone stress injuries and what to do once you expect that your patient has a possibility of even having a femoral neck bone stress injury. because sometimes that decision on what to do might be a little daunting. And so I'm going to present this information in a bit of an algorithm format. And I'm not the biggest fan of algorithms because our patients don't often fit perfectly into the algorithm boxes that we need them to fit in to in order to progress along that algorithm route. But this one I actually think makes a lot of sense and I think it's pretty straightforward so hopefully it will be helpful for you in your clinical decision-making process. So I'm also going to make some assumptions that you have already done your subjective exam, you've already done your objective exam as well, and you are ready to make some decisions and you've decided that your patient has potentially a femoral neck bone stress injury. Now that part is really important because if you are even suspecting a femoral neck bone stress injury, then you need to consider it a femoral neck bone stress injury until it's proven otherwise. And that's important because as physios, we can't tell if that's a high risk or a low risk femoral neck bone stress injury. All we know is that there's potential there and one, they're treated differently, but two, the high risk can progress on to be a more serious injury. And so it's really important that we treat them as femoral neck bone stress injuries until that condition is proven otherwise, or it's proven as a femoral neck bone stress injury, and then we can move on in that treatment algorithm. So once you have made that decision, this person sitting in front of me is potentially a femoral neck bone stress injury or has one. The first thing we're going to do is refer them out to an orthopedist. They need additional imaging. And again, that's because we really need to determine one, if this is a femoral neck bone stress injury, and two, if this is a high risk or low risk, because again, they're treated a little bit differently. And so that referral to the ortho is going to jumpstart that part of the process where they can then get additional imaging. MRI is the gold standard to diagnose bone stress injuries. You could also refer them to their primary care provider. Their primary care provider can certainly refer them for an MRI, but ultimately they're going to go and see an orthopedist. And so it's nice to just take out that middle appointment and you can always communicate this information to their primary care provider, especially if they were the ones that referred them to you in the first place. Okay, so all of the patients are going to start out with their referral to the ortho, and then hopefully go for an MRI. Now the results of the MRI are really important because they're going to dictate at what path in this algorithm they're going to take. So I'm gonna give you three different scenarios based on the results of this initial MRI. The first scenario is that the MRI is positive for only bone marrow edema. It is a femoral neck bone stress injury, but it's only bone marrow edema. There's no fracture line. So this patient is then going to do six weeks of non-weight-bearing. Kind of a bummer, a hard conversation to have, especially if there's no distinct fracture line, but they still need six weeks of non-weight-bearing to prevent further progression of this injury. After the six weeks, whether or not they get a follow-up MRI is really dictated by that orthopedist and their experiences. Typically they don't if it is bone marrow edema only, And so at this point, they would likely begin a weight-bearing progression. And that weight-bearing progression is going to be gradual, likely over the course of a couple of weeks. After they are able to weight-bear normally, they're going to then start into a normal walking program and a formal rehabilitation program. With that being said, during that six-week period of non-weight-bearing, certainly they could do formal physiotherapy, but you could also send them home with exercises they can do on their own to prevent atrophy, to maintain the strength that they do have and the muscle mass that they do have. That, of course, is a conversation between you and the patient and the orthopedist on where they want to spend their time, potentially money, potentially number of visits for physio, because you know they're going to need them once they start that weight-bearing progression. I'm not going to talk a lot about the details of that weight-bearing progression because I want to stick to this clinical decision algorithm, but in that weight-bearing progression, it would then work itself into also a return to sport progression as well, but that's where it starts. Okay, so to summarize that first scenario, you have your patient, You have differentially diagnosed them with a potential femoral neck bone stress injury. You referred them out to an orthopedist. They had an initial MRI, which was positive for bone marrow edema. Then they did six weeks of non-weight bearing, and then they progressed into a loading program to get them to load normally and walk normally, ultimately probably run normally, and get back into the sports and the activities that they want to do. Okay, so the second scenario, we're going back to that first MRI. They come in with their results. Their results say that they now have a stress fracture, okay? And so this is a totally different scenario than the first scenario with bone marrow edema only. Now, the location of a femoral neck stress fracture is really, really important because that's going to determine whether or not this is a high-risk or a low-risk bone stress injury. So if the fracture is on the underside of the femoral neck, it is deemed a compression-type fracture, and it is going to be more low-risk. If the fracture is on the superior aspect of the femoral neck, it is deemed a tension-type injury, and that is going to heal a lot more slowly with a lot more difficulty. It is deemed a high-risk bone stress injury, and it's treated very differently from the low-risk or compression type fracture. So the MRI is going to describe the location of that fracture as well as occasionally the severity. If that person presents with a compression type fracture, so on the underside of that femur, and it is 50% or less of the width of the femoral neck, they are going to then, surprise, do six weeks of non-weight bearing, okay? And so they have a fracture line, but we're still going to treat them conservatively in this scenario. After the six weeks of non-weight bearing, typically they will have a second MRI or follow-up imaging. Occasionally that can be x-ray if they were able to visualize the fracture line on an initial x-ray. So a follow-up image, and based on the results of the follow-up image, they're going to be filtered into basically three different paths again. And so if that follow-up image says that they are making good progress and healing, so maybe we don't see a line anymore, maybe there's callus, maybe there's less bony edema, then we're going to filter them back into that progressive weight-bearing approach. And so the same thing that we use for scenario one, they're going to do a progressive loading program into full weight-bearing and then walking and then running and then return to sport, et cetera. Okay, that is if they were asymptomatic and they demonstrate healing on that follow-up image. If the follow-up image does not show any progress, it doesn't show any regression, it's just kind of stagnant, or the patient is still symptomatic, they're still having symptoms in that hip. Now, granted, they haven't been weight-bearing for six weeks. they're going to restart that six weeks weight-bearing. It is a tough, tough conversation, and nobody likes it. Not you, not the orthopedist, certainly not the patient. They're going to start that process over again, and they're gonna start back at the top of that six weeks non-weight-bearing, and then they'll likely have a repeat image at the end of that second six weeks of non-weight-bearing. I should mention here that I keep saying six weeks non-weight-bearing It's a start and I think it's important to educate our patients on that. It is just a start very often they will go into Longer durations of time non weight-bearing in order to treat this condition Okay, so the third scenario after the second image the follow-up image is that there is a regression and so this is not based on symptoms it is only based on that second image and this now shows a progression in the injury, maybe the fracture line increased, maybe the edema increased, but there's been some basically like regression in the issue. And so, or progression in the injury, however you want to take it. And so with this situation, unfortunately, they've now become a surgical candidate and they will likely stay under the care of that orthopedist. Okay. So to summarize that second scenario, They have come into your clinic, you suspect a femoral neck bone stress injury, you refer them out to an orthopedist, they come back with a positive MRI for a fracture line, but that fracture line is less than 50% of the width of the femoral neck and it is on the compression side or the underside of that femoral neck. They then do six weeks of non-weight bearing. They get a follow-up image. Based on that follow-up image, they will either continue in a progressive loading program in formal rehabilitation, repeat the six weeks non-weight bearing, and then do another follow-up image, or go on to be a surgical candidate, depending on the results of that second image. Okay, our third scenario. They come back with their first MRI, and the results show, again, a fracture line. This fracture line, though, is one of two scenarios. It is either a fracture line on the superior aspect of that femoral neck, which is a high-risk, tension-tight bone stress injury, or that fracture line is on the compression side, or the underside of that femoral neck, and it is greater than 50% of the width of that femoral neck. Either of these two situations, unfortunately, are going to necessitate, likely, a surgical intervention. So an open reduction, internal fixation, to stabilize that fracture and make sure that it doesn't progress into a more severe injury. The type of that ORIF is obviously very dependent on that surgeon as is the weight-bearing status post-operatively. So some will do non-weight-bearing for an additional six weeks, Some will do partial weight-bearing and then some will do full weight-bearing immediately after surgery. It is obviously just up to that orthopedist. And so that third scenario is quite short compared to the others. Your patient came in, you suspect ephemeral neck bone stress injury, you refer them out to the orthopedist, they come back with the MRI results with a positive for either a fracture line on the underside of that femoral neck on the compression side that is greater than 50% of the width of that femoral neck, or they have a fracture line on the tension side, the superior aspect of that femoral neck. Either of those two situations are then going to necessitate some kind of surgical fixation for that injury. Obviously, that is always a discussion between you and that patient and the orthopedist and whatever team they have around them in terms of if surgery is the appropriate intervention for them. Obviously, this is just a basic algorithm and then to help guide some of these clinical decision-making processes. Okay, so the themes in this algorithm that I want to highlight are regardless of what that initial MRI says, basically all roads lead to six weeks non-weight bearing. It's kind of an unfortunate part of this injury is that we definitely don't want this to progress from a low risk to a high risk bone stress injury. That's the worst case scenario because if we can prevent that in any way, even if it means six weeks non-weight bearing, we have to do that. So any roads, maybe with the exception of that third scenario where it just leads to surgery, all of the other paths essentially lead to that six weeks non-weight-bearing. So just know that that might be in their future. The other thing is, is that any progression that we do formally as informal rehabilitation after they've done their six weeks non-weight-bearing and they've been basically released to physiotherapy or released to progress to walking or weight-bearing, all of the progression has to be asymptomatic. Any progression that is symptomatic, creating symptoms in that hip, it must be backtracked. And so if they are initiating weight bearing and they are symptomatic, they're likely going to have to backtrack into a few weeks of non-weight bearing again. Really hard conversation again, but it's necessary in order to really prevent progression of this injury for obvious reasons. So the two themes, six weeks non-wavering and any progression must be asymptomatic. SUMMARY All right, that is the content I have for you today. Just want to make a couple of mentions of our upcoming Rehab of the Injured on our online course. We are currently in the middle of our, our current cohort is right in the middle of this session and All of the online cohorts this year have been on our new ICE app, which has been fantastic. It is really generating a great online community of therapists that are interested in treating endurance athletes. And so we've had some good discussions on there and it's really just fostering a great community. So if you haven't already taken Rehab of the Injured Runner online, I would definitely encourage you to do so. Our next cohort starts, I believe, in June. We will see you there. I can't wait to see you there. And have a great Friday and a great weekend. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 13, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses 5 tips to begin to get more comfortable with technology & improve your productivity Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, P10i's Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan. Happy to be your host today here on the PT on ICE Daily Show. It is Leadership Thursday. We talk all things practice management, small business, ownership, and leadership. Today we're going to be talking about a bunch of technology tips. Today is Thursday, though, which means it is Gut Check Thursday. We've been waiting to post this workout for a while. Our CEO, Jeff Moore, requested this a couple weeks ago. An interval workout every three minutes for five sets. You're gonna complete 50 double-unders, and then you're gonna hit a 400-meter run. Already, those of you that are less cardio-inclined are thinking, ooh, gonna skip that one. So our goal of that workout is obviously to get done before the three-minute mark so that we have some rest. So trying to get those double-unders ideally performed unbroken. and then completing a fast 400 meter run, trying to get done maybe between two to two and a half minutes so that we have 30 seconds to a minute of rest, and then really trying to hang on and be consistent and not let that building fatigue slow us down too much. We have a bunch of different scaling options over on our Instagram page. If you can't do double unders, if you don't have any equipment, a bunch of different options on how to modify that workout. So remember, if you participate in Gut Check Thursday, If you record a time lapse and you post it to your Instagram page and tag us, you are entered into a drawing to win a free lead from the front or be about it ice t-shirt. So don't forget, there's a little something in it for you for participating. So today, we're talking about technology tips. Now, especially for those of you that run your own practice, understanding technology is really important because it's going to let you do a lot of stuff on your own that's going to save you time, hopefully, and also save you money. In our brick by brick course we talk a lot about how important it is that we become as a profession, especially those of you who want to run your own practice and run your own business, become more comfortable with technology. The end goal of technology is that it lets us do more work in less time if we're doing it correctly and we understand the basics of technology and how that technology can help augment our back-end skills and our practice. Unfortunately, I would say as a profession, as a country, as a species, we are not very good at technology. And something to think about is that if you are 52 years of age or younger, you have theoretically had access to a computer your entire life. So very often we see folks say, Oh, I'm, I'm too old. Like I'm too old for technology. And then I find out that that person is like 42 years old and they've, they've been using a computer most of their life. And it's a lot like a car, right? You can understand how to drive a car, but not know how to fix a car, how to optimize driving your car. And it's possible for two truths to be present at the same time that you understand how to drive your car in a legal manner, in a safe manner, but also that you have no idea how your car works, how to fix it, maybe how to become a better driver, that sort of thing. And we see that same comparison with technology. THE IMPORTANCE OF TECHNOLOGY As practice owners, and even as clinicians, and maybe if you never have a goal of owning your own practice, we need to understand the expectations that the average consumer has around technology. 95% of Americans have high-speed internet access. That is almost everybody. 92% of Americans have a smartphone that connects to the internet, and 77% of Americans want to communicate digitally with their healthcare provider. They want to do self-service stuff, book their own appointments, pay their own bill online. They want to text instead of call or talk to you in person. They want to text or email. So understanding where we're at in 2024, we have a consumer base who has a really high expectation that not only are we going to understand technology, that we're going to be able to offer those services through our clinic. That folks can go to our website, book their appointment, text us a question about their homework, and maybe engage with us on an app. And we really, really need to become more technology forward if we're going to meet those expectations of our patients. Some folks are worried about artificial intelligence about robots. We always see these blog posts of our physical therapist going to be replaced by AI or robot. And if I've learned anything over the past 10 years or so, it's that people hate robots. We've certainly gone through our phases here at ice with chat bots and things like that. And overwhelmingly people want to talk to people So I don't think we need to be worried about being replaced as a profession. I do think you need to be worried about how somebody who understands technology better than you having an easier time running their practice with less expenses in a manner that is going to create a gap between you and them competitively. And technology can help you close that gap. So you'll find yourself working harder or paying somebody else to do this stuff for you. if you don't become more comfortable with this stuff. So today, I want to talk about five different tips that are really, I think, going to dramatically change your understanding of technology and really help dig away at that gap that you might be perceiving in productivity of are there programs, are there apps, are there software? that can help me be more organized and be more productive? The short answer is yes. So we're gonna talk about what is a computer, what are the parts of a computer that are important to understand as far as maybe purchasing a new piece of equipment, understanding how and why different pieces of software can help your practice, password keychain, things like Boomerang, which is an extension we'll talk about for your web browser, for your email, and how to do things like bookmark folders. WORK IS ALWAYS FASTER ON A COMPUTER THAN A PHONE So let's start with tip number one. This is tough for us to understand, especially those of you, you might be in your twenties maybe and you've had a smartphone your whole life. Computers, a laptop or desktop computer will always be faster than a cell phone. Not only will it be faster physically, what we call the hardware, it will run smoother, with the software, the pieces of technology, the graphical interface we interact with will be better, but you are able to type faster on a computer and overall be more productive on a computer than a phone. So phones are great for looking up the weather, getting directions to go to dinner, answering a short text message or something like that. But they're not great for a couple things. Number one, writing out long messages. You've all probably found yourself looking at a paper sent to you via Instagram messages or text message or something. You're thinking, gosh, not only is that going to take me forever to read, it's gonna take me forever to respond to on my phone, and you're not alone in that feeling. We've actually studied this, a really cool study, Palin and colleagues from 2019, looking at what is the speed difference between typing on your phone and typing on your computer, and finding that the slowest phone typer is only typing 13 words per minute, and the fastest computer typers are typing over 100 words per minute. that's a 615% speed difference. This paper going on to summarize that the average person is 25% slower trying to work on a phone versus a computer. So sometimes we're out and about, we don't have a computer with us, we don't have a way, even if we have our computer, to maybe get it connected to what we need to do and our phone is our only resort. But this first tip, if you have a computer near you and you're trying to do something on your phone, it's going to be a lot faster for a number of different reasons for you to just get on the computer so when in doubt switch to that computer you'll be amazed at how fast much faster you get relatively simple tasks done like answering a longer email like logging into a website or something like that so keep in mind that all pieces of technology are created first on a computer. They are optimized to work on a computer. Humans type faster on a computer. There are a number of different ways about why you'll be faster and you'll get more work done in less time if you can get on a computer versus trying to do everything on your phone. And that can be a big mindset shift for a lot of people thinking that phone is the best option or maybe the only option when they might literally have a computer within arm's reach. UNDERSTAND YOUR HARDWARE My second tip is understanding what is inside of your computer or phone can go a long way especially if you're making a new purchase to understand what makes a quote-unquote good versus a quote-unquote bad computer. Understanding we have four main components that matter that can change as far as hardware is concerned when you're looking at a new computer or phone. The processors or the central processing unit or CPU is one of them. The RAM, or the random access memory, is another. The video card, or what's sometimes called the graphical processing unit, or GPU. And then your hard drive, where things are actually stored. And so, understanding these components, understanding why usually more is better, is really important in having an actual computer or phone that can do the work you're asking of it. So the central processor, the processing unit of a computer, is running what's called operations per second. This is very similar to our brain. I love the comparison to our brain. The human brain is conducting one exaflop of operations per second. That's one billion billions every second. So a processor in a computer is a lot like nerve conduction velocity in your brain. Now compare that 1 billion billions to a fast modern desktop or laptop computer that's only processing about 36 billion operations per second. So 1 billion billions versus 36 billion. So human brain much faster, desktop computer not so much, but the only thing slower than a desktop or laptop computer is a phone. It's a myth that the phone in your pocket is the supercomputer that is equal to a desktop or laptop computer, and that's simply not true. Why? Size. Your laptop, your desktop can fit more stuff in it, and the stuff that it can fit is things like more processing units. So the iPhone 15 can only run 15 billion operations per second. So the average laptop or desktop computer can process two to two and a half times faster than your phone. So again, another argument to whenever possible switch from your phone to your computer. When you're shopping for a new laptop or desktop computer in 2024 we want to see 8 to 12 processing cores and we want to see each of those cores be able to process at least 3 gigahertz that's operations per second. So that is something you could find when you're looking to purchase a new computer. Often one of the first things you're shown is the brand of the processor, how many processing cores the computer has, and how fast each individual core is. Again, this is the case where more is better. The second most important hardware piece of a computer is the RAM, the random access memory. This is the thing that allows those processing cores to pull up data and begin to do operations on it. So I like the comparison to RAM is your brain's ability to multitask. It is your computer or your phone's ability to multitask. If you're somebody that keeps 700 tabs open in your web browser and you're always complaining about how slow your computer is, it stutters, it's slow, it freezes up, it locks up, it shuts down, it turns off, whatever, that is because you are asking your computer to multitask beyond its RAM's capability. Again, this is a case where more is better. More RAM, more multitask ability. In 2024, we want to see a computer have at least eight gigabytes, eight GBs of RAM or more. A really high-end desktop computer is going to have 32 to 64 gigabytes of RAM. You're going to be able to watch a TV show on one screen, process a video on the other, have a third monitor where you can still do email, and you're not going to really experience a slowdown. Vice versa, if you don't have that much RAM, you're not going to be able to multitask as much. So RAM is really important. The third component is a video card or that graphical processing unit. This is the piece of equipment that generates all those outputs from the processors and the RAMs into what you see on the screen, on your phone screen, on your laptop screen, on your computer monitors at home, on your desktop. Again, here more is better. Graphical processing units or video cards have processors and RAM built in them. Bigger is better. The more processing power your video card has, the quicker you're gonna do things like process and edit videos. So if you are someone that is doing a lot of video or audio editing, you're making content maybe for your clinic's blog or your clinic's social media, you want a computer that has a really nice video card. It's going to make it less work for your computer to do that. It's going to get it done faster. If you've ever tried to maybe render a video on an old computer, it can sometimes take hours. And during that time, it is consuming so much processing power from your computer, you often can't do much with that computer. It's slow, it freezes, whatever. You basically have to set it and leave it alone until the video is done. So if you find yourself doing a lot of video editing or you want to do a lot of video editing and you're a market for a computer, you want a really nice graphic card. And then finally, hard drives. Hard drives are not as important as they once were. We have cloud storage now. Basically, you're storing your files on somebody else's computer when you're using cloud storage. But having a solid state drive, an SSD hard drive, is really important. Hard drives used to be mechanical. They used to have gears turning. They used to have literally etching of your data ones and zeros into a physical thing inside of your hard drive. If you're old like me, you remember when your hard drive was about to fail, it started to make a lot of clicking noises, right? It was literally running out of space to write and do that physical gear turning. In today's day and age we have solid state drives. There is no physical gears present. That means that hard drives are faster, it's easier to access memory, it's easier to pull up stored files, and overall it's not, again, as big of a deal in the era of cloud storage, but having a big hard drive and making sure it's a solid state drive is going to go a long way to making sure your computer runs very fast. We're used to, and we want in this day and age, when we open up a program for it to load instantly, when we open up a website we want it to load instantly, and some of that comes from whether or not you have a solid state hard drive. So making sure you have a lot of processors, fast processors, you have a lot of RAM, you have a nice video card, and you have a big solid state hard drive are the four things you're looking for if you're going to be purchasing a new computer anytime soon. Remember, you get what you pay for. If you cheap out on this stuff, you should not be surprised that you have a device that is slow, that freezes a lot, that has a lot of problems. My last three tips here are all software-based. So tips one and two were hardware-based. Tips three to five are software-based. PASSWORD KEYCHAINS The first thing is to get a password keychain. What is this? It is usually a program or a web browser extension that remembers your passwords. So when you go to log into a website, it automatically remembers your username and your password, and your job is now just to remember one password to log into that program or keychain. It's a very secure way to remember a lot of passwords. I see people every day forgetting their password and spending time trying to reset their password, calling customer support, whatever, and otherwise spending a lot of time remembering passwords. The research would support that that is true. Research would say the average person spends 12 to 15 minutes a day or about 12 hours a year just trying to reset, remember, or obtain via phone a new password for a forgotten password. So if you know that's you, look out for your future self and your time and get a password keychain. I use a Chrome extension, a Google Chrome extension called LastPass where I just need one password. I can log into it from any computer or web browser that I have access to and it remembers all of my passwords. It generates random, secure passwords for any new account I create and remembers it for me, and I just need to log in with that one password that I remember. I no longer know almost all of my passwords anymore. They are randomly generated, they are secure, and they are automatically filled in for me when I go to log into stuff. So, a password keychain can make it so you get hacked less often, you are spending less time trying to figure out or remember a password, and again, overall improve your productivity, and your internet security. BOOMERANG FOR GMAIL Tip number four, an email extension, again for Google Chrome, called Boomerang. If you find yourself overwhelmed by email, if you know you see emails and you think, gosh, I need to respond to that, but I don't have time, and if you are someone who finds yourself very often forgetting to get back to those emails, then an extension like Boomerang is great for you. You can tell Boomerang to send an email back to you with a bunch of preset settings. Send this back to me an hour. Send this back to me in a day, a week, a month. Send this back to me on a specific date and time that I tell you. Send this back to me every day until I get a reply. So even if you're waiting on somebody else to reply to you, you can use Boomerang to keep track of your email. Boomerang also has a great feature where you can pause your inbox. So if you're somebody, you go out of town, you go on vacation, you go on maternity leave, whatever. and you don't have the self-control to not look at and answer your email, Boomerang can become your self-control. So you can pause your inbox, people who email you will just get a message that says, hey, this inbox is turned off, come back later. And so that can be a great way, instead of just maybe a vacation message, where you let people know you're not in the office, but you're still receiving their emails, if you know you can't stop yourself, use the pause inbox feature on Boomerang. BOOKMARK FOLDERS And the last tip here is stay organized with websites you need to access very often. You can create bookmarks both on your phone and on your computer. And on your computer, in your browser, if you use a browser like Google Chrome, you can actually create folders on that bookmark bar. have a folder for everything related to your clinic. You can have a folder for everything related to your personal taxes, to whatever you want. And now as you save and bookmark links, you can organize them by those folders and keep track and organized track of a lot of different websites that you might frequently visit in a very organized and logical fashion and whatever makes sense to you of how to organize and name those. So you can have Hundreds and hundreds of websites organized in a drop down folder by folder by folder across that bookmark bar on your computer. On your phone, you can bookmark anything you want directly to your phone's home screen. So a lot like apps that you use frequently, if there are websites you find yourself using often, bookmark those, create a shortcut, put it on your home screen so that you can just tap it and go right to that website that you need to visit very often. SUMMARY So, five tips. Thinking about hardware style, hardware importance, that you will always get done stuff faster when you use a computer versus a phone. A lot of that has to do with the hardware in a computer. A computer is always going to be faster. we're looking to make sure we have a lot of processing or cpu cores we're looking to make sure we have a lot of ram or ram that we have a big solid state hard drive and that we have a nice modern video card if we're going to be using our computer particularly if we're going to be doing a lot of multitasking we're going to be trying to answer email, and watch a meeting, and do notes, or we're doing maybe video editing, we're producing and cutting videos, maybe for social media, we want all four of those things on board. Software-wise, save yourself time, look out for your future self, get a password keychain like LastPass, get Boomerang for your Gmail inbox so you no longer lose emails, and you keep your emails more organized, you respond to your emails in a more timely fashion, and then keep yourself organized with websites that you visit frequently either using bookmark folders on your website browser on your computer or by bookmarking those websites and putting them on your phone's home screen. So I hope this was helpful if you're learning looking to learn more tips about how to be more efficient with business, with running your practice. Our next cohort of Brick by Brick starts Monday, July 2nd. The course is already over half full, so we hope to see you there. I hope this was helpful. We'll see you next time. Have a good Thursday, have a good weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 12, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett as she discusses experiencing loss, processing grief, and its impact on being a geriatric clinician. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our geriatric division and today I want to talk a little bit about grief. This is kind of a personal conversation, but it's also one that I think is really important when we are working with older adults. So personally, I've kind of been speaking a little bit on my social media. I lost somebody very close to me very recently. So I lost my godmother. She was my aunt. She was in my top 10 list of favorite people and she was somebody who had battled cancer a long time ago. They found out a couple of weeks ago that she had a metastasis in her brain and her first radiation she didn't do very well and she passed away like very very suddenly. And to say that this rocked me, like, I don't know if I'm going to keep it together on this podcast. I'm going to try. But to say that this rocked me was like an understatement of the world. And it was devastating. I'm still not OK. And it made me think a lot about grief. So I am 34 years old. And over the last two and a half years, I have lost three people that are really close to me. I lost an uncle that was my dad's best friend, my aunt who was my mom's best friend, which means that they were around us all the time, and I lost my grandmother who I was really close to. And as I was reflecting on this most recent loss, which my aunt was probably the closest person that I have ever lost, I reflected a lot on the process of grief and I thought a lot about how my older adults must feel. And so it reminded me of a conversation that I had with my grandmother. So my grandmother passed away just shy, a month shy of her 98th birthday. She lived a very long life. Her husband was alive until he was 93. And she was just this incredible role model of successful aging. somebody who was able to keep cognitive capacities, physical capacities in the realm of what she wanted for a very long time. And I was having a heart-to-heart with her one time, and I'm sure many of you have had similar conversations with loved ones that have lived a long life. And I said, you know, Grandma, I want to be like you and live to 100, because at that time I was certain she was going to be a centurion. And she turned to me and she said, you don't really want to live to 100. And I asked her why, and she's like, because everybody around you is dead. And to be somebody at, I'm 34 years old, to have had this feeling of accumulated loss, I'm only starting to potentially scratch the surface of what she could possibly mean and what all of our or so many of our older adults may be experiencing in their life. And so while I feel the acute sting of losing somebody really close to me, what I'm also like really recognizing is that there's also a accumulation effect that weighs heavily on my heart around having multiple people that I've been really close to that have passed away. And if I am feeling that at 34, I can only imagine how many of my older adults are feeling when it comes to, you know, they've lost parents, all parents, both parents, their in-laws' parents. They may have lost siblings or, God forbid, kids. Like there's friends and family, like you know, there's jokes around how our older adults are one of their social calls is going to funerals because they experience loss around them so frequently. And I never truly appreciated, I think, how much of a toll that would take on an individual's soul and their experience in some of their zest for life until I felt like some of the accumulated effects over a relatively short amount of time of experiencing a significant amount of loss. what this got me to think about is the way that we interact with grief with our older adults. And when we, really as a culture, how we interact with grief. And so I had one of our TAs, Rachel Moore, she's one of our lead faculty for Pelvic. We were having conversations about this and she said, you know, it's so interesting because everything else just keeps going and you feel like you're stuck in this loop of, oh my gosh, this person has left. And it's true, right? We are with individuals in that short amount of time where we're doing funeral preparations and all those types of things, but that grief weighs heavily on a person's soul and on a person's mind. And we don't really teach individuals how to deal with grief. And when it comes to older adults, we oftentimes think that this is such a normal part of the aging process that I don't think we ever truly hold space for individuals when they are dealing with grief. And so when I was reading a book called Breaking the Age Code, this really came front of mind. So we talk at an MMOA about the psychosocial considerations of working with older adults, about how it can be so great for us to put a heavy deadlift in their hand or get them getting up off the floor for the first time in a decade. And all of those things are really wonderful. But if there are other buckets that are just leaking because they do not have the financial resources, the mental resources, or the skills in order to help with these big buckets that are truly just hemorrhaging, then we're not really gonna give them the best type of care. And when I was reading a book called Breaking the Age Code, it really came front of mind for me about this. where when we look at mental health disorders, and not to say that grief is not a very healthy expression of sadness, but Becca Levy, who wrote The Code Breaking the Age Code, she's the one that we talk about with all of our ageism literature. She wrote a section in this book, her book on mental health, and she talks a lot about how the knee-jerk reaction with our older adults is to give them anxiolytics and antidepressants, without truly leaning into grief and leaning into talk therapies and conservative cognitive behavioral therapies that can just be so, so beneficial when we're working with our older adults. And she described some literature where she actually said, you know, many of our older adults may do even better with talk therapies than some of our younger individuals do because they're creating that connection so intensely. are craving those skill sets that they need in order to make it through their day because their grief is so heavy and your grief doesn't just last for two weeks. And so I was reading, kind of thinking about all this and the weight of grief and the thoughts around grief and how this relates to our older adults and how personally this is relating to me. I started reading a book called The Collected Regrets of Clover and there was a couple of things that they really talked about that I think is helpful for the way that I'm approaching now or thinking about approaching conversations with some of my older adults that I am working with who are experiencing loss or who have disclosed to me that they have lost a lot of people that are close to them. This book is it's fiction. It is so beautiful. It talks about a woman who is a death doula who basically comes and supports individuals through the end of their life. Similar to how a postpartum doula would help a new baby come into the world or a pregnancy postpartum doula, a death doula helps people end their life and end their life on their terms. And they talk about how when we're thinking about grief, First, it's this large weight that is on their frame. And as time passes, that big backpack turns into a purse. And what she's saying is that your grief is always carried with you, but the weight of it becomes easier to carry with time. It never goes away, but we start to be able to function in some ways with it. And I think that's really such a powerful thing to speak to. And when we are working with our older adults, they may be holding a lot of purses. They may be carrying a lot of bags of loss in the non-literal sense that can create this expression of apathy or a lack of engagement, which can sometimes create this space where it may be hard for individuals to engage with us in rehab. sometimes being able to dig deep into some of those considerations and create resources for them can be one of the best things that we can do. And so in this book, she had this quote and I read it on my Instagram a couple of weeks ago, but I'm going to read it to you now. And then we're going to finish off this podcast with a couple of things that I'm thinking about as a geriatric clinician to recognize that there is a lot of grief with our people that we are working with that we cannot see that are influencing who they are and how they show up in the world. And so in this book, this was literally the fifth page in. So if you're a fiction reader, this is such a beautiful book, but they said the most important thing is never to look away from someone's pain, not just the physical pain of their body shutting down, which we see all the time in rehab, right? But the emotional pain of watching their life end while knowing they could have lived it better. Giving someone the chance to be seen at their most vulnerable is much more healing than any words. And it was my honor to do that, to look them in the eye and acknowledge their hurt, to let it exist undiluted, even when the sadness was overwhelming. And so to put this into the context of rehab, I think there's a couple of things that I can think of as a clinician. And the first is that physical vulnerability and emotional grief, they are challenging to navigate. And we want to recognize that not only are we working with individuals who have low physical reserve, but there is an emotional piece of recognizing the loss of physical capacities and the emotional load of the loss of people that love them and they loved. as they get older. So my dad is 67. He has lost his mom, his brother, his best friend, and another friend from school in the last two years. And he's like, this might be it for me. All these people that I planned my retirement with are no longer with me. And I don't want to go to the golf courses anymore. I don't want to engage in physical activity because the people that I wanted to engage in physical activity with are no longer there. diving deep into some of those conversations, we say at MMOA to get truly curious, but not only physically curious about the things that drive individuals, but emotionally curious about maybe some of the things that are holding them back. And I think that can be a really, really wonderful way to get into some of the barriers and recognize that it's a little bit more complicated than them just not wanting to engage in doing squats with us, right? And so that's kind of number one. Number two is it's heavy for us to be able to listen to things that are really sad, but we can have a very big role in trying to mend and heal some individuals who do not have somebody to talk to. We have a loneliness epidemic in our older adult spaces, really all over our generations, but that is compounded, that loneliness is compounded when the people that you are not lonely with have passed away. And so recognizing trying to create resources, whether that is resources within the community like seniors associations or gyms where individuals can connect and have new kinships, especially in the face of loss when they are ready to. is one way for us to create resources and networks. But additionally, having a person that you can refer that is a psychologist, a talk therapist, a psychiatrist too, but where the knee-jerk reaction isn't just prescribing medications. And I am not anti-medication, do not mishear me, but I think that the addition of, you know, our conservative side, we talk about how we are not anti-surgery, we are conservative management forward. Why are we not applying this same mindset when we are working with our older adults who are dealing with really heavy emotions and maybe have never been taught how to deal with grief? I am a parent who is trying to not hide, but make appropriate the work that, you know, of grief and grief processing with my five-year-old. And I am acutely aware of trying to teach her skills to manage sad emotions. But so many of our older adults don't, they don't have those skills. And so it's important for us to recognize some of those resources. And so where I'm going to challenge you all today is one, to lean into these conversations if you have them with some of your older adults. But two, is to do a quick Google search to see if you can find a talk therapist in your area that you could have in your referral network when these conversations do come up. And inevitably, if you're working in geriatrics, the concept of grief and loss will come up. I recognize that in the United States and in Canada, one of the hardest things is finding someone who's in network or taking Medicare and finding somebody who doesn't have a super long wait list. I totally recognize that. It may require a little bit of digging deeper and that can oftentimes be one of the biggest barriers for individuals seeking care through talk therapy and why our primary care physicians are leaning into med management. But sometimes, you know, the best thing we can do is try and find some providers, find individuals who work with older adults on the regular, and try and create those bridges and those connections when appropriate. All right, I hope you found that helpful. I kept it together pretty good, I think, considering all things considered. If you are looking to get into some of our older adult live courses for the summer, we have a couple of opportunities coming up. Our last opportunity in June is in Charlotte, North Carolina with Julie. That is June 22nd and 23rd. In July, we have three courses going. We have Virginia Beach, July 13th, 14th. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And if you truly want the full experience of all of our MMOA faculty and staff, we have our MMOA Summit where Dustin and I are going to be teaching the course, but all of our teaching assistants and other lead faculty are going to be there. That is going to be in Littleton, Colorado, July 27th, 28th. That is going to be a super fun time if you are interested in hanging out with all of us and geeking out about older adult care, like that is the time to take MMOA Live. So if you have any other thoughts, questions, concerns, let me know. If you want to share some of your grief journey, I am all ears because It has been quite the couple weeks that I know that I'm just at the front end of this journey and I'm not gonna shy away from it. And it's definitely given me some new perspective as a geriatric clinician. Even when I thought I kind of had done my research and I've been in a lot of experiences talking about grief, it is so different when you're experiencing it yourself. All right, hope you all have a wonderful week. Signing off now, bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 11, 2024

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Management & Pain Division lead faculty Justin Dunaway discusses new research regarding patient expectation & tissue healing. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Total Spine Thrust Manipulation or Persistent Pain Management courses, or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. JUSTIN DUNAWAY All right. Good morning, YouTube. Good morning, Instagram. Looks like the cameras are looking good. Okay, here we go, team. Welcome to PT on Ice, Clinical Tuesday. I am Justin Dunaway, lead faculty with Institute of Clinical Excellence. I teach in our Total Spine Thrust Manipulation courses and our eight-week Persistent Pain Comprehensive Management courses, which the newest cohort began this week. Still plenty of time to jump in if you're interested. Just coming back from a weekend in Bozeman, Montana, teaching Total Thrust at Excel PT with Jason London. Big shout out and thank you to that group for bringing me out. If you've never been to Bozeman, it's an absolutely beautiful town, totally worth your time to get out there and see it. All right, today's topic, expectation and tissue healing. This is an absolutely fascinating, fascinating study that came out in December of last year. I'd been on a bit of a hiatus from PT on ice, and when this study came out, I was super excited for the opportunity to jump back on the stage, and I knew that the first topic had to be talking about this stuff. So, I'm a bit of a nerd in the beliefs and expectations space. I think there's so much really cool evidence, some really cool, really intricate, fascinating studies that have been done. And we know that the way patients believe about their body, about tissue damage, what they know and understand about pain, and the expectations that can come from that can change pain, pain perception, motion, pain pressure threshold, all of that stuff. We know that patients' beliefs around interventions, they believe that this intervention can be helpful or harmful, they expect this intervention to help or hurt, will absolutely change their outcomes with that intervention. We have seen research that shows us that patients' beliefs aside, provider beliefs, If I believe in the intervention I'm about to give a patient, versus if I don't, that will change the outcomes of that intervention as well. We know that beliefs and expectations around exercise, when all things are held constant, when everything about the patients are held constant, when everything about exercise is held constant, we just look at beliefs, we know that beliefs around exercise as it relates to my job, how physical my job is. If I believe that my job is physical enough that it counts as exercise, it can actually have positive effects on blood pressure, resting heart rate, body composition, and weight. We know that when I think about my beliefs around exercise, it relates to my peers. All things being held equal, if I believe I exercise less than my peers, it actually has a negative effect longevity some really interesting cool research from Ellen Langer a handful of years ago but she took older adults put them in this this five-day retreat where where they set up the whole building to be like from 1952, all the shows for a certain month that year, all the pictures and the furniture and the magazines and news articles. And they were only allowed to talk about stuff from that year for five days. And then they had massive changes in all kinds of physiologic stuff. They had massive changes on disability and like six minute walk tests and things like that. And what's fascinating is they took a picture pre and post this five-day retreat and then had independent reviewers look at these pictures. And the independent reviewers rated the five-day post pictures as years younger than what they looked like when they went into the trial. So just incredible, fascinating stuff in the world of how powerful the mind-body connection is. Now there's this interesting new line of research that I just kinda stumbled on recently where the expectation variable that they start to play with is perceived time passage. So time is held constant, but in very creative ways they get patients to believe that more or less time has passed. One really interesting trial is they give subjects, they feed subjects, they measure blood glucose, they hold time constant, And then in some sessions, they make the subjects believe that more time has passed. Some subjects believe that less time has passed. And what you find is that blood glucose levels track better with perceived time passage than actual time passage. Another interesting trial is they took humans and they short sleep them, give them six hours of sleep and measure a bunch of cognitive tasks. And obviously you do worse when you're six hours asleep on cognitive tasks. But then in the second piece of that, they give you six hours of sleep but they make you believe that you got eight hours of sleep and a good night's sleep. And then that mitigates that and they actually do significantly better on those tasks. So that's kind of everything leading up to this point, but this study, and there's so much more, it's such a really cool body of literature in this space, but the study I want to talk about here came out in Nature, super well-respected journal, in December of last year, and it's called Physical Healing as a Function of Perceived Time, from Peter Engel and Ellen Langer. This is going to sound kind of nerdy because it is, but if researchers had baseball cards, I would have an Ellen Langer rookie card framed in my office. Her body of literature in this space over the last, since like 1970 to now, is just absolutely incredible and has really paved the way for everything about beliefs and expectations. So here's the premise of this study. And this study was mind-blowing. What they did is they brought subjects in. And subjects, they had three sessions. Each session was an hour long. Sat the subject down, put a cup on their forearm, just like a standard biofascial decompression therapy cup, put the cup on, gave it five pumps, left it on there pretty tight for 30 seconds, popped the cup off, took a picture immediately, and then had a timer on the wall for 28 minutes. At the end of the 28 minutes, took a second picture. And then during those 28 minutes, they had the subject, specific time intervals, rate their healing. Asked them a handful of questions, but this is basically about how much do you think it's healed, how red is it, how swollen is it, is it painful, blah, blah, blah. And then at the end of the 28 minutes, then they had just a random, unrelated task to kind of fill the rest of the hour. Like they watched TV and rated commercials and played a video game or things like that. So then the trial itself looked like this. When you came in, you were randomized into one of three scenarios. Scenario one, everything I just said, there's a 28-minute timer on the wall, pre and post, and they do the things. Scenario two, they come in, and there is a 14-minute timer on the wall. Now, they're in the room for 28 minutes, but the timer is altered, so it ticks down a bit slower. So even though I'm in here for 28 minutes, I believe I'm only in here for 14 minutes. Scenario three, timer on the wall. The timer is set for 56 minutes. Again, it's only 28 minutes long. It just ticks significantly faster. So at the end of that 28 minutes, I believe that I've spent 56 minutes in the room waiting by healing. Okay, so that's how the trial's set up. Really interesting way that they controlled for this, and they controlled for kind of the after-minute variables. I won't dive into that. But the outcomes, the outcomes are where it really gets neat. So the first piece of this outcome is not gonna be mind-blowing. The patients, or the subjects, when you've looked at their self-report of healing, what they believe happened is they looked at their arm each time, When they were in the 56-minute trial, when the timer ticks 56 minutes, even though it was only 28, they believed that more healing had taken place than when they were in the 28-minute room, and more healing took place in the 28-minute room than in the 14-minute room. I thought I was in the room longer. I feel like more healing occurred. Cool, but that's not mind-blowing. The mind-blowing piece is this. Those pre and post pictures, they sent those off to independent reviewers that didn't know anything about the trial. They just said, hey, take a look at these pairing of pictures and tell us which ones healed more, which ones kind of healed, which ones didn't heal nearly as much. And without a doubt, when looking at the pictures, the pictures that came from the 56-minute room, showed more healing than the pictures that came from the 28-minute rooms, and those showed more healing than the pictures that came from the 14-minute rooms. And again, remember that they were all 28 minutes. Every picture was taken pre and post 28 minutes. The only difference was how much time I perceived had passed. That is fascinating. What the conclusion of the trial was is basically that tissue healing Isn't just a function of time passage tissue healing time. That's still important, but that's not the only piece tissue healing is at least in part a function of Perceived time passage, but it's not really perceived time passage, right? It's it's me believing that more time had passed Really put me in a space where I believe that more healing has occurred and when I believed more healing occurred. I It did. Even though that was such a short trial, even though it was so acute, just believing in that space that my body was healing faster, it did. Now, this has massive implications in my head, from acute injuries through through tissue healing from surgeries. It doesn't matter if we're treating a patient that's got persistent 10-year centrally dominant pain, if I just rolled my ankle, if I was just in a car accident, if I just had an ACL reconstruction or anything along those lines. If tissue healing and tissue health is a piece of the puzzle, then my beliefs around my capacity for my tissues to heal or how quickly they're healing or what's going on in my body since that injury, that is gonna have a direct implication and direct effect on how quickly and how healthy those tissues can heal. I think that's the direction that this line of research is going. So what do we do with this information? What I'm not suggesting is that we start messing with the clocks in our clinic and bring people in for a 30 minute session, but make them feel like it was an hour or things like that. Although that's kind of interesting, right? And I think Dr. Langer, if you're listening, I think a really cool trial would be to take a whole bunch of humans Relatively untrained, you put them on a bike three times a week for the next six weeks at 30 minutes RPE of six, and a third of them believe they're on the bike for 15 minutes, a third believe they're on the bike for 30, a third believe they're on the bike for an hour, and I bet what you find is that the hour group outperforms everybody else. It's pretty fascinating, but… What I think that this means for us from a clinical perspective is that when we think about like patient education, we think about beliefs and expectations and things like that, we tend to focus on, importantly, but we tend to focus on teaching patients about pain. We tend to focus on trying to test, retest so they can show immediate improvements in the clinic. We try to get patients to kind of believe in the interventions that we're doing. But there's a space in the education, there's a space in whatever the patient's mindfulness practice is, there's a space in trying to get patients to really think about their tissue healing, thinking about their rate of tissue healing, thinking about the health of the stuff inside their body, and shifting that in a very positive direction. Because what Ellen showed us is that that is going to affect tissue healing. So at the end of the day, this is just another really cool facet of information in this mind-body connection space. And from a treatment perspective, we need to not just be thinking about having really good clinical reasoning, really good skills, and being able to really match the right intervention with the right hypothesis, with the right patient, things like that. But we've got to be thinking about the context in which our treatments occur. We've got to think a lot about where the patient's beliefs and expectations are about themselves, about their body, and the interactions they're having outside the clinic. The more work we can do to get the patient's mindset in a space that's positive, that's healthy, that is pro-healing, whether it's understanding pain, whether it's believing in the treatments we're about to do, whether it's really just understanding that they have a very, very powerful capacity for their tissues to heal and heal well and heal quickly. Those are the things that are really gonna drive outcomes forward. And I think that the novel piece of this study is that it's more than just about physiology, it's more than just about pain and pain perception. Now the belief piece also will actually affect, speed up, slow down the rate at which our tissues heal. Alright team, so again, absolutely mind-blowing study. Another really great piece of information, this mind-body connection. And thank you all for hanging out for the last 12 minutes. It was awesome to be back on the stage, chatting with you all. Hope to do it again very soon. Have an awesome day in the clinic. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 10, 2024

Dr. Shaelyn Sharbutt // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Shaelyn Sharbutt makes her debut on the podcast, discussing how to execute a successful pelvic workshop geared toward coaches. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. SHAELYN SHARBUTT What is up? Good morning and welcome to the PT on Ice daily show. My name is Dr. Shae Sharbutt and I am on faculty for the pelvic division here at ICE. Today we're going to talk a little bit about doing a workshop for local fitness professionals and coaches based around pelvic floor issues. So this is really important because so many of those people's clients will either put their memberships on pause or stop working out completely during this new phase of life. They're trying to navigate it. Maybe it's their first time being pregnant or their first time being postpartum. and they might not have a pelvic floor specialist friend or a good provider telling them that it's okay to do these things. They might have a really good relationship with their coaches and so this is going to be the first person they talk to about these things. CONTACTING THE GYM & PLANNING THE WORKSHOP So typically whenever I first start talking to a gym, I will contact the gym directly, either their gym manager or their gym owner or their head coach about the interest that they might have in a workshop like this. We can DM, we can email, and you might even have a close enough relationship to text these people, but it's really best if you can get a meeting face-to-face and build that relationship. This not only gets that gym owner or that head coach super excited about what you're going to tell them, but it also lets them see the value that you're going to bring the other coaches and their members. So whenever you go to have this sit-down conversation, it's best to be prepared. I always have a PowerPoint or a presentation to give to these coaches when I do these, and I'll bring that along to that meeting with that gym owner or head coach to kind of show them what to expect from this workshop. It helps them feel a little better prepared, know what kind of equipment I'll need before I teach their coaches, and how much space I'm going to take up. It's then important to make sure that they understand that it needs to be during a time when we don't have open gym going on and we don't have class times going on. Maybe see what time of the gym is the least busy and they can block off a schedule and say, hey guys, we're trying to get our coaches the best education we can. Please don't come to the gym from this time to this time this Sunday. Have them kind of plan that ahead for their members. And that way the coaches can focus everything on what you're saying and what you're teaching them. And then they're not distracted by gym members working out or maybe wanting to cue somebody's lift in a corner or what have you. KNOW THE GYM'S PAIN POINTS So whenever you're creating content for this workshop, you really need to think about what these people do. Are you going to a CrossFit gym? Are you working with contact sport athletes like in a martial arts gym or a jiu-jitsu gym? Is there going to be running involved? Are there gymnastics movements being educated? Are there heavy barbells that people are getting under. You really need to understand what these people are doing day in and day out to be able to educate their coaches on progressions and regressions. So this should really be a community that you're involved in and that you understand what they're doing and those coaches are going to respect you even more if you're involved. So from there, we want three main things for our pelvic floor workshops for these coaches. GIVE SOME PELVIC BACKGROUND The first thing is a little bit of background. Most people don't even know that they have a pelvic floor, let alone that they can struggle with issues with this area of their body. So give these coaches a little bit of background. Educate them on these muscles. It doesn't have to be a full-blown anatomy lecture. Nobody wants to sit through that except maybe a nerdy PT student. But make sure that you give them a little bit of background. Maybe you show them a couple photos of what the pelvic floor muscles look like. Maybe you whip out a model. But if you can relate that back to something they're familiar with, like hip structure, hip and glute muscles, core canister, maybe some abdominal muscles, that'll kind of relate it back to things that they cue day in and day out and are way more familiar with. From there you want to give a background also on symptoms that they might have their clients complaining about in the gym. So a lot of CrossFit coaches are going to understand that there are women who leak with double unders and running and lifting, but maybe educate them on some abdominal pain, maybe educate them heaviness in that vaginal region. Really make sure that they understand that these symptoms are not the same for everybody and that points of performance are most important and we'll get to that here in a second. But giving that background and giving some symptoms to look out for can be really helpful. GIVE GOOD DEMONSTRATIONS Part two of the pelvic floor workshop, you want to make sure that you give good demonstrations. So let's say for example, I'm in a CrossFit space and we're talking about pull-up regressions and progressions throughout pregnancy and postpartum. If I'm talking about a banded pull-up, I'm going to take out my band and I'm going to show them different variations of a banded pull-up. I'm going to show them what I like even more, a toe spot pull-up or a low bar pull-up. we're going to go over points of performance, we're going to talk about engaging the lats, we're going to talk about holding that nice hollow body position, and cues that we might give someone who has a baby in their belly, such as hug baby or pull baby close to your spine, and then have the coaches practice that with each other. So, demonstrations are super important. Have them watch you set it up. And from there, you want to have a discussion and get their minds thinking about when they would use these different variations. So, if we're going to stick on this pull-up progression example, let's say that we're talking about a workout being done in class FRAN. That's a great, easy example. So for those of you that don't know, FRAN is a 21-15-9 of thrusters and pull-ups. Let's say I give them an example like someone is five months pregnant. It's their first pregnancy. They're having some uncomfortable stretching on the abdominal region. They don't like it. They are really good at kipping at baseline, but doing that large kip is really bothering them. What kind of scale would you give them? Question these coaches, ask them these questions and get their brains thinking and have them think through some different variations that they would use. It's also important to teach these coaches and have them think about timeline. So you don't want the time domain for this pregnant or postpartum athlete to be vastly different than everybody else in class. So if she can't do strict pull-ups or it would take her forever to do strict pull-ups and this Fran workout is taking people in class five minutes or less, what variation could we give her? What rep scheme could we give her to give her the similar stimulus to the rest of class and make her feel involved? So having the coaches build this discussion with each other and get out of their comfort zone from their typical scaling options can be super fun and helpful. Also lets it be a little bit more active. From there, I typically get a million more questions about specific movements. So, be prepared to answer questions about rowing. Be prepared to answer questions about going upside down. Maybe they'll ask you about bench press. Not only laying on their back, but getting up from that bench press and not being uncomfortable. They're always going to ask about core exercises. So have things ready, have examples ready to go for more demonstrations, but really make it a discussion and that'll be a lot more fun and involved of a seminar. So, that's part two we covered. Part one being give a little bit of background. Part two being some good demonstrations and examples of class workouts. GET COACHES ACTIVE & INVOLVED Part three that you want to make sure you get is the coaches doing these things. Get them involved. Get them moving. We already talked about it a little bit with pull-ups But if we're talking impact progressions make every coach in there get their plate out and they're gonna do toe taps with you Make sure they're coaching each other through different breathing techniques under load and then from there on We're always talking about hashtag be about it here at ICE. Get a group workout going. Have everyone have to choose a variation that they normally wouldn't do, a scaled option that they normally wouldn't do. Some of our coaches are games athletes and they're fantastic coaches and they're fantastic athletes, but they've never had to do a toe spot pull up in their life. Have them practice toe spot pull-ups in a workout. It is hard. Have them practice that form. Have other coaches pick them apart, just like they would any of their other clients. That can be a super fun way for them to practice their coaching skills, but also feel what it's supposed to feel like. And then they can imagine, man, if I had a big old belly with a baby in it, how hard would this movement be? So that can be super fun as well. So lastly, you want to make sure that you feel comfortable being the subject matter expert. Don't be ashamed to refer to yourself as the expert in your field. You want to make sure these coaches have someone to ask, someone to talk to. someone to send their clients to that they don't feel comfortable modifying their workouts or they have more questions that are just out of their scope. It's okay to be the subject matter expert. It's okay to know what you're doing. I think sometimes we apologize for that and we just need to be confident and know that we're the person that they should refer to. We are the fitness forward professional and we are in it with them. We understand what these mamas want to do. So make sure you're cool with being the referral source for these coaches. SUMMARY Guys, thanks for listening. Our next cohort for level one, if you want to learn more from your pelvic crew, that is in July, and then that's selling out really fast. Make sure you also get signed up for level two if you've already done a level one. We're wrapping up a level one right now, so you know those people are going to hop on that level two as soon as they're done. They're all fired up. And then lastly, We have a live course in Cincy, Ohio. Get signed up for that as well. We love the live course. We go over in detail a lot of the variations of progressions and regressions I just discussed. So if you're not comfortable with that, sign up for that Cincy course. We can't wait to see you there. And if you need even more info, get on our pelvic newsletter. It is a blast and it is best practice. So that's sent out every month. We will talk to you guys soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 7, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app/switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PTonICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today here on the PT on ICE Daily Show. It is Fitness Athlete Friday. We talk all things CrossFit, powerlifting, Olympic weightlifting, endurance athletes. For that patient, athlete or client of yours that is recreationally active, Fridays are all about topics for that person. We are finishing out deltoid week here at ICE, so we're talking all things shoulder, in particular the deltoid muscle, exercises for the deltoid, manual therapy for the deltoid, so go back if you haven't been listening the rest of this week to all the episodes from all the other faculty, Monday, Tuesday, Wednesday, Thursday, dry needling techniques, cupping techniques, exercises, modifications, importance of deltoid exercises for pregnant and postpartum moms, we've got it all. Plus, we have a whole bunch of great content on our Instagram page as well, related to the deltoid and all of those topics. Today on Fitness Athlete Friday, we're going to tackle the deltoid from its role in functional fitness. So in particular, we're going to be talking about vertical pressing. So we're going to talk about anatomical considerations of the deltoid as it relates to lifting weights overhead. We're going to talk about clinical considerations of why do we care about someone's deltoid when they come in for physical therapy treatment. And then we're going to finish talking about how we think you should actually train the deltoid with these patients and athletes in the clinic. THE DELTOID: ANATOMICAL CONSIDERATIONS So a brief anatomy overview to start. What are our considerations for the anatomy of the deltoid? We need to understand and recognize the deltoid muscle is large, it is designed, it is built for blunt force trauma. If we come away from social media and computers, and the past 2000 plus years of human progress, and we go back to ancient man and even before we became humans and we were walking around on all fours, understanding the role of deltoid, but as we're crawling around on all fours, we have hip extension from our hip, we have glutes and quads as our primary lower extremity muscles, and in the upper body, we are pulling ourselves along the ground. We are designed for vertical pulling in particular, We all understand the importance of the lat. There's probably not a single person, if you walked into a room and recommended that the average person could benefit from doing some strict pull-ups, there's probably nobody that would voice opposition or concerns. But yet, when we start to talk about vertical pressing, all of a sudden, the conversation changes. Whoa, don't lift your arm overhead. That's dangerous. We've heard things, and I've heard things, like even when I was in school, that the shoulder is so mobile, it's just really not optimal to lift your arm overhead. Which, if we go back to our history and our evolution, doesn't really seem practical. And I think it's a fundamental misunderstanding. of how the deltoid functions and its role in providing that stability to the shoulder joint. So being quadruped, now bipedal organisms, now standing up resisting gravity, great at vertical pulling, not great at vertical pressing, especially when we don't do it. Why? The shoulder is inherently mobile, it is inherently unstable. It does not have a lot of bony support. The deltoid is the primary muscle that gives us that stability. throughout the whole range of motion of the shoulder. The deltoid is primarily responsible for flexion and abduction. It is the prime mover of shoulder elevation. And in particular, as we begin to approach 90 degrees of flexion and abduction and move up towards 120 degrees and beyond, the deltoid really becomes the only mover. A lot of the other smaller muscles, upper traps, rotator cuff muscles, whatever, really fall off and the deltoid stands alone as moving things overhead. And so we see that that does not happen. That does not happen in a lot of people. We already know most people are sedentary. They're not lifting weight overhead, pushing or pulling. But for those folks that are, we need to get them doing probably more vertical pressing to train that deltoid to really understand and respect the anatomy that we need to have a really strong deltoid if we really want to have a strong and stable shoulder. Really great evidence on the importance of the deltoid as the prime mover of the shoulder. An article back from 2021, the Journal of Elbow and Shoulder Surgery, Hecker and colleagues, Really cool study. They took people, they gave them an axillary nerve block on one side, and then they gave them nothing on the other side. And they tested maximal isometric strength. And what they wanted to find out is how much strength comes from each of the shoulder muscles, at what degree of shoulder flexion, shoulder abduction, internal or external rotation, adduction and abduction. And what they found is when they blocked the axillary nerve, and they tested isometric strength, instantly with the arm still at rest, moving into flexion, the shoulder strength was reduced to 76%. In flexion and in abduction, it was reduced to 64%. And now again, as we elevate that shoulder further up towards 90 to 120 degrees, the strength fall off was even more significant. Flexion now at only 25% strength, and abduction at 30 strength. So the deltoid is involved in the entire range of motion of primarily flexion and abduction. But in particular, as we get up towards 90, and as we start to bring our arm all the way overhead, it is primarily deltoid, which means we need to be training the full range of motion, and we need to be training more pressing patterns, and not so much laying on our back or laying on our stomach and doing prone rotator cuff work, trap work, whatever. That stuff is great early on in therapy, but if we really want to get the deltoid strong, we need to move it through the range of motion that it controls, which is all of it, and in particular, all the way up and overhead. THE DELTOID: CLINICAL CONSIDERATIONS So discussing clinical considerations, who might we see with a deltoid problem? How could we pick up that somebody might need to get stronger deltoids? I would argue just like with glutes or quads, it's every human being, right? There's no one that is checking the box on strong enough muscles. I don't think you'll find a single elite athlete who thinks, I don't need to train anymore. I've made it. They're probably always aware of their weaknesses and things they need to train. and I would argue vertical pressing, training the deltoid is true for every single person. But we do see these presentations come in. where we start to think, hmm, what I'm seeing, I think I'm treating the symptom of a bigger problem. So when the deltoid isn't doing its job, that's when the other smaller muscles of the shoulder complex take over. That's when we have people with upper trap stiffness or upper trap pain or headaches or posterior cuff pain or issues up in their neck, trouble with rotation, side bending, whatever. those smaller muscles that can act to elevate the shoulder are taking over because the deltoid isn't pulling its weight. The long-term solution isn't to only train those muscles, it's to train those muscles if it makes the person feel better, but again, get back to training the deltoid. So when we see those patients come in the clinic, oh, my traps, my traps, my traps, my traps, my neck is stiff, I've got a headache, and we start to dig into the subjective, what have you been doing? Oh, we've been doing a handstand push-up cycle at my gym. Oh, we've been doing a split jerk cycle, a clean and jerk cycle, a snatch cycle, whatever. you start to hear that this person has increased their volume and overhead lifting and they're complaining of all of these secondary symptoms of upper trap, neck, headache, whatever. When I hear that, I'm thinking this person, this person, yes, needs my help. reducing pain, restoring range of motion, but I'm also thinking, I need to get this person on a vertical pressing program. Especially a functional fitness athlete, I need to be getting them doing strict press, I need to be getting them doing handstand pushups, strict handstand pushups, whatever they can tolerate, wherever they're at in their fitness journey, maybe it's handstand pushup, eccentrics, whatever, but I'm thinking, we need to start integrating some vertical pressing in this person's program, because yes, while we're treating their symptoms short term, the way they're presenting tells me they would benefit a lot from stronger shoulders. These symptoms are probably going to be less likely to show up in the future if we do that. And so as we're reducing the symptoms, resolving the symptoms in the local tissue, we then need to evaluate if the deltoid needs strengthening. A lot of folks ask, how strong should your shoulders be? We have a lot of really great evidence on bodyweight normalized exercise in the lower extremity. We know the stronger your squat gets relative to your bodyweight, the less likely you are to develop lower extremity injuries. So the stronger a 1x bodyweight back squat, a double bodyweight back squat, stronger, stronger, stronger, less, less, less injury. We don't have a lot of that research in the upper extremities, but I would say that a strong person should be able to press 50-100% of their bodyweight overhead. Now that's going to depend on a lot of things. Training age, right? Somebody that just started lifting overhead six months ago is probably a very long time, like years or decades away from achieving a bodyweight strict press. Somebody that has been training a lot and is close is obviously going to get there a lot closer. But we don't necessarily need to get there with a strict press. Somebody that can push press their body weight, somebody that can jerk their body weight, somebody that can show me a strict handstand push up, that person really tells me that they have really strong shoulders. Arm length plays a big role here. Those of you with longer arms, I know you're listening right now, nodding your head. I'm five foot seven. I have these little T-Rex arms. I don't have a lot of range of motion before my arms are locked out overhead. Someone built like me. isn't actually going to have a stronger press, a stronger handstand push up capacity than someone that is six foot six and their fingertips touch the middle of their fibula, right? So consider that as well. Don't hold people's feet to the fire on that too much. But no, we want to see people getting a strong press, we want to see them move towards a 50% bodyweight press, and then continue to train that as much as possible. We have a number of different tools we can use as well to look for asymmetries in the clinic. I love to just stick with a dumbbell strip press in the front rack. Hey, let's try a five to eight rep max. Let's see if we have an asymmetry. If somebody can't tolerate that due to pain, I love to go to a landmine press and try to find a five to eight rep max there, and then try to see if I can observe any asymmetry. And then we know if we talked here on the past on the Daily Show, to clear up asymmetries, we need to be training the weaker side three to four times the volume. So that person needs to be doing maybe four to five sets of pressing work for every set that the strong side does. So that's always a consideration as well. When we look at ratios in the upper body, we need to understand the upper body is or at least should be a little bit weaker compared to our lower body. Humans are primarily legs. We do have those people out there. You probably all have a friend that has a 400 pound bench press and a 200 pound back squat. They're just built. They're built different, right? They love upper body, skip leg day a lot. But in general, our legs should be stronger than our upper body. How strong? About 40-60, maybe 30-70 at the most. But when you start to get to a ratio of 80% of my strength is in my legs and 20% is in my upper body, we really get into an issue where now our lower body can generate more power than our upper body strength can handle. And so we have some really cool research, Matt Sura and colleagues, 2023 Journal of Science and Medicine and Sport followed swimmers and asked that question in their research. Hey, is there a ratio where lower body strength leads to upper body injury? And the answer seems to be yes, which is really interesting research. So this study followed 48 competitive swimmers across six months. At the start of the study, these swimmers had no pain. Across the six months of training, 20 swimmers developed pain and the researchers testing baselines and reassessments throughout the study wanted to pick up on how can we determine who's most likely to develop a shoulder injury across a season of competitive swimming. And so finding that folks who developed a stiffer shoulder across those six months, worse posterior deltoid range of motion, And those folks who had higher ratios of lower extremity strength to upper extremity strength went on to develop pain. Their legs were able to generate so much power in the water that their shoulders were too weak to keep up. And over time, we're assuming and carrying forward that that led to overtraining essentially of the upper body. We can see that in the gym, with movements like push press or push jerk, we know the legs provide the majority of the motion and the power for those movements. And if our shoulders are not strong enough, yes, our legs can help us get that weight overhead. But if we're doing that a lot, and our shoulders are just not inherently stable, because we have a weak deltoid, then we can run into trouble where the ratio becomes so skewed that it can now be harmful. So I like to think of this is the legs begin to write checks that the shoulders can't cash, right, the shoulder is not moving through the full range of motion. And now those other muscles have to take over because that ratio is so skewed. And that's who shows up in your clinic door, right? I have stiff traps, I have a headache, I can't turn my head, I did a bunch of push jerk, I did a bunch of kipping handstand push ups, whatever, we need to treat that person's symptoms, we need to get their shoulders stronger, we need to control that ratio a little bit better. THE DELTOID: TRAINING So as we finish up here, how do we do that? How do we train the deltoid? A lot of people think they're training the deltoid, they think they're training shoulders, but they're not really doing it effectively, which is why they don't see a lot of results in whatever their goal might be for the shoulder, even if it's just to not have shoulder pain during exercise. And so we see a lot of what we might call bro shoulder press, right people sitting or standing in the gym. That arm is cocked out to 90 degrees of abduction and then they're kind of just pumping that weight up and down overhead, right? They're in a neutral grip. They're in a small amount of abduction They are technically in no flexion in a small amount of external rotation so in that movement that kind of seated or standing dumbbell press where the weight is just floating out in space is EMG studies would say that person is primarily training the triceps. If you ask that person in the moment, where do you feel this, they would probably tell you their triceps. And so getting people to understand what does deltoid training look like. is very important because some folks may think they're doing it, they may think they're doing a lot of it, and they're not. They're probably training triceps, they're probably primarily overloading a different muscle, which is just exacerbating the whole problem. They're probably allowing a dip in their legs in the strict press. So again, the legs are primarily generating the momentum for the movement. And they're probably just not performing full range of motion. And again, The deltoid is on the whole range of motion, especially at and above 120 degrees. So we need to be training full range of motion if we want a really strong, robust deltoid. Most people skip deltoid training completely, which is another factor, right? Coming into the gym and doing five by five strict press is not fun. It's not sexy. It's not as cool as ring muscle ups or a heavy deadlift or a heavy power clean or something like that, or even just doing push press or push jerk. It's more momentum. It feels cooler. You can lift more weight. And so strict press often gets left behind, which is the thing that some athletes and patients need to be training the most. Other athletes might be thinking, hey, I bench press a lot, I have strong shoulders, but when we look at studies of what muscles are active at what degrees of incline in a bench press, we see that we have to elevate that bench to almost 60 degrees just to begin to get a little bit of anterior delt work. And that we have to incline it to 90 degrees, which is, you know what, no longer a bench press, you are sitting upright, to begin to target the lateral and posterior heads of the deltoid. We had a cool study from Rodriguez, Redallo, and colleagues in the Journal of Environmental Research and Public Health in 2020 that looked specifically at that and said, hey, primarily in the bench press, even at an incline, you are still primarily targeting the pec muscles. Yes, at 60 degrees of incline, you begin to get more anterior delt, but bench press is for the chest, which some of you are saying, Alan, I knew that already before I listened to this podcast, but others out there might be thinking, hey, I thought that was also getting my delts. It's not. So we need to recognize that we cannot bench press our way to stronger deltoids. That will certainly get you a stronger chest, better push-up capacity and ability, but it will not do anything to really train your deltoids, and if that's a weakness area for you, help shore up that weakness. And so we need to get folks training shoulder flexion and shoulder abduction through the fullest range of motion possible, training them together. Yes, barbell strict press, alternating dumbbell press, standing, sitting, Z press, whatever. And in really, really being sticklers for people that they work the full range of motion. If you're going to use dumbbells, they need to start in the front rack position where the head of the dumbbell is on the shoulder, and you are pressing through 180 and 180 degrees of shoulder flexion and abduction. and you're not hanging out here and just giving it that little tricep hump that people like to do. Train the full range of motion. For those folks who are needing or wanting to do handstand pushups, handstand pushups are also a great way to train the vertical pressing pattern. If folks already have strict handstand pushup capacity, working at it as accessory work is great. Adding things like plates for a deficit will challenge bigger ranges of motion that will develop and continue to progress in a linear fashion vertical pressing, and deltoid strength. If they can't do strict, but they can kip, we can have them kick up to the wall, lower themselves through that range of motion, and do a handstand pushup negative. That is a great shoulder strengthener. I have a lot of athletes do that for accessory work. Even athletes that have strict handstand pushups and have good strict handstand pushup capacity, working that time under tension, especially if they can tolerate a deficit, is gonna make really robust shoulders, a really strong, healthy shoulder, And because they're training a deficit so often, when a workout shows up with regular handstand pushups or regular strict handstand pushups, those athletes fly through those workouts because their capacity has increased so much. At all costs with those folks, we want them to avoid kipping unless they're doing an eccentric, because again, that's the same as if they were standing up and doing a push press or a push jerk. We want to avoid having the legs help us train the shoulders. When we need to get strong shoulders, we should be training the shoulders. Folks can benefit a lot from complexes, things like doing a bunch of strict press followed by push press or push jerk. That is a great way to train the deltoid under fatigue, which relates a lot, especially to those athletes who are going to be using a lot of vertical pressing under cardiovascular fatigue. So one of my favorite ways to do that is 3 sets of 3 strict press, add some weight, 3 sets of 3 push press, add some weight, 3 sets of 3 push jerk. Starting fresh, working the deltoid, sets of 3, very heavy load, getting stronger. is the deltoid fatigues, using the legs a little bit to help it out with the push press, and as it gets really tired, using the legs even more in our push jerk. You'll find if you do a big complex like that, that your shoulders are tired, your shoulders are sore the next couple days, and that is really a unique feeling to have soreness in the deltoid that a lot of people don't experience because they're primarily not training the deltoid, or other muscles are taking over for them because their deltoid is so weak. For accessory work, the EMG exercise with the largest deltoid activation is a prone Y with the arm unsupported, moving in and out of 120 degrees of flexion abduction with the hand wound up and as much external rotation as possible. So that's from Mike Reinhold and colleagues, they have a bunch of research on EMG activation in the shoulder muscles. That's where the delt works the most out of a number of different exercises. So after training is done, after we've got our strict press or handstand push ups in, we can go to that prone Y do some burnout sets, something like that, and really begin to overload the deltoid in a way that facilitates a lot of strength. SUMMARY So the deltoid, largest or should be largest, strongest muscle in the shoulder built for work, built to move the shoulder through the whole range of motion, but only if we train it. Otherwise, those smaller muscles are going to take over. The shoulder is inherently unstable, that full 180 degrees of freedom. It doesn't have bony approximations that give it support as much as the hip or other joints, which means we need strong muscles, in particular, a strong deltoid to act as the stabilizers for us. In the clinic, we're primarily treating the aftermath of what happens to people when their shoulders are not as strong as other parts of their body, their legs, their traps, their posterior cuff, whatever. We need to clear up those local symptoms and then get that person on some sort of deltoid strengthening program so that the deltoid begins to do the work. Most folks will find that their capacity in the gym, in their fitness, often increases with overhead lifting, and they have less symptoms, less stiff traps, stiff neck, headaches, so on and so forth. A lot of folks have no issue doing vertical pulling. They might be doing vertical pulling multiple times per week, really training the lats, pull-downs, pull-ups, chin-ups, muscle-ups, whatever, but often they are avoiding vertical pressing, or they're using a variation of a vertical press where their legs help them a lot when they should be focusing on strict movements. Strict movements like strict press, strict handstand push-ups, and training the full range of motion. Remind these folks they are welcome to do as much bench press as they like, but you cannot bench press your way to a stronger deltoid. And when in doubt, again, keep it strict. So I hope this was helpful. I hope you have a wonderful Friday, a great weekend. If you want to join us online, our next cohort of fitness athlete level one online starts August 2nd. Fitness athlete level two online starts September 2nd. And then a couple chances to catch us out on the road. Zach Long will be teaching this weekend in Raleigh, North Carolina. And then in two weeks, we have the fitness athlete summit here in Fenton, Michigan at CrossFit Fenton. We'll have all four lead faculty from the division here, as well as our four teaching assistants, so our full staff will be on hand for that course. That's gonna be a lot of fun, so we hope to see you in two weeks here in Fenton. Have a great Friday, have a great weekend, bye everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 6, 2024

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses when, why, and how to perform cupping to the deltoid muscle. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How is it going? Welcome to Technique Thursday. My name is Dr. Lindsay Hughey. I am division lead of extremity management along with Dr. Mark Gallant, and I am here to talk to you about a deltoid myofascial decompression technique. So in honor of deltoid week, I want to share just a common technique we'll use. First, I will kind of give a little context of why we would use this technique, and then I'm literally going to show you how we'll do cup placement, and then how we'll follow that up with active movement. So we do passive, and then we actually do a little neuroreeducation to that area. WHY CUP THE DELTOID? So why we might choose this technique is someone that literally has pain with palpation at that deltoid, baby with abduction, they have a painful arc, and or when you manually muscle test into abduction and or flexion, they have some pain symptoms. So this would lead us to want to do this treatment. In our extremity management course, we usually call this the weak shoulder bucket. A lot of these folks fall under that umbrella. So I actually have an assistant with me today. So Paul is going to come and sit, and I'm actually going to have him sit like this. I usually have the patient either lay in supine, side lying, or prone to do this technique. But for ease of you all to view the deltoid, I want to have him sit, and then we'll have him lay on his side. So we want so just to orient us to the deltoid and I'm going to move this camera just a little bit right so the deltoid actually gets its name because it looks like an upside down delta so if these points all the way down to that deltoid tuberosity by the way to dive deep into the anatomy of the deltoid check out Clinical Tuesday with Ellison Melrose because we are doing all things deltoid this week. And she did a fabulous episode on not only the anatomy, but the function. So take a look at that. But here we're going to target, we want to target the anterior, the medial, and that posterior region. So some people think of this as like clavicle, acromion, or spinal. So what we're going to do is attach our cups to each of those regions and then all the way to that deltoid tuberosity. So I'm going to grab my gadgets. So practical things we need are some kind of lubricant. I'm going to use Free Up today, but it doesn't really matter, kind of your favorite lotion oil that'll help this stick. So I'm going to put a little lotion anterior, medial, and then that posterior, right? Because we have three main parts here. And then we'll go down to this deltoid tuberosity area. So I'm going to use these nice curved cups. These are actually the newest cups from our colleague and friend, Cup Therapy. So Chris DiPrato just came out with these and his team, and they are awesome for suction. We really, by the way, love myofascial decompression because it's really the only thing we have that really offloads tissue versus like our dry needling, our exercise, our massage, our wonderful treatment adjuncts. but they're compressive in nature. So sometimes this decompressive technique is just a novel stimulus to help that muscle relax and move better and activate better. CUPPING THE DELTOID So I'm going to start with that middle portion and I want For muscle, we usually want about 300 to 600 millimeters of mercury or pressure taken off. And there are gauges that pumps that actually show you that pressure. This is just a standard pump today, but just to keep that knowledge in your back pocket. And then we're going to go posteriorly. So again, I want to make sure lotion is there. I'm going to attach here. How are we doing, Paul? Such a good patient. Such a good model. And then we're going to go anterior. So I'll just kind of shift my body so that you all can see that. Again, we're pumping up. We try to get enough besides that 300 to 600 millimeters or mercury, but enough that they don't pop off. And if this do pop off during this demo, we'll just reattach. And then finally, down here, a little bit more lotion. And then we'll pump. We're getting a little slidey there, doing OK. Sometimes you're doing OK. Sometimes hair gets us, and we might. User error is always fun, too, when your hands are sliding. I'm just going to change this out. Here we go. That one, we needed to go, I think, a little bit smaller. That one was a little too big for the surface. That's why there's different size cups. OK. To visualize, we have anterior, medial, posterior, so we're hitting all parts of that deltoid. And then we're trying to sink into that deltoid tuberosity. For our treatment, I'm going to have Paul lay in sideline, so that shoulder is up. First part of this, and I'll just adjust the Instagram camera a little bit, is we're going to do some passive movement. So we're never just having the patient sit with the cups and doing nothing. It's very rare that we would just let this be a static treatment. So I'm going to take Paul's arm, and then I'm going to move him into all the motions that the deltoid produced. So that anterior is more flexion, internal rotation, abduction for that medial and then posterior contributes to extension and external rotation. So I'm gonna move in and out of all those positions. So I'll demo just a couple of those and then the next part is let's let the patient own this movement with some neural re-education. So then Paul will do those movements and I'll show you our favorite sideline trio for that. So I'm going to flex him and I'm moving my body with this. And then I might mess with a little bit of internal external rotation. And when you're up close to the cups, what you see is some pumping on off of that tissue. And I'll do just a couple more of these. And then I can even abduct. A little bit for Paul on off, and I would spend like a minute or so kind of going off on off and deflection, internal external rotation. I might even go into a little bit of extension. And then I want him to do some of these movements. So I'm going to go from behind to direct Paul and get out of your way. But one of our favorite things for the weak shoulder and to really light up that deltoid and even the cuff, because we know they work together in upward elevation, is we're going to do external rotation. Elbow straight, do flexion, come down, and then go to 90 and do horizontal abduction. So we're hitting all parts of that deltoid and the cuff with this movement. And we'll have Paul do a few of these reps unloaded, but then I'm going to give him a change plate, and I'm actually going to have him load this up. And probably the hardest part is just remembering all the movements. It doesn't quite matter what order you do it in, but what matters is kind of targeting all the different areas of that beautiful deltoid muscle. So go back to external rotation, and this is just like a real patient, right? There's going to be some error in each movement. Again, it doesn't matter necessarily the order. And then horizontal abduction. To make it a little harder, we're going to go ahead and give him a weight. So he's going to go ahead externally rotate. I'll just guide him through those first reps, elbow straight, go ahead and flex. Meanwhile, the pods are still attached, offloading that tissue. He'll come back to 90 and then horizontally AB duct, right? And then we'd give him a sweet spot. You can go ahead and relax. A sweet spot, what we call an extremity management, the rehab dose because we are targeting local tissue. So our rehab dose is anywhere from 8 to 20 reps, 3 to 4 sets, and we're taking a rest break of about 60 to 90 seconds. And our intensity varies from 30% to 80% depending on tissue irritability. But we've done this out. SUMMARY So some key things, we apply the cups, right? But then we actually move the human passively. Then we have them actively do the thing, neuroreeducation. And then finally, we take the cups off. And what we would do is reassess one of those things that blipped an exam, whether it was palpation, whether it was that presence of a painful arc, and or our manual muscle testing to see, did NPRS change with our palpation? Did painful arc, was quality of movement improved, and or NPRS, less pain associated with that elevation? The other thing, one little other pearl I want to share with the cups. So we remove the cups and then we'll massage that area a little bit. But what's neat is you can even take some pressure off. I'm taking this last cup off, but I can reduce the pressure a tiny bit and I can end with like a sliding technique where there's a little bit of offloading still present, but we're sliding along that tissue. for overall treatment dur be more than like 3 to 5 technique. And what's neat asterix very quickly. And pain. The motor bands tha immediately are a little and then they're able to elevate their arm better. And so this quick and efficient technique is one that I would really encourage you to use with your folks that have any deltoid and or cuff issues. You've heard me throw out some terms today regarding weak shoulder, the rehab dose, and the sideline trio. These are all terms that are really common to our extremity management course. So if you haven't taken it yet, Mark and Cody and I and our team to see you on the road an offerings. If you check u dot com in the summer. So in Salt Lake City with Ja and 14th will be in Kent, Washington again. And then July 20th, 21st will be in Hendersonville. So Cody will be there. That is bound to be a blast with that Hendersonville crew. And then it keeps on coming. We have another course in July, Bend, Oregon. So a lot of West Coast opportunities. So my West Coasters join me. I will be doing all those West Coast courses. And then we have more offerings in August. So you can't miss us. Thank you for joining me on Technique Thursday to learn a little bit more about the deltoid. And thanks to Paul, my patient who always looks like he's sleeping, but he's actually awake and with it. I hope you all have a beautiful day. Take care. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 5, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses three tips to give older adults permission to succeed in physical therapy: acknowledge their concerns, craft experiences that ensure success, and focus on belief change. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JEFF MUSGRAVE Welcome to the PT on ICE daily show. I'm going to be your host, Dr. Jeff Musgrave. This podcast is brought to you by the Institute of Clinical Excellence. It is Wednesday, so it is all things older adults. So excited to be here with you today. So even if you're not treating primarily older adults, I think you're gonna find a lot of value in today's topic. So today's topic, we're gonna be discussing permission to succeed. So this is very common in the older adult space, but you're gonna see this in lots of different populations that you're gonna be treating. where because of the interactions that older adults or any of your patients on your caseload have had, they've got a very negative outlook on their ability to recover, their ability to return to the things that they love. I've seen this across acute care all the way into the fitness realm. and especially people when they first come to us in the fitness realm for training as older adults in stronger life, they will need some encouragement. They will need some reframing of what is possible and reframing of how they see themselves. So I believe that you will not get the person physically if you do not first get them mentally. You have got to build that confidence in between their ears. They've got to see and understand a path forward before you're going to get the body on board. So I would love to share with you today some tips to make that just a little bit easier. I think a quote that really sets the stage for this discussion is from Dr. Justin Dunaway. We love to quote him in the older adult division and one of our favorite quotes of his is, beliefs and expectations are the foundation upon which outcomes are built. Beliefs and expectations are the outcome are the foundation upon outcomes are built. So we really have to believe that it's possible. We've got to know our patient's beliefs and we've got to set the stage for them to be successful. So, because our older adults have heard, you've got the worst case of, insert diagnosis, bone on bone, you've got degenerative disc disease, they've heard all these nocebos or noxious language that strikes fear in the hearts of our patients. Whether they're older adults or not, you're going to see this in younger populations too, but we see it a ton in our older adult population. So I've got three tips for you today to try to help move patients towards a mindset that's going to allow you to be successful. ACKNOWLEDGE CONCERNS So the first one is acknowledge. You need to acknowledge their concerns. Our older adults come with some baggage typically. They've lived more years, more decades, they've had more injuries, and oftentimes they've been told more negative things than our younger patients. They've been told You can't get better, or you'll never do X, Y, or Z again. Jog, run, swim, lift heavy things, insert the favorite activity that they love that is part of the reason they're living their life. This happens all the time, unfortunately. So, we need to hear those concerns. If it looks like we're running into a barrier where they think they can't do what your job is to help them do, we've got to ask some clarifying questions. We need this information anyway. Why do you think it's not possible for you to fully recover from this back injury? Is it a bad experience with physical therapy? Is it negative expectations that have been set from another provider? Is it an experience a friend or loved one had? And then you get the opportunity to find out what was their bout of care like? What type of treatment intervention were they getting? Was it even appropriate? Was it the right movement? Was it at the right intensity? Was it across the right duration? Was there such a huge disconnect between what they actually wanted to do and what they were being asked to do? that they didn't see the connection, they never did their home exercise program. There is so much we need to know about why they have the negative outlook that they have. And then you get the opportunity after hearing everything, because if you cut them short in this phase, you will not get them. If you don't hear all their concerns and why, you can't give them the information they need to help them bridge that gap from I can't get better to oh, maybe I can get better. You don't have to completely change their mindset in one or two visits. Unlikely you'll be able to do that anyway. What you need to do is inspire some curiosity. You need them to be curious about the possibility of getting better. If you can get them from, I don't think it's possible, to now I'm curious, you've cracked the door open and created just a little bit of hope. you may be wildly successful with this patient. So, once you've heard everything, you get the opportunity to share some success stories. And you can say, man, I hear you. I know you've been told by this provider, and I can understand based on what you've seen, based on your imaging, based on your past experience, why you would be concerned that maybe you can't overcome this. but I've seen people in your condition with this diagnosis at your age, maybe even older, maybe even less healthy than you, get over this. It's gonna take time, it's gonna take hard work and consistency, but man, how would your life be different? If you could bridge the gap to a full recovery, what would you do differently? How much better would your life be? Let's just be curious. We've got time together. Let's do this thing. So I would call that step one. Acknowledge their concerns, ask clarifying questions, share success stories. have to do that first. Let them get it all out. You want to know every objection they have so that you can tell them why they don't need to be concerned about that. CRAFT EXPERIENCES THAT ENSURE SUCCESS The second piece, your job is to craft. Your job is to craft experiences that ensure success. There are two ways that we commonly do this with older adults that I assure you work with younger adults as well. The first one is make it laughably easy. In the older adult division, we call this intentional underdosage. This could be because someone is fearful, This could be because someone just has very low confidence. This could be because they're in unfamiliar setting or they've never done any weight training before. You're getting to set the stage for them. And you can do that by building successful reps. You want to make it so easy there's no way they can fail. Ramp it up a little bit. Let them be successful. Oh man, that's awesome. You're stronger than I thought you were. Ramp it up a little more. Ramp it up a little more. But what you don't want to do here is get greedy. If you get greedy as a clinician, I've done this several times, where you're like, man, I think they can actually deadlift 100 pounds, let's see if we can knock that off the list on day one deadlifting. And then they get scared, they get fatigued, or maybe you just misjudged it, and they can't lift that up, and now you've ended on an unsuccessful rep. You've shot yourself in the foot. So when you make it laughably easy, you intentionally underdose, make it easier than what you know they can do, you want to stop short of their maximal capacity. typically on that first visit, unless you're calculating an estimated one rep max, which is a whole nother topic. If you're already familiar with estimated one rep max testing, that is not the same as intentional underdosage. We're talking day one, building confidence, okay? So that's how we're going to, that's the first way we can craft an experience to ensure success is to intentionally underdose. The second thing that we're gonna do is test retest. We're going to show them that we can be successful. We're going to identify the asterisk sign, the comparable sign, whatever you want to call it. Doesn't matter. Especially when the primary concern is pain. Often with older adults it's function, but sometimes it's still pain. So I don't know, you know, the reason I'm here is because I can't get my arm up into the top cabinets anymore. I get shoulder pain. I get stuck. It hurts. Your job as a clinician, after you do your assessment, you figure out their range of motion, their strength, you've done a solid subjective, you ruled everything out, you've got a pretty good idea of what's going on, you're gonna give them some treatment, and then you're gonna retest, right? You need to make it very clear, you need very accurate measurements, and you need to tell the patient, here's where you got to. Man, that was about here, wasn't it? and make it really clear to them. You want them to remember that first measurement because what you're going to do is you're going to make them better. You're going to use your voodoo, right? You're going to throw your darts. You're going to do some manual therapy. You're going to do some exercise. You're going to put all those components of a solid treatment together and then at the end, you're going to knock their socks off, right? They thought that their shoulder could never get better. They've already been to PT several different times or it's been 10 years since this has been going on and you're going to show them. You're going to crack the door open on a successful recovery, just enough to at least make them curious. Test, retest. So when you craft that experience, you've got two solid options here. You can Intentionally underdose, if you're looking at a strength or a functional goal, or you're gonna use test, retest. Make it very clear, be very accurate on both measurements. Make it super clear, make sure it's your asterisk sign. You're gonna show them success. You're gonna give them the experience of being successful when they walked in the door and thought they could not be successful. FOCUS ON BELIEF CHANGE And then the third thing, once you've done that, you've still got work to do. You've got to focus them. You're going to have to focus them. You're going to have to refocus them throughout the entire bout of care. These beliefs go deep. They've been going on for a long time. You're going to have to chip away at those across the entire bout of care from the first interaction to the last one. Okay, especially if these beliefs have been long standing. So once you, the bedrock of changing their beliefs is giving them a successful rep and then reminding them of that success. You would think it would be obvious. There are so many client interactions where I did not do a good job of sharing. Remember, here's where we started. You can only slide your hands down to your knees when you came in and you had searing pain down your leg. And then they're at mid-shin, or maybe almost they're touching their ankles in the first visit. When that is their comparable sign, they're like, oh no, I moved that much. like you absolutely did not, but I did not make it clear enough what was going on at the beginning to show you how you progressed. So you need to make that painfully clear. After that, you need to remind them of their progress. Each visit, remember where you started. Remember where you started. The first day you walked in, you thought that it was going to be impossible to lift up this 10-pound weight from an elevated surface. You looked at that weight. You stared at it. You looked at me. You looked back at the weight. You were like, this is not happening. And then what happened? You walked up, you moved that thing. You got several reps. We even got up to 15 pounds that first time. You didn't think you could do 10. You thought that was out of reach. Now you're lifting 30 pounds. 30 pounds. You have had a 300% increase in your functional ability. Incredible. Now you're doing it off the floor. Think about how that opens up your life. How many things in your life weigh 20 to 30 pounds? Now you're doing it for reps. Think about all the things you can do now that you could not then. And the reality is, our patients aren't gonna have this nice, linear progression. So the third step on focus is going to be to share with them, these are a couple of my favorites I like to use, is progress is non-linear. We like to think it's just going to go up and up and up and every visit is going to be a smashing success. It's going to be the most you've ever done. It's going to be incredible. But that is not the case. We know that it's more like a good stock in the stock market. A really solid stock has got down days. and your patients are going to have down days. Medically, especially with older adults, they tend to be more medically complex. If you've got a progressive neurological condition, you've got someone with MS, and they're going through an exacerbation, there may be two weeks where there's flatline progress or reduction, but if it's still above where they started, you need to highlight that. Yeah, but we're not where we started, and we know this is going to end. And then we're going to start climbing again. And when we back up and look at this picture, it's going to be off the charts. When we back up, we've still got a solid line going up that day. So the other quote is, every day is not going to be your best day. Come in and give me what you got. That gives our patients permission to do what they can. And sometimes that is enough to crack the door open on a really solid recovery. I love this quote. Now, I'll share it with you. It comes from a spiritual realm, so I'll share that and then I'll give you the bit for it. So, a man with an experience of God is never at the mercy of a man with an argument. A man with an experience in God is never at the mercy of a man with an argument. So, if we reframe this around our patient's beliefs and expectations, their argument of I can't get better, we're gonna chip away at that by producing these successful experiences, building on success. We're gonna chip away at those beliefs. It's like, man, I know you thought you couldn't do it, but you've already done it. You're already someone you didn't think you were. SUMMARY And that's what I've got for you, team. So three steps to give your patients permission to succeed. One, acknowledge their concern. You've got to listen well, ask clarifying questions, know all the barriers that are in your way, and you're going to push those out of the way with success, stories of sharing how you're going to be different. Second thing is you're going to craft successful scenarios. You're going to ensure success, whether it's an intentional underdosage or test-retest. You're going to show them what they didn't think could be done. You're going to do it. Not you, they're going to do it. They're going to be the ones that are going to show themselves. those experiences, and then you're going to focus them on that success. You're going to focus on the long game, how their life's going to be different. You're going to be highlighting how those little incremental changes are going to change their life. And over time, you're going to change their beliefs, their expectations about themselves, and you will change the way they age. You will change their life if you can do those things. Team, if you've got other strategies, if you found any of these things helpful or you've got other strategies you want to share, I'd love for you to drop that in the comments. If you're watching this on Instagram. If you want to learn more about what we're doing in the older adult division, our next cohort of level one is going to start August 14th. Level two, the last cohort completely sold out. So just so that's on your radar. It doesn't come around as often, but that next cohort is going to be October 17th. I'm going to be in Houston, Texas this weekend. We still got some seats. If you're in the area, you don't want to miss it. It's going to be an absolute blast. Then the 22nd of June, we're going to be Charlotte, North Carolina. Then I'll be back in Victor, New York on July 20th. And team, after that, we're going to have an MMOA Summit the following weekend. So that's going to be 727 Denver, Colorado, MMOA Summit. Almost all the faculty is going to descend on Denver, Colorado, and bring you the goods. Team, I hope you have a wonderful Wednesday. We will see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 4, 2024

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling faculty member Ellison Melrose discusses the form & function of the deltoid muscle, as well as clinical applications for dry needling to the deltoid for different patient populations. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to Jane.app slash switch. And if you do decide to make the switch, don't forget to use our code IcePT1MO at sign up to receive a one month free grace period on your new Jane account. ELLISON MELROSE Good morning, PT on Ice daily show. We are live on YouTube and on Instagram. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I'm super excited to be here for deltoid week. So I kind of compare this to like the sharp week from childhood, right? So this is the most exciting week of the year for us. Um, we are here to talk all things about the deltoids. So we came off of yesterday. Jess, um, started talking to us about the importance of deltoid strength during motherhood and how we can maybe implement some deltoid strengthening in some um, early postpartum period, right? Using more of like a hypertrophy style training versus, you know, diving right into things like CrossFit right away. So that was really awesome. Um, I'm here to tell you guys today about the form function and some clinical applications of deltoid strength. So let's dive right in. Um, if you have been to an upper quarter course with either myself or Paul, we spend a few minutes just on the deltoid side, just talking about how cool the deltoid is. THE DELTOID: FORM So let's start with form, right? So if we look at the deltoid, there is no other muscle in our body that is shaped like the deltoid. Some may compare it to the glute, the glute max of the lower quarter width, you know, how it kind of spans that, that joint and has multiple origins to the single point insertion, um, similar to the glute max. But if you actually look at the deltoid, the origin is almost a full circle, right? So it's about 300 degrees of, um, contact with our, lateral third of the spine of the scapula, the lateral border of the acromion, and the lateral third of the clavicle. So it's about 300 degrees to a single point insertion at the deltoid tubercle. Right? That's like really, really cool. There's no other muscle in our body that does this. This allows us to move in multiple planes of motion. And we'll talk about the function in a little bit more depth later. But just by looking at it. There's nothing else like that we have in our body. Next, we have its innervation, which is also fairly unique, right? So the axillary nerve, its number one job, let's see, its number one job is to provide a motor response to the deltoids. I'm having a little bit of issues on Instagram, We'll come back, we'll just keep it going here on YouTube. So, its main motor branch is to the deltoid. It does innervate teres minor, but I would argue that's probably the smallest muscle we have in our shoulder girdle. And likely the most important part of the axillary nerve is its motor contribution to the deltoid. So if we did not have an axillary nerve, what would that look like in the shoulder girdle, right? That would look like a significant sulcus. So we would not be able to use any of the other muscles in the shoulder girdle without the axillary nerve. Next, we have different regions of the deltoid. So we have the deltoid can be separated into three primary regions, right? We have anterior deltoid, we have middle deltoid, we have posterior deltoid. Well, in 2010, what they found, there was a study that looked at those compartments and what they found was there's actually a further fascially subdivided region in both the anterior and the posterior delt. So each of the anterior deltoid and the posterior delt, each of those have three separate fascially subdivided regions. Really cool. What they also, another study looked at was the EMG activation throughout the deltoid. And what they found was there's at least six differentiations with EMG activities. So we have those fascially subdivided regions can be turned on and turned off, maybe independent of each other, which allows us to maybe think about the function of the deltoid a little bit differently. Right? So our form, we have a very unique origin and insertion. We have a very unique innervation with only a single nerve. And that's main job of that nerve is to innervate the deltoid. Our brain perceives that muscle as really important when things, when we have one nerve and its main job is to just provide motor function to that muscle. So it's super important. We also have the form as the we can divide it further from those original three divisions that we kind of think about back in PT school to seven different subdivisions that we may be able to activate, turn on and turn off independent of each other. THE DELTOID: FUNCTION So let's dive into the function, right? There are four main functions of the deltoid. The first is it's a mover, right? And that's what we think about when we think about the deltoid. We think that it moves into flexion, abduction, extension, internal rotation, external rotation, right? It's a mover in our primary planes of motion. It can also fine tune movements, right? So now that we know that like the deltoid has all of those subdivisions and we can maybe recruit those independent of each other, we can fine tune specific movements. It acts as a synergist with other primary movers in different planes. For example, the posterior deltoid is a great synergist with infraspinatus. We're thinking about, you know, end range external rotation or external rotation in that abducted position. The deltoid may be able to help or maintain that movement pattern and act as a synergist with the infraspinatus. Really cool stuff. So it's a mover. It's also a stabilizer. So I mentioned earlier that if we had an axillary nerve lesion, that would look like a detrimental sulcus sign to the glenohumeral joint, right? So the deltoid, when we think back to PT school, we were like, I at least put a lot of emphasis on the bicep tendon, you know, maintaining its humeral head placement, the rotator cuff, fine-tuning those movements so that it stays in that ball, the humeral head stays in the glenoid fossa appropriately. But if you took away the bicep tendon, right? People do that all the time. We have biceps tenodesis. We still have a functioning shoulder, right? If you took away the rotator cuff, we see that a lot. People have full thickness tears of specific rotator cuff muscles, and they still have function of their shoulder. If you took away the deltoid, you would not, right? you would not have the ability to use the rotator cuff, to use the bicep tendon, to do their primary movements. So it is a stabilizer to the glenohumeral joint. It almost provides an accessory like suction to that labrum to help maintain that humerus in the glenoid fossa. It also provides stability to other joints in that area. So if we think about where it crosses, it spans the AC joint. There's only one other muscle in our body that spans the AC joint, and that's the upper trap. So when we think about if we have damage to the AC joint or our passive structures have maybe been or have been impaired, we have an active stabilizer in the deltoid and the upper trap that cross that AC joint. So again, deltoid strength may be able to help maintain that stability in the AC joint when some of those passive structures have been lost. So it's a mover, it's a stabilizer. Next, it's a cushion. So we don't really think about this often when we think about muscles, but muscles cushion the bones, right? So they cushion the bones, they protect some higher, more sensitized structures in the region. And in this region, in the axillary region, we have brachial plexus and all of its branches exiting the axilla. So we have some very important neurovascular structures close by. So what could be very detrimental to those tissues would be a proximal humeral head fracture. So what the deltoid can do is it can cushion or kind of dampen the blow to a blunt trauma to that bone, which may help reduce the impact, and reduce the likelihood of a proximal humeral head fracture. So really cool stuff. So we're thinking maybe patient populations, that would be beneficial for. And we'll talk about that in a second. So it's a mover. It's a stabilizer. It's a cushion. Last but not least, it's a pump. A lot of what we do in physical therapy, we're just pumping fluid. Our goal is to reduce chemical irritation in that tissue. if we have pain, for instance, right? So we need muscles that help facilitate hemodynamics. When we look at the upper quarter, one of the best muscles to do that is the deltoid, not only by its pure mass, but its capillary density. So it has a higher density of capillaries, which helps with it both, you know, the hemodynamics and the perfusion in that area, but also its proximity to the lymphatic axillary watershed. and just the venous structures, right? So if we think about our venous return coming up into the axilla, all of those things are very important. And when we look at research that was surrounding lymphedema and edema reduction in the upper quarter, what they found was that the deltoid plays a key role in edema evacuation from that upper quarter. So function, right? We have, it's a mover. Not only is it a gross mover, but it's a fine tuner. It's a stabilizer. We would have no upper quarter function without the deltoid. It is a cushion. So it can provide some cushioning for any trauma that occurs in that upper quarter, which is going to protect some of those more sensitized structures we have in this area. And it's a pump. We're pumping fluid, right? So it can help with edema reduction, any sort of acute injury in the distal extremity, not only thinking lymphedema, but also thinking like acute injury. Maybe we don't want to target those tissues. Speaking specifically from a needler, maybe we don't want to needle the tissue that's the issue because it's in an acute inflammatory stage. We want to think proximally. What can we do proximally? we can needle and stem the deltoid, which may help with that fluid dynamics. THE DELTOID: CLINICAL APPLICATION Lastly, I want to talk about three different patient populations that may be beneficial to think about improving the robustness of the deltoid. I'd argue that every single patient population could benefit from a more robust deltoid. But when you look at the research, First, let's talk about operations. So shoulder surgeries. When you look at the research, the deltoid, the strength and mass of the deltoid is one of the number one predictors of a positive outcome from both rotator cuff surgery and something like a reverse total shoulder. So no matter what the surgery, what they're finding is that if you have a stronger deltoid going into it, you have better outcomes coming out of it. Right. So say we had a patient who, you know, they've come, they've been seeing us for a few months, conservative methods of rotator cuff for rotator cuff tissue healing. Right. And they're like, you know what? I'm still in pain. I think I'm going to get the surgery. And you're like, great. Let's keep hammering that deltoid. Right. You have six weeks until surgery. Six weeks is a great time for some progressive overload, some hypertrophy and strength building to that deltoid. It's only going to set you up for more success post-op. So I believe Paul will be putting out some research for that or a post about post-operative implications with deltoid strength today. So look for that on Instagram. Next, we have our hypermobile shoulders. So when we think about shoulder instability, may have had some recurrent subluxations or have had trauma to this area where some of those passive structures have been stretched or maybe aren't doing the job that they were meant to do, right? When we think about the detrimental effect of not having a deltoid, not having the ability to maintain that humeral head in the glenoid fossa or at the glenoid fossa, like how detrimental that can be to upper quarter function. We know that strengthening the deltoid, or we should know, we should implicate that the strengthening of the deltoid would significantly improve their tolerance to loading that shoulder girdle, right? So we kind of, you know, you think about, we're always hammering people with rotator cuff exercises. And sometimes I think we forget about the big guy of the deltoid. because we don't necessarily contribute that to maintaining that glenohumeral joint support, right? So we're thinking pre and post-op, we're thinking shoulder instability, and last but not least, we're thinking our older adult population. So this is going to kind of follow into tomorrow, where we'll have the older adult division diving into the importance of deltoid strength in that older adult population. But let's speak a little bit to the research. So as we all age, we know that we have some sarcopenia that typically occurs, right? So we have a little bit of change in our muscle mass. And when we look at independence in the older adult population, one of the things that helps folks maintain their independence is being able to lift things overhead, right? Their overhead capacity. So deltoid not only does that movement, but as we age, what we find is we have a shift in fiber type or maybe mass. And we'll talk about that gender specifically. So males, as they age, they don't necessarily see significant atrophy in the number of fibers or the overall size of the deltoid. But what they do see is they see this shift from type 2 fibers to type 1 fibers. So we have atrophy of type 2 fibers and more preferential activation of type 1 fibers, which is going to limit their power producing ability in the upper quarter. Females, it's a little bit different. We don't see that shift in fiber type, but what we do see is we see general atrophy, right? So we see loss of muscle mass in the deltoid, which is significantly going to impair their independence with that overhead movement. Don't want to steal too much of that for tomorrow, but three main patient populations that may benefit from a more robust deltoid, pre and post-op, hypermobile or instability, and then the older adult population. SUMMARY So today we kind of dove into all things form, function, and clinical application of the deltoid. Hopefully we can get this post up onto Instagram so our folks over on Instagram can also enjoy today's content. So for those that are looking to learn a little bit more about the deltoid, head on over to our Instagram. This whole week we're going to be posting different things of how to load the deltoid. Paul will be posting some different ways of how to needle the deltoid to access both the anterior and the posterior shoulder in different positions. So head on over to Instagram and check out those posts this week. If you're looking to join us on the road, Paul and I will both be Doing a lower quarter course at the end of this year, we have a few upper quarter courses remaining this year, where you can learn how to, you know, needle the upper quarter and particularly the deltoid. So hop on to PT on ice. Yeah, ptonice.com to check out some of those courses coming up this fall, and I hope to see you on the road. Have a great Tuesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 3, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the role of the deltoid and upper extremity strength in pregnant & postpartum moms. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. JESSICA GINGERICH Good morning, PT on ICE daily show. My name is Dr. Jessica Gingrich and I am here to kick off deltoid week. So if you are wondering what that is, the faculty have come together and we are going to take this week and we are going to talk about the deltoid. This is gonna be a really fun week. We are going to learn just how to assess it better, how to use better pain management strategies, and really ultimately how to load the deltoid better and just treat shoulder pain differently. Now, we are coming hot off of semifinals over in Knoxville. We had wonderful, also Monday, here's my dog again, if you can hear. Olive with the trash guy We are coming hot off of semifinals where we watched Tia Claire to me dominate That was really cool You know, there are other athletes out there Haley Adams. I'm wearing her shirt today I mean coming back and just in just doing such a phenomenal job, but Tia crushed it and that was really cool to see her coming back postpartum So we're going to take today and we're going to talk about the deltoid and the pelvic floor. I know you guys are probably like, I'm sorry, what? How are you going to put that together? And you know, I a little bit thought that as well because we're not going to palpate the deltoid and then bring on pelvic floor symptoms likely. So the deltoid, we know abducts the arm. It's going to flex and internally rotate with those anterior fibers and it's going to externally rotate and extend with the posterior fibers. We want to make sure that we can take this muscle and maximize it for motherhood. So we are going to further break down the pelvic space with the deltoid, and we are going to bring this into the pregnant and postpartum space. Motherhood is a journey. I'm not yet a mother, but I treat moms every single day, and I see the different pieces that they have to do, the challenges that come with it. We have new tasks, right? Like tasks that look different than when we were before a mom. Getting back to exercise, a lot of the times is a massive goal of a lot of people. We're starting to see pregnant and postpartum people just infiltrate exercise, like the exercise space. And that's so fun to watch. So we are gonna first break down and talk about pregnancy. PREGNANCY: A PERFECT TIME TO BUILD STRENGTH So pregnancy is a wonderful time to build strength. A lot of times we have moms who don't feel great all the time, especially further into their pregnancy, getting their heart rates up. In doing these metabolic conditioning pieces, going on long runs, they don't necessarily feel great all the time. Some moms do. But we can take that time and we can bodybuild. and we can hit a strength piece and then we can sit down and rest for three minutes and maybe that rest for three minutes is also the same time as giving our baby some attention. So things that we can do in the pregnant time is work on things like push-ups, bench, elevate the bench if you have to, go down to your knees for your push-up, elevate the push-up. overhead press, variations of overhead press, whether we're doing a push jerk, a strict press, a Z press, a bent over row, hitting those posterior delts, and then even doing things like a front rack hold or a front rack carry. These movements are going to mimic a lot of the movements that they're going to have to do postpartum or they may already be doing if they have another kiddo at home. So in pregnancy, focus on setting the foundation for upper extremity strength. Breastfeeding, bottle feeding takes up so much time. Sometimes that time is valued and sometimes it's not and that's okay. Sometimes that's very frustrating. Let's prepare mom so when she's breastfeeding or bottle feeding every two to three hours that she doesn't come in and she's like oh my neck and my back hurt because we're building that strength. So now we're going to switch and go into the postpartum space. The postpartum, we have this with a zero to two weeks is our healing timeframe, right? We aren't doing a push jerk at 70%. So maybe we're doing things like stretching the posterior delt with a sleeper stretch. loading the delts with banded I's T's and Y's, stretching the anterior delts and the pecs with a doorway stretch, and then doing some banded pull aparts. And maybe we can incorporate that after every feed, or maybe if that's too much, can we do it at least once a day to help utilize these muscles to decrease back pain and decrease neck pain? So, we're gonna dive further into this week with other divisions, so extremity, dry needling, where they're gonna talk about pain management strategies. So using dry needling techniques, soft tissue, cupping, joint manipulation, and other loading strategies to help load the deltoid, make the deltoid feel really good, and incorporate this into your moms, into your pregnant women. help them. You look at them as a whole body, not just pelvic floor because that's rarely what it is. So, if you are thinking about taking pelvic courses, head over to PTOnIce.com. We've got our live course, our L1 online course, and then we've actually recently added a third L2 at the end of the year due to high demand. So if that is something that you are or that is on your list, head on over and check it out and we will see you at 9am tomorrow. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 31, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the principle of Specific Adaptations to Imposed Demands (SAID), the principle of Somewhat Humdrum Adaptations to Rehab Treatment (SHART), and how to help patients & athletes reach & meet specific goals. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. Welcome to the PT on ICE Daily Show. It is Fitness Athlete Friday. I'm your host, Alan. I currently have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. We're here on Friday, Fitness Athlete Fridays. We talk all things CrossFit, Functional Fitness, Endurance Athletes. If you have a patient or client who is active on a regular basis, Fridays are for you. We have an exciting announcement next week you'll see on our social media. An entire week, thanks to dry needling faculty member Paul Killoren, an entire week dedicated to the deltoid. So you'll see the podcast next week, all the episodes will be about the deltoid, and you'll see all of our social media posts next week focused on educating you, everything related to the deltoid muscle. If you've taken our upper body dry needling course with Paul, you know that he has quite the obsession with the deltoid muscle. So we're really excited to see just how much shoulder content we can give you all next week. So tune in beginning June 3rd for an entire week of deltoid themed content. Today, the topic for Fitness Athlete Friday, what are we talking about? The SAID principle, specific adaptations to impose demands. You may have heard of this principle at some point in your life. You probably heard a very generalized definition of this term that maybe did not really help you understand what it is or how it could possibly apply. to exercise or to clinical practice. WHAT IS THE SAID PRINCIPLE? So the SAID principle, really, again, very basic definition that training a particular movement pattern, training a particular skill, training a particular time domain or energy system will result in the most efficient adaptation to that imposed stimulus that imposed demand on the body. And when we uncover, when we unpack the definition of the said principle a little bit more, we talk about actually the two ways that we see changes from this. The first being structural, that we see muscle size and shape takes place, and the other being neuro or neuromuscular, that we get a more efficient recruitment of muscle fibers, that we're able to recruit more fibers, larger fibers, recruit them in a more efficient sequence, so on and so forth. So that's the said principle in a nutshell. Today we're gonna talk about why it matters, give you a practical example from the gym, give you a practical example from the clinic and kind of wrap up why maybe we need to reconsider this. Maybe if we did learn this back in high school or undergrad or grad school or maybe all of them, maybe why we need to consider this more often in our practice, whether we're working with patients in the clinic or athletes out in the gym or a more active setting. So when we interact with folks in the clinic, whether they're patients for physical therapy, whether they're athletes coming to us maybe even for performance help, they don't necessarily need help with a physical therapy related issue. They come in and they may complain about a plateau about not making progress with their physical therapy about not making progress with their performance in the gym in their running plan or whatever. And if we take the time to unpack, and if we take the time to assess a couple things, what we usually find with these folks is they seem to be at a plateau, but it's really because they're not doing things specific enough to create the adaptation that they're wanting from the stimulus that they're giving themselves. Their rehab exercises, their exercises in the gym, their strength training, their endurance training, whatever that might be. WHY DOES THE SAID PRINCIPLE MATTER? And so why does the said principle matter? Training similar things may result in some carryover, but people I think fail to understand that it won't result in the most efficient, time-wise, in the most efficient carryover to develop a specific skill, a specific movement pattern, a specific progress towards a goal. So we often say, hey, well, doing a bunch of strict pull-ups make you better at strict pull-ups. Yes, of course. Will doing a bunch of strict pull-ups make you better at free climbing El Capitan? Well, there's gonna be some carryover, right? But probably the best thing to do to get really better at free climbing is to do free climbing. And arguably, we would say and not or. The best thing to do would be to practice the thing you want to get better at and then do accessory stuff like strength training to further enhance your way onto goals. We see this a lot. In the gym and CrossFit, folks always complain about not being great at running. We do run in CrossFit, but often lower volume, shorter distances than someone who would consider themselves a runner would consider running. And so when folks want to improve their 5k time, or they want to run a 10k or a half marathon, or maybe even become a marathon runner, They often say, I'm not getting better at running. And when we ask, okay, how often are you running? And they say, oh, well, I hate running. Running bothers my shins. So every time there's running, I just row or bike. Again, is there going to be carryover from rowing or biking or doing some other cardiovascular modality to running? Yes, of course, but not as specific, not as great as if you did running training to improve your goal of getting better at running. There are certain things that happen when you run more, You get an improved running economy. You get more efficient in that movement pattern because you're spending time in that movement pattern. And yes. We can get cardiovascular adaptations from rowing or biking, but it's just not gonna translate 100% to that specific thing. So that is why the said principle matters. PRACTICAL EXAMPLE: "GRACE" When we look at our practical example in the gym, we just had a benchmark workout last week at our gym called Grace. You may have heard of this CrossFit benchmark workout. 30 clean and jerks for time at a standard barbell weight of 135.95. And talking to members that day, people asking, hey, like, what is the world record on this? Do you know? I do know it's it's 59 seconds, right? With some people completing it, CrossFit Games athletes under 90 seconds. And so the conversation began, okay, If this takes me eight minutes, and it takes them 90 seconds, what is the difference between them and me? And I think a really lazy answer when people want to improve their performance when they want to break through a plateau, whether that's in the clinic, whether that's in the gym is well, they're just in better shape than you, right? That's a very lazy answer. When we break down why is that person better at doing that workout than you, we can start to unpack some characteristics, some specific characteristics of why their performance is higher than yours. We look at somebody like Matt Frazier, five time CrossFit Games champion, a minute 18 clean and jerk, grace time 30 clean and jerks for time, which is faster than a clean and jerk every two seconds. So moving fast, moving unbroken for 30 clean and jerks, what do we know about that athlete? Again, the lazy answer would be, well, he's been doing CrossFit a long time and he's just in better shape than you. Yes, but why? And the why matters, the specifics matter because that can turn into a training program for a person who wants to maybe cut 15 or 30 seconds off their grace time. or cut time off their 5K, or get better at strict pull-ups, or rock climbing, or whatever, right? When we look at Matt Frazier, why is he better at that workout? A long history of Olympic weightlifting, very familiar with a movement like the clean and jerk, very efficient in the clean and jerk, very strong, not only in the clean and jerk, but the movements that support the clean and jerk, the front squat and the strict press, an athlete who can strict press above his body weight, an athlete who front squats several times his body weight, and an athlete who has a 425 pound clean and jerk, right? So when we look at 135 pound barbell compared to a 425 pound clean and jerk, a 500 pound front squat, a 250 pound strict press, we say, okay, this is a very strong individual and specifically related to things like the SAID principle, he is very well trained in this specific movement pattern. It makes sense that because this is an incredibly light barbell for him, but he can hang on to it for 30 reps, move it touch and go unbroken, and get that workout done in 90 seconds that might take you five minutes. Why? You don't have as strong of a clean and jerk. You don't have as strong of a strict press. You don't have as strong of a front squat. You aren't as efficient at cycling that barbell because you have not been doing CrossFit as well. And in specific, we also look at time domain, right? He is getting a workout done while he is still in the anaerobic glycolysis time domain. He still has a lot of high power output. versus when you transition, when it starts to take you more to two to three minutes, we know your power output goes down. We know you're transitioning into your aerobic energy system. He's getting it done because he's more efficient at it before he runs out of gas. And so, how do we take that and translate that to a training program for that athlete? Well, of course, we need to work on your front squat. We need to work on your strict press so that your clean and jerk gets stronger. We also need to train your clean and jerk so you get more efficient at clean and jerks. We need to train your clean and jerk where you do touch and go reps at a light to moderate weight so you get efficient in the endurance of the clean and jerk, not just the strength. And we need to train a very fast, explosive time domain for you, right? That is a great athlete where we might say, hey, every minute on the minute, I want you to do five clean and jerks, seven clean and jerks, 10 clean and jerks, progress it and make them work in the time domain in the movement they want to get better at, right? This is what endurance athletes do all day long. They progress their volume, they progress their time domain, and they get very specific in what they're doing, right running, biking, swimming, maybe all three of those, maybe just one of those, but spending a lot of time in the movement pattern you want to get better at spending a lot of time in the time domain you want to get better at. THE SAID PRINCIPLE IN THE CLINIC Switching gears, we see this happen in the clinic as well. Just like somebody is plateaued maybe on a workout like Grace, we have patients who are maybe plateaued in their plan of care. And if we're not careful, if we're not specific, if we're not assessing in the clinic, if we're not using our clinical reasoning, we can develop a very high quality loading program, a very high quality accessory program for the wrong area, for the wrong athlete, for the wrong time domain. I call this the specific humdrum adaptation to rehab treatment or the sharp principle, right? A very boring adaptation that serves no purpose, because that person in rehab was forced to do what we told them to do. And maybe we weren't giving them specific enough of a treatment. So without proper assessment, we may not know what people need to work on. And so we're often surprised and curious and maybe upset when Gladys comes in and she hasn't improved her 30 seconds sit to stand. She is still only getting four reps done in 30 seconds. She's been here for six weeks and we look back at her treatment plan and most of her treatments consist of coming into PT and riding the new step at zone one heart rate for 30 minutes or most of her session. We should not be surprised when we reflect back on the said principle that Gladys is making no meaningful improvement, right? She is struggling with a high power, short time domain demand, a 30 second sit to stand, and her treatment almost entirely consists of relatively low intensity, long duration endurance activity. Again, specifics matter. What we have our patients do, they will adapt to. If we give them the wrong stuff, or maybe just not as effective stuff to do, we should not be surprised when we do not see them make a lot of meaningful progress. We can see the same thing with patients who are symptomatic. Why are we surprised when Mark comes to the clinic, he's made no progress on his lateral elbow pain, and all we're giving him in PT is high volume, low load, banded, or lightly resisted exercises. We know that's a tendinopathy, we know it needs load, specifically it needs time under tension, and it needs progressive loading. Giving that person a high volume, low load dose is likely what caused that condition in the first place, so we should not be surprised that that person is not making any meaningful progress. So getting specific, adopting the said principle matters. Avoid the sharp principle. We can make people pretty averagely better at stuff they don't need to get better at or don't want to get better at if we're not careful with our rehab treatment. I truly believe we have a lot to offer patients and clients from both a rehab and performance perspective, but only if we take time to assess where is this person weak in their game? What is the most important thing or the maybe most important two or three things they need to work on? That's what our rehab plan, maybe that's what our accessory program for the training they're already doing should look like. Keep it specific, especially if that person needs or wants a specific result. We can be very good at giving a lot of general treatment that gives a lot of general improvements, but if it's not helping that person meet their specific goals, then it's not as effective as it could be. SUMMARY So remember, what is the said principle? Specific adaptations to impose demands, train in the time domain, exercise in the time domain they want to get better at, you want them to get better at, train the movement patterns they need to get better at, and you'll be surprised at how quickly somebody makes progress. Avoid the sharp principle. Avoid just giving a general exercise prescription. We see this a lot in students who are so happy to walk in and write down a 30-minute AMRAP on the board or 24-minute REMOM and sometimes we have to stop them. We appreciate the enthusiasm, but we have to let them know, hey, you're just giving that person a bunch of general stuff that may not translate to them getting specifically better at the stuff they need or want to get better at to meet their goals. We have a lot to offer, but we have to make sure that we're assessing, reassessing, and we're being specific. So I hope this was helpful. If you want to learn more from us in the fitness athlete division, we'd love to have you. A couple chances coming up in the month of June. Zach Long will be down in Raleigh, North Carolina, the weekend of June 8th and 9th. And then we have our Fitness Athlete Live Summit here in Fenton, Michigan. That's the weekend of June 22nd and 23rd. We'll have all of our lead faculty, all of our teaching assistants here. That's gonna be a really fun weekend. Online, our next cohort of fitness athlete level one online starts July 29th. That course always sells out. And then our next cohort of fitness athlete level two online begins September 2nd. So, I hope this was helpful. Remember, keep it specific. Assess, reassess, keep it specific. Have a great Friday, have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 30, 2024

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses three different variations to load the lateral shift: side plank variations, RNT side bends, and unilateral carries. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JORDAN BERRY All right, what is up PT on Ice Daily Show? This is Dr. Jordan Berry, Lead Faculty for Cervical Management and Lumbar Spine Management. And today we are continuing our theme of the lateral shift. So we've had a few episodes over the last few weeks. For the first episode, we were chatting about how do you actually recognize the lateral shift? Like from a subjective, from an objective standpoint, how do you pick up a lateral shift in the clinic so you're not gonna miss it? Second, we went over what are our lateral shift correction variations. Besides the standard one, then standing, what are some other ways that we could correct the lateral shift based on the patient irritability? Today, we're talking about loading the lateral shift. So this is something that comes up in courses quite often for our lumbar management courses when we're talking about the lateral shift and we have some different ways to reduce symptoms and to correct the shift or reduce the person's pain, decrease the irritability, but then what do you follow that with? Like in the session, right? We're not oftentimes just doing 40 or 45 minutes of a shift correction. We want to try to apply load to the person's system as well. And if we can start to load that person, the shift correction is going to quote-unquote stick more or be more effective during the session, between sessions. As long as the irritability allows for us to start to apply some load, we want to be able to. So we're going to go over three exercises that we commonly use in the clinic to start to load the lateral shift. So I've got Jenna again with me. Jenna is part of our fitness athlete division. She's going to be demoing some of the exercises while I'm talking through it. So let's get the camera set so we can see the ground a little bit better right here. Okay, perfect. SIDE PLANK VARIATIONS The first way that we're going to talk about that we load for the lateral shift is a side plank variation. So I want you to think about really just loading unilaterally. Whether it be the midline, core, whether it be the lateral hip, we're just trying to load that side to get the person to load that part of the spine. So for example, let's say Jenna had left-sided symptoms. Left-sided symptoms. So we said in a previous episode, almost always the lateral shift is going to be away from the side of symptoms. So, it might be slightly backwards depending on what platform that you're watching with the camera, but we are shifting away from the side of symptoms. So again, we're saying this side here, and if you're listening on the podcast on whatever platform that you're on, be sure to hop on either Instagram or YouTube and watch this episode as well so you can see the exercises in real time. Okay, so the first exercise. So we're going to say again that left side is painful and we are shifted towards the right. So we are going to do a side plank variation in order to load in to the painful side. So we're going to start with our standard side plank variation. The painful side is going to be down. So again, the side towards the floor would be the symptomatic side. And you can appreciate as Jenna comes up and squeezes the glute, squeezes the midline here, she is loading this bottom side that is towards the floor. Now, we could of course go through our same variations with the side plank that we would if we were loading the lateral hip to increase or decrease the difficulty, right? We could have the feet together, we could have knees together, we could also have that top leg floating that makes the bottom side work even harder. How would we regress that? if the person can't tolerate that full version. So Jenna, you can come up here. We would go to an elevated surface. So you could use a bench or you could use a box or you could use a table. But what Jenna is going to do is mimic the exact same position. only now she's at an angle, right? So she's not fully on the ground and we've taken out some of the load. So now it's likely only about half of her body weight that she's having to hold up. And again, the painful side is still down. You can appreciate if this is the painful side and we went here, that's basically the way that Jenna would be shifted. But when she contracts, that is the same thing as a shift correction. Only now we're applying load. instead of regressing it, how would we progress it? We could just add some resistance to the side plank. So we've got a band right here around the rig here. And what you would do, I'm gonna lift this up, Jenna would do the exact same side plank, only she's got this resistance band right around the hip. Much more challenging. When she comes up, she has to press into the resistance band and now she's getting way more load and working way harder to correct that shift or load that shift after we have done the lateral shift correction. You can come out of that, Jenna. So that's number one, a side plank variation. There's a million different ways. You just have to respect the irritability. RNT SIDE BENDS Number two is essentially an RNT side bend. So RNT meaning reactive neuromuscular training. So we're going to take a band and put it around Jenna's torso. And the band is just essentially pulling her in the direction that we don't want to go so that she has to fight against it and go in the opposite direction. So we're going to take this band, Jenna's going to wrap it around, and then bring your arm over top. Perfect. So we've got the band here, okay? So we are saying again that the left side, side here, is the symptomatic side. So if we had a lateral shift, she would be going this way. Well now, in order to stand in midline and keep herself centered, she now has to push in to that resistance band. So again, the band is pulling her more in the direction that we don't want her to go, right? There would be more in the direction of going away from the symptoms. So the more that resistance band or the more resistance the band has and the heavier, thicker that band is, the more she's going to have to fight against it to self-correct into that position. essentially a standing version of the side plank that we just demonstrated. Okay, so that's number two. UNILATERAL CARRY Number three is going to be a unilateral carry. Unilateral carry. So you could use dumbbell, you can use kettlebell. We typically will load it with a kettlebell. But again, just to stick with the same theme, saying the left side would be the symptomatic side. So Jenna would almost always be shifted away towards the right. we are going to put the weight on the right side. So we are putting the weight on the side opposite of symptoms so that she has to fight against the weight and correct back to midline. So again, the weight is pulling her in the direction that she's already going, avoiding the symptoms. And the heavier the weight is, she's going to have to work that much harder to pull herself back to midline. So you could start with just the static hold with the kettlebell. We could also add in a march to make it more challenging. And she's just lifting one foot at a time, going nice and slow and again, trying to just make sure that her midline is really engaged and active and holding her in this neutral position, fighting against the direction that she would typically be going to avoid the side of symptoms. SUMMARY So those are our three variations. We've got the side plank, very similar to how we would typically load the lateral hip. We've got progressions and regressions, just based on the patient irritability, find something that they can tolerate that does not increase symptoms. We also have that RNT, that banded side bend, where the band is pulling more in the direction that we don't want the person to go, so they have to fight against it. And the exact same thing with the unilateral carry. Whatever side the symptoms are on, the weight is on the opposite side, so they have to self-correct and pull themselves back towards midline. Three ways that you can start to load a lateral shift in the clinic. So again, we've got three parts now in this series that we're doing on the lateral shift. Part one, how to actually recognize it in the clinic. Part two, what are the lateral shifts? And three, how do we actually start to load the lateral shift? All right, that's all I've got. Have a great day in the clinic. And we have a few lumbar management courses coming up this month. We've got Anchorage, Alaska, and we've got Paoli, Pennsylvania. So check out PTOnIce.com for tickets. All the other dates coming up. Have a great day in the clinic. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 29, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses the management of urinary incontinence in the older male, implications for function, and quality of life. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. CHRISTINA PREVETT Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in our geriatric division and today I am hoping to talk a little bit about urinary incontinence in the older male. A lot of times we focus a lot of our conversations around pelvic health on the female side of the sex spectrum. But today I really want to talk about males. We talk a lot in MMOA, especially in our Level 2 course where we do an entire segment on pelvic health for the older adult. around how every clinician is a pelvic floor clinician. And the reason why we say that is because if you're interacting with hip and low back pain, then you're interacting with the pelvic floor as part of our core canister. And urinary incontinence is a leading cause of institutionalization and a very big reason why some people may not want to engage in the dosage of exercise that they need in order for them to gain the independence that they're hoping to gain. And so we really want to make sure that we are at least doing our due diligence in screening. When we are working with individuals, we wanna know if there's any urinary incontinence on board. And then we wanna talk about what is going on with respect to the male aging pelvis and how that interacts with signs and symptoms like urinary incontinence. So the biggest, biggest, getting bigger area of the male pelvis where there's a lot of conversations around its impact with age is the prostate. So we do know that there is an enlarging of the prostate that occurs with age. And the main roles of the prostate is to create seminal fluid and help with propulsion of ejaculation of that seminal fluid when mixed with the sperm when achieving orgasm. And what we recognize is that as individuals age, there is a growing of the prostate, an enlargement of the prostate that occurs. that is called benign prostatic hyperplasia. Now this is non-cancerous. This is not a malignancy. This is a part of aging physiology in the pelvis. And what we recognize is that there's also a lot of discrepancies of if this is something that we need to worry about or not. So enlargement of the prostate happens in almost every human with a penis. And it can be associated with lower urinary tract symptoms. In the literature, sometimes it's called BPE, benign prostatic enlargement. If it is associated with symptoms, that is not always consistently done, but there is screening that can happen. And then that enlargement, if it does have cancerous tissues in it, now we're thinking prostate cancer and individuals are going for screens for malignancy in the prostate, and then leading to potentially intervention, including radiation and, or radical prostatectomy. And I've done podcast episodes on radical prostatectomy before. When we're thinking about lower urinary tract symptoms, that can include stress urinary incontinence. And oftentimes in males, because of the length of the urethra, the level of incontinence is significantly less than in the female pelvis. So only about 5% of individuals over the age of 65 have incontinence. And usually it is as a consequence of conditions like radical prostatectomy. So it can be radical prostatectomy. Individuals can have pelvic fracture trauma. Some neurodegenerative conditions can also have a urinary condition associated with it. And so usually there's a precipitating event, not always, but most of the time there is some sort of precipitating event that has happened around the pelvis that has led to urinary incontinence. For example, when you have a radical prostatectomy, the prostate is removed. That includes the areas around the external anal sphincter. The urethra is then pulled up to reconnect to the bladder, which can disrupt the pelvic floor, the deep pelvic floor muscles that are responsible for kinking that hose of the urethra in order for a stress urinary incontinence not to occur. And so it makes sense why there's a disruption to that longer urethra can lead to things like stress urinary incontinence. When you have an older adult with stress urinary incontinence, I know it doesn't sound that, that surgery doesn't sound that great, but it is minimally invasive and people do respond pretty well to it, but we have podcast episodes on the, the surgical art of radical frost detective and what we can expect postoperatively. So when we're working with individuals, urinary incontinence is something that we may be managing and we have a big role to play in helping with post-operative or the new development of urinary incontinence. And so when we're thinking about management, we have kind of our conservative buckets, and then we have surgical management. If you are a person who's had a radical prostatectomy, the natural physiology is that many symptoms resolve within a year. So usually we are not doing any follow-up, or your urologist is not doing any follow-up surgical intervention around the pelvis until a year post-operatively with individuals post-radical prostatectomy. But we do have conservative methods that we can use in the shorter term, and hopefully to try and avoid a subsequent surgical management. And so those buckets are pelvic floor muscle training, penile clamps, and surgical intervention. And so the first and go-to knee-jerk reaction is always going to be conservative management, especially if initiated pre-operatively or pre-event, where individuals who are males get an awareness of the pelvic floor system. Because incontinence and pelvic floor issues in the male pelvis are not as common, many times education around the pelvic floor is not as widespread, individuals are not having these conversations as frequently, and then recognizing how to contract and relax the pelvic floor muscles can be something, especially if there is a training effect that we are doing with appropriate dosing, can help with mild to moderate urinary incontinence post pelvic event in the older male. When we are thinking about pelvic floor muscle training, we are trying to cue the pelvis either to stop the flow of urine, or to try and shorten the base of the penis. Those are the two cues that have been shown in research to have the highest EMG activation of the pelvic floor when trying to teach the pelvic floor contraction in an older male, and trying to get a strengthening effect with appropriate dosage. And there's some protocols in the post-radical prostatectomy world that tries to accumulate 20, 30, 40 reps. It's a bit variable, but we wanna make sure that we are getting a training effect based on where individual's baseline status is. initiating pelvic floor muscle training, seeking a pelvic floor physical therapist, or if you're okay with palpating externally, you can go kind of medial to the sits bones and see if there's a contraction of those pelvic floor muscles in the male. If you are a non-internal pelvic floor physical therapist, then you can work on some of that coordination and contraction in individuals who this is a barrier for them going out into the house. So that's kind of our first option. Our second option is a penile clamp. And so if you're aware, in the female pelvic space, we have a device called a pessary, which is inserted intravaginally, and basically what it does is it kinks off the urethra mechanically in order to help reduce symptoms of pelvic floor prolapse, or pelvic organ prolapse, rather, or urinary incontinence. We see this a lot as a conservative management in order to avoid pelvic surgery, We have a similar type of compression device for the male, but obviously there is not an intravaginal hole for our male anatomy and therefore it is placed externally. So what a pelvic clamp is, is It is attached to the mid shaft in a flaccid penis and it has a little bump on the bottom of the device. So there's a compression and on that bottom ridge, it essentially applies the same type of compression as the pessary to the bottom of the male penis in order to avoid incontinence issues. And what we see is that it can significantly reduce the number of pads or reduce the pad test, which is urine coming into a pad in a certain amount of time by weight. and the amount of subjective reports of incontinence. When we are thinking about penile clamps, comfort is going to be one of the biggest concerns where, you know, individuals, I think the last study that I was looking at was like about half of individuals reported that it wasn't really that comfy to be wearing the clamp on the shaft of their penis. It may be because of, you know, making sure that we have proper education or finding the right fit of the clamp, but something for us to be thinking about or, you know, having conversations about with the individual where we may be suggesting this conservative management strategy. And then the second thing that is a really important part for us to be considering is vascular health. We know that a lot of issues around the pelvis, including benign prostatic hyperplasia and erectile dysfunction, have a big vascular health component, aka we're screaming from the rooftops about health promotion, including around the penis. It's just super important for us to consider if individuals have poor perfusion, that even with a small amount of compression, we have to think about vascular health and skin integrity concerns. So trying to figure out who this might be the best individual to be using this type of thing with. Individuals who may really like this option are those who are very adamantly against having surgery or those who are not a candidate for surgery. So here's that double edged sword, right? Where a lot of individuals with high amounts of vascular concerns are going to be individuals who cannot undergo another surgery. They may be the ones that we are thinking about, you know, using this clamp, but we're going to make sure that we take a lot of breaks from wearing it. There was a study that was done out of Japan that was showing that individuals were able to wear it for two to three hours with a 15 minute break. and there was no adverse events to using it. Other studies have talked about doing an hour on, hour off, or using it when trying to do activities around the house. So you're kind of using it for a specific goal or task in standing to try and prevent some of that UI issue from happening. So that's bucket two. So we have our pelvic floor muscle training, We have our conservative penile clamp, and then we have our surgical interventions. And so for the two interventions for our males, we have a urethral sling, which is done through the trans or obturator foramen. And it is essentially a meshing tape that helps to apply resistance to the urethra with or without additional compression, depending on the technique that we are leveraging. in order to help keep the sphincters closed when we want them to be closed. These are indicated for mild to moderate types of urinary incontinence and not usually indicated for more severe cases. When we have individuals with more severe cases, individuals are using an artificial sphincter. So what this is, is it is a device that comes in and essentially creates a clamp with a balloon, or a cuff with a balloon rather, over the urethral opening, not the urethral opening, mid urethra, and your urine starts to accumulate in your bladder. Person's body is going to get the cue that they have to go to the bathroom, and when they go to the bathroom, they release a button in the scrotum that's placed in the scrotum, and it deflates the balloon, allowing the urethra to unkink and for urine to be able to pass through. And then the mechanism goes on a timer. So either it's between 90 seconds and three minutes, depending on the device, and that allows the urethra to be open for that amount of time. And then after that time has elapsed, the cuff closes. Yeah, it's really incredible. Like the technology is really intense. So when you're thinking about who might be indicated for using this artificial sphincter, dexterity and cognition are two big issues in an older male population where we may be thinking about, you know, are they gonna be able to get to the release mechanism on the scrotum? Are they cognitively gonna be able to do the procedure in order for the cuff to deflate? In more severe cases, this is indicated. And there is a fairly severe revision rate. So 20 to 30% will require some sort of mechanical revision, whether the device is kinked, whether there's clogs or hoses, like there is a higher chance of that happening because it's a more, it's a mechanical device, like there are moving parts. And so those parts can break down versus in a sling where you're essentially tacking up that resistance against the urethra. It's something that's a little bit more, doesn't have the same amount of moving parts. So there's a very high success rate for both of these surgeries. Infection rates and things like that tend to be fairly low and it can help to improve sexual function and be able to help individuals achieve better quality of life and physical function and is a good option for individuals who have exhausted their conservative management and have not seen the improvement that they wish to see. So if you are working with these individuals, usually the post-operative instructions are to avoid heavy lifting for six weeks. and then can start returning to moving around. It's not very smooth where individuals can get back to what? That is a conversation for another day. But overall, management can be quite good. So I hope you found that helpful around the way that this is kind of managed from a medical perspective. We can be very helpful in the conservative management piece where it can come along individuals in the post-operative piece or perioperative moment. And it's a thing that we see when we're working with our older adults, right? That we see it in geriatrics. So hopefully that was helpful and kind of fills in some knowledge gaps for you if this is not an area that you practice in all the time. All right. If you want to get all of that information in our UI section, that is in our MMOA level two. So you have to have taken MMOA level one in order to get access to our special populations because we build on a lot of questions. Thank you so much. That's so sweet of you. And we build that into level two. If you are looking to take MMOA live, we are still on the road all summer. It is nice weather, but we are visiting all over the United States. We are in Scottsdale, Arizona, June 1st and 2nd. Spring, Texas, 8th and 9th. We are getting toasty in those places. Let me tell you, I'm not doing those courses. Those are all dusted and jammed. June 22nd, 23rd, we are in Charlotte, North Carolina. And July 13th, 14th, we are in Virginia Beach. So if you are around and you want to take out live content in the summer, we got you covered. Other than that, please have a wonderful week. I hope you all are enjoying your post Memorial Day week and we will see you all next time. Bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 28, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses tips to build the perfect HEP: time availability, equipment availability, and dosage. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. CODY GINGERIC All right, good morning, PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity management division, and I'm coming on here today to talk about building out the perfect HEP. Okay, so there's several factors revolving around building out what is considered the perfect HEP. Now, perfect means best ability for our patients to complete the HEP that we want them to, okay? And so what I'm going to go through is all the different factors that you need to consider, including what you are deciding you're doing, but also the patient's expectations and what they have the ability to accomplish when you are trying to say, all right, these are the HEPs. These are the exercises that I want you to do at home. What factors do you need to consider to build out the HEP that is going to give you the most compliance? Cause ultimately you can build out the perfect HEP as far as these are the exact exercises that I want them doing. These are going to be what I consider the perfect exercises for what I found. But if the patient doesn't do them, that HEP is no longer perfect because they can't get it done and they're not going to progress the way that you want them to. Okay. HOW MUCH TIME DOES YOUR PATIENT HAVE? So starting off the, the number one thing that you have to figure out is what time does your patient have? Okay. I know a lot of times when you know, you're going through your, if it's an initial examination, you're trying to figure out the first HEP, you're, you could have multiple different exercises available to you. Um, so let's say, you know, it's a shoulder issue and you're wanting to give them three, four, maybe five exercises that immediately you're like, Oh, okay. This would be good. That would be good. This also would be good. But if it takes 20 minutes for your patient to do and they have five, they're not going to say, oh, well, I'll just do a couple of them and get, they'll do none. Okay. So the first thing that you have to figure out with the patient is what time available do you have to, do you think to get these things done? Some people will say, whatever you tell me I'm going to do. And those people are great, right? You know, they're going to do it. Whatever you think is best. That's great. There are other people that said, you know, they've got kids, they've got to take care of family members. They've got jobs that are stressful. They've got all kinds of things. Maybe they're traveling a ton. And so they're like, you know, honestly, I may have five minutes at the end of the day to be able to get something done. Or they say, I can get to the gym five to 10 minutes early to get things done. Or, you know, I can get to the gym, I'm like running in like two minutes late every time, I'm barely, you know, either for class or it's like right at the end of the day. And they're like, well, yeah, but I could end class and stay 10 minutes extra. Um, and so that's where you then have to start figuring out, all right, well, if I choose two things in each and I give them a rep scheme that can get accomplished what I want and still get them in and out and under 10 minutes. Now, all of a sudden we have something that they feel confident that they can get done. Okay, what I would consider then 1A and 1B is like time is 1A, but 1B or maybe flip-flop those two things would be, you know, what are you trying to accomplish as far as your exercises in general? DOSING So in extremity management, we talk about dosing a lot, and that's one of the primary factors as far as when you're treating people out is dosage, and it matters. And there's a strength dose, and there's a rehab dose, and there's a power dose. And you need to make sure the HEP is equally as dialed into that as what you're doing with them in clinic. So up front, you need to think, am I trying to get this tissue legitimately stronger? in which case you are building them out their HEP for probably closer to that five by five right at about 80 percent of their one rep max or around that like three sets of six to eight somewhere like that where it is heavy load being lifted on whatever tissue you're trying to accomplish And in that moment, they may not need to do that multiple times a day, maybe not even every day. So if your brain is saying, well, this tissue needs to get stronger and I'm going to dose this out as a strength dose, then you could say, hey, you know, I might ask you to do this. It might take you more like 15 to 20 minutes, but can we do this three times a week? We want to really hit this hard. We want to make sure your tissues are going to significant fatigue. but then we're going to give you at least a full day of recovery in between. Those tissues also need to be able to recovery, repair, and then come back stronger. So then you have a day in between. Now I'm only asking you to do this three days a week. Could you do that for me? If you're thinking more of that rehab dose, you're wanting more blood perfusion to those tissues. Maybe now you give your one exercise that you think is going to be best, but they're highly irritable, and you need to get just as much blood pumping to that system as possible. Maybe you give them something that takes one minute, but you ask them to do that four, five, six times throughout the day. Because we need a lot of touch points on that tissue often throughout the day, as opposed to saying, I need you to do a lot X amount of time for this specific thing. But if you're saying I need blood pumping, they're sitting at a desk for eight hours a day, but they then have. 20 or 15 minutes where they do something to their shoulder, it's probably not going to bump them forward as fast as possible. But if you say, Hey, 30 seconds to a minute of this, I just, anytime you think about it, like set an hour timer, can you do one minute every hour or every two hours? A lot of times that becomes, um, more manageable for people to do. And then even if they, you know, you're like, Hey, could you do the six to eight times in a day? They say, yes, maybe though that gets accomplished three to four times and you're still doing okay. Okay. Those are kind of your one A, one B. What time do they have and really what are you trying to accomplish with their tasks that you're giving them? EQUIPMENT AVAILABILITY Okay. The third thing is what equipment do they have available to them and how willing are they to potentially go and get equipment? So that means before you start doing anything, you need to ask, do they have bands? Do they have weights? What kind of things do they have at their house? What access do they have to anything at a gym? Different gyms have different equipment, right? Do they have kettlebells? Do they have dumbbells? Do they have small looped bands? Do they have big pull-up type of bands? You can manufacture exercises from almost anything and your goal There is no one perfect exercise. There is the exercise that's going to get the person doing what you want them to, to the tissue that you think is most involved, and then you build that exercise for that person, right? So, let's say they have absolutely nothing at their house, but they go to the gym five or six days a week. That first visit is not the time where you say, you know what, I need you to go by XYZ. Nope. You say, great, your HEP is only going to be done at the gym. I need you to do this every time you step in the gym for five minutes, whether that's before or whether that's after you can make that choice, but you need to build out the HEP so that they can get that accomplished as simply and easily as possible when they go to the gym. That's the only way that they're going to get it done. Alternative, if they have nothing at their house, at our clinic a really good option is have either bands for sale or an Amazon link or something. The best one is bands for sale right there and then. Or if you can find them in bulk somewhere and can just hand those out, if they're like a dollar a piece, maybe eat that cost and give them out. But that's a really good way to say, okay, well I need you to do, you know, some band pull aparts or some 90 90 raises or something. And you have one of those like booty bands that you can hand them. And now all of a sudden they have something to accomplish at home. So that's where you need to get a little bit creative up front and maybe at home they've got like a two pound dumbbell or a five pound dumbbell or they've got one band, right? That is again where you start navigating that whole question of what exercise can I build based on the equipment that they have available to them. Potentially then after you have built a little bit of rapport or if that person in front of you is like, Hey, I'm going to do anything you want. You just tell me what to go and I'll go get it. That's when you can start shooting off Amazon links. Be like, Hey, go to play it again. I need you to get a 10 pound dumbbell. I need you to get a kettlebell. I need you to get this band. There are those people, but those questions have to be asked before you say, here's what I want you to do for your HEP. SUMMARY You first have to ask how much time do you think you have in a day? Your own brain has to be saying, what's my goal for these HEP exercises? Is it strength dose? Is it more rehab dose and blood perfusion? Then you say, okay, well, what do you have at your house? Do you have anything, any type of equipment that can be built on weights or whatever? Or is everything that you do at the gym cool? What is your gym routine look like? Do you get there super early in the morning? Do you get there in the evening? Do you have more time before? Do you have more time afterwards? Right? All of those questions have to be asked. Ideally, before you start thinking, I need them to do this exercise, this exercise, and this exercise. Now on that first visit, you might pitch optimal a little bit more heavily and say, Hey, this is really what I would like to do. And like for you to do, even based on those equations, Then they come in and say, Hey, you know, I don't think I was, I wasn't really able to get those things accomplished as much as you told me. After the first visit, if they're not able to do that, that first time is on you because then you have to say, okay, well what can I do to make your life easier? I have other options that we can do. There are more things, more different ways that we can make this HEP more accessible to you. If you don't answer that or ask that question, then the reason they're not doing their HEP still falls in your hands, not on theirs. If they say, you know, this is really easy. I should be able to get this done. And they take responsibility for it. Great. But until that happens, I would still say that you need to figure out how can you still make it easier? pitch optimal, then we negotiate acceptable. And you can still have that conversation and say, look, this isn't exactly how I would like it to be, but I think we can get the job done if this is really all you can commit to. Okay. So in that sense, now they know that like, Hey, this probably my, you know, my shoulder pain isn't going to go away quite as quickly as Cody probably hoped because I'm not able to do exactly what he was thinking. But if I still do something, it's still going to bump forward. And as long as they're okay with that, you have to set those clear expectations. But overall, that's how we are building out a really nice HEP that people are going to also be compliant with. Bring them into that. Use your creative mind as far as exercises are concerned, because really it's not the exercise that matters, it's the dosage. You need to know what tissue that you're hitting, and you need to know what dosage that you are trying to use to try to make those tissues happier. If they need to be stronger, we could potentially pull back the actual number of times per week that they do it. Give them an opportunity to recover. If it's more blood perfusion and a rehab dose, maybe make that incredibly short where they can do that one time for 30 seconds to a minute. You give them one exercise and say, hey, you're hammering this over the next week. You're pumping as much blood to that. When you come back in next week, then we're gonna adjust and do something different. But overall, you then need to know what equipment do they have, what do they have access to, what are they willing to go and get? Can you provide them with something that will help them get that accomplished? Whether that is selling something in store or in house, whether that's handing them something that costs a dollar to $2, something like that, that again, lets them be more compliant with what you're hoping for. Okay, so those are three things building out a perfect HEP. The perfect HEP, shocker, is not the exercise that is the best one. It is the exercise that they're gonna get done, that you have dosed out perfectly, that is going to be compliant, and you know what dosage and tissue that you're hitting. Okay. That's all I got for today's PT on ice. If you want to catch extremity on the road, we've got two courses happening this coming week, one down in Texas, one up in, um, Wisconsin. And then in a couple of weeks from that, we've got one happening out in Utah. So hit one of those up sometime in the next couple of weeks, we're all over the country and I will see you next time. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 28, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the CrossFit hero workout "Murph", including modifications & considerations for pregnant & postpartum athletes. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at signup to receive a one month free grace period on your new Jane account. RACHEL MOORE My name is Dr. Rachel Moore. I am here this morning on Memorial Day to chat with you guys about the MRF workout and reflections for the MRF workout as a prenatal or maybe postpartum athlete. So whether you yourself have been that athlete and been prenatal or postpartum while doing MRF, or maybe the population of patients that you see is this prenatal space. I want to dive in to some reflections on that today. So first of all, we're going to kick it off. If you are not familiar with the CrossFit space, you're not in the CrossFit space. What is the Murph workout? So Murph is a workout. It's called a hero workout. it's done typically on or around a memorial day so whether memorial day weekend or memorial day itself it is a hero workout which is a named workout in the crossfit space for somebody that has given the ultimate sacrifice and paid their life for whatever the reason so michael murphy Um is who this workout is honoring he was a navy seal and he died in the line of duty So the workout itself is a one mile run 100 push-ups or sorry 100 pull-ups 200 push-ups 300 air squats and then you cap it all off with a mile run and the rx version of this workout is wearing a weight vest 20 pounds for guys 14 pounds for ladies If you have never done this workout, it's a long one. Most people kind of fluctuate like earlier times or fast times or sub one hour, but a lot of people tend to hover around that one hour a little bit more mark if they're doing a quote unquote full Murph. We also can do a half Murph, which is where we take that workout. and cut that volume in half. So the Murph itself is one of those workouts that is a really powerful symbol within the CrossFit community. Typically, most gyms are getting together, whether it's on that Saturday or on that Monday. It's a large community event. It's a really exciting thing to be a part of and a really exciting thing to come together. A lot of people really look forward to this workout every year. not only for the reason of what it represents and the fact that we're paying honor and tribute to people that have given that ultimate sacrifice of their lives so all of us have the freedoms that we have. but also because it is a pretty big test of fitness. And depending on what season of life we're in, sometimes those tests of fitness can be hard. Whether it is physically hard or emotionally hard, regardless, it can be tough. And in one of the largest seasons where we see that is in the perinatal space. So when somebody is pregnant or when somebody is maybe newly postpartum, and they're trying to figure out how to tackle Merv. it can be tough to set aside that athlete brain. It can be really hard to turn that off, especially if you're somebody that's done Murph maybe in the past, and you want to know where you shake out. Or if you're brand new to CrossFit, maybe you started doing CrossFit, found out you were pregnant shortly after, and you're seeing everybody in your gym get super excited about testing their fitness and seeing where they're at, seeing how they compare, maybe doing it for the first time, and knowing that you can't do it the way that you would quote unquote like to. So let's unpack that a little bit. For one, we at Ice really preach that we don't modify unless we need to modify. Just because we're pregnant, quote-unquote, is not a reason to modify MRF. If you're somebody that this workout is in your wheelhouse, maybe you are doing pull-ups and have been doing pull-ups in the gym. maybe push-ups are not bothersome to you, you're early enough on in pregnancy that your bum's not getting in the way, you feel good doing all those push-up volume, air squats feel great, running hasn't gotten to a point where it's bothersome at all, then there's no reason to modify the workout. We don't modify the workout because of pregnancy. We may be able to tweak it slightly, so maybe you partition instead of doing all of the reps in a row to save some of your core fatigue, So instead of doing 100, 200, 300, you do 5, 10, 15, and just give yourself some breaks in between. But if none of those movements are problematic for you and the volume isn't problematic for you, then it's okay to just do the workout, maybe a little bit slower than you otherwise would have, but it's okay to send it. If you're somebody who has issues with one of those movements, whether it is the pull-ups. You don't have that midline strength and stamina anymore and you're seeing a lot of that coning repeatedly over time and it's something that's bothersome to you or maybe the push-up volume is way too high for you or squatting below parallel triggers some pain. It's also okay to modify the workout. Modifying a Murph is not a sign of shame. Doing the Murph in and of itself is huge. modifying the MRF, whether that is because of pregnancy, whether that is in the postpartum season, or whether it's because of an injury, or you're a new CrossFitter, it's okay to modify when we have a reason to modify. It's still exciting to show up. It's still exciting to be a part of your community and do that workout. I have done this workout myself. This was my sixth MRF this year and I did it as a new postpartum. So it was three months postpartum and I was a newer crossfitter. I've done it as a, I think 18 week pregnant crossfitter. I've done it as a year-ish postpartum crossfitter, and then I've done it Rx twice. And in each of those seasons, the challenges were different. When I was a pregnant athlete, I wanted so badly to send it. I wanted to do a full MRF. I wanted to do the entire volume. But my body didn't feel great with that. And so that year, my husband and I ended up splitting the MRF. So we ran the mile together. It was a little bit slower than I otherwise would have ran. and we did you go, I go rounds and we took turns so that I had some built-in rest breaks because for me at that stage in my pregnancy, my heart rate was skyrocketing and I was having a really hard time managing that much volume with that high of a heart rate for that long a period of time. That was a challenging year for me. It has nothing to do with the physical side. Honestly, when we finished our MRF that we split, I was just like, okay, like that was fine, I guess. I'm excited I was here. But physically, it didn't feel like that much of a challenge. But that was the most mentally challenging year. On the flip side, the very first time I did MRF, I did a similar thing. I split a Murph, quote unquote, with a friend. We did you go, I go rounds. I was a newer CrossFitter and I was postpartum. So I scaled the pull-ups for ring rows. I did push-ups for my knees and I did air squats, but I did it all with a vest because I wanted to know if I could. So half a Murph shared with somebody, quote unquote, with a weight vest on, so reduced volume and scaled movements. And I have never felt so powerful than when I finished that workout at three months postpartum. It was awesome. So those are two very different seasons, two very different iterations of the workout from the standpoint of RX movements versus scaled movements, weight vest versus non-weight vest. And the outcome was different. One, I felt physically strong, mentally strong, felt super empowered. And one, honestly, was a really hard mental load for me because I wanted to do what all of my friends were doing in the gym and I wanted to be able to push myself. that athlete brain is tough to turn off. So if you are one of these patients, or one of these people that is doing MRF this year, or has done MRF by this point at 9.20 on a Monday Memorial Day morning, and you struggled with that, it's okay. If you have patients coming in in the future, and they're talking to you about, I wanna do MRF this year, but I just don't really know what to do, it's okay to tell them to modify. It's also okay if they wanna send it. At the end of the day, we're not modifying just for the sake of modifying. We had a gal in our gym last year who was in her 30th week of pregnancy. She's a former CrossFit Games athlete. She crushed it. She swapped out the pull-ups for ring rows, but otherwise did everything else RX and did fantastic and felt fantastic for her body. that challenge and that load was appropriate. We've also had people like myself who at 18 weeks pregnant decide that I need to modify. I'm not going to do a full Merv and I'm going to scale the movements. All of these options are okay. The beautiful thing about this workout is there are so many ways to modify it. There are so many ways to modify the movements themselves. There are so many ways to break up the volume. There are so many ways to cut the volume down. And at the end of the day, showing up and being a part of the community is what is really key this weekend. Being there, paying that tribute, showing that respect, and getting to be a part of your community is huge. If you're somebody that's been in this season and wants to chat more, shoot me a message. I would love to talk with you more. This is a topic that I'm super passionate about because I've been there. I've been in those shoes. And sometimes, you know, we just need to commiserate together about how hard something was. SUMMARY If you are looking to join any of our pelvic courses, we have got, we're about halfway through our L1 and our L2 cohorts. So we've got another L1 cohort kicking off. Our next L2 cohort is not until the fall. If you're interested in that, hop into it because it's going to fill out. Catch us on the road this summer. We've got a lot of opportunities to get to the live course where you can sit for that cert test and become ice pelvic certified. I hope you guys have a great rest of your day. If you did MRF today or at any point this weekend, make sure you take care of yourselves. Hydrate get your electrolytes in make sure you're getting protein in take care of your bodies And I know I'm feeling a little bit sore from my Saturday Murph So just know that in the next couple days you may be feeling some type of way, but it's temporary and it'll pass See you guys around OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 24, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the science and practical application behind hydration & recovery drinks. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, I have the pleasure of serving as our Chief Operating Officer here at ICE and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday, it is the best darn day of the week. Today we're gonna be talking about salty science. No, we're not gonna be talking about how upset Drake fans are by how badly they're getting beaten by Kendrick Lamar's diss drops. We are talking about the new era of salt-based hydration and what that means and how that compares to previous eras of things you might be more familiar with. Gatorade, Powerade, those sorts of things. So today we're going to talk about the origin of hydration in recovery drinks. We're going to talk about the pros and cons of what we might call the first generation of those recovery drinks. And then we will move in and talk about the new era of sodium-based drinks that may or may not have any sugar included in them. THE HISTORY OF RECOVERY DRINKS So recovery drinks really started as we know it a long time ago back in the 1960s, actually 1962 at the University of Florida. Researchers created a recovery drink for the Florida Gators. You now know that is Gatorade, A-D-E. Back then it was spelled Gator dash A-I-D like a band-aid, Gatorade. And this formula was rather simple. It was water, sodium, and some lemon juice. And when we look at the macronutrient breakdown of the original formula of Gatorade, if you're old enough, you may, even if you were a kid in the 80s or maybe even 90s, you remember it used to come in that glass bottle and it really had nothing in it. It had 50 calories total, it had 14 grams of carbohydrates, it had some sodium, and that was essentially it. And that was a 20 ounce bottle, 20 ounce serving. So a little bit of sugar, a little bit of sodium, and that was it. A lot of credit went to Gatorade in the 60s and 70s when the Florida Gators went on to win and many other collegiate and professional teams went on to win sporting events, they maybe sarcastically credited Gatorade with their success, and at that point Gatorade took off into orbit. That is very different from the Gatorade of today. The current formula of Gatorade is significantly different. It has a lot more calories, as you may be aware, that is primarily sugar. So for the same serving, a 20 ounce serving, a 20 ounce now plastic bottle that you might find in the store or the gas station, 160 calories, so over three times as much. caloric density, way more carbohydrates, three times the carbs, 42 grams of sugar, which is a lot. More sodium now, giving credit, 10 times more sodium, 300 milligrams of sodium, but also a lot more potassium, 90 milligrams of potassium. What's changed from the 60s to today? Pepsi bought Gatorade, Pepsi sells Gatorade, You may know Pepsi owning a lot of the snack brands and soda drinks that we are very familiar with. So it's not really surprising when you find out that Gatorade is now owned by Pepsi that it's just kind of pumped full of sugar and it's essentially turned into a soda drink. THE CRITICISM OF SUGAR-BASED RECOVERY So that being said, what is the main criticism of Gatorade? as it relates to its functionality as a recovery drink or not. The first thing to consider is just looking at it from a molecular level, it's sugar water. The primary ingredient is sugar. It's a bunch of calories. Yes, it has a little bit of sodium. Yes, it has a little bit of potassium. But it is primarily sugar water. Now, we may think, okay, we know we sweat, we know we burn calories when we work out, surely we can put that sugar to good use. But it's really important to know that the majority of people drinking these drinks are perhaps not exercising at all. They might be sitting at a computer desk and or they may not be exercising to the level that they are losing that much sweat and that much glycogen from their system. Certainly somebody running, cycling, doing a long endurance activity, 90 minutes, 120 minutes, longer, running a marathon, ultramarathon, triathlon, Ironman, that sort of thing, that person does need to consume glycogen to keep their aerobic energy system running. But those folks just recreationally active, going to CrossFit for an hour, going to run a couple miles, working out in an air-conditioned gym where they may not be sweating at all, don't really need that amount of caloric replenishment and sugar during their workout to keep their workout intensity high. Go way back to episode 1552 of the PTA Nice Daily Show if you want to learn a little bit more about fueling during exercise, we talk about how the human body has about 400 grams of glycogen stored inside of it, inside of our muscles, and about another 100 grams in our liver. So we have the ability to go 90 to 120 minutes before we dig deep enough into those reserves that we need to consider drinking glycogen, drinking glucose to sustain our energy system. And again, the argument and the largest criticism, especially in the past 10 to 15 years or so of Gatorade and similar drinks Is it simply too much sugar? Some really good papers here. Zimmerman colleagues way back from 2012, sports drinks, not just sodas, drive up weights in teens, looking at 11,000 kids aged nine to 15 and finding that kids gained two pounds for every two years in which they drank a can of soda per day. So if they drink a can of soda per day for two years, they would have gained two pounds per year. If they drank two cans, they would have gained four pounds, three cans, six pounds, and so on. And so we say, yeah, Alan, we know that. We know soda is bad. But what is really, really, really interesting about this study is they also looked at sports drinks. They looked at things like Gatorade and Powerade. And this is kind of shocking that they found the same level of consumption, one bottle of a sports drink, two bottles of a sports drink, et cetera, following that same scheme for every one bottle consumed per day. kids gained three and a half pounds per year, two bottles per day, seven pounds, three bottles per day, so on and so forth, 10 and a half, 14, all the way up. And so, recognizing that these drinks actually contain as much or more sugar per ounce of basically table sugar than a can of soda, a can of Coca-Cola or Pepsi or something like that. I love the conclusion from this paper, sports drinks fly under the radar, The danger is that they're sold as part of a healthy and active lifestyle, and it's just part of something you do being active. Most kids are not getting the two hours of high-intensity exercise needed every day to justify refueling with a sports drink. And so, finding that because they have so much more sugar per serving, and that it is so much more acceptable to drink a Gatorade versus to drink a Mountain Dew or something like that. Shout out to Brian Melrose, the Mountain Dew King. that these kind of fly under the radar, and there might be kids that drink these every day in their lunch. They might drink one for lunch and one after school, after playing outside, and it's not surprising that we're racking our brains to figure out why we have a childhood obesity and type 2 diabetes epidemic when it's right in front of our face. Gatorade just simply has too much sugar for the folks who are drinking it on a regular basis. Now, if you're out there, you're running marathons, triathlons, Ironmans, whatever, you're working out for hours at a time, you're working in the heat, you're sweating a lot, ignore me. But for most of our patients, for most of our athletes, we need to understand why that criticism of Gatorade is there and that it's pretty cemented that it is simply too much sugar for the small bit of electrolytes that you might get out of Gatorade. And so that's maybe what we call the first generation of recovery drinks. THE ERA OF SODIUM-BASED RECOVERY The new generation you may have heard of a product called LMNT Element. There are a lot of similar brands now. A sodium based recovery drink that has no sugar. This high sodium drink, which also faces criticism of, isn't salt bad? Doesn't that give us high blood pressure? But really finding that these drinks are entirely different on a molecular level from something like Gatorade or Powerade. That again, they have no sugar. They have 10 times more sodium, a thousand milligrams, one gram of sodium. They have a little bit more potassium, usually around 200 to 250 grams. And they also come with some magnesium. What is the scientific argument for drinking something like Element or similar compared to something like Gatorade or similar? Understanding that individuals that are active and exercising may not be using muscle glycogen to the point where they need to drink sugar during or immediately after their workout, but also recognizing they are sweating, which means they are losing especially salt from their system, and that if we replenish that salt, people will probably feel better without feeling the need to go and drink 50 grams of liquid table sugar during or after their workout. A really good article, Sharif and Sawaka, 2011, the Journal of Sports Science, finding that folks can lose up to seven grams of sodium out of their body through sweat per day. If they're active with exercise, if they're maybe somebody outside working, whether that's for a job or just active in the garden for a couple hours on weekend days, that sort of thing. And so we are losing a lot of sodium. And there's kind of a catch-22 here of active individuals don't tend to eat a lot of processed food. And so active folks are not naturally taking in a lot of sodium yet, because they are active, they are losing a lot of sodium at the same time. They're sweating in the gym, they're sweating out running, biking, whatever. Maybe they're sweating outside at work or in the garden or doing lawn work or whatever, and they're simply not replenishing it unless they happen to be somebody that really salts a lot of their food to taste at home. which again may not be the case. So this argument for high sodium, isn't sodium dangerous? Not if you're losing seven grams. Replenishing with just one gram is really just trying to bring you back to balance. We're not as concerned that somebody drinking a sodium based recovery drink is going to run into issues with maybe their blood pressure or any sort of cardiac issues because they're not drinking seven grams at a time. But again, also they're losing it by being active. Why does this matter? What is the science behind a sodium based drink? It's the sodium potassium pump. Way back in like sixth grade biology, you probably remember the pictures of the cell. It looked like a little half sandwich with some ridges in it or something and little circles were moving around. We probably learned about it again in exercise physiology in undergrad and maybe you heard about it again in PT school, but the sodium potassium pump in the membranes of your cells does a lot of work. It is responsible for a lot of body functions. It powers muscular contraction. It transports glucose into your cells to power those contractions, power that cellular activity. It regulates neuronal activity, the actual firing of our nervous system, our synapses. It regulates our body temperature, and overall it maintains our physical performance. of a workout where you sweat a lot, it was really hot, you felt terrible, low energy, you may have even felt cold even though you knew you were really hot, your sodium potassium pump was running out of the sodium needed to power itself. Three molecules of sodium come in, two molecules of potassium come out. So that is the rationale behind a high dose of sodium compared to a relatively smaller dose of potassium. maintaining that sodium potassium pump. And the end goal is, without consuming a lot of sugar that you probably don't need, we can help sustain your current activity or the activity you're about to do, or feel better and recover from the activity you've already done by drinking one of these sodium-based energy drinks. PRACTICAL APPLICATION FOR PATIENTS AND ATHLETES Now, the history of Gatorade, the history of sugar-based recovery, element in similar, the new era of sodium-based recovery, what is the practical application at the end of the day for our patients, for our athletes? For those folks who are not already active in exercise program, which is statistically 90% of the human race, they don't really need to be drinking Gatorade. They probably should never be drinking Gatorade because they're not expending enough calories, they're not burning enough glycogen to really justify housing 50 grams of liquid table sugar. That being said, even folks who are active, if they are not active for 90 to 120 minutes of higher intensity exercise, they probably also don't need that much Gatorade. Certainly if you go out for a run for an hour on a warm day or maybe 90 minutes, You might want to cut that Gatorade with some water and dilute it down. That can be beneficial to maintain your energy levels, maintain your hydration, but you don't necessarily need to take two full bottles of Gatorade out on your run and house 500 calories and 50 grams of table sugar. I'm sorry, 100 grams of table sugar while you're out on that run. Now what about our athletes who are training really hard folks who might be in the gym for a couple hours, folks who are long endurance athletes, I would argue those folks probably already have their fueling plan dialed in for what they're going to be drinking, what they're going to be eating. So just leave those folks alone. They probably already know what they want. They probably already know what they like, and they probably already know what their body can handle as far as digestive system issues. So if it's not broke, don't fix it, right? Leave those people be. However, you can give the recommendation of if you're not already drinking something sodium-based, you might want to consider that. Why? Because if they are using things like Gatorade or Powerade, whether it's the pre-liquid version already sold in the store, or whether it's the mix, that stuff just simply does not have a lot of sodium or potassium anyways. Again, it's primarily sugar. So recommending to those folks, even if they feel like they have their fueling plan dialed in, of hey you might want to consider a packet of element or something similar before your long run or your long bike or whatever or maybe during maybe after whatever and just see how you feel feel if you feel that you're able to perform better you're able to recover better maybe both And then what about our regular folks? Our folks who we maybe say, you don't really need Gatorade or Powerade, but we can feel very optimistic and very comfortable recommending something like Element to them, even if they're only going to the gym an hour a day, even if they're only going to run a couple miles or bike a couple miles or something like that. Why? There's no sugar in it, right? It's just sodium. We know they're going to sweat it out anyways. And so really it's about their body maintaining balance and they're not going to be worried about extra weight gain or anything like that from drinking more calories than they're expending. So in general, these new sodium-based recovery drinks can be a really safe recommendation for folks to improve their hydration, improve potentially their performance, and also improve how they feel and how they recover after. So that is salty science for this Fitness Athlete Friday. SUMMARY If you want to learn more from us out on the road, we have a couple chances coming up for a Fitness Athlete Live course this summer. Zach Long, aka The Barbell Physio, will be down in Raleigh, North Carolina. That will be the weekend of June 8th and 9th. You can join all of the faculty all of the teaching assistants from the Fitness Athlete Division, June 22nd and 23rd. That'll be right here at CrossFit Fenton, here in Fenton, Michigan. That's gonna be a fantastic weekend. If you've been looking to take Fitness Athlete Live, that's the one you wanna be at. Online, if you wanna learn from us online, our next Fitness Athlete Level 1 course starts on July 29th. That course sells out every cohort. That course sells out every cohort. Don't be that person emailing us the Tuesday after asking to get in. It won't be possible. And our next cohort of Fitness Athlete Level 2 Online begins after Labor Day. That will be September 2nd. You must have taken Fitness Athlete Level 1 to get into Fitness Athlete Level 2 Online. Just like Level 1, that class always sells out every cohort as well. So I hope this was helpful. I hope this is a great resource for yourself, for your own exercise, but also a great resource for you, your patients, and your athletes. Have a great Friday. Have a wonderful Memorial Day weekend. See you next time. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 23, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses three things to consider when changing positions: transparency, pay, and communication. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane, an online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions. Today is Thursday, Leadership Thursday. We talk all things small business management, practice, ownership, and management. But more importantly, it is also Gut Check Thursday. This week's Gut Check Thursday, coming up on Memorial Day weekend, we have Murph, the infamous hero workout performed by CrossFitters and functional fitness enthusiasts across the planet. This is a very long, grindy, aerobic bodyweight workout. If you've done this workout before, I don't really need to tell you anything about it. a one mile run, 100 pull-ups, 200 push-ups, 300 air squats, and then finish with another mile run. You can't manipulate the order of the mile runs at all. You can change and partition or not partition the pull-ups, push-ups, and air squats in the middle any way you want. As long as you get 100 pull-ups done, 200 push-ups done, and 300 air squats done, you are good to go with that work that you get done in the gym. Typical times are going to be 40 to 60 minutes and obviously a little bit slower if you wear that 20 pound or 14 pound vest. A lot of different ways to approach this workout. We have a lot of scaling options over on the Gut Check Thursday post on our Instagram account. But there are numerous ways to modify and scale this to get a really good workout in on Memorial Day before you head off to hopefully celebrate some barbecues, some beers, that sort of thing. Today, Leadership Thursday, what are we talking about? We are talking about things to look for if you are considering changing your job position. So we're gonna talk about transparency, we're gonna talk about pay, and we're gonna talk about communications and leadership presence. JOB CHANGES ARE NORMALBefore we talk about the three things we think you should look for, the first thing I want to say is to understand, and we can have a lot of reservations about this, we can get in our head a lot about this, it is completely normal to change your job, and even to change your job on a regular basis. Bureau of Labor Statistics. It's a government agency that posts a bunch of data about really a wide variety of topics related to working and the workforce. They have data that shows the average person will change their job 12.4 times between the age of 18 in 54. So the average person is changing their job maybe as frequently as every year or maybe every two to three years. So I think that's really important to understand that it's normal to move on for whatever reason that you feel like it's normal to move on. Often we can encounter a lot of shame, a lot of pushback of I can't believe you're going to leave, who's going to treat all of these patients, so on and so forth. But we need to recognize That is not your problem and that it is normal to want to move on again for whatever reason you feel like you need to move on. A different schedule, more flexibility, less work, more work, more pay, different location, whatever. It is normal to change your job positions. About 30% of all Americans change their job each and every year. And then why do we look at that? All the reasons that we think about in the profession of physical therapy are the same across other industries. 80% of people leave a position because they feel like they are burned out. 70% feel like work is overtaking every aspect of their life. They're losing that balance between work and personal life. and then about 50% leave because they believe they are overworked or underpaid or both. And certainly, in the profession of physical therapy, we can relate to that. GET IT IN WRITING Before we talk about transparency, pay, and communication, the other thing I'll say is that as we get into these topics, it is in your best interest, and I cannot reinforce this enough, that whatever you discuss, whatever is told to you in words, should go into writing, and any unwillingness about specific details of your job tasks, of productivity, of pay, of time off, of other benefits, so on and so forth, anything related to the fine details of this position you might be considering should go into writing. And unwillingness or hesitancy or any sort of mystery about that should be immediately a beige flag, I would say a red flag in your mind that already you're thinking, why would I accept this position if it is not willing to be put into a contract? that I will be promised these things in writing, that I am being promised verbally. So, that's always front of mind, that if it's not in writing, it's probably not going to happen, and you'll just find yourself likely, eventually, in the near future, thinking about changing job positions again. TRANSPARENCY IS KEY So getting into our first point, the most important thing I believe related to perceiving a job position to be a good fit is transparency. That in the profession of physical therapy, in the field of physical therapy, whether it is being a frontline staff clinician treating patients, whether it is being in a management or ownership position, there is no secret to what we are doing. There is no mystery formula. secret technology, government secret for national security that we can't talk about, that transparency rules the day, especially in a profession like ours. A healthcare profession, a medical profession, a graduate level, doctorate level profession. Transparency should be there in all things. How are people paid? What are they paid? We should not go home every night and wonder if someone is making more or less money than us for whatever reason because I am a female and they are a male or vice versa. We should have very clear cut transparent lines of how does pay work and where does the strategy and where does the logic for that come from? How does productivity and time off and benefits Again, all the stuff that you would care about and all the stuff that you would want to see in writing, where is that at? It should be there. It should not be hidden. It should not be something that is not told to you. We live in a day and age. It's 2024. We know how much we are charging. We know how much we're receiving. We know how much we're getting paid. It should not be a big mystery. Any reluctance there, any hesitancy to share? First of all, regarding what the clinic gets paid in 2024 is illegal. As of 2021, we have to have our rates published on our website or somewhere posted publicly that patients considering care with us can find it, right? That's the no surprises act of 2021. So we should at least have an understanding of how the clinic and what the clinic is making for revenue and understand how our pay is calculated, how our productivity and everything that kind of follows downstream from that. So there's no secret that we have to hold on to. Certainly if you work at NASA or something, I could see that being a little bit secretive is important, but in the field of physical therapy, that just does not make sense. You should, again, never go home and have to fester about this stuff. Am I being underpaid for whatever reason? Am I being asked to do more work for whatever reason? All of that goes out the door when you work in a really transparent workplace. PAY MATTERS The second point is pay. High quality leaders, and I will take this to my grave, high quality leaders recognize that pay is very important when you want high quality folks to join you at your business and help you grow your business. No one is happy when it is National Physical Therapy Month and you work in a hospital or some other big group clinic and instead of a bonus or an extra day off, what comes through the door? Some old, stale, gross, soaking wet Jimmy John's sandwiches, right? That really just makes everybody upset. You don't feel like you were awarded. You don't feel like you were valued. Pay is one of those things that is just Part of going to work, whether you're going to work for somebody else or somebody else is coming to work for you. Several high quality papers exist now. We've talked about several here on the podcast. The most notable one is Killingsworth and colleagues back from 2023. establishing an objective database link between pay and satisfaction. Job satisfaction, life happiness. We know that human beings fall into buckets. Not everybody is motivated by money, but most people are at least somewhat motivated by money. That paper is really profound to me knowing that there is about 33% of the population who does not really seem to care about money beyond having their basic needs met. That being said, the majority of the population, therefore, is motivated by not just enough money to have food and a place to sleep, but having enough money to start a family, buy a house, retire, all the other stuff that we do with our money. So we know there's a middle portion of the population that sees a linear increase in happiness up to and beyond $100,000 a year of household income. And there's also another a third of the population, another 33%, that sees an exponential change in the relationship between their pay and their satisfaction up to and beyond $100,000 a year. We've said it here a thousand times, we won't beat the horse too much here today, but pay matters, and in specific, if you're not getting a raise every year, you are taking a pay cut. So pay should be one of those things that's included in transparency, and it should be a big factor, and it should not be a thing that is a mystery when you're looking for a new position. You're not quite sure how it works. And again, everything related to pay should be put into writing. We talked to a lot of people who are presented a salary or an hourly or a per visit or whatever pay scale that then find out later, Oh, by the way, that's based on X productivity. And because you did not hit X productivity, you are now being paid Y instead of Z. We see this often related to a percentage of arrival, that if only 90% of your patients showed up this week, you only receive 90% of that promised salary, for example. So be really careful, ask a lot of questions about pay, and make sure that stuff goes into writing, because if it's not in writing, again, it's probably not going to actually happen when you accept that position and you begin working. COMMUNICATION IS CRUCIAL And the final thing here is communication and presence of leadership. I think communication is really important. I think we can over communicate. We can have a lot of meetings that are maybe seen as wasting time. But I also think a lot of workplaces, a lot of communication between owners or managers and staff clinicians does not happen often enough. There is no inclusion of the other people that work at the facility of hiring somebody else. Is that person not only a good fit for the clinic, but is that person a good fit with everybody else who works at the clinic? And so having open communication, having the ability for folks to ask questions, Again, not necessarily over communication, just to communicate, but making sure that when decisions are made, as much as possible, everybody else who works at that clinic should at least know what's going on. Maybe it's not relevant for them to have a say in, you know, that you switch toilet paper brands or something like that, but at least the option to have that open line of communication should be included. And with that comes the presence of leadership. I truly believe that to run a very successful business and to have a staff that works really well together, the people in charge should probably be there on a somewhat regular basis. Very often we hear that clinic owners are living in the Caribbean or across the country at their second house. They haven't been seen for weeks or months, and they're primarily just collecting their ownership distribution from the business at that point. It's really difficult to feel connected to the business side of your job when you are not even sure who is in charge and what they're doing. We see this in our bigger clinic groups across the country, that the people that own the company are not even physical therapists. They've never been a physical therapist. They've never treated a patient in their life. an investment banker or a stockbroker or some sort of real estate mogul. And the physical therapy business is just numbers on a spreadsheet to them. It's just profit and loss. And it can be naturally very difficult to feel connected to that position, to feel like you're doing meaningful work, and to also feel like you're being rewarded for that meaningful work when there's not that communication and there's not that presence of leadership going on. SUMMARY So, what are three things that you can very quickly use to screen in and out a good position? Making sure that everything that is talked about is put into writing. Focusing on transparency of understanding why and how the business is run and what those decisions and how those decisions are arrived at. Knowing that pay is very, very important. We need to recognize both that from the ownership and management side of the equation as well as those of you seeking a new position. It would be, Not a great optimal decision to change positions for a lateral promotion or even a decrease in pay unless it meant living in your dream geography or something like that. And then the final point, communication is important. Having open lines of communication with ownership, with leadership, both ways. Having a say in important decisions or at least being able to voice your thoughts on the matter. and having active presence of your leadership and ownership in the actual business. When is the last time the clinic director or the clinic owner has maybe even been in the same state that their clinic is in? Those are all important things to consider. So we hope this was helpful. We hope you have a wonderful Thursday. Have a fantastic Memorial Day weekend. Have fun with MRF. If you're looking for more business practice ownership information, if you're looking to start your own practice, whether it's insurance based, cash based, you're not sure based, check out Brick by Brick, our practice management course. The next cohort starts July 2nd. Have a great Thursday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 22, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses a framework to begin to better assess balance & tailor focused interventions for patients, including assessing risk factors, understanding inputs that affect balance, and how to measure outputs from balance. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. DUSTIN JONES Good morning, folks. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division, and we are going to be talking about a framework for balance, about how we can think about balance from the assessment side of things. over to the intervention side as well. I feel like this area is very kind of misunderstood in the rehabilitation realm and it's often handled very poorly from what I've seen and I'm definitely guilty of this as well. Let's kind of play out the typical scenario when we're talking about trying to assess and improve people's balance, right? We have someone if you're an outpatient they likely came to you for you know some type of painful issue right back pain shoulder pain whatever and then you realize oh this person you know reports that they feel unsteady or that you may notice it yourself or you may have gotten a referral that said they've had a fall and we need to look at balance then we do our assessment and typically what we're doing is throwing some type of of you know quote-unquote balance outcome measure that we learned in school, probably something like the Berg, you know, balance test, where we take them through that test and we see a score and we say, oh my gosh, all right, you are at risk of a fall. I saw some deficits in some of these activities and man, all right, I'm gonna give you my balance program, right? So you've got your balance exercises. There's probably, you know, some tandem stance in there, semi-tandem, maybe one-legged stance if you're feeling funky, right? you're maybe doing some obstacle courses, maybe tossing a ball back and forth, you may be having to stand on an Airex foam pad, right? We kind of got this kind of generic balance program that does challenge people's balance capacities, but what we often see is that that generalized program is not specific to the deficits that that person provides. Balance, I would say out of any other facet of performance is probably one of the most complicated, because there's so many different variables that can influence someone's balance ability, and we need to identify those and then address those specifically, as opposed to giving these kind of generalized balance exercises, quote-unquote balance program, crossing our fingers and hoping that they actually make a significant difference in these people's lives. All right, so let's talk about a framework for assessment that's ultimately gonna lead to intervention. I think one of the big takeaways for many of us when we start to really look at people's balance abilities is we have to zoom out and look beyond their performance on outcome measures. We focus solely on that, and we miss the boat on some very, very important factors and variables that are contributing to that poor performance in the outcome measure that we see. All right, so think of this in three steps from the assessment side. You want to look at risk factors, you want to look at inputs, and then you want to look at outputs. If you go through those steps, you're going to get some very, very valuable information. I'm going to go through each of those three. RISK FACTORS FOR FALLING All right, so risk factors. We can put risk factors that are going to influence people's balance ability or increase their risk of falling in kind of two buckets is how we typically think about this. Intrinsic and then extrinsic risk factors. These are areas that some of y'all may be thinking about, talking to them, asking questions, maybe getting a good idea, but a lot of folks may be completely ignoring some of these things, right? So like intrinsic risk factors could be their medical history, right? Permanent medical diagnoses that are gonna have an influence on balance. Type 2 diabetes, if they have peripheral neuropathy, they don't have that somatosensory input, they're going to have issues. Think Parkinson's disease. If they have Parkinson's disease, they probably have some issues with initiation of movement, maybe reactive, postural control is a little impaired, that's going to influence their balance. We need to have a good idea of their medical history. We need to have a good idea of their current medications. Think of the last time you did medication reconciliation. There are a lot of medications that can actually impair balance, balance capacity, reactive, speed, that can ultimately increase the risk of falling. These medications are in their own category called falls risk increasing drugs. Other things that we can think about is there their vision, their foot health, their footwear, for example. There's a whole host of these different intrinsic variables that are a lot, right? There's a lot of things to work through. but they will give you valuable information that is contributing to their impaired performance on some of the outcome measures that you're seeing. There's a lot, a lot of intrinsic risk factors. What I'm going to point you to that's going to be a really helpful resource is the CDC's study, S-T-E-A-D-I. This is going to give you a framework to be able to work through some of these contributing variables, particularly the intrinsic risk factors, that can negatively impact balance. And it'll give you a really good framework to be able to address those. Then we have our extrinsic risk factors. This could be assistive device use, the fitting of the assistive device, which we often see it's not properly fitted, whether it's a cane walker, so on and so forth. What's the home look like? Do they have that pesky rug that they end up tripping over? almost every day, right? Can we do something about that? Probably not, but you can go ahead and try. We can think about lighting in certain areas, particularly at night. Let's say if they have nocturia and they have to go use the bathroom at night, we need a well-lit area to reduce their risk of having a fall, improve their balance capacity in that particular situation. So CDC study is going to be very, very helpful for you to work through some of these risk factors, intrinsic and extrinsic, all right? So I would start there. So that's risk factors. Get a good idea of that. Check. INPUTS THAT AFFECT BALANCE Next is going to be inputs. This is where we're looking at those afferent signals, those three main systems that are giving us really helpful information that allow us to execute and maintain our balance. That's that somatosensory system, the visual system, and then the vestibular system. There's some different ways we can check this. From the somatosensory side, we could look at their proprioception, their joint position sense. We can do this starting distally, maybe at the big toe, and get a good idea if they're able to tell where their big toe is in space. that's going to be really helpful because that's going to carry over to their proprioception when they're on their feet navigating a complex environment, for example. Do they have protective sensation? This could be monofilament testing where we're seeing if they're able to be able to feel that little pinprick that seems Weinstein monofilament. If you're working with someone that has blood sugar issues, type 2 diabetes is on their chart, This is something you definitely want to check because that's going to influence that input, that information that they're getting that's going to negatively influence their output that we're seeing with that outcome measure and there's some things that we can do about that. Then we look at their visual system. How's their visual acuity? How's their depth perception? How are their visual fields? We need to have a good idea of the health of their visual system because we may want to make a referral to get it reassessed if it's been over 10, 15 years since they've updated that prescription in terms of their eyeglasses, or we may need to teach compensatory strategies to overcome some of their depth perception issues or their visual field loss that they have. You could throw all kinds of generic balance exercise at these people, but if they have visual deficits, you need to have visual specific interventions that are addressing that visual deficit. And oftentimes it may be compensation, right? So we need to address those inputs. And then the vestibular system. This is where we can do a vestibular screening. We can look at their smooth pursuits, for example, which is more kind of in the visual realm, but it's very closely tied to that vestibular system. Smooth pursuits, vestibulocular reflex, or that VOR. How is the health of that VOR? Is it intact? Are they able to cancel that VOR and be able to move their head and eyes at the same time without an onset of symptoms? And then we can do different positional testing as well. If we can do a vestibular screen, that is gonna be very helpful to identify, hey, this is more of a vestibular issue than anything. You doing your tandem stance, tossing a balloon back and forth, probably ain't gonna do much for that, right? So it's gonna influence our interventions. OUTPUTS FROM BALANCE So we take those risk factors, we take the information from the inputs, and then we do the outputs, which is our outcome measures that we typically think about. Many folks will do a Berg balance test, That. is not the perfect test for everyone, right? There's a lot of issues with the Berg Balance Score. It doesn't really address a lot of different variables of balance in terms of balance performance. What we really like to recommend for folks is looking at something like the Mini Best Test. It is more of a well-rounded test. It looks at people's ability to anticipate maybe a destabilizing event, maybe their ability to react to a perturbation in terms of their reactive postural control. How do they handle different scenarios where we've limited vision or limited that somatosensory input or kind of muddy the water in terms of the vestibular input? How do those people respond in that situation? How they do in a dynamic gait scenario where they have to do different tasks or they have to do, they have to emulate but then also add on a cognitive dual task. That mini best test is going to reveal a whole host of different common scenarios that these folks are going to be struggling with that we can work into our intervention plan. For someone that may be more in a seated position most of the time, we can do the FIS, the function and sitting test, which is as well-rounded as the mini best test that will give you a good idea of their performance in a seated position. And so we take those risk factors, we take those inputs, and we take those outputs in our assessment. And then what we find, we have a individualized, tailored program to that person. And so for some people, the first thing you may do is call their physician or pharmacist to have their medications looked because they're on a couple of FRIDS or false risk increasing drugs that we need to take a look and make sure that they're still appropriate and they're still necessary because we know that they have a negative influence on people's balance ability. You may realize that, man, this person is very visually dependent, that as soon as we close our eyes and we're asking more of the vestibular system and the somatosensory system, their balance really starts to crumble. Then we know, all right, we need to maybe restrict their vision in some of these balance training activities to really strengthen up these other systems, to be able to compensate in the event that we don't have that visual input, make these people more resilient. And you may notice, maybe in the mini best tests, where man, when we do that cognitive dual task, timed up and go, that's a part of the dynamic gate portion of the mini best test, Betty's performance really, really crashes. but she did fine on everything else. Well, what do we need to do? We need to do some balance-based activities where we are going to add on a cognitive dual task. There's so many things out in the real world that demand that, we can practice that in our sessions. And so you go through those risk factors, you go through those inputs, you go through those outputs, and you're gonna get a very tailored program that's going to address that person's specific deficits to overcome them and make a significant improvement in their balance ability. Right? How we typically do it where we're just giving our general balance program to people not really knowing what the true deficits are. It's like throwing darts blindfolded. You're just crossing your fingers, praying to God that you're going to hit that bullseye. Take the blindfold off, assess that person, understand their deficits through that framework, and then you'll be throwing those darts, hitting bullseyes every single time. All right. I will drop some links in to the comments. You can shoot me a direct message as well, and I can give you those links. The big ones are going to be the CDC study. It's going to give you that framework to particularly look at the risk factors. That's what that one's really helpful for. and then I'll link to that mini best test and then the FIST, the function and sitting test as well. So you all have some resources as a result of today's episode. All right, hit me up with any questions. Let me know your thoughts, any other things that you'd add to the conversation around balance. I think we can really level up here. SUMMARY If you want to learn more about balance, if you want to practice some of these interventions of how we can take that information and really put it into a tailored program, I want to recommend our live course, MMOA Live, where we give a bunch of intervention ideas related to this framework. We've got a bunch of courses coming up. I'll just mention the ones coming up in June. We're going to be in Scottsdale, Arizona, June 1st and 2nd, in Spring, Texas, June 8th and 9th, and then we'll be in Charlotte, North Carolina, June 22nd, 23rd. We also hit on this in depth in our MMOA level 2 course where we take a step deeper into the topic of balance. Alright, well I'm gonna get off here. We got our first MMOA level 1 call for this cohort coming up in about 15 minutes. I hope you all have a lovely rest of your Wednesday and I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 21, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses assessing, treating, and loading the upper traps when suspecting their involvement in neck or headache symptoms. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ZAC MORGAN All right, good morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the spine division, teaching both cervical and lumbar spine management. And this morning I wanted to bring you all a technique Tuesday, looking at the upper trap, thinking more in that cervical management arena. So I think we all really appreciate that a lot of our patients with neck pain have some upper trap dysfunction. That's a very common muscle to have issues with, whether you're dealing with mechanical neck pain, Maybe you're dealing with cervicogenic headache patients, patients with TMD, temporal mandibular joint dysfunction. We see it a lot in our patients who have an irritated nerve root, something like a radiculopathy. They'll often hold some tension in that upper trap to kind of slacken their brachial plexus over time. Lastly, folks who are just really stressed out, which I think we all can kind of appreciate. That's most of our clientele. Most Americans carry around a ton of stress. I think all of these pathologies really lend themselves to quite a bit of tension in the upper trap. I wanted to talk this morning a little bit about actually like soft tissue assessment and kind of how to progress your vigor throughout that assessment to replicate those symptoms. But then I also wanted to just bleed that straight into treatment because they look quite similar and show you all some things that I find that are very useful for both identifying the symptoms and then eventually eradicating these symptoms doing some soft tissue work. So let's move to the table and we'll talk a little bit about the actual hands-on assessment of the upper trap and some key points to not miss. So we'll go ahead and shift gears over here. I do think having a little bit of soft tissue cream can be helpful when you're assessing the upper traps. So I like the company Deep Prep because Deep Prep is still, you can still get a grip on the muscle, but you get a little bit less friction, which is nice. There are plenty of soft tissue creams on the market. This is just the one that I typically will use. So I'm just going to kind of coat that whole region of the upper trap all the way up into the cervical spine with some lotion just to get it to where I can feel all of those fibers without getting too much grip on the person's skin. So, starting out from an assessment standpoint, the big piece that I don't want you to miss is the anterior side of the upper trap. So, I think a lot of times we feel these things with the person in prone, and we miss that anterior side of the upper trap, and I always like to think of it like a wave that's crashing over the shoulder, and we wanna feel that anterior side, or where the wave's almost curling. And so really, all the way down at the clavicle, I like to find the AC joint, and then start to just gently stress that lateral upper trap. And typically for palpation of the upper trap, I'm going with a grip like this. Kind of a lumbrical grip and avoiding DIP flexion. DIP flexion is what gets really uncomfortable, really pinpoint for the person. So I'm almost trying to sandwich that upper trap like this with my hand. So I'm going to feel that distal anterior upper trap and basically just make a couple of quick passes. I'm going to feel my way up through the anterior side of the upper trap. A couple of passes through there. I'm going to feel it as it connects to the neck right there where it's starting to dive into the actual cervical spine. And then of course the last place is up at the nuchal line where it's proximal insertion is. So you want to feel through all of that just with some really gentle strokes to start. you might pick up that the patient's a little heightened as you're feeling through this and that might be plenty of palpation to kind of elicit the symptoms but if the symptoms are a little less irritable and you want to kind of up the vigor of what you're doing here What I would suggest first is to just hold some tension in the upper trap and then push it straight down towards the table. So you won't be able to see my hand move down towards the table much because it's just bearing in the pillow. But essentially what I'm going to do is find each third of that upper trap, so the clavicular the AC joint attachment, like right there at the end of the clavicle, the middle of the trap, and then up towards the neck. I'm gonna find a tense spot, hold pressure, and drag it straight down towards the table, like this. So I would call that like pinning and then depressing. And then same thing in the middle of the trap, pin and depress. And then same thing up here at the neck, pin and depress. You'll often find that when you drive that trap down towards the table, that tension creates some of those cervicogenic headache symptoms, maybe even just their plain neck pain you might replicate like this. But if you really want to stress it even a little bit more, what I would encourage for the assessment is going to be pinning it, depressing it, then stretching it. So it's a pin and stretch, but we want to make sure we get that depression in as well. So I'm going to hold the bottom of my client's head like this. And so this part of my hand is going to be on one side of their head. Their head's going to lay across my forearm. That way I can add all of the motion that I want through my arm really easily. So I'm just going to gently slide my hand under their head, swung all the way through. Now I had easy control of her head and neck and I can come in, pinch, depress and stretch. move to the middle of the trap. Pinch, depress, and stretch. Team this technique for assessing the upper trap is the most common way that I'll wind up eliciting a lot of those soft tissue symptoms for the person. It's because it's pretty vigorous. As you pull that tension into the trap and then pull the proximal insertion away from the muscle, that often gets a lot of tension through that big muscle and the person will feel their symptoms. So make sure as you're assessing, pay special attention to the anterior side of the trap build your vigor slowly, start out with just gentle palpation throughout the muscle belly. If that gets the job done, no need to get more vigorous, but if you haven't found those symptoms and you're suspicious of the upper trap, then add a little bit more pinching and depression. If you want to get more vigorous still, pinch, depress, and move the head. Now from a treatment standpoint, thinking about soft tissue techniques that we can do, basically what I will typically do is take the depression out, but still do the pin and stretch. If you really want to get vigorous, you can of course add the depression back, but for most people you won't need that depression to get them a really big stretch and get their soft tissue a bit looser. So for that, it's the same thing that I just showed you from an assessment standpoint. But I'm going to do a lot more passes. And I typically think about the trap, the upper trap in those thirds. So there's like the lateral third, the middle third, and then the medial third. And I probably am going to do 10, 15 reps at each one. So I'm going to hold, side bend 10 times. Hold the middle, side bend 10 times. Hold the proximal, the part closest to the neck, side bend 10 times. Go back through, do the exact same thing with rotation. Go back through, do the exact same thing with flexion. And then the most vigorous or last one that I would do would be like that flexion quadrant where you're getting flexion rotation and side bending all at the same time. Those can look like this. So again, I'm gonna have that same exact grip of their head like this. I'm gonna find whatever that spot is and then just side bend. And it doesn't take much side bending for you to feel a lot of tension between your thumb and like index middle finger where you've got that kind of pincer grip. you will feel quite a bit of tension as you side bend, and I'm just going to loosen that up. Encourage the person to just breathe normally. This can be pretty intense. When I want to look at rotation, same thing. A little less tension and rotation than side bending, so often not quite as big a deal, but can just work rotation right here with the neck, holding just tension through this part of my hand. Last thing that's useful is flexion. Definitely more tension here in flexion. You're going to get a lot of stretch across those anterior fibers. This will often feel a little bit symptomatic for the person as well, but they'll often tell you how it feels like it needs to happen. It's kind of a hurts so good type of thing. And then last thing would be flexion quadrant. So moving into this diagonal. So I'm here and there. That'll be your most vigorous. So I'm thinking about moving her nose towards her armpit each time. That'll be definitely the most vigorous of all of these. So team, all of that is some nice ways to sort of assess and treat the upper trap. A lot of our neck pain clients would benefit from that. A decent amount of them are carrying tension already, whether they even have neck pain or not. Our clients are commonly complaining of tension there. They'll feel tense when you check their range of motion exam. This may not be the first thing you go to throughout their plan of care. There may be some other things that you do to address the local tissue. But throughout a lot of my clients with neck pains plan of care, I'm gonna do that deep dive into the upper trap, feel all the fibers, figure out where it really is the most tense, and then address that with a bunch of reps of soft tissue work. This works great and I think you'll find that it bumps people's symptoms down pretty well. The other thing is people love it. People generally love to feel thoroughly assessed, soft tissue and all, and it's rare that someone doesn't feel some tension here, so often patients just like for you to go ahead and take that nice broad overview of the upper trap. So make sure, whether it's a cervicogenic headache, mechanical neck pain, radiculopathy, you name it, there's a lot of patterns of neck pain that show up. Assess the upper trap. You will often find that you're able to bump those asterisks forward even better when you do so. And so I would really encourage you to make that a part of your practice. SUMMARY If you're looking for an upcoming spine course, if you're looking for cervical specifically, we've got a few coming up. So June 29th and 30th, Kent, Washington. So make sure you check us out there on the west coast. July 13th and 14th, Charlotte, North Carolina. So back over on the east coast. And then July 20th and 21st, Oviedo, Florida. So down south, right next to Orlando. If you're looking for lumbar management, June 8th and 9th in Anchorage, Alaska. So if you're out there in Alaska, join me for lumbar. June 22nd and 23rd in Paoli, Pennsylvania. And then July 13th and 14th in Amarillo, Texas. So several good course offerings upcoming. We'd love to see you out there on the road where we cover full head-to-toe management in spine conditions. Thanks everyone. I will catch you on the next one. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 20, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the benefits of birth control and when we should be thinking more positively about these medications and methods Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. CHRISTINA PREVETTHello, everyone, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty in our pelvic divisions. And I am coming to you from a hotel room. I'm about to get back after teaching MMOA Live here this weekend. So you got my hotel version of today's podcast. Today we're going to be talking about advocating for birth control. And so this might be a bit of a hot take hot topic, because in the allied health or birth provider space, there has been a lot of anti birth control messaging. And so I want to kind of play devil's advocate a little bit. and speak to some of the potential pros of birth control, and then really try and loop this into why it is so important, especially as healthcare providers, that we become more nuanced in our approach, right? It is so easy with social media for us to be thinking in 30 to 60 second snippets. But one of the reasons why I love the podcast is that we're able to kind of dive into nuance a little bit more. So firstly, the development of the oral contraceptive pill was one of the big revolutionary medical marvels that allowed women to have reproductive choice in a lot of ways, right? The idea behind oral contraceptives was that females could have some, you know, obviously when they're having intercourse, but like they were able to prevent unwanted pregnancies and that gave them some sense of control in a lot of ways. So the development of oral contraceptives outside of barrier methods was truly such an amazing medical advancement that paved the way for a lot in reproductive healthcare. With the use of exogenous hormones, what we have also seen with the use of oral contraceptives is that it has been used in the management of different gynecological conditions. So here's where we get to messaging numero uno. When people take birth control, they aren't actually balancing their hormones. Something is doing it for them and it is a band-aid and it's making all your sex hormones go down. This is the messaging. So we shouldn't be giving people birth control because it's not fixing the problem. So let's talk about an argument where that works, and let's talk about an argument where it doesn't. Okay, so in our pelvic division, we talk a lot about relative energy deficiency in sport. This is for individuals with primary or secondary amenorrhea, where because they are not fueling their body appropriately, their body goes into battery saver mode, which means that they are not doing any bodily processes that require excesses of energy out like energy out because they don't have enough energy coming in, which can include pregnancy. And so we suppress the HPT access to prevent ourselves from ovulating because right now we're not taking in enough fuel for our body to function. We're definitely not taking in enough fuel to support a pregnancy. In those circumstances where individuals are not getting their period because of under fueling, sometimes birth control can be recommended and The argument can be made that. we're not getting at the root cause for the hormonal imbalance, because you need to have that fuel to the root cause, and we should see a hormonal re-regulation, and reds from the literature that we have right now is reversible, right? So that makes sense, right? If individuals are highly active, they're in low energy availability, and they're not screening for root causes of issues with hormone status, and we give birth control as a knee-jerk reaction without doing the proper investigations, I can see where that argument of it's exogenously balancing your hormones would work. But here's where it doesn't. Okay, here's where it doesn't. So birth control is also used as a frontline treatment for a lot of fertility-impacting conditions or gynecological conditions, such as PCOS, endometriosis, and fibroids, right? PCOS, is a androgen excess and it is a chronic disease. It is a chronic disease. It is a chronic disease that has no cure. So there is no cure to be able to balance your hormones naturally with PCOS. Does health promotion potentially help with becoming more regular with your menstrual cycle? Does it help with bringing you to a more regular cycle where you may be more ovulatory with PCOS? Yes. Are you going to change to a, within normal levels, your androgen access? Probably not. So guess what? The birth control pill is being used to bring androgen load down, right? And that is how we treat chronic diseases, right? I don't give a person, oh, I'm not, I'm not a physician, but physicians don't give a person a blood pressure med and we get mad at the physician for giving them a blood pressure med because they're treating the symptom of the high blood pressure, but they're not getting to the root cause of the issue, which is cardiovascular disease, right? These medications are given specifically to manage the symptoms. which is the exact same logic that we are seeing with individuals with gynecological conditions. We are not giving oral contraceptives in order to balance their hormones because they are chronic diseases, right? Outside of excision for endometriosis and fibroids, where we may see a reduction in symptoms, that is not a guarantee. And the only known cure for true 100% cure for endometriosis and fibroids is a hysterectomy. So if we have individuals with a high amount of symptom burden, heck yes, we are going to treat the symptoms, right? And so we can use oral contraceptives to treat those symptoms, right? If I wanted to pull this into our physiotherapy logic, that would be like saying, well, this person has a disc bulge on MRI. If we can't fix the disc bulge and get it back in that spinal alignment, then all of our interventions for pain don't matter because we're not fixing the root cause, right? So, but, PT we say you are not your image like we're not just going to treat you mechanically we're gonna treat how you're feeling within your own body and yet we flip that in our health care providers spaces when we talk about birth control and we make women with heavy menstrual bleeding with heavy periods with individuals who are suffering from fatigue and lethargy because they have anemia we have cyclical pain that could be treated with oral contraceptives and we make them feel bad that they're using it or make them feel fear that they shouldn't be using this because they should be able to balance their hormones regularly and so inadvertently in an attempt to help we're kind of gaslighting them, right? And, and I, I mean this in a very, like, I want to have a fruitful conversation about this because I have seen this messaging over and over and over again. And when individuals have gynecological conditions, birth control can be a management strategy. Should it be a knee-jerk reaction for everybody without the need for further investigation or evaluation? No. Are individuals oftentimes dismissed with birth control because they're not actively trying to get pregnant? Yes. Do some people not tolerate certain types of oral contraceptives or different types of birth control methods? Absolutely. But it is a trial of treatment that has some evidence to back it up. and it can be helpful in some circumstances with some individuals. So having this knee-jerk reaction and saying, well, it's not getting to the root cause or it's not balancing our hormones in the background of a chronic disease with no cure, we are missing the mark on our messaging. And so many of our clients come to us as pelvic PTs and they trust our opinions. And we are trying to lock shields with physicians, not battle with swords. And we need to be mindful of that, that by being very dismissive or not getting to the nuanced approach to contraceptive care or using birth control methods, we are not doing ourselves any favors and we're not helping our clients by not getting into the nuance of it. So the first argument that we see a lot is you aren't balancing your hormones, like it's doing something for you. It's taking your HPG access and bringing it down to nothing, right? That's not always the case and not always the method of oral contraceptives. It can blunt the HPG access, but it doesn't make it go down to zero. And then the secondary piece that individuals have fear on when thinking about oral contraceptives is future fertility. So, There was a cross-sectional study that said that almost 70% of females surveyed were worried about long-term fertility because of oral contraceptive use. We do not have evidence. We actually have multiple systematic reviews and meta-analyses that actually demonstrate that there are no changes in fertility upon cessation of long-term birth control utilization. All right, let me repeat. We do not have evidence that being on birth control negatively impacts future fertility. It does not. What we see is that using hormonal, non-hormonal IUDs, oral contraceptives and patches, the rates of live pregnancy or positive pregnancy rate for contraceptive versus non-contraceptive users in age-matched cohorts appears to be the same. where we can kind of get into this bias, this selection bias, is based on the reason for individuals going on birth control. So if you were a person who went on oral contraceptives in order to prevent pregnancy, but you did not have any fertility related concerns, and that wasn't a factor in your prescription, once you stop taking oral contraceptives, maybe after a couple months things will kind of re-regulate, you should have no future impacts on your fertility. Where you can have downstream fertility related issues is based on the reason for being on those oral contraceptives. So if you are on oral contraceptives for heavy bleeding or cyclical related pain, or hirsutism or clinical androgenism as a consequence of PCOS, we know that PCOS, endometriosis and fibroids can negatively impact your fertility and increase your chance of infertility. So in those situations, because we were treating the symptoms of your condition, we do not have the capacity outside of excision and endometriosis and fibroids to cure these conditions, that downstream fertility consequence is still going to be present upon removing your birth control method or upon removing oral contraceptive use. So it is not the pill itself, it is some of the reasons why you were on the pill that can negatively impact future fertility. And so I have now been talking for about 11 or 12 minutes on the nuance of birth control. The final thing that I will say is it is hysterical to me that the clinicians who are absolutely adamant against birth control for reproductive age individuals, are big advocates for using topical estrogens and hormone replacement therapies, menopausal hormone therapies, for individuals going through the menopausal window, because they are treating the symptoms of menopause, right? We are not trying to fix a person's hormones. We aren't gaslighting them and saying, oh, well, you know, this is your natural aging consequences, so you're just gonna deal with your menopausal symptoms. No, we're at the forefront advocating for topical estrogens and the use of exogenous hormones to be able to help individuals at the end of their reproductive window. So then why are we telling individuals with chronic diseases like PCOS that we can't or shouldn't use, that we should be fearful of using oral contraceptives in their reproductive window when they do not want to be pregnant? Right, and we know that it is a chronic disease that has no cure, and we make them feel bad for treating the symptoms with these exogenous hormones. So we just need to be so careful in our profession about how we are catching onto these trends. I always talk about the fact that I am scrunchy, not crunchy. I am a huge advocate in holistic care. And I think that holistic care can come alongside Western medicine in an evidence-informed way. All of my research is in health promotion, which means that I am in the science-based crunchy. So we just need to be mindful about not having this knee-jerk reaction and saying that birth control is bad. That is the messaging that I'm seeing. And that is absolutely not true. In the messaging, the logic in the messaging is flawed. When we're thinking about gynecological conditions, many of them are chronic conditions that do not have 100% curative rate. PCOS is a chronic disease with no cure. Endometriosis and fibroids can have excision, but the only thing that's going to guarantee that you are not gonna have another growth is a hysterectomy, which is not obviously a viable option for individuals who wanna get pregnant. And therefore, using oral contraceptives for managing signs and symptoms of those conditions is a evidence-informed utilization or medication that people can do. That does not mean that it is for everybody. That does not mean that people can self-select. It's okay for them to self-select away from it. We just wanna make sure that they're getting the right information about what it is and what it isn't. Birth control does not impact your future fertility. We now have multiple systematic reviews and meta-analyses that pending normal reproductive status, normal fertility rates, that we have no infertility-related conditions that there is no difference in conception rates once getting off birth control. And then we are huge advocates for the use of supplemental hormones through menopausal hormone therapy at the end of a person's reproductive window. All right, that was my rant for the day. I hope you guys found that helpful. I really just wanna get into the nuance of this, right? Like we wanna make sure that we are being mindful of our messaging and we are not, inadvertently shaming people or making them fearful or Gaslighting them and saying you don't need birth control you can use all these natural methods When we don't have the same effectiveness data in some of those health promotion technology or health promotion interventions SUMMARY All right You probably wonder why we're deep diving into this. This is because of level two, right? We have a huge role, right? We are doing level two right now for our pelvic course, and we are trying to do fitness-forward pelvic PT in a variety of different conditions. Fertility, baseline fertility, infertility-related conditions, and our role coming alongside those who are going through assisted reproductive technologies is in our curriculum. So we are in the weeds of that research and talking about the ways that we can be involved in rehab. And then if you guys are interested in seeing us live, we have two courses going June 1st and June 2nd. I am in Highland, Michigan, and Alexis is up in Alaska with Heather. And then June 8th and 9th, I'm in Mineola, New York. I'm near New York City at Garden City CrossFit. So if you are hoping to jump into a pelvic live course, I hope that I can see you at the beginning of June. Otherwise, have a really wonderful week, everybody. Hopefully I won't be so nasally and sick the next time I'm on the podcast. One can only hope. And have a really wonderful week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 17, 2024

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the difference that one degree can make when performing adjusts to a cyclist's bike fit. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. MATT KOESTER Okay, we are live on Instagram and live on Facebook. Good morning, everybody. Welcome to another episode of the PT on Ice daily show. I am your host today, Dr. Matthew Keister. I am an elite faculty in the endurance athlete division with a specialty in bike fitting. So today I definitely am excited to step in and have a conversation about one of my favorite aspects of bike fitting. And that is the really nitty gritty small details that we love and we talk about every course and we get really into the weeds on. But I think sometimes to the outsider can be a little confusing. Before I step into that realm, though, I do want to take a second and highlight a few upcoming courses. This weekend, Jason London, my co-faculty, is going to be in Minnetonka, Minnesota. That course is pretty darn full. If there was any spots left to grab, it's probably the last second to do it, and they might not even be available. The next course we've got is in Bellingham, Washington. That is June 1st and 2nd. That course is sold out, and we're currently building out a wait list. We're also working on setting up a second course offering for that in the fall right now, but there's more details to come on that. And then we have another course set up. Next one coming in is July 27th and 28th in Parker, Colorado. That is going to be an awesome course. Just an easy place to get to in Denver. Always good to ride around there and get some time outside in the mountains. So super stoked for that one as well. That's it. That's it for the upcoming courses right now that I wanted to talk through. THE DIFFERENCE OF ONE DEGREE WITH BIKE FITTING Let's get into the title of today. I called it one degree away and I think When we think about like one degree, first of all, the margin of error for that with our measurements is often really, really hard to overcome. It can be incredibly hard to take a look at somebody and say, I'm going to make a one degree change on this and think that that's going to be clinically significant or meaningful to their pain or their experience. It gets a little bit different when we talk about bike fitting, though. When we talk about bike fitting, we're often using a little bit more precise measurements. We're using laser levels. We're using digital electronic levels, things that give us really specific data. And then when we think about the other part of bike fitting, when we make that adjustment to whatever componentry it is on the bike, and I'm going to talk through two specific cases in a moment, but whether it's the pedals or it's the seat, when we go to make adjustments there, that adjustment, while small at the instrument, one, two degrees, has upstream effects or downstream effects that are pretty pronounced when you extrapolate that one degree as it gets further and further away from the axis in which you made the change. So I think sometimes that's the missing piece when we try to have conversations about making a one degree change or a two degree change to something really small. So I mentioned we're gonna go through two different cases and I think the first one is the one that is oftentimes the trickiest when we're actually at the course. We spend a ton of time in the course talking about the art of trying to improve somebody's pedal stroke so that their legs are driving more up and down like pistons and less with dynamic changes or aberrant motions that are in the frontal plane. So knee valgus or going more into abduction. We try to kind of eliminate those things because any power that isn't going straight down the pedals is wasted. So one of the ways that we typically will make a change to get somebody into a better position or consistently riding in a better position is we'll add shims to their shoes. The shim is like, I mean, think about it the way like you would shim anything. It's a, it's a little wedge. It's thicker on one side than it is on the other. And it goes right underneath the shoe or sometimes inside the shoe. We can put that on the medial aspect of the foot. If we want to push that knee out a little bit into more abduction and stop a little, stop some of that abduction or potentially dynamic valgus. We can also, for the individual who rides with their knees pushed out a little bit, We may have to solve other things around the hip and the low back, but for that individual, we can also shim laterally and drive the knee in some to create some stability and drive them into the more neutral up and down position. Every single time that we break out one of these wedges though, they seem like, how could that thing make the change? It is one degree or it's one and a half degrees. And I think that's where things get lost a little bit. It's not the one degree made at the foot that makes the impact. It's what that one degree does when you extrapolate that 12, 18 inches up through somebody's shin bone. When you take it up through all that to the knee, we see some changes. And I grabbed this old-fashioned measuring tool. I had to pull it out of the dirt to get it here. But if we have our goniometer, we have it set up, and I make at the bottom, from a perfect 180, if I make a one degree change and I push that thing over. Down here, that is almost a non-measurable, hard to even see that change happen. But when we get up here towards the top, it's pretty crazy how that one degree change, just in this amount of space, moved us out probably four to five millimeters. Or for those who like freedom units, that's more in the quarter inch range. Many people's tibias are not this length. They'll think even further, take that out even more. All of a sudden now that person whose knee was riding like a half inch or a little bit more outside of what we'd want in a neutral position, as one degree change down here might have a dramatic shift at the knee. So it's really cool when you actually see it. And every time we put it, we put one underneath the client's shoe as fit as ourselves. I think we're constantly amazed. that we put that thing in and we're like, well, we'll see how this goes. And then it's amazing how much different it is and the patient can feel it too. They'll be like, yeah, that feels really good. My foot feels really supported. And you're like, okay, that one degree really did it, did it great. Another really key case for this, there's been research done by Andy Pruitt, who's kind of the godfather of bike fitting. He's done a ton of the leg work for the style of fitting that we do nowadays. When he was early on in his career and he started to really put a lot of content out for this and put a lot of effort and research behind it, he got partnered with Specialized. They're one of the largest bike brands in the country and they wanted him to help create what they considered their body geometry line. The body geometry line was essentially a best attempt to create the best contact points on the bike possible. So that's the cleats, or the feet, so the shoes, the seat, and the handlebars, or like the grips. So they put a ton of effort into their shoes. What they found after just time and time again testing folks, they found that everybody benefited from some level of a medial shim in the shoe. So they were like, over and over and over again, if everybody's benefiting from this and we're getting less adduction and a more piston-like vertical motion, why don't we just build this into the shoes? At this point, they actually do. Specialized, with all of their shoes, the Torch is one of their most, like their flagship and most consistently sold shoes, is baked in with a three degree medial shim to take up some of that flexibility in the foot so that the power we're putting down isn't lost in these aberrant motions, it's more direct into the pedal and it's nice and sturdy. So, that's one of the main changes that came out of the research from Andy Pruitt and Specialized. And I think it just kind of goes to that point of, we know how impactful a degree can be. The person who's dealing with knee pain that is definitely coming from these constant, shifty, aberrant motions, we start to clean that up. We start to get a cleaner picture of what's going on. That all starts with a one degree change. Now, I think the interesting one and the more pronounced version of this is actually at the seat, though. So we're not talking about now adding components or putting new things onto somebody's bike. We are talking about just making an adjustment to tip or tilt the seat. If we bring the nose down, which is a pretty common change for a lot of riders, it makes pretty pronounced changes in low back pain as well as some of the perineal pressures. So you can imagine that if this was the front of my seat and it's tipped up, there's going to create a lot of excess pressure in the perineum. This is a great conversation for any of our pelvic physical therapists to step into because the ramifications of sustained pressure in those areas is definitely in their ballpark and certainly outside of mine, especially if I make the changes and it doesn't quite get what I want. However, when we bring that seat down to try and fix those problems, we want it level or potentially slightly nose down. It's usually like one to two degrees. The reason we want that one to two degrees nose down is because what it allows the person to do is achieve a more relative anterior tilt. They're able to get out of this posteriorly locked lumbar flexion and roll a little bit forward and get into a little bit more favorable position to take stress off the low back when they're riding. This is a space where you go to make your adjustment and you put a electronic level on their seat with a nice level platform on top, and you might make a tiny little adjustment, one degree down. And in that moment, the client is sitting there going like, why did I come in here for this? That was the tiniest little adjustment I've ever seen. And then they hop back on and it's incredible how much better they feel. And the reason for that is the same thing that I already explained at the knee. When we're talking about a one degree change at the axis where you make the change, it has a lot of ramifications upstream. So I'm gonna use my Sangoniometer example. If I look at a one degree change, so let's just say I wanted to get somebody's shoulders more upright, get their back out of some flexion. I make a one degree change nose down. At this point, I've got my quarter inch, maybe a little bit more at this point. Think about somebody's torso being almost double this. and then consider the fact that we might have made a two degree change. I've already got a half inch here. By the time I get to the shoulders, I've probably got a full inch or more change. And that's just a rough estimate, assuming that the person's body was a super rigid straight line. Think about the fact that we have this chain link of vertebrae going up. If you can reduce stress up each one as it goes, you actually can get even more range of motion out of that. So it's pretty profound when you take somebody from a locked out lumbar spine position make a one degree change to something that's sitting right underneath their pelvis. It allows their pelvis to get into a one degree better position, but what it does up the chain is pretty incredible. You'll have somebody immediately go, Oh, that feels so much better. Like I don't feel that pressure underneath my butt anymore. That was really giving me numbness. Oh, I already don't feel that tension on my back. I don't, I feel like I can like get myself upright a little bit. I can get myself into a more neutral position and neutral coming in air quotes there. Cause it's a little bit different. Um, like we're not actually in lumbar spine neutral, but they get closer to it. And that can be the thing, getting out of that fully locked out position, getting into a slightly more neutral position is something that happens with a one degree change. So when we're talking to these folks and we're talking about the adjustments we want to make, it can almost sound really unexciting when we do our wrap up. We're saying, hey Sally, when you came in today, we made some adjustments to the bike. The first one we did is on your shoes, we actually added a shim to them. I put a one degree shim in there. And then when we went to the seat and we made our adjustments, we made a one degree change nose down and we actually slid it forward two millimeters. Those things don't sound really exciting when you say them out loud, but when you start to put together what those things are doing throughout the chain, throughout the whole body, bike fitting ends up becoming one of these things where we can make a very minute change now and have immediate, immediate reductions in pain, immediate improvements in performance, immediate changes in posture and positions and access to those positions. So getting into the nitty gritty, getting into the details, knowing that if you're going to make a one degree change or a two degree change, that it's going to have even bigger effects, talks even more to how important it is that we're accurate with those changes. If you are really, really interested in learning about making those changes, how to keep them accurate, how to make sure that we're not Throwing something else out of whack while we make one adjustment, I highly suggest you join us on the road. The BikeFit course is probably one of the most unorthodox courses in all of ice. It is the most niched down, it's just a bunch of people who love riding bikes and love tooling on bikes. And it's also folks who have absolutely no experience turning wrenches. People who come in who's first time using a torque wrench is in the course and we love that. It's a beautiful thing to have in the clinic and this is one of the main reasons why. It's those tiny adjustments that give us access to positions that we never would have had access to otherwise or would not have been able to fix even if we'd spent a ton of time in rehab when we could have just made the one degree change. Thanks y'all. Appreciate ya. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 16, 2024

Dr. Ellen Csepe // www.ptonice.com In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses which patients are prone to sleep apnea, how to identify signs & symptoms, and when to know to refer & who to refer to Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ELLEN CSEPE Good morning everybody and welcome to the PT on ICE daily show brought to you by the Institute of Clinical Excellence. My name is Dr. Ellen Csepe. I'm an outpatient physical therapist. I'm also a teaching assistant with the modern management of the older adults division. I'm coming to you live from Littleton, Colorado today, repping my Denver Nuggets playoff shirt. And today, my goal has been for several months now to make sure that physical therapists are here to support the growing patient population with obesity. I really want to make sure that physical therapists are involved in this conversation to meet their needs because this population is growing rapidly and the healthcare world needs all hands on deck to help support this patient population. Today, for today's Leadership Thursday, We're going to be talking about obesity and sleep apnea. So in a lot of our course conversations, we talk about the importance of sleep hygiene. We talk about how important sleep is to mitigate the risk of injury, to help with healing, to decrease pain. But I think it's a really missed opportunity if we don't talk about how obesity can cause sleep apnea and sleep disorders. And I think we should feel compelled as physical therapists to know those risk factors and also kind of be the first responders for our patient population to make sure we pass the baton to the right clinician to help them with a potentially life-threatening problem. So what you can expect today, we're going to talk about how sleep apnea and obesity are related, but not mutually exclusive. Then we'll talk a little bit more about what the symptoms of sleep apnea are in both adults and children. Next, we'll talk about our screening tools that we can use in the clinic to look for sleep apnea. And last, we'll talk about where to pass the baton to make sure that we refer patients to the right discipline to help manage this issue and what treatment might look like with them. THE RELATIONSHIP BETWEEN OBESITY & SLEEP APNEA So first, obesity and sleep apnea are very closely related. Sleep apnea incidence has increased significantly in the past several decades, largely because of the increase in obesity rates in our country. Sleep apnea is basically a loss of breathing or difficulty breathing at night, which can be life threatening. Obesity is a disease and how we look at it. And that disease is kind of twofold. First, we look at obesity as an adiposopathy disease, which basically means sick fat disease. What that implies is that excess adipose tissue basically sends excessive chemical messengers throughout our bodies, which puts us at risk for diseases like cancer, heart disease. diabetes, also hypertension, all of those are chemically mediated from excess adipose tissue in our bodies. Then we also look at obesity as a fat mass disease. And what I mean by that is that excess adipose tissue puts physical pressure on our joint structures, like our joints, increasing risk factors for arthritis, But the way that sleep apnea is a disease is because excess adipose tissue in our bodies puts pressure on our chest, our throats, and even excess adipose tissue in our tongue can make breathing very difficult at night. I'd like to bring up this point that obesity isn't the only risk factor for sleep apnea. And as we're learning more about sleep apnea, there are lots of different things that can cause sleep apnea, from centrally mediated sleep apnea with risks of medications, to actual physical changes in our jaw and our throat structure which makes breathing difficult at night. So people with obesity aren't the only ones that can have sleep apnea and the rates are increasing for several different reasons. I'd like to bring up that those with a lot of muscle mass in their thorax or breast implants can also have obstructive sleep apnea, increasing that difficulty because of the physical pressure to breathe. So here's some annoying things about sleep apnea. It makes managing obesity way harder because we know how important sleep is for our overall health. But having disordered sleeping patterns or difficulty sleeping or literally stopping breathing while you sleep makes your risk of cancer, heart attack, having all of those increased risk factors because of poor sleep makes this even more difficult to manage. Additionally, when we're in a decreased sleep kind of pattern. And when we're sleep-deprived, our food choices kind of gear towards higher nutrient or higher calorie density foods. So if we're not sleeping well because we're struggling with obesity, we automatically go to higher calorie food choices because our brains are in a sleep-deprived state. And that's what we think we need. So sleep apnea makes managing obesity and the risk factors for lots of the sequelae of that disease significantly more difficult to manage. And in fact, people die from sleep apnea. I know this is really kind of hard to understand, but 38,000 people in the United States die annually because of unmanaged sleep apnea. That's about as how many people die in car accidents in the United States. That's a big number. And I feel like it's part of our job to see that risk and to know what the signs and symptoms are. So we know that people with obesity are more likely to have sleep apnea, but it's not the only risk factor. We know that a lot of other patient populations can have sleep apnea as well. SIGNS & SYMPTOMS OF SLEEP APNEA Next, let's talk about some of the signs and symptoms that we'll see in those with sleep apnea. So as adults, we'll hear a lot of Okay, they're snoring really loudly, louder than they would talk. You can hear them on the other side of the door, so snoring. Patients with sleep apnea often express daytime sleepiness, fatigue, difficulty concentrating, depression, anxiety, because they're in a sleep-deprived state constantly. They cannot breathe. Additionally, they'll likely have hypertension, walking headaches. they'll likely be more likely to get sick in their daily routine. So those adults with sleep apnea are more likely to be tired, snore, have apneic events that are observed by other people. Like, dude, you stopped breathing for an entire minute when I was sleeping next to you the other day. So being mindful of what that looks like as an adult is really important, but sleep apnea and sleep disorders are affecting children more. As we kind of go into the weeds, we know that sleep apnea is related to our jaw shape and our upper airway shape, both of which are influenced by our food choices. And with foods becoming softer and softer throughout the past millennia, We don't have to develop why jaws and our airway and our tongue and our palate all change because of that. If you've read the book, Jaws or Breath by James Nestor, it kind of talks about, okay, our jaw size is very closely related to our risk of sleep apnea and breathing disorders. So in children, sleep apnea can look similar. You know, stopping breathing, snoring, mouth breathing at nighttime, more likely to have allergies and throat infections. Bedwetting is another really common side effect of having sleep disorders as a child. Additionally, ADHD and inattention are very closely related to sleep disorders. In an adult and neurological conditions, pediatric neurological conditions, we always like to know how well they're sleeping because we know how impactful sleep is for our overall health and our brain specifically. So, okay, we talked about what symptoms patients might come to if they have sleep apnea. SCREENING TOOLS FOR SLEEP APNEA Next, let's talk about some screening tools that we as clinicians can look out to see, okay, is this patient struggling with sleep apnea? How can we get them to the right place? The questionnaire that I often use in the clinic is the STOP BANG questionnaire. So, STOP BANG looks at sleepiness. So, we like to see, okay, are we having snoring at nighttime or apneic events? So, STOP looks at, the letters are kind of mixed up. But looking at daytime or nighttime snoring, we like to look at hypertension because adults with sleep apnea are likely to have hypertension. We look at daytime sleepiness. If they're having a lot of daytime sleepiness, that could be an indicator for sleep apnea. And then the BANG stands for BMI, so if they have a BMI over 35, that's problematic. The O stands, or I'm sorry, BANG, B-A, looks at age. If they're over 50, that puts them at a likelihood of having sleep apnea. N is for neck circumference. So if your neck is bigger than 17 inches, that's problematic and puts you at an increased likelihood of having sleep apnea. And then G stands for gender. Males are far more likely to have sleep apnea than females. So that's a really great screening tool. I'll put a link in the comments on Instagram so that you can use it in the clinic if it's helpful. A few other clinical features that we can look at in our patients is looking at the tongue. If their tongue is having a lot of scalloped edges or wavy edges, that could be a risk factor for sleep apnea. If they have venous pooling under their eyes, so a lot of purple dark bags under their eyes, could be indicating that they're not getting quality sleep. And then the MalinPati score, so if you have your patient open their mouth as wide as they can and stick out their tongue, you want to be able to see their uvula and their soft palate. You want to be able to see a lot of structures at the back of their throat. I'll link this score as well, but if you can't see their soft palate, their uvula, and can only see their hard palate because their tongue is in the way, that is a really strong predictor with excellent specificity that that person is likely to have obstructive sleep apnea. So those clinical tools are very helpful for us as physical therapists to be able to pick up on these problems. So next, let's kind of talk about who we would pass the baton to. If we were thinking, okay, yeah, this person is having episodes of sleep apnea, they're snoring really loudly, they're having a lot of daytime sleepiness, they're high blood pressure. We've got problems here. Their tongue is really impeding their airway flow. They even have that weird scalloping on their tongue. REFERRING PATIENTS WITH SLEEP APNEA What do I do next? So of course you could refer the patient to their primary care doctor. That's an easy pass there. Additionally, I have found dentists to be hugely helpful. I'd like to give a shout out to my favorite referral source, or place to refer, Dr. Pat Prendergast. He helped me kind of prepare this podcast this morning and wish me luck. But we talk a lot together about how to manage patient sleep apnea without using things like CPAP machines or oxygen at nighttime. And dentists are taking kind of the charge here and looking at airway disorders and breathing problems at night because this is such a huge problem in our communities and in our world. So dentists are another great referral source or another great place to refer patients to if you're concerned that they have sleep apnea. And then obviously pulmonologists, ENTs would be appropriate disciplines for patients to see if they had structural problems or pulmonary problems that could contribute to their sleep apnea diagnosis. So treatment can look different from person to person. So Depending on the findings, we might suggest that a patient lose weight to manage some of their obstructive sleep apnea. That is a really exciting new thing that we're finding, that managing weight can be hugely helpful in minimizing the risk of sleep apnea. New medications like the GLP-1 agonists, Ozempic, Wegovy, those have been helpful in managing sleep apnea, and bariatric surgery is helpful in managing sleep apnea too. So understanding that those weight loss efforts will likely impact somebody's sleep is huge to recognize. Additionally, we have options from jaw devices or oral appliances likely created by a knowledgeable dentist like Dr. Pat. Mandibular advancement devices kind of pull your jaw forward to open your airway more. You could have a retainer or different options that they would fabricate to kind of improve your tongue positioning. Additionally, there are other techniques like vivos, which is actually here in Highlands Ranch, Colorado, to basically spread out your palate and change the shape of your upper airway and your jaw to make it so that your airway is more open and allow breathing. Additional interventions, there are CPAP machines and other machines like it which basically force air into your airway, into your nose and your mouth. Some attach only at your nose, some attach throughout your nose and mouth. Those, as physical therapists, we like to know if those are changing or new because they can put excess pressure on the suboccipitals. change pressure there. But we really want to encourage our patients to use those because they can be life-saving and if that's what their primary care doctor recommended, we don't want to ignore that recommendation. Additionally, there are surgeries that can be performed to get more airway through that upper airway and even newer technologies, newer interventions like the Inspire which basically has a battery pack, monitors your pulse oximeter, looking at your oxygenation in your blood, and has an electrical stimulation to your tongue that if you were having an apneic event it would stick your tongue out and get it out of the way so that you could breathe. I've had several patients have the Inspire procedure and been really happy with that intervention. SUMMARY So we talked about a lot today. We recognize that patients with obesity are far more likely to have sleep apnea, but not everybody with obesity will have sleep apnea, and not everybody with sleep apnea will have obesity, and it's a growing problem in our culture, in our world, and with our patient population, and we need to care. So we recognize that obesity and sleep apnea are related, but not mutually exclusive. We talked about some of the symptoms of sleep apnea in both adults and children. We talked about the screening tool, the stopping screening tool, and looking at that Malin-Potti score. looking at the tongue and other clinical features like bags under the eyes, that venous pooling, those are the things that we want to look at in our patient populations. And then we talked about who's the right person to take it from here, knowing that dentists are underrated and how they could be helpful in managing this if they're aware of sleep dysfunction and how to treat it. So we recognize that there are a lot of different interventions and those will likely impact our patients in some way, whether or not that's going to impact their jaw positioning and potentially need treatment for their jaw or their upper neck, their suboccipitals. So thank you guys so much for joining me this morning. I hope that this information is helpful in managing this growing crisis that we see in our patient population. Have a great rest of your morning and go Nuggets. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 15, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how environmental factors influence all aspects of the aging experience, including movement, nutrition, and social interaction. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently, I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. CHRISTINA PREVETT Hello everyone and welcome to the PT on Ice daily show. My name is Christina Previtt. I am one of our lead faculty for our geriatric division. I am also one of our leads in our pelvic division, but today we are going to talk about all things older adults. So I have been away for the last two weeks because my family and I took, my husband and I took a vacation to Italy. And it was the first time I've ever been in Europe. It was an incredible, incredible trip for a lot of different ways. But of course it got my Jerry brain working and reflecting on differences in culture and the way that we interact with older adults and how I saw older adults who were moving around their environment in Italy. And so, I just kind of wanted to go on today and talk a little bit about some of those differences. If you have followed the MMOA podcast, you know that Ellen and I and some of our MMOA team did a grouping of episodes around the blue zones. So the blue zones are areas around the world that have a above average number of individuals who live to 100. And it's been a big area of research and trying to figure out like the secret sauce of being able to live to a hundred. And one of them was actually in Italy. So it was in Sardinia and that was, that's not where I was. Um, I was in Rome and Maori, but a lot of the concepts and themes that they were talking about in the, that mini series and in the book on the blue zones, it made a lot of sense and it just made me highlight or see a lot of the differences in our North American culture than what we're seeing over in Europe. And Going into Rome was the craziest experience. It's so busy. It is almost impossible to drive. And then going into Maiori, which was in the southern part of Italy, we were in a very small town, not one of the bigger touristy towns along the Amalfi Coast. And it was being in Maori that I really saw some of, or I was more able to really look at how individuals are aging in different areas, in different countries, and made me think a lot about our aging experience in North America. So the biggest thing that I saw in our culture, and these are things that we cannot control, and I'm going to kind of bring this back to our course content, is It is very difficult. The environment at which a lot of the cities in Europe being so old are developed. are very walkable. They're very walkable and it almost is not disincentivized, but it's almost a net negative to have a vehicle. In Rome, for sure, it would be terrifying to drive around Rome. But even in Maiori, like a lot of the areas were very condensed in terms of the groceries and where you would grab most of your main amenities for the week. And it allowed for individuals to walk a lot of their tasks. And not only was that environment one where walking was really the main source of transportation, the environment at which you were walking was not a straight plane. This was a big area, like it was obviously had a coastal, like mountainous coastal plain. And so there was a lot of steps. And so one day my husband and I, we went on a lemon hike or a pathway of the lemons, which I became obsessed with, but it was literally a straight shot up. It was, I think we did like 17 flights of stairs to get to the pathway. for this hike and there were houses that were littered across the side and so I saw a person they were in probably their early 70s and they had groceries in each of their hands and they were gradually working their way up these steps. And a lot of the times, we know some of our recommendations for our older adults is to walk more. When you're walking around this town, you are going up and down hills. And there is an intensity to that. My heart rate was not low. And when you're adding in groceries in your hands and there isn't a handrail, it forces you almost to maintain a certain amount of physical activity in order to maintain your independence. And so the first thing that I was really, it really struck me about being in an Italian city was how the environment really was conducive to movement. And it wasn't low intensity movement. It was actually quite high intensity movement just because of the way that the city was built. And it made me reflect a lot on our thoughts of just walk more, right? Like there's a lot of debate about is walking intense enough for us to be able to incur either some physical activity benefit or to be able to maintain physical activity as we get older. And when I compare and contrast the way that cities are designed in North America that has so much more space and does not have the same historical architecture that's trying to be maintained, we don't have walkable cities in a lot of ways, right? If I think about the current city that I live in, it is very, very spread out. And it is almost impossible outside of the downtown center for you to be able to walk and have yourself walk to get groceries or pick things up. It is always the knee-jerk reaction that you get into your car and go places. And when you are walking, at least where I am, I'm not in like a beautiful area like Colorado that's all hills and mountains. It's pretty straight plain. And so When that happens, a lot of the blue zones are in areas where physical activity is forced into your day-to-day interactions. If you want to go see your friend, you have to walk up the hill to their house. If you want to get groceries, then you need to go down four flights of steps to get to the market. That is not the same. And so when we think about our industrialized cities, And the way that technology and car transportation has really changed the way that we build out different cities, what we recognize is that when our environment does not create opportunities for physical activity, that is when purposeful movement needs to be scheduled in a person's day. And I think this is a really interesting concept, right? Because the blue zones were in a lot of these areas where the environment was conducive to intense exercise, at least in a moderate intensity zone because of the way that the cities were developed. That is not true in a lot of the areas where we are practicing. And so this This dichotomy between just walk more can work, but the intensity oftentimes isn't there because of the way the environment is set up. And when that environment isn't set up to encourage physical activity throughout our day, we can very easily get into the slippery slope of sedentary behavior. And when that occurs, we have to make purposeful movement a priority in our day. And this is not just for our older adults, this is for everybody. But this is where gyms come in, right? This is where purposeful exercise programs now are coming front of mind and are becoming a really important aspect of our culture. Because so many of us now, or the people that we are working with, our older adults that we are working with, are not in gyms. those environments anymore, like that is not the way that our environments are set up. And so we have to be mindful of that when we're thinking about our interventions. So the difference in the environment and how easy it was to walk with intensity when we were in Italy was so, so different than what we see in our very typical North American cities, where you have to get into your car. That was probably one of the biggest things, is just looking around the environment and seeing just the stark differences. One of the things that I also really enjoyed watching, especially when I was in a small town in Italy, was the way that slow-paced, naturally occurring, intergenerational conversation happened. When I was walking down a street with my husband, I would look around and people would walk and they would see people in the city square and there were moms with their little kids and they were talking to older members of the community. And again, the environment made it so that this intergenerational conversation happened as a natural consequence of a person's day. And instead of rushing by each other, and maybe giving a head nod of acknowledgement if we weren't head down in our phone, people stopped and interacted. Now, I'm not saying that everybody in Europe is in this area, but definitely the area that I was in, which is very closely structured to the way that Sardinia is, I saw these interactions happen every day where you are walking down the street and they had a place to go, but they weren't so rushed that the thought of a five minute conversation was something that they could not handle, or they weren't ready for, or they weren't rushing from one place to the other. And then these social interactions occurred where you could just see this transfer of knowledge that was happening from older generations to younger generations. And there was just this sight of respect and reverence of these communications that was just so lovely to see. Again, I'm not saying the North American culture does not have that front of mind, but we live in a place where I don't know many people who stay in the very close proximity bubble of their family, right? Like I talk to clinicians every single weekend where I say, where are you from? And they say, oh, well, I'm living in North Carolina now, but my family, of, yeah, my family is in Michigan, or it's not abnormal for people to be very far away from their family or their loved ones. And the culture is so busy that even calling loved ones weekly can be something that has to take a lot of conscious effort because it's so easy to get into the rhythm and fast pace of the week that, and this is speaking to myself as well, that those stop and pause conversations with someone on the street. They're not as commonplace and especially across generations where you're seeing a mom with their little baby stop in a group of older Italian men who are playing a board game outside in the community square and you're seeing that interaction happen in such a beautiful way. And so seeing some of that intergenerational communication because of the way that the environment was set up was just so lovely to see and made me think a lot about how we have this loneliness epidemic in North America. And it is really from the fact that we are so spread out, we are so far apart, that it makes it really difficult for those interactions to happen very naturally. And it creates this spot where, you know, my grandmother had 10 children. My mom was one of 10. We don't see that size of family as often anymore. And there would be times where my mom would visit for 45 minutes, but that was the only interaction that my grandmother had throughout the day. And her kids would call, and this is not like a negative on them. It is very much the fact that, you know, the way that our culture is set up now is that those interactions don't happen very genuinely or very easily. And they take a lot of effort and there's a lot of things on our time. And so that, again, that environmental piece is like this big umbrella where the environment was set up that allowed for physical activity, but it also allowed for social interaction. And so subsequently with those two things, it being very easy, those barriers were almost stripped away for movement and for interaction. What I noticed was that the pace and stress of life was very different. So we went from Maori, we went back on a plane or on a train rather to the Rome terminal, which is a crazy busy terminal. And on the last day of our trip, we ended up going back around rush hour. So we took a six o'clock train from Salerno and we went to Rome. So we ended in Rome around 7.30, which is peak prime time. And if anyone has been in a train station or taken public transportation, I used to go into Toronto and Union Station is a very big hub. Toronto is a very big center for commuting. So the GO train is very busy. And if you are in Union Station around rush hour, It is true chaos. People are trying to get on the train, but they're still on the clock, so they're on their phones. There is a rush to get a seat. It is stressful. You find out 10 minutes before, which is similar to the Rome Terminal, about where you are going, and it is a rush. It is so busy, and there is this stressful environment that is in the air, and people get so used to it because they do this every single day. Their commutes are really long. I was kind of expecting to see that in Rome, right? Like Rome is a very big central hub for Italy. It essentially mimics what we see in Toronto or other big city centers. But even though people were dressed and heading to work, that stressful environment wasn't there. People were walking casually to their job. They were not racing. They were not running. And it made me think about the underlying stress that our culture and our community is under. and how this translates into our aging experience. Like what is our nervous system primed for when we are in a very high stress state all of the time? And then we retire after being in that high stress state for 40 years and go into retirement, right? There is a well-known statistic that there is an increased incidence of health events in the year following retirement. And there's a lot of conversations around, you know, purpose and drive and changes in status. But maybe part of that is that you're changing your sympathetic drive so drastically that your body is having a hard time adjusting and it can show underlying issues. The stress piece on our culture in North America, even in the busiest centers of Rome, like the chaos of the Colosseum or around the Basilica, it was not there. Like that feeling of underlying stress and tension for having a group of people who are all very hastened and rushed to get into a lot of different places, despite Rome being crazy busy with tourists, like they were telling us about the millions of people that come into Rome every year for tourist related activities. And it was wild to me to see how much of a difference, even with that amount of tourist attraction, even with that bustle and busyness, that that underlying stress was not there from even people who are local to Rome, who are working in Rome. And so I think about how that presence of stress for us in middle age, what does that do on the system or on the resiliency of the system with age? And so Again, the change in the environment really was opening up my eyes to a lot of the things that we see in our fast-paced cultures and made me reflect a lot on how that changes a person's aging experience. And when you are forced to do movement and you retain a certain amount of physical capacity, and that allows you to engage in life, that allows you to live at a pace that is amenable for your mental health, and you're surrounded by, honestly, so much beauty, it just makes me think about how Italy can so easily create successful agers. And I'm not saying that North America can't and that the US and Canada can't, but it definitely takes more effort, I think, in North America. I think we need to think a lot more about the way that we are aging and the way that we are interacting with our environment, with our people, and make a conscious effort to engage in physical activity, engage in purposeful interactions, engage in a pace of life that works for us and our family. And that is just so ingrained and it is so easy to do in Italy because of some of the cultural considerations that are there when we are working or we are seeing individuals interact. Now, of course, I am the outsider looking in, I am an aging researcher who just finds this super fascinating, but I want to know what your guys' thoughts are. If you've visited Europe, especially if you've been in a small town in a European country Do you see those differences? How can we think about the way that the environment in a lot of European countries and cultures is set up to make successful aging a little bit easier? How can we create that with our people? How can we create that type of environment that makes successful aging easier, that makes successful aging for us easier? Because that environmental switch it just takes away a lot of the work of it. Like there was no processed food in the markets. If you wanted to get processed food, you would really have to look hard for it. And that was in Rome too, right? There wasn't a ton of candy, like there was pastries and things like that, but you were making it when you were in Maiori. And it just, it made some of those health promoting decisions easier to make and more intuitive. So it made me think a lot about that. I have had an incredible time, but seeing some of the older adults in Italy was definitely one of the highlights for me and seeing just the way that they interacted. All right, if you are aiming to get into one of our MMOA live courses, we have two courses going up this weekend. So I'm going to be in Bismarck, North Dakota with Trissa. We are also in Richmond, Virginia this weekend. June 8th and 9th, we have a smaller course in Spring, Texas. So if you're looking for a lot of one-on-one time and attention from the instructor, that is Jeff Musgraves going to be out there in Spring. So really encourage you to jump into our live course. Today is the last day to sign up for MMOA level one. So if you are hoping to get into our online course, that is your last opportunity is going to be today. We get started this week on the circle platform on our ice physio app. I'm super excited for that and all of the newness of the app. If you have any questions or comments, I want to hear about your European aging experiences. Let me know. Otherwise, have a really wonderful week, everyone. And I'm going to get off here before Alan kicks me off. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 15, 2024

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division division leader Mark Gallant Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. MARK GALLANT We're live on YouTube, we're live on Instagram. This is the PT on ICE Daily Show. I am Dr. Mark Gallant coming at you here on Clinical Tuesday. What I wanna talk about today is the paradox of being a fitness-forward clinician. So when the Institute of Clinical Excellence first started back in 2012, so 12 years ago now, the physical therapy landscape was quite different at that time. As a profession, in orthopedics or outpatient orthopedics, what we really tended to focus on was very local tissue intervention. So we would have specific tests to indicate a local tissue or a region, and then we would apply either an exercise or a manual therapy stimulus to that very specific local tissue. And that was pretty prevalent in general throughout the profession. The other thing that was true in the physical therapy profession at that time was most of our referrals, or most of how we got patients, was through physician referrals. So either through a hospital system, an orthopedic surgeon. We were not getting nearly as many direct access folks. There were performance physical therapists, but there were far fewer folks doing that. And so because all of our folks were, most all of our folks were coming from the medical community, what we tended to see was people who were not as fit overall. So people who had a lot of medical comorbidities, they were metabolically unwell, just not as robust of a population. And that makes for a very interesting combination where you have people who are generally not very fit overall and you're going after very specific local tissues. Those things don't tend to work well together because If the overall human, the overall organism is unhealthy, it becomes very challenging to treat local and specific things. If cortisol's high, if inflammatory chemicals are high, if the nervous system is having to allocate resources to keeping basic organ function alive, to keep this person going, it is not going to be allocating resources to fix specific tissues. And on top of that, what we see, What we now know from pain science and general fitness is a lot of the reason these local tissues were getting sensations of pain or not feeling well was because the overall organism wasn't doing well. So when the company started in 2012, Jeff Moore, our CEO, who a lot of you have heard on this podcast, he started to notice this and some of the other early faculty and we've got to get better as a profession. in helping the overall human, getting general exercise better, nutrition, sleep hygiene, stress management, all these things to make the overall human a bit more fit and robust so that we can then potentially go after more of these local tissues. And then in 2016 when the fitness athlete division came on board, when modern management of the older adult came on board, Then we really started getting a lot better at making these folks fitter, getting their metabolic health in check. And what we learned from those two divisions is The CrossFit model of intensity is really the shortcut to metabolic wellness. So the more intense that person can exercise at, we're gonna see more of a direct correlation to their general overall fitness. And what we learned from the CrossFit model and fitness athlete and modern management of the older adult is the definition of intensity is work divided by time. the more work you can do in a given time domain, we're gonna see a lot of correlation to general fitness overall. And that could look like a wide variety of things. So if someone's really into CrossFit and they improve their FRAN time, so 21, 15, nine of pull-ups and thrusters, we're gonna see oftentimes a direct correlation to their blood markers, their overall metabolic fitness. on the same side of someone's more deconditioned, if you get them on the new step and you say, I want you to do as many steps as you can in five minutes, and then we see a 20% improvement in that over the course of a month or two, we're also gonna see a correlation to metabolic wellness. And that's really what this company was about, is showing folks and getting the profession on board where we've got to get these folks more metabolically well and get that intensity up. Now as someone gets metabolically well, if we go the next spot on the pyramid above intensity, you're going to find work. So just if we take the time domain out of it, how much load can that person move? How many reps can they do? What distance can they go without time as a domain? So we're taking that intensity out of it. That could become the constraint. someone who gets really into CrossFit and they're like, hey, I'm getting a lot fitter, I'm metabolically more well, I'm unable to do FRAN because I don't have the pull-up capacity. Okay, well let's take the time domain out of it and let's build your pull-up strength, let's build your pull-up endurance. Now what that person might find at the tip of that pyramid is, ooh, the reason I'm not able to do these pull-ups is because I have some legitimate constraints at my shoulder. The range of motion in my shoulder is not good. The rotational capacity of that shoulder is not good. And now we can work on some more of those local tissue things. Always keeping in mind that the base of that pyramid is that intensity and that metabolic wellness. And everything is a means to an ends to get back to that general overall fitness. And so that's what ice has been about for a long time now. Intensity, metabolic wellness at the bottom of that pyramid, get these folks feeling better, and then if they need to focus on some local work capacity, they need to get their deadlift better, their press better, their pull-up better, we'll work on that. And then if there is a local tissue constraint, then we'll take care of that. And what we often found is once these people get metabolically a little bit better, all of a sudden their joints are moving better, they're feeling better, and you don't have to look as far up the pyramid, that intensity and that metabolic wellness resolves a lot of things. THE PARADOX OF THE FITNESS-FORWARD CLINICIAN Now the paradox of the fitness forward clinician is now that you folks, all of you who are listening are out in your communities and you're known as the fitness forward clinician in your community, what you're starting to see is way fitter people are coming into your clinic because they know you know how to coach. They know that you know how to program fitness. They know that you believe in fitness yourself and so they identify themselves with you. They're like, oh man, April is like me. She is really fit. She likes to do this stuff. I'm going to go see her because she's not going to tell me to stop doing CrossFit or to stop rock climbing or that it's ridiculous that I want to start running again at 76 years old. She's going to help me build up and make a plan from there. So when you start seeing these fitter folks, the interesting thing is they don't need you to train that intensity. They already know how to do a lot of work over a given time domain. They are already very metabolically fit. When Kelly Benfie, who's in our fitness athlete division, comes to see me in clinic, Kelly is one of the fittest humans on the planet, like literally one of the top 200 to 300 fittest humans on planet Earth. Kelly does not need me to coach her how to get faster at her FRAN or how to do any given of the classic CrossFit workouts faster. What Kelly likely needs to see me for is that because of the high volume of gymnastics and Olympic lifting she's doing, her shoulder gets a bit irritable. She needs me to do some dry needling, some myofascial decompression to calm that shoulder down and build up some of the rotational capacity and capacity of the lats for her to tolerate those overhead positions. She now needs me to do the 2012 thing. She needs me to focus deeply on those local tissues because the overall organism is so fit and doing well. And now we can deeply turn our attention to making those specific joints, those specific regions as optimal as possible, which will then allow Kelly to keep doing her fitness at a very high intensity level. So either one of these folks can come into your clinic and anywhere on the spectrum between the two of them, What it's up to us is to be really good at both things. PHYSICAL THERAPISTS MUST BE GOOD AT LOCAL AND GLOBAL INTERVENTIONS We need to do the modern fitness forward physical therapy thing where we can coach gymnastics movements, we can coach the deadlift, we can program fitness to build intensity, we can track fitness to help people build intensity and metabolic wellness over a given period of time. What we also need to be really good at is the old school physical therapy thing, so that when really fit people do come into your clinic, you know how to treat the local shoulder. You know where you want to put your needles and what settings you want on your E-stem. You know where you want to put your myofascial decompression. You know how to specifically load that shoulder at various positions, at various amplitudes of motion, under different loads and at different speeds. It is up to us to treat all of these people and to recognize which one of them is coming into your clinic and give them the best optimal program for that N equals one patient overall. Hope this helped overall. Again, paradox of being the fitness forward clinician, that bottom of the pyramid, intensity with work next and then local tissue. Now, because you're the fitness forward clinician in your area, oftentimes that pyramid will be flipped where your focus is gonna be on working on the local tissues for that folks, so that they can keep their intensity. Comment in the comments, we'd love to chat more about this. If you wanna catch extremity management on the road, Lindsey is gonna be out in Bellingham, Washington this weekend, so definitely go hang out at Onward Bellingham and catch her out there. I'll be in Dallas, Texas, or Hazlet, Texas, right outside of Dallas, June 1st and 2nd. I would love to see you all out there. Hope you have a great Tuesday. See you on the road soon. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 13, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares a case of an OBGYN client with lumbar radiculopathy and the unique approach to core training that increased the client's tolerance to sustained positions with less pain in the OR. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. APRIL DOMINICK Good morning, PT on Ice Daily Show. My name is Dr. April Dominick and I am here with the Ice Pelvic Division to talk to you about a current client case I have on cutting to the core, a case of the low back pain in the OR. So today I'll talk to you about a doctor with lumbar radiculopathy. radiculopathy that I've been treating, and the unique approach we took to core training that increased her tolerance to sustained positions in the OR and reduced her pain. a bit about my client. She is a cheerful female obstetrician in her early 30s who lives a very healthy, active lifestyle. She is strong. She loves to ski, hike, lift. She also lifts really heavy, which we love. And she came to me with a myriad of complaints of TMJ pain, headaches, cervical thoracic pain, and reports about 80 to 90% improvement with those issues. And then for the purposes of this podcast, we will just focus on her hip and low back pain. So she described it as aching, stabbing, and she, that was for the low back pain, as well as her right-sided hip pain. It was a six out of 10 at worst and three out of 10 at best. that intermittently worsens. And her pain originally started after she had to sit for a prolonged period of time in order to study for her boards for residency, something that we all are very familiar with. And she sought PT care with me about six months after when the pain had been steadily worsening. And then the final straw was she had 10 consecutive days of pain in her hip and back after a really long shift in the OR. So things that made it worse, exacerbating factors, prolonged sitting, prolonged standing, so any sort of prolonged positioning, sometimes heavy lifting days at the gym, especially leg day, and work days. And then easing factors, stretching, changing positions, supportive shoe wear at work, or sometimes exercise would help it, So after her subjective and objective exams, signs and symptoms pointed towards lumbar radiculopathy, coupled with some right hip labral pathology, and she had moderate irritability. So I took her through the typical lumbar radiculopathy and intraarticular hip treatment, including manual therapy like manipulation, dry needling plus stem, I dialed in some back and hip strengthening and mobility. And then she also responded really well to a little EMOM that I gave her for when she had acute severe flare-ups in between our sessions, which included some cardiovascular bike intervelling to address her chronic inflammatory state, nerve glides, and isometrics. So after a few sessions, she made really awesome improvement in, she had improved in neurodynamics testing. Her weekly frequency went from having pain daily to every couple of days, which was great. And then her intensity and duration of those pain cycles also reduced. Love it. And then her progress stalled, and she continued to have some low-level symptoms that would flare. And the culprits seemed to be work. Particularly, we narrowed it down to her labor and delivery shifts, where she had to hold sustained positions, as opposed to when she was working in the clinic and she was getting up and down from her stool or moving between patients' rooms. THE HIP & PELVIS SHARE MUSCLES So it wasn't until we unpacked two key pearls that we began to make another difference. So during initial eval, she had, when I asked her, she had denied any bladder, bowel, or sexual dysfunction. And given that I was able to reproduce her pains, why she came in, with specific exam of the lumbar spine and her right hip capsule and surrounding musculature, Pelvic floor dysfunction wasn't high on my hypothesis list, but given our roadblock in progress, I decided to go ahead and screen the pelvic floor externally. And when I palpated her obturator internus externally, and then we did some further testing internally, it reproduced her lingering secondary hip pain on the right lower extremity. So she had like a major hip pain. And then we found out she had, um, another hip pain that she hadn't really noticed as much, um, because of the other pains had kind of been so overpowering. So, um, she also had some difficulty, um, from the pelvic floor side of things and in relaxing, she had some hypertonicity throughout and then, um, some coordination issues. So we treated the pelvic floor, did manual therapy, dry needling to the obturator internus, along with some circuits with her low back and hip. And that seems to have really helped her quite a bit as well. So that was the first thing that helped us in this stalled progress was lesson number one, don't forget that there are bits and pieces of the hips that share a wall with the pelvic floor. and that the OI lives in that pelvic bowl and it's a direct connector over to the hip via the greater trochanter that it inserts on and it influences hip stability, hip rotation, and that was one of our key pieces in helping her get some more improvement. ADDRESSING JOB-SPECIFIC DEMANDS The Second piece that really helped move the needle and address those lingering back and hip symptoms was getting more specific about her job demands and environment. So specifically when she is working in the OR, our operating room, if we can't change her job duties, like she has to deliver babies, that is her job, what can we affect? Can we set her environment up for success, specifically as it relates to VOR. So in the clinic, we set up her operating room using what we could, and we went through things like, what is the table width and the height? We positioned her tools. I asked her where her coworkers stand in relation to her. We talked about the amount and direction that she's leaning over the OR table. She ended up describing a really common position that she ends up in, which is a right side bend and rotation. And that is, if you remember, her hip pain is on the right side. So that was really helpful. And then we also looked at the percent of or we kind of labeled it in an RPE way of the isometric pull during retraction of the abdominal tissue for her C-sections. So I basically had her try out different percentages of pulling and and she kind of landed on, okay, this is about how much I have to pull when I am either using my own strength to do that retraction, or if I'm using tools to do that retraction. So we then, after I got her table set up in my brain, I also asked about detailed information of the surgeries itself. So of the C-sections in particular, about how, With the C-section itself, how is time split up? You have to do a lot of retraction. That seems like the thing that she's doing in a sustained position. When does that happen? And come to find out for her, it happens in two-thirds of the time that she's in the C-section. So there's like a first retraction and then there's some other things and then there's a second retraction. So that was helpful to know that there were some breaks, so to speak. And, um, then we, uh, we talked about her, uh, average time it takes to have her symptoms come on during the C-section. And, um, she has to do multiple C-sections a day, uh, intermixed with some vaginal deliveries. So we, we talked about, is it within the C-section if it's a particularly long one for some reason, about when does your symptoms come on or after about how many. So all of that was really helpful information. And then we, we did some treatment. So we brainstormed strategies that she could use in the OR. Can she Use the retractor tool instead of her actual hands or her own strength to help reduce some of that burden on her body. And then can she use tools like a step stool to increase her height or get closer to the table, redistribute her weight, use the step stool to put one leg up on top, or even the bottom of the table sometimes has that. And then an anti-fatigue mat or supportive shoe wear. And then I asked her if she would be able to sneak in some lumbar extensions or side bending just in the OR when she's not actively assisting with the retractions just to give her body a break from that sustained position. And then increasing reliance on the other staff on her residence to give her a break prior to her reaching that symptom threshold of more than five or six out of 10. So that was super helpful for what she could do in the OR. And then we talked about what she could do before her surgeries. And this is where the core piece comes in. So she sometimes is able to return back to her office or back to the floor between her C-sections and vaginal deliveries for her shift. which led us to creating a quick core rehab EMOM, every minute on the minute, that focuses on multi-planar core strengthening and endurance for those long duration positions. It's that duration piece that seemed to really exacerbate her symptoms. So the core remom we came up with includes neutral and extended trunk work, side bending and rotation of the trunk. And we threw in some isometrics as well as mobilizations just to help with both the pain from an analgesic effect with the isometrics and then some mobilization given that she is just in that sustained position for so long. So for the core remom, I gave her basically three to four categories that she could choose one exercise for to do for a minute. And she could do anywhere from a three to four minute remom all the way up to 12 to 16 minutes, depending on what time she had. So for the core remom, in the neutral slash extension category, she could do a reverse plank for a 45 second hold. And then we talked about having a tote bag filled with a bunch of the medical textbooks that are just collecting dust in her office, two tote bags actually, and that was going to be her load for some of these exercises. So she could put the tote bag on top of her for that reverse plank to add load. We also did a side plank plus a top leg raise hold. She could use her loop band that she brought if she wanted. And a loaded windmill. So that was the, sorry, the loaded windmill is actually in the side bending category. So for the neutral extension, she had the reverse plank for about 45 seconds. as well as prone press-ups. And we found out that the prone press-ups tended to make her feel better from the discogenic symptoms she would have after the surgery itself. From a side bending category, so next category side bending, we had her do standing heavy farmer's carry with a band on her feet. So she'd have to work her hip flexors during that time and anterior core. and obliques. And then she had the side plank with the leg raise and then the loaded windmill. And then from the rotation category, we had her pick, or actually we just had her do a banded doorway. She could either do diagonal chopping, so that P and F pattern, or lifting. And that was really helpful because it really mimicked the retraction kind of pull that she had to do. And so I had her do it in different positions, tall kneeling, all upright, tall kneeling, half lunging, and then standing. And I had her match the percentage of pull or the RPE that we talked about, I had her either match it or go a little bit higher that she has to use her own body weight or the retractor tools in surgery. So we could kind of get her used to practicing that pull with good breathing mechanics and then also good awareness of her core. And then a bonus, was some hip and back mobility, like banded long axis distraction, quadruped rocks, or thread the needle. So that's a bonus if she wanted as well. So all that, she only needed a long band, a loop band, and then her tote bags filled with the medicine textbooks. And with that, She's been able to incorporate that into, um, before some of her C-sections or at least before the first couple, as well as, um, in between. And she has had some really awesome results in terms of reducing her low back pain, hip pain, and being able to tolerate standing in the OR and working on these individuals as much as she could. Um, so love that. And it was really cool to be able to, brainstorm and put ourselves in her actual environmental situation as best as best that we could to figure out what it was that she was doing with her body and how we could use her core to better support her so that her hips and low back didn't have to do all the work as well. SUMMARY So Our pearls from today don't underestimate the power of a 30 second external pelvic floor objective screen, even in the absence of bowel, bladder, sexual dysfunction, when there's hip involvement on the table. Even me as a pelvic floor PT, I missed that in this particular case, she did have a lot of other things going on, but it was interesting to find just a little bit of that secondary hip pain that we hadn't uncovered initially. And then taking that deeper dive into understanding the nuts and bolts of someone's job duties and environment to paint a clearer picture. And then with this case in particular, OI-focused obturator internist-focused treatment, as well as brainstorming strategies to alter the environment during the case itself, as well as priming the anterior core and hip with that focused multi-planar remom, helped her diminish some of her lingering hip and back symptoms. And we were able to raise the threshold that she could tolerate in terms of the number of C-sections that she could complete. So, success all around. If y'all want to dive deeper into the latest research on the core as it relates to pelvic health and some examples of actually some of these remoms that you can practice with early core management or advanced core management, then join us live. You can grab a seat on PTOnIce.com. Our next courses are in Kearney, Missouri this coming weekend, May 18th and 19th, and a double header June 1st and 2nd will be in Anchorage, Alaska and Highland, Michigan. Everyone have a wonderful week and I hope that helped you out with some of your cases. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 10, 2024

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses how to earn more as a PT working with fitness athletes, including learning to understand how much you're currently generating & earning, as well as ways to increase your take-home pay. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, the May 10th episode, Fitness Athlete Friday, always the best day of the week here on the podcast. Excited to chat to you all today about a couple of different strategies for us to earn more money as physical therapists. We all know how much money that the average student is coming out with in terms of Debt when they graduate and that's we're constantly as a profession complaining about these declining reimbursement rates while it's becoming more Expensive to become a physical therapist But I think we're missing the boat on a lot of different things that could actually help us generate more money Whether we are a business owner or an employee. So I want to hit a couple strategies for that For you all today Before we jump into that topic, I do have to mention one thing that we have coming up inside the Fitness Athlete Division. That is June 22nd and 23rd in Fenton, Michigan. We are hosting our first Fitness Athlete Summit. So we're going to have the entire team there. All of our instructors are going to be together for one course. That one is going to be an absolute blast. Check that one out at PTOnIce.com. Alright, so we're going to talk about a couple things specific to the fitness athlete in terms of earning more income. But before we get to those specific things, I want to talk a little bit more big picture on some things that I think are incredibly valuable for us to research and know and think about if our goal is to earn a little bit more income here. UNDERSTANDING WHAT YOU'RE GENERATING And so the first, whether you're an owner or an employee, and this is going to be more particular to employees, most owners hopefully already know this, is we need to be educated on how much money that we are generating for our clinic. Or if you're an owner, you need to know how much money is each one of your employees generating for you. But I really so frequently don't see employees understanding this. And so one thing that I did throughout my career when I was working for different people, now I own my own businesses. But even when I was an employee, I was always diving in these numbers because I wanted to understand what I was doing for the company that I worked for. So, you know, depending on what software your clinic uses for billing and things like that, that might just be a couple of clicks to be able to see how much money you've generated over this entire year. Or you might have to do a little bit of math yourself. I've been in situations where that number was readily available. I've been in situations where that number was really hard to find. But in general, if it's hard to find, then you just have to figure out what your average reimbursement if you're in network is per visit and multiply that by how many visits you see per year. And you're going to get a decent idea of how much overall money that you're generating for the clinic. And then what you wanna do is you wanna take that number and compare it to your income. How much of that money that you're bringing in are you taking home? And I don't, you're gonna find a lot of variation in that number in terms of what you're taking home versus what you're generating. I will say that the number that I've heard thrown out repeatedly is the 30 to 40% number. At Onward, we're at a network, Onward Physical Therapy. So we believe that that number should be 50%. or maybe even a little bit more than that, depending on a number of different factors. But 30 to 40% is the number that I've seen thrown around the most. I'm always really shocked at how often when I'm traveling and teaching and talking to different physical therapists, at how often some of them are in a model where they're seeing four patients at once. And if we do four times $75 times, you know, however many patients per week, that is times, however many weeks per year you work, I've run into a number of physical therapists that are out there generating 500, $600,000 a year for their clinic. while making about $80,000. We'll make it like 20% of that number, which is just insane. And you have to be educated on this so that when you go in for your next contract negotiation, you kind of have an understanding of where you sit here. Now, again, that number is going to slide back and forth quite a bit. And I think one of the things that that would slide back and forth considerably on is if you were taking a salary, a set in stone salary versus you having a deal in place where you take some sort of percentage of revenue or you're paid per visit or something along those lines. And that tends to scare a lot of physical therapists that tend to want that set in stone salary. But I'll say like, if you really want to have the ability to make more money, then I think a lot of times we need to do a better job of just betting on ourselves and being willing to say, yeah, I'm happy to take a percent of my revenue. I know that up front that might be a little bit harder as I'm building my caseload. But on the back end, I could potentially make more money as long as I'm doing a great job providing clinical outcomes to people so that more and more people want to come see me. That is a great way to make more money as a physical therapist. The first time I went from a set salary to that, it obviously took me a little bit of a while to build my caseload up. but it resulted in me making $30,000 more per year. Once I got past that first year of rebuilding my schedule, that helped me pay off my student loans dramatically faster because I was willing to bet on myself and take a percent of my collections rather than a fixed set in stone salary. And I'll also say, if you're an employee, there are a lot of owners that love that idea as well, because they're not going to have a fixed expense. They're going to have somebody that's in this eat what you kill model. And they know that that's going to keep you hungry. That's going to keep you working a little bit harder, things like that. So it can oftentimes be a very big win-win for all parties there. And, you know, if you're an owner, one of my favorite parts about being a business owner is being able to pay my employees really, really well. And so I love to see when they're really dialing in on their clinical skills or doing a great job marketing and selling, and then they're getting rewarded for their hard work. And I wanna pay them so much money as a reward for that hard work that they never want to leave my clinic because of the finances of it. I want them to stay with me forever because they know that I'm gonna do the best job I possibly can of taking care of them financially. So think about betting on yourself and taking a percent revenue instead of a flat salary. With that one other tactic that you should consider is are there things in your contract? It that you don't need So let me give you an example of this a few years ago I was working for a clinic and I was making 40 of my collections from that company That resulted in me again making a big jump from my previous salary, but they also offered a couple other things They had a health insurance plan that they offered and they also gave me 15 sick days Valued at 150 dollars per day. So I don't remember the exact math on that. But when I ran the numbers here I recognize that number one I could use like a religious medical sharings insurance option instead of their insurance option And that would cost me less money and get rid of the fixed expense for the business And I also recognize that this was earlier in my career before I was married I wasn't taking that much vacation time and I wasn't taking any sick days. So I'd get to the end of the year and I'd have all these sick days at $150 per day. And I recognized that, goodness gracious, I could take those five sick days, but I generate more money when I'm in the clinic than $150. So I'd rather work. This was when I was trying to really aggressively pay off my student loans. And so I actually did the math on this in terms of the insurance versus the sick days. And if my My percent collections went from 40 percent to 41.5 percent That was like my break-even point there So I went to my boss and I said look you've got these fixed expenses of sick days And my insurance and I don't need either one of those So what if instead of that we just change my percent collections to 43 percent? My boss was thrilled. He was happy to get rid of a fixed expense And so just by doing those numbers and thinking through what I valued and didn't value as much I was able to come up with a strategy that made me several more thousand dollars per year probably resulted in about Probably results in about two and a half to three thousand extra dollars per year, which is wonderful So negotiate those things away that you don't need And then another thing that I think is really important for us to do when we just talk big picture numbers here is to set your goal income, then backtrack to the amount of money you need per hour. And this is one that's really important for both employees and owners. But like if you're an owner of a business and you're trying to decide how much to charge for different services, especially the ones that we're going to talk about here in a minute, what I like to think of is what's my goal salary for that year? Divide that by 2,000 hours and that needs to be the net income that I make per hour. So let's say just for simple math, you want to make $100,000 per year divided by 2,000, that's $50 per hour that you need to be taking home. And so that means that you then have to factor in your admin time, marketing time, your expenses, et cetera, et cetera. But that gives you a really good idea of where to start from your pricing standpoint. And you got to have that in mind if you really want to grow financially a little bit. Final big generic thing before we get into a few fitness athlete specific tactics is that I think overall, we need to worry dramatically less about the alphabet soup behind our name. Our patients don't really care that you have the ABC and the XYZ certification, et cetera, et cetera. What people are looking for now more than ever, especially as people are more and more educated, there's more information available online. They are looking for specialists in the areas that they are having issues with. If they're having hip pain, they want to see the best hip physical therapist in the area. If they're struggling with running, they want to see the best running physical therapist out there. If their shoulders hurt with snatch, they want to see a physical therapist that understands the needs of the fitness athlete. So worry less about the alphabet soup and more about building an undeniable skill set with your target demographic that you can then market to and have basically a guaranteed nonstop, um, influx of patients into your door. That's why ICE is really working on revamping our course logistics here. We're really pushing people towards our certification, such as our fitness athlete certification or older adult certification. We just want you to start to become known as the go-to person in your region for X or Y. That way you can really market that and leverage that in growing your business. CHARGING FOR ADDITIONAL SERVICES That then brings us to our fitness athlete division. And some of the specific things that I think that we teach in our courses, that we think that a lot more physical therapists should be marketing and selling to add additional revenue into their clinics money, or maybe some of these things become a side hustle that you do. So I'm gonna throw just a couple of different ideas out at you. Number one, mobility programming. Especially in the fitness athlete space where we're doing some really complex movements that take our muscles and joints through more range of motion than we see in almost any other sport. So take somebody that's working out trying to improve their strength at a global jump. Maybe they're doing lat pulldowns. Well, that pulldown usually take your shoulder to about 160, maybe 170 degrees of flexion. If you join CrossFit and you're doing kipping pull-ups, bar muscle-ups, etc, your shoulder is being taken to absolute enrage. If you don't have 180 degrees of shoulder flexion, you're going to be in really poor positions. You're not going to perform as well. It's going to often lead to some little aches and tweaks. So writing mobility programming is something that so many CrossFit athletes are looking for. And if you have that skillset, you should be marketing that to them. It doesn't take a ton of time. You could do really quick, you know, once a month, 30 minute follow-up sessions and you write them, you know, three or four days a week. Here's your 10 minutes of mobility work that you should be doing before or after or on your off days in relationship to your workout. So think about mobility programming. Alongside of that is accessory programming. Like say somebody comes and sees you for, for back pain. You analyze their squat and they've got a good morning squat pattern. You recognize that they need a little bit more quad emphasis, a little bit more quad strength and hypertrophy to help improve that movement pattern a little bit and reduce those aches long term. write them some accessory program. So that could be like two or three days a week. You're writing them, you know, 10 to 15 minutes of work to do after class. It could be that maybe they're dropping one day a week across it and they're doing really specific work on the areas that they are held back in a little bit. Because I think a lot of times we forget, you know, CrossFit's broad general fitness. So if somebody comes into CrossFit from an endurance athlete background, they're going to have a big hole in their game, like their strength is going to be behind their aerobic capacity. So maybe they need more strength bias in their programming and maybe one day a week you program that for them. Maybe somebody comes from a powerlifting background, they need the opposite. And so you start programming them some accessory Zone to work to really build that aerobic base There's a lot of stuff that we could do in the accessory programming standpoint, too And I honestly I don't see a whole lot of CrossFit gyms doing this right now So most of the time you won't be stepping on your local CrossFit gyms toes by doing this because they just simply usually don't have the time to handle extra programming. I also have a friend that does full programming. So like when he discharges his patients, he offers them fitness programming on the back end of that. So he works for a standard clinic and he's adding, last time I checked in with him, $20,000 extra per year that's straight to him. His company doesn't mind him doing this at all. Straight to him an extra $20,000 a year, just programming for people that he's already discharged. So a lot of these things don't even require that much more work, that much more marketing, and simply just offering this to your existing customer base as a little bit of add-on. In terms of like the specific like fitness athlete, you know, crossfit or powerlifter, limit weightlifters, I think one other thing that we should really look at is regular maintenance work. And physical therapists always get really up in arms when we talk about maintenance work, but I think we need to recognize something about this. So many individuals out there are actively seeking out regular maintenance work. They see a chiropractor once a month to get adjusted. They see a massage therapist once a month. They talk to a personal trainer and they're paying for accessory programming online, something like that. Why not offer doing all of that in one spot? Like why would you not say, okay, Jimmy, I know we took care of your low back pain, that upper back still stiff, your pain's gone, but we need to get that upper back unlocked a little bit. So why don't we follow up once a month for the next few months, I'm gonna write you some accessory mobility work to do. But once a month, we're going to crack your upper back. We're going to spend some time doing some mobilizations there. We'll do some soft tissue work, et cetera, et cetera, et cetera. We can put all of that together in one package for them rather than them having to go out to multiple different places. And it's a win-win there. We're still providing valuable services that's helping out their performance, that's potentially preventing future injuries and issues from happening while simultaneously growing our business. So I think we dropped the ball quite a bit on maintenance work and we Need to be a little bit more open to that in certain situations when we're providing value to people still. And then finally, I want to mention a couple of things from the more endurance side of the fitness athlete division here, and that's things like bike fits. So we have a bike fit course at ICE. We also have a running evaluation course, but both of those are things that people are more than willing to pay cash for because they understand how much it's going to help them perform to their absolute best and reduce, you know, a little bit of those aches and pains that they get with those sports that do have a decent injury rate there. And then with that population too, we should also be thinking about programming for both. We all know that runners aren't doing enough from a strength training perspective. And so often they have a running coach that they're hiring that's programming their running. And usually when I look at the strength work that the running coaches program for them, it's air squats, unloaded lunges, glute bridges, things like that, that we all know are not heavy and intense enough to drive adaptive changes in that population that needs the heavier loading. So why do we not offer that? Can we not really quickly write twice a week, a 30 to 45 minute program to get those individuals a little bit stronger and help stay ahead of issues that they have going on? So I hope that gives you a lot of different ideas that you can do and market to your business. The question that I always get asked when we talk about different ideas like that is then how do I know what to charge for that? And that goes back to setting your goal income. So you set your goal income, how much money that means you need to generate per hour. And then you look at all of these different extra services and you say, how long would it take for me to do this? So let's say bike fit, for example, let's say a bike fit takes you 90 minutes. It also takes you on average, about 30 minutes of marketing to get every new person in the door. So we're saying it's two hours for every bike fit. Two times the amount of money you need to generate per hour plus your expenses results in you understanding exactly what you need to charge for these services. So I hope that really helps y'all understand a few different things. And as always, we look forward to seeing you on the road at Fitness Athlete Courses in your area. Have a great one, everybody. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 9, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the concept of poise, poise gone wrong, and poise gone right. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. ALAN FREDENDALL All right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the lead faculty in our fitness, athlete, and practice management divisions. Leadership Thursday, we talk all things business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. So this week's Gut Check Thursday, we have a partner workout. We're working our way with a partner through five rounds, 20 or 15 calories on that rower. Ideally, that's together, side by side, two different rowers. Coming off the rower, moving through 15 synchro toes-to-bar, and then finishing with a little you-go, I-go, working our way through 10 total sandbag cleans. I do one, you do one, until we've done 10. and then resting a minute after each round. That's gonna feel a little bit like anaerobic intervals, a little bit like maybe doing 400 meter repeats on the old cardiovascular system. Our goal there is two to three minutes per round, a minute per rest, get done with all of that work right around the 20 minute mark. I tested that yesterday in the garage, was able to hang with about 230 to 245 per round. My toes to bar are not the best, but a really nice workout, very simple, very easy to warm up. So that is Gut Check Thursday. Speaking of working out, May is Mental Health Awareness Month. We're happy to be partnered with Forging Youth Resilience. You may have seen at the Ice Sampler a couple weeks ago, we did the Ignite workout, a fundraising workout designed to support FIRE and support Mental Health Awareness Month. So all throughout the month of May, you still have time to donate to our campaign, which is for Forging Youth Resilience. We're trying to raise $10,000 to help some of those kids go to camp this summer in July up outside of Boulder, Colorado. So you can find more information about that on our link tree on Instagram. Find all about Forging Youth Resilience. Find all about the Ignite Workout and our fundraising campaign for FIRE. EMOTION CAN SPREAD LIKE A DISEASE Today we're talking about the concept of poise, the definition of poise, of staying in balance or staying in equilibrium. And in the context of today, we're really talking about staying balanced, staying composed, representing poise as it relates both to leadership within the clinic, you and your colleagues and your teammates, but also poise in front of our patients. So the idea of this topic came upon me actually several years ago. Two years ago in June, I had the pleasure of watching Dustin Jones and Jeff Musgrave teach Older Adult Live. down in Kingman, Arizona, and then we took a trip up to the Grand Canyon to do a rim-to-rim hike. So if you have never heard about that, you've never done it, rim-to-rim is half of the hardest thing you can do there, the other being rim-to-rim-to-rim. So starting at the top of the Grand Canyon, hiking down to the base of the Colorado River, and then hiking back up. Some individuals hiking south rim to north rim and then coming back. So many, many miles of hiking, very rough terrain, And this time of the year, spring, summer, very, very, very hot. So stepping off around 4 a.m., hiking down to the Colorado River. If you don't know anything about the Grand Canyon, it's really mentally defeating. It can be because as you come down in elevation, the heat actually goes up, which is not something our bodies are used to happening. So as you get closer to the river, it actually gets very, very hot, sometimes approaching 120 degrees. And then at the hottest point of the hike, at the hottest part of the day, you turn around and hike back up the Grand Canyon. So very, very tough, both physically and mentally. And as Jeff and Dustin and I were making our way back up the Bright Angel Trail, very wide trail, very exposed trail, sandy, not a lot of shade, very hot, very dry. And again, you're already halfway through the hike, so you are already pretty fatigued. And overall, I think it's fair to say that coming back up to the rim to finish the hike, most people are just trying to finish. They're looking forward to being done. And along the Bright Angel Trail, as you come back up, what you encounter along the trail are these things called rest houses. These are just little brick houses for shade that have a well pump nearby so that you can top your water off. And so, Jeff and Dustin and I, coming back up from the base of the river, making our way back out of the canyon, about halfway up, passed by one of these rest houses, decided to stop, take a break, top off our water. And we walked in this rest house, It was packed full every every inch of space had somebody sitting and hiding in the shade. And as we looked around, we realized a lot of these people probably had no business doing that hike. If you've never done the Grand Canyon hike, what you experience when you start the hike is signs everywhere. telling you, asking you, begging you not to do that hike, warning you that usually somebody dies every day hiking the Grand Canyon. It's very tough. It's very hot. And so as we're sitting in this rest house, we were sitting among some folks who maybe should not have been out on that trail. who were in a really tough spot physically and mentally. And unfortunately, on that hike, you're not really in a position where you can give much help to people. You certainly could not throw somebody on your back and carry them out. You're really not in a place where you could afford to give somebody any of your water or your food. Those folks, unfortunately, are just gonna have to wait until the sun goes down, until their body has recovered enough to hike back out of the canyon. And so my first experience with poise and with negative emotions was in that rest house, watching all those people really, really suffering and the three of us kind of sitting down, not as deep in our tank as some of those folks. But really, the longer we sat there, the more we realized kind of how quiet, how defeated those people were, and how that negative emotion, those feelings of maybe hopelessness, of extreme physical and mental fatigue, were actually starting to get into us. The longer we sat there, the longer we rested, the more we kind of let the whole vibe bring us down, even though when we walked into that rest house, we were definitely not in the same mood. And I'll never forget Dustin standing up and saying, okay, let's go. We have to get out of here. It smells like death in here. And what he was saying was, hey, we're actually not as bad off as these people, but if we sit among them for too long, we will convince ourselves that we are. So let's get going. Let's keep making our way Kback out of the canyon. We don't need to sit and rest here and feel bad about ourselves and how tired we are and how much we just want to be done. we can't let those negative emotions affect us. So, realizing that our poise, our balance, our equilibrium, our confidence can rub off on other people near us, and especially the larger group of people that is around, the more people feel a certain way, we can almost palpate those emotions, right? We've all felt that at a concert, or maybe you felt that at church during worship or something, you can feel kind of positive and negative emotions start to infect you almost like a disease. And so recognizing that is a concept that can happen and that we ourselves are in charge of not only how we pick up on other people's poise, but how we demonstrate our poise to someone else. KEEP YOUR POISE: GRIPES GO UP THE CHAIN OF COMMAND And so my second point today is learning a little bit about leadership in the military, going to non-commissioned officer academy, and really learning a foundational leadership concept that when you are frustrated, when you are upset, when you have suggestions, when you don't like the way things are going, your suggestions, your feedback, your complaints, your gripes, call them whatever you want. should always move up the chain of command, they should never move down the chain of command. And very similar to the Grand Canyon story, the idea behind that in the military is poise, is confidence, of we don't want to mislead people, we don't want to lie to them about the current situation, but at the same time, complaining to people beneath us about how tough our job is, or how bad things are going, especially if they think things are going well, and otherwise putting a damper on the situation again, can really bring in those negative emotions, can really start to fester, and really start to spread and infect almost like a disease. That if we're not careful, that if we complain too much about our business, about our clinic, about our patient caseload, about financials, about taxes, about any of the different things that we can have suggestions to improve, that we can have wishes that they were better, that we can have complaints about why they're not better. All of those things When we voice those things, especially to people in leadership positions beneath us, we need to recognize that we're just fostering that environment of negative emotion. And my final point is, why does this really matter? Even if you don't consider yourself in a leadership position, even if you're not in a leadership position in your business, in your clinic, you are in a leadership position with your patients. And just like complaining downstream can really have a lot of negative effects on a whole organization, having that same mindset individually with a patient about your business, about your clinic, about how busy you are, all of those things are concepts, are thoughts, are emotions that our patients are very easily able to pick up on. POISE WITH PATIENTS So my third point is, your poise matters probably the most with the patient in front of you. I truly believe it's our job to make that person feel welcome, to make them feel like their concerns are valid, and that we do have a way to help them, and probably most importantly, our poise is that we are excited about helping them. Not every patient that walks in is a high-level athlete and it's really fun to help them improve their snatch or their clean and jerk or something like that. Some folks come in and we know those patients. They are very deconditioned. Their therapy protocol can look very low-level to us, but it is our poise. It is how much We make it seem exciting to do things like sets of sit-to-stands, and one-pound dumbbell bent-over rows, and really partial range of motion burpees, and that we clap it up the first time that person's able to transfer on and off a bike for the first time, for an example. and that our poise, our balance, is always, if not neutral, erring on the side of positive. And when we really step back and question what are the benefits to having negative poise, to letting this person know how busy we are, how many patients we have on our schedule, how far away we think they are from the finish line, that really does not do anything to meaningfully move that person closer to their goals. If anything, it might keep them or slow them down from their goals if they pick up on the idea that they are not doing well, that their function is not great, that they are maybe making slower progress than we'd like to see. If they're able to perceive that, then we know those emotions can spread and those emotions can become reality. So being very careful with our own poise, making sure that when we have complaints about what's going on in the clinic, what's going on with our schedule, whatever is happening in our life, that those complaints go up the chain of command, that our patients don't hear them, that folks who work with us in leadership positions beneath or to the side of us don't hear about them, that those gripes, those complaints, those suggestions, those feedback things go up the chain of command so that the poise of the organization at least again stays neutral, ideally trending towards positive. Knowing the effect that those negative emotions can have. Despair, bad mood can really spread like wildfire if we're not careful to control it. And so recognizing when you show up for that patient your poise really, really matters. How steady you seem, how confident you seem, even how confident you seem and maybe not knowing something plays a big role into your poise. Hey, you know what? I don't know the answer to that question at all, but I'm going to look into that and as soon as I find out the answer or I find out somebody who maybe has the answer, I'm going to put you into contact with that person. So just trust me, that even if I don't know, it's okay that I don't know, and I'm going to help you find a solution. Just that poise, that level of confidence that we display, can go a really long way in patient buy-in. That if they leave the clinic and they feel like, man, my therapist knows what's going on, they know what I need to work on, they're happy, they're excited, they're stoked, they're measuring my progress, they're letting me know how I'm doing towards working towards my goals, and that overall it feels like a really positive environment, It's no surprise that those patients tend to show up for more therapy, they tend to do better in their plan of care, and even when their plan of care is done, they tend to be the folks that recommend new patients for us. And so, in those cases, having a really strong, confident, positive poise rewards everybody. SUMMARY So think about that the next time you're getting ready to stand up from your desk, you're getting ready to start your day, you're getting ready to restart your day after lunch break or something like that. Check your poise. Are you excited to work with this patient? Are you gonna clap it up that they do that one pound strict press, that they get eight cals done in a minute on the rower? No matter how low level it seems, no matter how basic it seems to you, maybe compared to your normal clientele, check your poise. I promise, the more you work on this, The more folks will have fun, the more you will have fun, and not surprising, you'll find yourself having more patients wanting to see you, then you have time on your schedule as well. So poise, think about it a little bit. That's it for today. I hope you have a fantastic Thursday. Happy Mother's Day to all those moms out there. Mother's Day, if you didn't know, is coming up Sunday. Still time to go get a gift if this is brand new to you. And then we're happy to restart live courses after a little bit break next weekend. So check out ptinice.com for all the live courses coming your way throughout the summer and into the fall. Have a great Thursday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. 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May 8, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the brand new "Build your own older adult fitness class" starter kit now available on the ICE Physio App. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JEFF MUSGRAVEWelcome to the PT on Ice daily show. My name is Dr. Jeff Musgrave, doctor of physical therapy, proudly serving the older adult division. And today is Wednesday. Wednesday means it is all things geriatrics. So it is Jerry on ice. I am super excited to be sharing with you today. some of the hard lessons learned and I think some helpful steps for building your own older adult group fitness class. So, getting more and more questions about this stuff, my business partner and I, Dr. Dustin Jones, who also is faculty in the older adult division, have built a community for people 55 plus and we have learned a lot of hard lessons along the way. I'd love to share those learnings with you and then also pitch a couple free resources that are coming your way that you can get when you download the PT on Ice app. So all that being said, super excited to share this with you, but we would be completely remiss if we just blew past and got to the nuts and bolts of building the program and not touch just a little bit on, oh, we've got some people on that are interested in doing the same thing. I love this. super remiss not to just share why we would want to do this. And the reality is, our older adults' lives are being destroyed from a lack of resiliency, that lack of reserve, that lack of extra physical strength. And it comes in many names, right? We like to call it one rep max living. We talk about limited reserve, limited resiliency. But they come in diagnoses like sarcopenia, right, dynopenia. We've got potentiopenia, that loss of power, loss of strength. We've got type 2 diabetes. We've got heart failure, cardiovascular disease, heart attacks. I know I'm preaching to the choir here, team, but it's just so sad to see the long-term outcomes and how that changes the trajectory of someone's life when we know that most of it's preventable. If we could get someone to high intensity, they've got a safe place to exercise where they can get the options that they need, then we could make these things go away. We have the solution. It's not like we're waiting on scientists to bring us a solution. We're not waiting on research here. The research is very clear that most of this is completely avoidable. Completely avoidable. So team, if this has got you pumped up, if you're curious about what it would look like to build this, I've got some simple steps and some considerations and then I'll share with you about a couple free resources we've put together for you. So the first step I feel like… We've got to be very clear about who we want to serve. You've got to know who is your best customer. Sometimes people will reference these as avatars or personas. Who is that person that you are best suited to treat? Who do you want to treat? The reality is, unless you're in a very rural community, a small community, you need to get very specific about who you want to serve. You need to know where they eat. You need to know what kind of car they drive. You need to know where in town they live. You've got to figure out where that geographical area in your community is you want to serve. You've got to know how to serve a very specific customer well. Let's be honest, the person that is maybe coming off of outpatient caseload, who is just barely above independent, community dwelling, older adult, Their interest in fitness and what is going to draw them in versus what's going to push them away is going to look very different than someone who has been a lifelong athlete, a master's athlete that's coming into your clinic because they've got an achy knee or an achy shoulder or something like that. I mean, those customers are going to be interested in a different intensity. They're going to have interest in different equipment, and we need to know how to speak that language. We need to know how to identify that very specific customer we want to serve, and then we've got to create an environment that is irresistible to them. It's got to be equipment they can use. It sounds like such a simple thing, but it's all fun and games in your older adult group fitness class until you try to get someone on a bike and you realize they physically can't get onto an assault bike or they physically can't use a rower anymore. What are you going to do with them during that class? Do you have a plan? But that is a completely different customer that's more like that person that just came off outpatient caseload versus someone like that Masters athlete where they're going to be able to use all the equipment that the general population in a CrossFit gym is going to be able to use. But you've got to be very specific about who you're going to serve because I truly believe you cannot serve everyone well. You've got to be very specific. You've got to niche down as much as possible. If you're in a small rural area, you may have to widen your lens just a little bit more, but be very specific. So the who is the first part. You've got to know who you want to serve. The second part of who is with whom. So the with whom is, are you going to do this alone or are you going to find a partner and partner with somebody? I'm very excited to say that I've got a wonderful partner. Dustin Jones is gonna be really upset that I said this, but I trust the guy with my life, okay? I don't have to worry about the decisions he's gonna make for our business. He is a very strong, has great character, he's dedicated to excellence, and he's gonna challenge me. He's gonna push me. outside of my comfort zone based on the mission that we're serving and the people that we're serving. And that is crucial. A great way to summarize that goal, and depending on the project you're trying to put together here for your older adult group fitness class, you may be able to do it solo and that may be fun. But I'm gonna give you some advice via Jeff Moore, via an African proverb, and that is, if you wanna go fast, go alone. If you want to go far, go together. And we found this true because we launched right before the pandemic. And I think if we hadn't had each other's support, there may not have been a stronger life. And man, what a huge missed opportunity that would have been to the people that we get to serve. So that's the first part. Who and with whom is what you've got to figure out. The second piece is you've got to know, you've got to start figuring out what model you're going to use to serve in this older adult fitness. You've got to figure out your space. You've got to figure out your equipment. So if we're thinking about different models that are out there, you could, um, Start like we started in a CrossFit gym, maybe in off hours. You want to make sure it's a place that's supportive. We were lucky that we were at CrossFit Maximus in Lexington, Kentucky, and they were all about having us in there during the hours they weren't using class. The equipment's there, the space is there. Team, these business owners, they're paying the rent. They're paying utilities through this whole time, but they're not getting any income during that time. Usually what you're going to find in those gaps, mid-morning and early afternoon, are you're going to find open gimmers who are paying the maximum price, but they're using maximum equipment, maximum space. And if they could get someone that was going to generate exponentially more income during that time, they'll probably take a shot with you on that. So that's one way you could do it. You could also choose to do a virtual model, where maybe you're using Zoom or you're using Google Meet, and it doesn't really matter where your customer lives, as long as your customer's tech savvy, right? They could be all over the world. So you're probably gonna have to build some type of following. You're gonna have to get your name out there. But a virtual model frees you up from having to have a brick and mortar space. It can free you up from the geographical barriers of not being able to get to your customer or your customer get to you. A lot of studies say people are only willing to drive 10 to 15 minutes for their group fitness classes. So if you take wherever you're targeting to put your spot, and you kind of draw a circle, that's how you can start looking for real estate in that market as well. You need to figure out, are you going to do only group fitness? Are you going to do personal training and offer one-on-one sessions? Will those be in person? Will those be online? You can mix and match these things as they meet your needs and the person you're trying to serve. Is that a good method to serve your ideal customer? So something that's probably gonna ruffle some feathers is equipment. So this discussion about equipment and space. So the thing we've got to get focused on is being focused on results and serving that customer well. Every piece of equipment that you find will not necessarily serve your customer well. Can they physically get on it? Can they use the piece of equipment? or not. You've got to figure out weight limits for things. Are you going to serve customers? Are you going to serve larger bodied athletes and patients that just came off caseload? Kind of like the C2 bike. I think the post can only hold like 200 or 210 pounds and it's tiny. If you're a larger bodied athlete, that is super uncomfortable. and you're probably going to break the equipment. Can you think about what's going to happen to your business early on if one of your larger bodied athletes breaks the equipment in class? How embarrassing that's going to be for you, for them? That story, unfortunately, is going to be shared very quickly and probably very widely. So you've got to figure that out about equipment, but also how much space does that equipment take up? How many people can use it? And is it gonna be an attractor or a detractor to your target avatar? Now, if you're working with more of a master's athlete population, they've been in the weight room before, they're maybe not gonna be upset about seeing dumbbells and barbells and all these different pieces of equipment in the environment that seems a little bit harsher, a little more, well, most of us would consider pretty badass, right? But you've gotta consider in a group environment, if you're trying to onboard people, that are terrified of a barbell. They've never seen it. Say you don't have training bars. Man, this one hit us really hard. We didn't have enough training bars when we launched. We had several members that couldn't even get the empty barbell out of the holder and move it to their spot. We're trying to build autonomy. We're trying to build their confidence and their strength. They can't even move the frigging piece of equipment around. Like, how upsetting would that be? You're terrified. You go to your first group fitness class and not only can you not use a piece of equipment, you can't even pick the thing up. It was, man, lots of hard lessons learned there. But we want to figure out with our model and our space and our equipment, how are we going to use these things? Does everyone need everything all the time? Do you need, if you're going to do a class of 15, do you have to have 15 rowers? Do you have to have 15 Ski Ergs. Do you need 15 GHDs? I love GHDs. They're fun. I use them all the time. But they're not the best to serve our avatar at Stronger Life. You will not find GHDs lining the walls in Stronger Life. Most of our members would not be able to use that piece of equipment. And it wouldn't give them the most bang for their buck on their time. So you've got to figure out, like, how accessible is your equipment? How much of it do you need? programming for stronger life, and the reality is you can program these problems in, or you can program these problems out. I mean, if you do a, if anyone is in the CrossFit space and done, shoot, Filthy 50, man, you gotta have a box, you've gotta have barbell, you've gotta have jump rope, you've gotta have rig, you've gotta have all these things. Like, the amount of equipment and space you need is incredible to run that class, if you're thinking about building out your own space or leasing your own space. But think about a workout like Fight Gone Bad, where you're rotating through stations. You need a fraction of the equipment, you need the fraction of the space, and if anyone's done any of those five gun bad workouts, you can get a tremendous workout that way. And I'm not saying that's the only format, but that is one example of where you can program in lots of expense, lots of overhead cost to make it really hard to open your space that's gonna push you into a much larger footprint than you need, and then you're gonna have hanging over your head a big lease a large utility cost, insurance, just the whole thing. And the more equipment you have, the more you've got to buy and the more space that takes up. So this takes me to a term when we're trying to consider all these things and figuring out if we can build a profitable business, we've got to consider things like operational capacity. So operational capacity is when you're looking at your space and you're trying to figure out, okay, I've got, say, 3,000 square feet and I've got this many square feet of bathrooms. I've got this much square footage in the lobby. I've got this much square footage for equipment storage. How much of the space that you're going to be leasing or using can actually produce income? You've got to figure that out. You've got to know how much revenue you can produce in your space, how you're planning to program with your customer. Because if you don't know how much income you can produce, like maximum capacity, then I mean, we've kind of turned this into like a volunteer job, right? And there's nothing wrong with that if you want to volunteer and do this for free. But if you want to build a healthy business, you've got to figure out your operational capacity. And this was first, I learned from Stu Brower's podcast, WTF Gym Talks. Now, if you don't like four-letter words, you may not get through his podcast episodes, but some very savvy business learnings there. WTF Gym Talks, Stu Brower. Brilliant guy. He's actually got a short episode on that that is really helpful and very eye-opening. I actually go through an example of looking at different operational capacities on the free resource on the ICE Physio page I'll tell you about at the end. So, that leads me directly into profitability. The reality is, team, if your business fails, you can't help anyone. So do your math up front. Figure this stuff out. Who am I going to serve? What kind of equipment am I going to use? What do I have the capacity? How many people can I serve? You've also got to figure out your pricing. You've got to be reasonable to the market, but also value what you can offer as a physical therapist or a physical therapist assistant or a fitness pro that has gone through older adult training to know what in the world is going on. What we need here is we've got to figure out where that intersection goes. When are we going to become profitable? Based on the number of people I can serve, how much I can charge reasonably, how soon I think I can fill this out, when can I expect to not be losing money but making money? And we've got on the PTI and ICE free resources, you can get access through the ICE Physio app. We're sharing with you a break-even spreadsheet where you can put in all your costs, what your pricing is, how many people you're expecting to serve. to figure out how many weeks until you have a break even point, when you're not losing money, but you're actually, you're floating. And the reality is this idea of reserve and resiliency dovetails very beautifully. with a business. If you've got high financial reserve, you're making way more money than you're spending, then your business is profitable. If your business is profitable, then you can invest in more equipment. You can invest in more advertising. You may be able to bring on a second person to help you or another coach that you can train. Those things are beautiful to be able to consider and to be able to share this dream and this vision with someone else. We like to call it building a bigger table, dreaming big. I would argue to say, once you have some level of success, you should be thinking about how you can share these opportunities with other people around you who are also passionate. But you've got to figure out the break-even point, and that can also help you figure out what profitability can you expect at a certain price point at a certain membership level. So once again, that's on the Ice Physio app under free resources. you can get access to that. SUMMARY So what we've actually got, I've got a lecture that's a little bit over 20 minutes long, going through these items in detail with some more examples of what your operational capacity would look like, what your profitability would look like, based on two different models, more of kind of the extremes like, master's CrossFit class that everyone needs a barbell everyone needs a rower and then an example of more like a cycling studio where it's like you've got a very small footprint you can really pack the house so you can kind of just see compare and contrast. I'm not saying either one is right or wrong it's just you need to be informed before you make decisions and move forward. You've got to know who you're going to serve and with whom. Are you going to do it solo or are you going to partner up? You've got to know your model space and equipment, a.k.a. the operational capacity of your business, if it's going to survive. You've got to figure out how long until you become profitable, how your equipment, how your programming feeds into whether you're going to be profitable or not. and make decisions as needed. You need to know your break-even point. That's going to give you your financial runway. How long can I operate and keep this dream alive financially until I've got to make money? And you can't do that with rose-colored lenses, team. You've got to take a hard look at the numbers and repeat these steps as many times as possible until you've got something that's really going to work. So team, that's it. All of that is wrapped up in more detail with a free lecture and that spreadsheet to figure out your profitability. That is the free starter kit on the Ice Physio app with the free lecture. Should be very helpful. So please check that out. Reach out to us. We'd love to hear your thoughts or questions. I wasn't able to keep up with the comments. I probably didn't answer any of your questions live on the call. I love that you ask questions, but please ask them in the comments and I will get back to you. If you have questions about this stuff, I love this. This is my passion, getting to live my dream. Love this. Check out the free resources. Ask your questions in the comments. If you're looking to see us from MMOA out on the road, we've got a few seats left in Level 1. That's going to get started on the 15th of May, so grab those seats. Level 2 already sold out this cohort. You're going to have to wait until October if you're trying to get into L2. Don't let that happen if you're looking for L1. Live on the road, we're going to be in North Dakota and Richmond, Virginia in the middle of May and then Scottsdale, Arizona early June. Team, I hope this was helpful. I hope this got your wheels turning. Check out those free resources and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 7, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren describes his ideal setup to travel with all the supplies & equipment needed to perform dry needling on at least 2 individuals. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. PAUL KILLOREN And good morning, Instagram. Paul Killoren here going live broadcasting worldwide PT on Ice daily show. If we haven't met before, I am the current division lead for dry needling division. And today I want to tackle a big FAQ, one of the top frequently asked questions. It comes up almost every course. It comes up during holiday season and travel season. And really any time that someone says, here is a box of needles and you're flying anywhere. So we're talking travel guide for dry needling. And to give you some background on myself, I had a brick and mortar clinic cash pay for almost 5 years, many years ago. Since that clinic closed, I have more or less been mobile, and mobile really means getting on airplanes to treat pro athletes. And that brings up a lot of questions. So whether you are truly traveling with needles, we'll talk TSA, baggage, all of that stuff, or you're just more of a mobile setup and you're looking for some solutions that maybe aren't your typical, like you don't have a cabinet, you don't have places, brick and mortar in a clinic. So we're gonna talk the travel guide to dry needling today. And first of all, I get zero kickback, zero financial incentive, but what I'm wearing here is actually the Go Rucksack, the GR1. I've actually traveled with this heavily teaching for a long time, almost nine years, and this thing has held up. So it gets my stamp of approval. It is an expensive bag, but for me, it has been more than valuable, and this is traveling consistently across the country. So this bag is, is just your standard backpack. And if you are traveling, let's say getting on a plane to see a, uh, an athlete, or if you're traveling for vacation to see family members, that bag is large enough that I have my laptop, all my normal personal travel carry on stuff. Um, but that is where I put a lot of my non needling supplies. So, I mean, if you're doing cupping or scraping or taping, any of your other things, that GoRuck gives me plenty of space to stick stuff in. But today, this is the pack that I think most people have questions about and will talk about the most. So this is my travel kit for dry needling. You can see the logo there, Instagram, YouTube. Medpack is the name of this company. Again, I have no financial incentives. Honestly, I've been wanting to carry their stuff for a long time, and I dry needle, but it's been just a tough distribution setup. But I do give this my endorsement, and the pack I'll show you today is actually the one I've had the longest, it's the smallest, and actually the least expensive. meaning if you go to Medpack site there are lots of different options and really they're kind of EMT or athletic trainer quality bags meaning they are durable, they do have nice sturdy locks and straps and holding longer straps I guess for carrying but they are high quality and they are medical grade bags. This bag specifically is their 300 series bag. It's their cheapest one. It's less than 100 bucks right now. And honestly, I like this better than some of the larger bags that I've used. And I'll show you everything this can fit in a moment. The larger bag has enough, it has more space, it has enough space really for more needles, but for two of the ES-160 e-stim units, which is nice. Larger means it doesn't always fit as easily in the overhead bins of some of the regional jets that I've been on or underneath the seat. And if anything makes me more uncomfortable and nervous on a plane, it's watching Bob try and cram his carry-on bag right next to my med pack that has two ES-160s. You know, you picture them spinning it around, cramming it in, doesn't fit, doesn't fit. There's been a few times where I'm just like, it's made me nervous enough that I prefer to travel with the smaller bag because it fits better, at the very least, underneath the seat in front of me. So this is the Medpack bag. Again, no financial affiliation by me. This is the one I've liked the best. The 300 series is less than 100 bucks. So let me walk you through it. And I've got Instagram here, YouTube over here. Try to give you the best angle. So again, what I like about this is it has sturdy straps. And you see big pocket one side, other side, these outer pockets. One is where I have my new gloves. So it's full of gloves that are unused, will be used. And the other side is my garbage. So during a treatment session, I travel to an athlete's home, I have gloves, I have swabs, I have all the needle debris. I'm sticking all of that in my garbage pocket during the session. I mean, really, I'm not trying to leave any waste or trash, even those tiny little shims, at a patient's home. So I'm constantly sticking that in here. Those are the two outer pockets. If we unclip here. First of all, I just have your standard cord pouch, I guess. Nothing fancy to this, but this is where I keep all of my lead wires for the ES160. And I will say that it's worth having extra of everything when you travel. That's batteries, that's lead wires, that's almost have a second everything, because what you wouldn't want to do is travel to a client and not have a functioning unit for whatever reason. So here are my lead wires, including a few extra and some extra batteries for my e-stim unit. If we take that out, another clip here you can see, here you go, inside of the purse. I'll try not to dump it out entirely, but what you see is that there are little compartments for almost everything. This middle one is actually customizable, meaning there's Velcro that I can make this smaller or larger. So I made it perfectly sized to actually have a pretty secure hold on a quart-sized sharps container. And then there's my needle, the main needle compartment. So I have 105-75s, and if you want a pro tip, I mean I'm biased, I use iDryNeedle, Needles, which means they have a shim tab. I really like having max packs for being in a patient's home Again, if the goal is not to leave any of the shims or any garbage much less clutter with the multi pack I like having those and then let's see if I can tilt this up even further two front pockets have my swabs so my skin prep swabs and You saw there a little gel electrode. If you know, you know that it's kind of nice to have one of these with the metal button. You can put it on a patient's skin, clip up an alligator clip to that metal button and then to a needle. So it's nice to have a few of those handy. And then in this front pocket is just more needles, smaller individual size needles. So needles, sharps, kind of cleanliness, skin swab stuff, more needles. And in the back, this is really why I like this bag specifically, is almost a perfect size compartment for the ES-160. So there is my 6-channel e-stim unit, slides right in back. Behind there you see that there's a little pocket or another compartment where I have the e-stim 2, so a smaller e-stim unit back there. There's a larger pocket where you can fit more supplies there if you need. That's where I used to keep my extra batteries, but then I kind of got the cord carrier. And then up top you have a zipped pocket, I guess. And I guess since real early on, like the first year that I started needling, Someone terrified me into carrying a hemostat just in case a needle would ever fracture. So that's what's in there right now. I've never used it, never had to use it, but a zipped pouch for whatever you'd like to put up there. So again, that is the Medpack 300 series bag that I travel with. Again, there are larger ones. If you're not getting on a plane, there are roller bags and backpack bags like there are MedPak makes a nice, again, more durable, more resilient, and almost healthcare grade pack, kind of EMT, ATC bag quality. So that's me getting on a plane. I have my GORUCK, I have my Carry-On. So let's talk plane travel specifically, because again, this commonly comes up. First of all, whether you've heard or not, you are allowed to carry on needles. They can be in a closed box. They can be in their loose sleeves. They can be in a sharps container. You are allowed to have needles. I know that from experience and also from Delta Airlines policy. So again, that bag I just showed you, I'm going through TSA pre-check goes through there. I will admit that 50% of the time it gets kicked to the side. So you're sitting there waiting for your bag. The person is going to ask, like, whose bag is this? Is there anything sharp or that's going to poke me? And that's when I say, yep, it's full of needles. Ha ha. And they don't believe me until they open it up. But once they do, there's been no issue. They basically say, like, oh, are you a health care provider? Are you an acupuncturist? And you say, I'm a physical therapist. It might be worth carrying or having a copy of your license should there be more questions, but me doing this for several years, there's never been more questions. They basically nod along. Honestly, why my kit gets kicked to the side half the time is either a hand sanitizer that I carry with me or a cleaning, like a table cleaning bottle, basically a fluid that's more than three ounces. They actually let you keep both of those after they test them. So even if your hand sanitizer or your cleaner is larger than three ounces, they will run a little swab test on it. Typically they give it back. I'm not sure if that's because we are health care providers or because there's some exclusion for sanitizer, but that is why it gets kicked to the side or it does look a little suspicious to have all sorts of wires and batteries under x-ray so half the time they don't even realize or care or know that your bag is full of needles they see eight nine volt batteries or eight c batteries with a bunch of wires and that looks kind of suspicious. So every once in a while, you'll get questions on what is that unit? And I say electrotherapy device, electro stim device, therapeutic device, whatever answer you want to say, but that is why half the time when I'm carrying through that pack, it gets kicked to the side. But honestly, never had any issues from there. Again, I travel pretty frequently. So those are the common frequently asked questions. I already gave you the pro tip that if you are traveling two clients on a plane or even driving, you should have extra everything. And that's needles, batteries, lead wires. Learning over the years only from one or two failures, but it is pretty embarrassing to show up and not have extra batteries. You're basically asking your patients if they have batteries. So just have extra batteries, have extra lead wires. Unfortunately, if you do travel or you are mobile for your treatments, It puts a little more wear and tear on your stuff. As far as stem units go, I actually haven't had any issues durability wise with the ES160. Aside from the wires, I've replaced a couple over the years. The E-stem 2 is one of the smaller, cheaper units that holds up really well. The Pointer XL and the E-stem, sorry, the ITO ES130, the 3-channel unit, do not hold up as well. So as far as the plastic inputs on the ES-130 or the wires, if you're looking for more durable units that really don't wear as quickly with travel, I like the eStim 2 and 3 and the ES-130. But that's what I got for you supply-wise. Again, no issue with TSA or otherwise with needles or sharps containers or e-stim. Really, I'd just be prepared for maybe one or two follow-up questions, but there's never been an issue. Other things that are worth having if you're just more of a mobile setup or if you are getting on a plane, I would always have extra consent forms or maybe a one pager for what is dry needling. You'd be amazed if you are mobile how it's not even a word of mouth referral. You're traveling to see one person or a mobile session with one person and they have a friend or a family member that just happens to be there during your session. Whether it was planned or unplanned, they just want to watch it, ask you all the questions while you're working with Gladys in her living room. So I would just have some reading material for that person First of all, to avoid distractions from them, but also to answer their questions, potentially gain a new client. Otherwise, consent forms, same thing. You find the opportunity to potentially do a trial treatment. I would always have extra consent forms with you, or just have an electronic version that's easy to pull up. I still do the paper. I have extra ones with me. I do scan it with a PDF scanner and can send it to the patient right away. But otherwise, I do the old school consent forms. But that is what I have for traveling with needles. Once this episode drops on Instagram, I'll drop some links for the bags. If you have any questions on travel, I think I hit the big ones. I think one other question that comes up, um, less so for the more formal like mobile or travel client, but more frequently with I'm at home at Christmas with uncle or grandma. Um, some other questions that come up are, is there kind of a less formal way to dispose of sharp needle or dispose of sharps? Um, and the answer is yes. And even depending on the state you live in, some states would say this is entirely legal, which is you should just put them in a water bottle with a cap that you can twist, and then dispose of it in recycling. Maybe put duct tape over the top of it. But maybe if you're at home on the holidays, you have a few needles in your bag, whether you are going to do gloved clean needle technique on family, that's up to you, like whether you have those sorts of supplies, but I would certainly dispose of the needles semi-properly, which might just be a water bottle and some tape. SUMMARY All right, team. So that's what I hope that answers some of the main questions you have. I know summer means you're going to be traveling a little more. Um, we're coming right off of sampler and honestly, the number of folks that came up to me and ask questions about treating athletes or, or travel treatments or mobile treatments were high. I think it's just becoming a model that even healthcare consumers are more intrigued by, you know, having the option of us driving to them, even if we charge them a premium. So when it comes to needling, there are some pretty nice setups. Again, I like this bag. If you want to know some of my failed or my less desired travel tips, I kind of went through the plastic tote phase that had a snap-on cover. I tried kind of, I guess, a makeup kit or a taco box. Nothing really seemed to fit quite as well as what I just showed you, which is the Medpack bag. But there are other options out there. So if you have questions on travel tips for needling, drop them once this goes live. Again, I'm Paul Cloran. I'm the division lead for dry needling. If you're trying to catch a course with us on the road, May we actually only have two courses and they're both the weekend of the 18th and 19th. Ellie will be in Virginia Beach. I'll be out here in Seattle. And really throughout the summer, we have some big courses, but we have a lot, we have fewer courses throughout the summer. We just know that you all are out there being active, friends, family, a vacation. We want our faculty to kind of decompress a little bit, but if you're trying to find courses throughout the summer, they are there. If you want more options or you're looking for something more convenient, check out our summer, but also our fall options for needling. All right team, thanks for tuning in. Drop any questions you have on traveling with needles. Signing off. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 6, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses two different presentations of pelvic floor patients who may present to the clinic. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. JESSICA GINGERICH Good morning, PT on ICE Daily Show. I hope everyone had a great weekend. It is Monday, so that means that you are live with the pelvic division. My name is Dr. Jessica Gingrich, and today we are going to talk about the most bang for your buck pelvic floor addition. So I'm going to present today two separate presentations. So I don't want to talk about necessarily a case study or two separate case studies, just different presentations that you may see in the clinic. if you are a newer pelvic floor clinician, you may feel stuck. You may feel, oh, I haven't seen this or haven't seen this many combinations of things. Where do I start? And so, that's what I want to talk about today. So, the first thing or the first patient we have is going to be the person that has pain. That could be back pain, that could be hip pain, SI joint pain, tailbone pain, pain with penetration, and that may be during intercourse, during a vaginal exam, whether that is a speculum or digital exam. They may even have a history of this with tampon use. Even bedroom toys can be an issue. They may also say that they have issues with bowel movements. They have difficulty emptying or they do have a bowel movement, but when they're done, they don't feel quite empty. From the urinary standpoint, they may feel like they pee all the time, so they have frequency. Or when they get the urge to pee, they really have to go, so more like urgency. And then this also may present with or without urinary incontinence. On the flip side of that, we have the weaker pelvic floor. And so this is someone that comes in and maybe when you're talking to them about their activity level, Well, I haven't worked out all that much or I like to walk. I don't really lift weights. I haven't done it in years. And they may also present with leakage. They may even have heaviness in their vagina or dragging sensation. All of these presentations may come with, um, babies or, or no babies, right? Back to our first presentation, that person also may have that type A personality, where they like structure, and they feel like they have to work out all the time. I wanna kinda go off on a little bit of a tangent about that personality. We tend to say that, oh, well, they have that type A personality, and that's not a bad thing, right? If we didn't have that personality, what would our world look like? What we wanna do is we want to help that person Um, lean in to how they can best just function, right? And so when it comes to working out for a type a person, it may be a lot of education, right? You don't need to work out seven days a week, but this is what it can look like. Here's what programming looks like to really maximize things. There's a great book that I'm currently reading. It's called A Guide to Losing Control or Type A, I'll have to post it in here. I can't remember the title of it. But it's a really great book around just the structured Type A personality and how to really lean into that and help that person just feel better and function better, really optimizing recovery, stuff like that. So I'll drop that in the comments here when I'm done. So what I wanna talk about is where can we start with both of these presentations if we don't know where to go? So with that weaker person, they need to be loaded, right? They need to get stronger. So that's the first and foremost. But maybe they're not ready for that. So what we're gonna talk about, there's a thousand different ways to do this, but we're gonna talk about relaxing, okay? This is not the, well, you need to just relax your pelvic floor. You need to just relax. No, it's more about knowing how to relax. So, the first thing that I want to talk about, and I know this is everywhere, but is the squatty potty or getting your feet elevated to some capacity. What this does from a mechanical reason, and I love talking about this in the clinic, is give them the reason why they're doing it. Don't just say, hey, when you go to the bathroom, elevate your feet. Okay, see you later. Tell them why. So what this does is it decreases that anorectal angle. So when that angle decreases, now we're not having to fight against natural angles in our rectum to help keep us continent. The other thing that it does is it allows that puborectalis muscle to relax, to just unkink the base of the rectum. So two biomechanical reasons as to why we are suggesting that they get their feet up. Now you may be asking yourself, why are we talking about a squatty potty to relax the pelvic floor? Cause that's maybe one or two times in a day, depending on the patient in front of you. So that is going to allow the pelvic floor to just work optimally, right? You're getting the pelvic floor. When the pelvic floor needs to be off, you are helping that to be off rather than sitting and without your feet elevated and your pelvic floor might be on a little bit, or if you're bearing down, maybe your pelvic floor reflexively kicks on. And so that's just optimizing your pelvic floor on day-to-day functions. that need to happen, right? Now, I will say that some people don't feel great with having their feet elevated, and that's okay. Also, the angle of which their hips are is different per person. Also, I feel like you guys can hear my dogs barking. They're making their PT on Ice daily show debut. Sorry about that. The second one is a diaphragmatic breath. And we hear this one all the time too. Well, let's just teach our patients how to diaphragmatically breathe. Yes, that's a really important thing, really for anyone, but we need to teach this well, right? We can't just say, here's how you breathe. Okay, go do it. We need to have them focus on what they are trying to feel. And so when we are diaphragmatically breathing, when we inhale, our pelvic floor should descend. Have them focus on that. Where does your pelvic floor go when you inhale? Focus on that movement. And also just… and have them do this in different positions. You know, they may be on all fours doing it. They may be in a deep squat. They may be sitting on the floor. And this is likely going to be a static thing that we're doing. So, having them be still really focusing on it. Don't watch Netflix and do this as you're starting to learn. Now, different cues that I like to use around where your pelvic floor is, it looks different for everyone. So, does your pelvic floor descend? Some people, they're like, yeah, it does. They kind of understand that they are aware enough about that. Sometimes people aren't, and so you have to give them one structure to focus on. One of my favorites, and I know you guys have heard me say this a thousand times, is feeling your butthole open. We know where that is most of the time, right? When we have to go to the bathroom and we are not by a toilet, we know where that muscle is because we squeeze it. That's certainly not everyone, but it's a good place to start, okay? Now, the third thing is incorporating that diaphragmatic breath that we talked about after a workout or even before intimacy. And that can be a really powerful thing if someone is having pain with insertion, painful orgasms, painful arousal. And that could work for people who own a vagina and for people who own a penis. So give those three things a shot. But remember, we always want the end of that plan of care to look like that person lifting weights. They also may be doing Kegels, right? They may need to have that base strength of where, or I say strength, Kegels can increase strength for someone, but it's probably going to be short-lived, right? Because A, it's really kind of body weight, and B, we don't function just under body weight, we function under load. And so, ending with your plan of care of teaching this person basic barbell movements, dumbbell movements, Kettlebell movements, maybe that's where they're starting and encouraging them to lift weights. This looks different per generation, right? We may have to convince some people that this is a really good thing. And then other times we may not need to, right? People are going to be a little more into it. So, go out and try these three things. We've got the Squatty Potty, we've got Diaphragmatic Breathing, and we've got Diaphragmatic Breathing following a workout or before intimacy. Give those a shot and let me know how they go. I will see you in a couple of Mondays. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 3, 2024

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko tackles the difference between grip endurance & maximal grip strength. Joe also provides several programming examples to help clinicians know what to program, who to program it for, and when to program it. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code icept1mo at sign up to receive a one month free grace period on your new Jane. JOE HANISKGood morning crew. This is Dr. Joe and it's going to One of the lead faculty of the fitness athlete division here at ICE. Coming off a great weekend last weekend out in Carson City, Nevada at the Sampler. It was fantastic to see 150 or more PTs from the ICE community there. Great times, great learning, and looking forward to next year as well, which I think is sold out. So if you are interested in going, hop on and grab a waitlist ticket. Pay attention. Jeff will be throwing out some dates for hopping on that waitlist as well. So today, though, team, my plan is to cover… One second, I got a camera issue here. My plan is to cover advanced grip strength. So about a year or so ago I did a podcast on grip strength and it predominantly focused on what I would say is the nuances of grip strength using more of accessory training to build a grip strength within a fitness athlete or just an individual specifically who was looking to build grip strength. But the more I've sat back and thought about it, The more I've independently tried to train my own grip strength, which I find to be one of my weaknesses in the sport of CrossFit, I really believe that there's two versions of grip strength, strength that we need to focus on, depending on what our athlete or our person is looking for to develop there. Basically, what I'm going to get at today is specificity of advanced grip strength. And what we're breaking this down to essentially is two categories. Either someone is looking to build grip strength from more of an endurance perspective, and in the world of CrossFit, I would say that would be like in the gymnastics world. we're often really taxed on endurance grip strength. That is, while we are on the bar doing things like pull-ups, toast the bar, or possibly on the rings doing more than likely ring muscle-ups of some kind. That is typically what we're going to hear athletes complain is one of their breaking points is that they just couldn't hang on or that their grip strength was weakening and therefore when we know through a lot of research now that when the grip goes so do a lot of the other power producing muscles because the energy transfer is just not as clean and clear there. So when I think about endurance grip strength, we're thinking about gymnastics grip strength training. So that's one silo. The second silo is going to be more in our weightlifting world of CrossFit, moving maximum loads. But I think that the thing that we haven't really thought about as much is that when we move max loads, we're not doing it for long durations. The bar is in our hands for only a few seconds or fraction of a second from the time that the bar leaves the floor until the weight lifting movement, the clean or the snatch, for example, is complete. In other movements like the deadlift, we have strategies like a mixed grip that seems to not be a limiting factor for most once they've figured it out, meaning that many people can deadlift their maximum capability with a mixed grip on the bar and their posterior chair and their legs their back are not though are the limiting factor I should say that their grip strength is not the limiting factor so we have a resolution to that in the deadlift but when it comes to the clean and the snatch which require hopefully a hook grip position oftentimes people's grip strength can be a limiter they may not realize it but often again similar to the gymnastics world when the grip goes our power and our connection to the bar is dampened and when we're looking to create speed through that mid zone through that second pull of the olympic lifts Often people lose that torque, that grab on the bar, and they lose power production, and the lift may eventually be failed because of that. So certainly it's not the only thing to consider with weightlifting, but when we're talking about grip strength, we're going to look at max grip strength on the barbell as a separate training thought process than we would look at max grip on a gymnastics movement, which tends to be more endurance based. GRIP ENDURANCE Let's talk about endurance first. When I think of endurance-based grip training movements, the one that jumps to me right off the bat is just long-duration bar holds, dead hang or active hang holds on the bar or on the ring. That would be the most obvious one because it's the most specific to the gymnastics positions and that we are moving on the bars or on the rings. You could add in some dynamic challenges like hip swings or beat swings while doing long duration grip and hold. We could add weight or loaded holds active and dead hang holds from the bar and maybe you would even consider things like farmer's carries in this group where you're sustaining a grip on an object for long durations but often the load tends to be relatively moderate compared to our maximum effort, meaning that if you're hanging from a bar for a minute, that clearly wasn't, it may have been a max effort for that one minute, but it wasn't a max effort overall in total grip, like max grip strength there. So those are some of the ideas of how we might choose certain movements, but they're certainly going to look more like the movement itself, meaning the gymnastics movement as the basis. I wanted to give an example in each of these categories as like a programming idea that we could use so that it kind of comes into play. So lately what I've been playing around with on my grip strength training for endurance in the gymnastics world is mechanical drop sets basically, or even just loaded dropsets I guess would be the better word here because we're not changing the movement as much, but a drop set. Meaning that we're going to start with something that is significantly more challenging. and then we're going to try to maintain work output throughout the following sets but we're manipulating a variable in this case it'll be load so that even though we're fatiguing we're able to maintain high work output over the span so A drop set of active hangs for me lately has looked like this. I have determined what my maximum effort of around 60 to 70 seconds of a hang is loaded, and I picked that one minute mark for a couple reasons. I feel like it's an easy trackable number that we can repeat over and over again. It is a long enough time in the bar where very rarely are we going to see an athlete maintain more than a minute on any type of gymnastics movement that would be kind of at the peak. So I chose that 60 to 70 second mark and I've over time I've tested what my max ability to hang in that one minute mark is with adding load onto my body. So let's say in this situation that I can do a 45 pound plate hang for 60 seconds. That would be set number one. I would then give myself about a minute of rest following that 45 pound hang. I'll let the grip recover, but not too long. We're thinking endurance here. We want to repeat this again and I'm hopping back on the bar, but this time I'm dropping by, we'll say maybe 10 to 15 pounds. So we go from 45 to maybe a 30 pound a dumbbell or a kettlebell that we're now hanging from. Repeat that one minute. There's the drop set that we dropped load, but we're still doing one minute of output here. Rest 45 to 60 seconds. Then maybe we go to a 20 or 25 pound weight. And ultimately I've been doing anywhere between four to five sets. So if I start at 45 pounds, my very last set over those four or five sets is going to be just my body weight and I'm trying to hang. My goal is 60 seconds. But often what I'm doing here now is just providing a opportunity for me to really test my max grip hold on the bar or on the rings at body weight after hyperloading it in the three to four sets prior to that. So this is an example of grip strengthening for the endurance training of gymnastics, but you could do a whole lot of other things. But again, as a summary for the endurance grip strength, we're looking at moderately challenging loads, for longer durations, simulating ultimately the experience of having to hang on to the rings or the bar for long periods of time. We could consider dynamic movements as well, like kipping to challenge the grip or load. Those would be my two best suggestions. And if you're really, you know, in a bind, we could consider things like farmer's walks or carries as well too. MAXIMAL GRIP STRENGTH So now this has to directly, sort of oppose the next scenario in which we talked about silo number two being grip strength training on a barbell we're looking to move maximum weight the literally the the absolute max of load that we can hang on to and move effectively and then how we change our ability to have a stronger grip during those movements and So for me personally, I mentioned this briefly before, I believe and I feel myself that often if my grip is going, it's not that I physically couldn't necessarily hang on to the bar, it was that it was starting to break my ability to hang on to the bar effectively and energy was leaking out of my hands and therefore as I was trying to create speed on a clean or snatch, once I got past the knees more than likely in that second pull, into triple extension through the following third pull movement that I wasn't able to create enough energy through the bar to keep it accelerating upward at the appropriate speed or height and I was failing to get my arms up and under it. So I've been working on training grip strength on the barbell in really heavy positions on the bar and not only incorporating load but also considering speed because i think speed will challenge the grip as you start to move upwards and everything in the world is trying to push that bar back down towards the floor that has a unique dynamic that needs to be offset by incredible grip strength so here in the olympic lifting world i like to treat this more like strength training max strength training. If I were trying to improve a one rep max back squat, bench press, whatever, I want to kind of treat grip strength training in this scenario very similar. So this could be movements like Simply put, maybe even if you're warming up your deadlift, we start working on deadlifting with a regular grip, not even a hook grip, just a regular hand over hand grip, which is often going to be the most limiting, but this is a great opportunity that as you're working from 135 to 225 to 275 and maybe into that 300 pound range as you're warming yourself up for your heavy loaded deadlifts that you're just doing a regular grip. That is one option of training grip strength on the barbell. You're only getting those three or four seconds of each movement. If you're doing multiple reps in a row, you may have to re-grip the bar and you'll also realize how quickly that fatigue in the grip comes into play with that. But it's certainly an option that we could think about building grip strength on the barbell during our deadlift and our deadlift warmups. If you are a trained deadlifter, you will probably run into the scenario that eventually Your body could move more, but your hands can't hang on to it. And that's usually when we go to a hook grip, a mixed grip, or possibly straps. But more recently, the way I've been going after this is doing rack pulls or heavy barbell holds with rack pulls. So in a rack pull, I can set the barbell height to be starting at around the knee level, which is right after that transition zone of the Olympic lifts. And what I'm often looking to do here is pick a load that I can regular grip that i can move with some sort of speed and intent and i'm moving through that second pull position quickly but just from the rack so grabbing the bar really gripping it standing up with good technique good form and pulling into that essentially hip crease position that power position taking the bar right back to the rack letting go and then repeating it is a short burst a short intentional burst of grip strength that I'm looking to train at loads that are often similar to the amount of weight or even slightly heavier, we'll say 90 to 110% of what I could clean or snatch. You could do this in a wide grip or more on your clean grip, either one would be fine. But essentially what we're doing is doing short bursts at high loads. So if we're thinking about building out like a working set for somebody, I've lately been doing anywhere between six or seven, upwards of maybe 10 sets, depending on how I'm feeling, of just sometimes one to two or three reps in a set. So let's say I have 300 pounds on a bar in that rack position. I grab the bar, squeeze it like hell, pull to power position, set the bar back down, and depending on how that load is feeling, I'd either re-grip and repeat for rep number two, or possibly three, or maybe I'm just doing eight to 10 sets of singles at my max effort. It's unique in that it won't be overly taxing from a stamina standpoint, but it certainly will start to train the grip from a speed, power production, and we'll just call it an integrity position, where it really has to commit to doing what you're wanting it to do, which is hang onto that bar as it's moving fast through your transition zone. So that's an example of a working set that I would do, six to 10 sets, one to maybe two or three reps total at anywhere between 90 to 100, 110% of your Olympic lifting capabilities to start to build confidence and strength in that second pull, or possibly off the floor if that's where you feel like you're weakest, but the second pull seems to be where that speed change is occurring, which will challenge the grip the most. The third phase of grip strengthening, I guess, would be back to my original podcast that I'd done a while ago now, which I think a lot of us are becoming more familiar with, which is just accessory grip strength training. And this is the things like, you know, doing forearm work, doing plate pinches, doing spherical or dumbbell head holds, where you're grabbing on the top of a dumbbell, training our grip in different positions, narrow to fat grip. There's so many different ways we can go after that. But if we're only focusing on the unique, accessory grip strength training, I think we're missing the ability to be more specific and whether that specific need is in endurance, long duration, moderate holds, or if it's in more of a strength world where it's maximum loads, quick, fast bursts, I think we need to be thinking about what our athlete is looking for, what we're looking for as individuals and starting to train within that bubble. So hopefully that was helpful guys. It's been certainly helpful for me to train this way. I've been really putting some time into it. I'm hoping to see some changes because I've worked on a lot of grip work for years on and off and I felt like, you know, pound for pound, my grip was okay, but it was starting to inhibit my ability to move barbells faster. So I've been putting a lot more of my energy into this max barbell grip and hold position. Um, Good luck with it. It's challenging. I think you'll learn from giving it a go. And it certainly fits that mold of specificity, which is always important in our strength training world. SUMMARY So last thing before signing off, CMFA live courses coming up here in May. I think Mitch is out in Bozeman, Montana. I'll be in the Duluth, Minnesota area here in the next few weeks. So if you're looking to get a course last minute and you're out in Montana or you're in Minnesota, Michigan, Midwest area, that Duluth course would be awesome. It's a cool town. We're already filling up out there. And then in Fenton in June, the third weekend of June, we are doing a fitness athlete summit, which we are pumped about. It is going to be myself. It'll be Mitch Babcock, Zach Long, Kelly Benfield will be there, Guillermo will be there, Jenna will be there, Tucker, all of our lead faculty and TA are gonna be there. We're gonna try to implement more fitness, but you'll have tons and tons of opportunity to learn from some of the best in the business, so I would absolutely get onto that course. It is filling up super fast, people are excited about it. Mitch's Gym, CrossFit Fitness is an amazing place to be. It'll be a great time, so if you're looking for anything this summer to get into, I would say don't miss your opportunity there. Have a great weekend, we'll talk to you later. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 2, 2024

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses using dry needling for recovery, including e-stim parameters using the ES-160 unit. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION ELLISON MELROSE Welcome to the PT on Ice daily show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am here to talk to you guys today about recovery, so dry needling for recovery. We are coming off of Ice Sampler Weekend, and we had two pretty intense workouts this weekend, and we're feeling it, I think. So we are pretty sore in the quads, so what I wanted to demonstrate today was a recovery method for primarily the quads. We're gonna go over recovery mechanisms, how to choose the muscles when you're thinking about setting up a recovery circuit, and the e-stim parameters that you want for dry kneeling for recovery. So there are three main mechanisms of action when we're thinking about recovery. The first is pumping, so hemodynamics. We're getting big muscles to pump. There are some muscles that are better pumps and better sponges, so they do a better job at the fluid dynamics. The second mechanism is washing out cellular debris from in that intracellular space. So thinking a little bit more microscopic than just vasohemodynamics or moving fluid. We're thinking cellularly. So we know that active recovery and facilitated recovery can do both of those things. What's nice about dry needling when we're thinking about recovery is that we're not putting any mechanical stress on the tissues, loading like we would with active recovery. Third, we have an autonomic nervous system response. DRY NEEDLING FOR HEMODYNAMICS So one thing that they saw throughout the research is that dry, or e-stim, facilitated recovery with e-stim, there is a longer base of dilation effect after we removed the e-stem from the tissue. And so what they postulated from that is that we have an autonomic nervous system response, so we have increased vasodilation, which is just going to improve our body's natural ability to pump fluid. When we're thinking about choosing muscles, again, as I mentioned earlier, there are some muscles that have better capacity to pump, but also absorb fluid and that is based off what we call O2 flux capacity. We're not going to dive super deep into that today, but pretty much what it means is that there's increased capillary density in those tissues and so they act as better sponges and better pumps. When we look at the lower quarter, there are two main muscles that are going to be pretty good or have higher O2 flux capacity. One is the medial gastroc and the other is the quadriceps. CHOOSING THE RIGHT MUSCLES FOR RECOVERY Another way to think about what muscles to choose are thinking about following the venous system. So again, we're trying to improve hemodynamics. So we want to follow the venous and lymphatic system to encourage that fluid to work its way back up towards the heart. And so thinking about a lot of the bigger venous structures, the lymphatic tissues run immediately. So when I'm thinking about setting up an entire lower quarter circuit. Sometimes, depending again on why I'm choosing these, we may be doing medial gastroc, medial quad, adductor magnus is a huge pump for the lower quarter. And then working into the glutes as well. And then, last but not least, is we have sport-specific muscle fatigue. So when thinking about, a great example I like to use is in CrossFit. After a really grip-heavy workout, we may be just specifically treating the forearm flexors, so the muscles that we're using to grip, right? In this case, we did a lot of thrusters on Sunday, so we are gonna be doing a quad recovery session for Sam today. We're just going to demonstrate bassus lateralis. When we look at e-stim parameters, so we want things to be a pump. So we need to have the intensity at a motor response. We also need it to be a non-fatiguing stimulus. So if our goal is recovery, we are thinking we want it to be non-fatiguing. So we're going to keep the frequency low. we are limiting pistoning. So we do not want to piston the tissue. Every single time we move a needle around in the muscle, we are creating a little bit more micro trauma to that tissue. And that is the opposite of what we want to do when we're thinking about facilitating recovery. So I'm going to get two needles set up in the vastus lateralis here, and we'll kind of go through the e-stim settings and, um, dive in a little bit deeper there. So for the, the needling technique, ready cleaned her skin here. We are going to be using a needle for the vastus lateralis that we feel like we have the most access to that tissue. So when thinking about choosing needle length for a larger muscle, we want to be using a longer needle where I'm going to be threading through the muscle here as I can have access to more muscle tissue. where I'd be going towards the femur. I am floating the needle in. I am not pistoning. If we get a twitch response, great. I'm not necessarily looking for a twitch response. Because we want a motor response with the e-stim parameters, we do want to be localizing our tip of the needle at a muscle spindle interaction, which is what elicits the twitch response. So what we're going to be doing instead of pistoning is a little bit of live redirecting of the needle under e-stem. We'll talk about that. So I'm just going to choose two big portions in the vastus lateralis here and thread across the tissue to have access to more. Oh, nice little twitch there. Because I did find a twitch, I'm going to leave my needle there as again, that is going to be the closest to that muscle spindle interaction where we can have better motor response. Then I'm going to choose a spot up a little bit more proximal, threading across the tissue. Perfect. Okay. So no twitch response there. Again, not necessary. We're not going to be pistoning to find that motor response. E-STIM PARAMETERS FOR RECOVERY So, I'm just going to be setting up a circuit here. And we are looking for, I'm gonna just pull these cords out of the way so we don't have that blocking our visual here. We are using the ES-160 today. All right, so e-stim parameters.. Low frequency, so we're thinking below 5 hertz. We want a motor response. Duration. So the longer the duration, the better. So when we're thinking about this, the research looked at 10 minutes versus 20 minutes, and they had almost double the biochemical clearance with 20 minutes compared to 10 minutes. And so we are thinking we want to set these up for longer duration, so thinking greater than 20 minutes here. We're not gonna be doing that for the podcast this morning, but we will set up that circuit and look for that motor response. So I'm gonna be increasing the intensity. Sam, let me know if it's strong, but still tolerable. Okay, we're looking for that motor response. And if we're not getting that motor response, we are going to do a little bit of live redirecting. So I have switched the, and parameters to just constant, you can do alternating frequency, but it's not necessary in the recovery session. So really whatever's the most tolerable for the patient is what we're going to want to do. So I'm increasing my intensity until we get a nice, strong muscle pump. DRY NEEDLING FOR RECOVERY So, this is what we're looking for when we're thinking about creating that muscle pump. Again, non-fatiguing, so we're thinking lower frequency, longer duration. Our muscles that we're choosing are either based off of following the venous system, looking at the O2 flux capacity in the muscle tissue, or sport-specific fatigue. Our mechanisms here, again, we're creating a pump. It's just a pump, it's really that simple, right? We're pumping fluid throughout the system. We're clear at a cellular level. We're clearing some of the, we're washing out the cellular debris. And then we are also facilitating vasodilation through the autonomic nervous system. If you have any more questions about this, feel free to check us out on the road. So we have a couple courses coming up on the third weekend in May. So the 17th and 18th is, you can check us out on the road. I'll be down in Virginia Beach. And then we hit, I'll be back in Florida, so maybe Florida first weekend in June and Longmont, Colorado on the 20th, the weekend of the 20th of June. So feel free to check us out on the road and have a great rest of your Thursday. See ya. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

May 1, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer translates lessons learned from training for a 50k trail run into strategies to use when working with older adult clients to help them become the person they want to be as they journey through life. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app slash switch. And if you decide to make the switch, don't forget to use the code IcePT1MO at signup to receive a one month free grace period on your new Jane. JULIE BRAUER Morning crew. Welcome to the PT on Ice daily show. My name is Julie Brower. I am a member of the older adult division, and I am going to be talking to you all this morning about my favorite thing in the world, running. So this morning I am going to share with you some lessons that I've learned from training and running a 50k that I just ran this past weekend and I'm going to translate some of the lessons I learned and give you all some advice on how you can use those lessons with your older adult patients. So This past weekend, I ran a 50K, that's 31 miles, in New River Gorge, West Virginia. It was absolutely beautiful, absolutely brutal, and I was out there for seven hours and 14 minutes. That gives you a lot of time to reflect and learn some life lessons. So I'm gonna share some things with you all, and hopefully you can translate these to be using with your patients this week. LESSON 1: THE TRUE FINISH LINE IS AT THE END OF YOUR LIFE Okay, so first lesson. The true finish line is at the end of our lives. The true finish line is at the end of our lives. This is a quote by Sally McRae. If you all have not heard of her, she is my absolute idol. She is a professional ultra mountain runner. She is known for her mental fortitude and crazy accomplishments throughout her career. She just did the Grand Slam of 200 mile races, which are four 200 mile races in the span of five to six months, which is absolutely insane. So she has a, her own podcast called the Choose Strong Podcast. And I started listening to her as I was starting to train. Um, when I first started trail running like a year plus ago, a little bit over a year ago, And I remember I'm running on the trail, I'm listening to her podcast, and she said that, quote, the true finish line is at the end of our lives. All of these start lines and finish lines and belt buckles and medals that we acquire, they're just adventures along the way. They're lessons learned along the way, the triumphs and the failures. What matters is the end of our lives. And it's a story that we get to tell. So I, as I was listening to this, I was thinking back to when I was younger and I ran track when I was younger. And when I was running in a race, it was first place or last place. My entire world hinged on me winning that race. If I didn't come in first place, I was gonna have a bad several days, my family was gonna have a bad several days because I was miserable. And so as I'm listening to Sally talk about this, and I'm training, I'm realizing that life is not a singular race or a singular goal to conquer, and then we're done. It's a journey. And it's not about winning, it's about becoming someone who endures. So that's my thought about this is a journey in our lives, that the end of our lives is the actual finish line. It's about, for me, becoming someone who endures. Developing the mindset and the habits and the lifestyle of someone who can go out and run 31 miles in the mountains. Okay? So when you're thinking about this with your patients, especially when we work with older adults, it's never just about their one episode of care with you. From day one, when you're sitting down and you're talking to your patient or your client, you want to be speaking to them as if this is a journey that you're going to go on together. This isn't, we're just creating goals for you to accomplish at the end of our eight week plan of care. This is about connecting with their life journey. Who do they want to become? How are you going to help them develop the habits and the lifestyles to become the person that they want to be so that the next several decades of their life are happy, purposeful years? Start that conversation early. Start talking about what's next. Again, it's not we are ending this relationship in eight weeks. What's going to be beyond that? Do you have a side gig that you do private wellness in folks' homes and you're going to then provide personal training for them? Are you going to refer them to a gym and you start that process early so you find the right fit for them so they can continue on with fitness? Start talking to your older adult clients as if this is a long-term relationship and this is a lifelong journey. Start talking to them about who is the person that they want to become and how you are going to help them get them there. Okay, that's number one. LESSON TWO: PAIN IS MORE EASILY ENDURED WITH FRIENDS Number two, pain is more easily endured with friends. Pain is more easily endured with friends. Team, I have never experienced pain like I have when I was out there on the trail this past weekend. There was about 5,000 feet total of elevation gain and loss. You're climbing up rock scrambles, like vertical rock scrambles, treading through water, slipping on mud, rocks and roots the whole entire time. The terrain was absolutely brutal. I've never felt this type of pain before. I mean, my ankles and my knees and my feet were just absolutely destroyed and screaming at me for a long time. I went out on that second 15.5 mile loop and I knew, I was like, this is gonna hurt the entire time. It was not my cardiovascular system holding me back. It was the pain in my joints. Every single step was grueling. And I started to think, as I'm in this much pain, I'm starting to think about our older adult clients who have aches and pains and arthritis, and I'm like, man, this may be a little bit of something that they feel on a daily basis, right? I know that this pain for me is temporary. When I finish this 31 miles, it's gonna be over, for the most part, until the DOMS sets in, which has definitely happened. But older adults, pain may be a part of their lives. Now, we know that we can get people strong and we can influence their environment and help with their diet and their stress management and their sleep. Like, we can do a lot of things that can help with pain that they feel, right? However, I don't think it's fair to come at someone with rainbows and butterflies and tell them, like, you're never gonna experience any pain. I don't think that's fair. Pain may be a very real experience for older adults, even amongst them doing all the right things and getting really strong. And we have to realize that. So this is what I want you to think about. Pain is better endured with friends. And I will tell you when I was out running and I was on that second 15.5 mile loop, just miserable and miserable amounts of pain. The one time that I wasn't feeling it as severe were the times when I was running alongside someone. When I was having a conversation with someone else on that trail who was experiencing the same thing as I was. When I was meeting people and hearing their journey of their training and why they signed up for this race, and who's waiting for them at the finish line, and what they were experiencing in that moment, and you're distracting each other, and you're learning about each other, you're making friends with strangers. I did not feel that pain as severe as when I was spending time with someone else on that trail. And I will tell you one moment in particular, I was running with this one guy pretty consistently at the last like five, six miles of the race. And I was telling him like, I ran a 20 miler and then I jumped to this 50K. So skip the marathon. And at one point, we're continuing on and he turned around and he says to me, hey, you just ran a marathon. And I was just so taken that this individual, who's trying to concentrate on his own footing and his own race, turned around to give me the benefit of, hey, you just ran a marathon. You just PR'd. And that right there, I didn't feel any pain. I was so grateful for this human. I didn't feel a darn thing. So when you are starting to work with your older adult clients, I want you as quickly as you can, starting day one, try and get them to be a part of a community. I said it before, how are we going to plant that seed early to get them to discharge to fitness, right? To go on to their second part of their journey, start getting them a part of a community as quickly as possible. The pain that many older adults experience throughout the day is because they're bored. They're bored. They're not doing anything. They're not spending time with anyone. Try and find them friends as quickly as possible, whether that is a fitness facility, a walking group, a church group. Find them community ASAP. Get them to be socially interacting with others more than just you for that one time in the week. Because their pain they're experiencing, I promise, is going to be able to be endured easier when they are spending time with others. LESSON 3: FORWARD IS FORWARD Okay, next one. Forward is forward. Alright? Forward is forward. I had to keep telling myself that. especially before I was heading out on that 15.5 mile loop, that second one, because there's no way I was like, I am in so much pain. There is no way I can be in this much pain for 15.5 miles, especially knowing how much climbing I was having to do for the last five and a half miles. I couldn't believe that it was possible. All right. But when I kept on going back to focusing on becoming someone who can endure, Focusing on that goal. It's not about winning this race. It's about becoming. I am focusing on becoming someone who can endure. I am having people along the trail who can distract me along the way. Even amongst insane amounts of pain, you can move forward. And I had not experienced that until this past weekend. It's incredible what the body can endure if you just focus on continuing to move forward. regardless of what that looks like. There is so much grace in forward. For me, it was, okay, running quick, like my first 15.5 miles, I was zooming, I was flying, it felt awesome. The second loop ate me alive. Running quickly became jogging, okay? Jogging slowly, my jogging slowly became hiking. all right my hiking became i am leaning up against a tree hunched over absolutely miserable and making deals with myself like julie count down from 10 and then keep moving and i out loud was counting down from 10 and then i would say go and then i would just continue moving forward it is insane how you can chip away at miles and chip away at time and chip away at pain if you just focus on forward but you give yourself grace as to what forward means so applying this to your patients especially when you are putting them through an emom or an amrap have options for them, especially those who are high achievers and they want to be able to do the level one, the highest level of the exercise you're giving them. So have options for them. So I have a fellow right now, he was just diagnosed with pulmonary fibrosis, idiopathic pulmonary fibrosis, incredibly sad diagnosis, but cardiovascularly he's very deconditioned, but also he just feels like there's an elephant on his chest that he can't get air in. And so he gets very tired very quickly when we start exercising. But I know that it's so important to build his capacity any way we can. So I will say, OK, I want you for two minutes. burpees, okay? That's the goal. When you can no longer do burpees, then I am going to have you do some jumping jacks. Take away that transitioning from up to down. When those jumping jacks become too hard, I want you to march in place. When marching in place becomes too challenging, I just want you to walk. I want you to walk down to the driveway and back up. The only thing I care about is that you continue to move forward. Give your patients options and make sure that you let them know that whatever type of forward it is or moving that it is, it has value. Continuing to move forward through discomfort, through pain, giving a lot of grace there, that's going to build a lot of confidence and mental fortitude with your patients. LESSON 4: SOMETHING>NOTHING AND DONE>PERFECT Okay, last one, last one. I could do this forever, but last one. We're getting close to where we're getting too long. Okay, so last one. Something over nothing and done over perfect. Something over nothing and done over perfect. So this is another quote by Sally McRae. Something that I have just had etched in my mind ever since I heard it on her podcast. Team, the consistency of chipping away at a goal every single day. and saying yes to yourself versus no is so much more important than hitting your A goal every single time that you go out to train or you go out to compete. I wrote myself a note. It's right here. I put it on my fridge so I could see it every single day. I'm going to read it to you. Hey Julie, remember last time you felt like shit before going on a run? Consider not going, but walked out the door and went for it anyway. Data shows that when that happens, you regret saying yes to yourself 0% of the time. Say yes, start moving. xoxo that's exactly what this says and i looked at it every single day every single day because no matter how bad you feel and how much you want to say no when you say yes and you do something something it doesn't have to be My goal was to do six miles, and if I don't do six miles, I'm throwing the day away. No, that could be I do two miles. That could be I stay and I do 20 minutes of strength in the garage. When you say yes, and you continue to build that consistency, you build resiliency. You are building reserve. Every single time you say yes, you are building mental fortitude. And 100%, You will feel better when you say yes. You will never feel bad for saying yes. You always feel better. So when you are working with an older adult, You're making sure that, again, you give them options. Maybe they don't do their entire HEP, and instead of them, well, I wasn't gonna do the HEP, so I just didn't do any exercise. Make sure they understand that saying yes is so important. It's the same thing. Forward is forward. Yes is yes. If they don't want to do their entire HEP, my goodness, just do five minutes of it. Five minutes. Guys, they said yes. And yes is so incredibly powerful. If we know that we wanted them to do that high intensity EMOM, we're trying to increase their aerobic capacity, but they just weren't feeling it that day, they can do yoga instead. It's still movement. We know with older adults, something is always better. than nothing. And the more you say yes, and what I did, I started to tally up the amount of times that I said yes versus no. And every single time, how did I feel afterwards? I felt so happy and proud that I said yes, and physically and mentally I felt better. Once you elicit that same feeling with your older adult clients, and maybe you write something for them too, you write them a note to put on their fridge, and they track the amount of times they said yes, it's momentum. It's going to be so much easier for them to continue to say yes every single time. SUMMARY All right, guys, that's it. We've been here for 20 minutes. I could talk about running and lessons learned forever, but let's recap. Number one, that true finish line is at the end of our lives. It is about the story we want to tell. It's about becoming someone who endures. becoming someone who endures. Make sure you're connecting with an older adult's life journey and who they want to become. Two, pain is more easily endured with friends. Make sure day one you are starting to figure out how to decrease social isolation and help your client find friends to work out with, to experience different sorts of pain and competition and training with. They're going to experience their pain at a lower severity, I promise. Next, forward is forward. There's so much grace. Make sure that they understand that they've got options and you are hammering in that if you can't do that level one goal, We've got options for you and as long as you're still moving, it's still forward progress. And lastly, something over nothing and done over perfect. If we're not going to reach that A goal, it doesn't matter. Just say yes to yourself consistently every single day. It's going to build resiliency and reserve and confidence moving forward and saying yes is going to become a lot easier. All right, y'all, I hope you have a wonderful rest of your Wednesday. The last thing I will leave you with are what courses we have coming up. We've got both of our online courses coming up in May on the 15th and the 16th. 15th, level one starts. 16th, level two starts. And then on the road between May and June, we are in North Dakota, Virginia, Arizona, and Texas. PT on ICE is where you find all that info. Hit us up if you want to talk about 50ks and running. I'm here for it. Have an awesome day, guys. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 30, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division faculty member Cody Gingerich discusses the importance of focusing on the subjective exam during the first 2-4 follow-up visits to ensure patients are making appropriate progress. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. CODY GINGERICHAll right, good morning PT on ICE daily show. My name is Cody Gingerich. I'm one of the lead faculties with the extremity management. What I wanted to come on here today on our clinical Tuesday and talk about is when things are not going to plan. Specifically the subjective exam on visits two, three, four. Okay, so when people come in and they say, hey, you know, I don't think this thing has gotten any better. I'm feeling potentially even worse, or they had a flare up since the last time you saw them on that initial eval. And what then does that subjective exam look like when they come in on visits two, three, four? How do you dive into, do you need to make an adjustment on your plan of care? Do you need to make an adjustment on dosage? Do you need to make an adjustment on anything? Or do you stay the course and you dive into really heavily on what exactly happened? Okay, so that's what we'll talk about today. If you did a good, really good initial exam, right? And you're like, man, this thing presents like I expect. We're going after it. You choose a dosage and a diagnosis that you feel confident in what you have given that person leaving your clinic. And let's say they come back in in one week. Most of the time I'm seeing people on a once a week basis, but even if they come in later on that week and they come back in and they're like, ooh, you know what? We are not really feeling any better. They come back in, something happened, flared back up, and now you have a pretty difficult conversation, right? Because on an initial eval, if you felt confident, you probably provided that confidence to the patient of like, Hey, you know, I think we found this thing. This is definitely coming from your shoulder. Probably the more of those muscles in the back of your shoulder. And you know, if we do these two, three exercises over the course of the next couple of days, I really think things are going to get better. Right. And then they come back in and all of a sudden that confidence is not as high because they're like, Hey, you know, this is not getting better. And then what, where do you go? Where does that conversation lead you? GATHER MORE INFORMATION BEFORE YOU ABANDON SHIP So a big thing that I want to emphasize today is you need a lot, a lot of information from that person subjectively before you decide to abandon ship on what you were doing. Okay. And the reason being is there are so many variables that can happen in that time from when they left your clinic to when they show back up. Okay, and if you did that really good initial exam and you're thinking like, hey, I'm really on this thing, then your first initial thought when somebody comes back in, shouldn't always be a, oh, we did the wrong thing. More times than not, you want your curiosity to be, hey, okay, what did you, first of all, did you do the things exactly as I prescribed them? Secondarily, what did those couple days in between actually look like? A lot of times our patients have no real understanding of what actual movements can be their aggravating factors. When you did their exam, their subjective exam, and you asked for aggravators, then you did your objective exam, you found their aggravators. That does not necessarily mean that the patient understands then that those particular movements are going to aggravate them. They know the two or three that they told you, but there are so many other things in life that could potentially also be aggravating factors for them. And they're not going to be able to always put those pieces together. So go into that first conversation with curiosity and be saying, Oh, okay. You know, that wasn't exactly as I expected it to go. I thought we were really on the right track, but I want to dive into what did those couple of days in between here look like? Like, what, what did you get into? You know, what did you, um, spend your time doing? What did you do at the gym? If you were going to the gym, all of those types of things. Did you do those exercises we talked about as I prescribed them, or did you feel like you needed to do extra because they weren't hard enough? or did you not particularly do them? And that is going to start that conversation in a much better way than you just saying, oh, okay, in your brain, like, oh, okay, well we definitely did the wrong thing and we need to fully go back through an entire new eval and figure this thing out again. A lot of times those patients somewhere in that subjective are going to give you some clues on what actually was going on in their day-to-day life. A couple examples of that, okay? A big one, if we're talking about like a gluteal tendinopathy, okay? So think glute med tendinopathy. Potentially you've given them some kind of leg lift, maybe a side plank, some kind of glute, maybe side steps with a band, glute need, strength training, blood flow type of thing. Okay. Well, let's say that person also, you did not tell them, you didn't really even have this discussion of like other things that they potentially could be doing, or a lot of people try to manage their own symptoms. Okay. So if you didn't potentially give enough explanation of, Hey, this blood flow thing is the thing you need to do when you are hurting. I have seen many, many times where they are consistently stretching and stretching and stretching that glute med, bringing their knee across their chest into more of that like pigeon pose stretch. And if we're dealing with the true tendinopathy where irritability is fairly high, that can be a pretty significant aggravator to those tissues, even though the patient feels like it is helpful because it's tugging on the thing that is bothering them. Okay. So then they come in and you're like, man, they did the exercises. This is a pretty clear cut. Like this is glute tendinopathy. I don't know exactly what else it could be. Cause my hypothesis list, like we checked off, like we cleared the back, nothing's going on there. Um, but then they start talking about like, Oh, the only thing I can get relieved for, like, I spent all day just like yanking and yanking, trying to stretch. I'm stretching a bunch. And so then that has to be a, oh, okay. That conversation goes into, hey, I know right now that feels okay, but what we really need to do with those tissues is get some blood flowing to them. And what is actually happening is when you're sitting all day and then stretching, we're actually almost occluding blood flow and taking away more blood flow than what can get to it. And so all of those exercises that I gave you, although they feel like work, are also the thing that's going to make it feel better And you can use that as a symptom reliever. But we need to pause on stretching for the time being. And that language needs to be also relatively clear on this is a temporary pause. Temporary pause on this thing, it is not a you should never stretch your hip end of conversation, is a right now that is something that's aggravating you. So we still have a really good plan in place, but we need to control that variable and decrease that stretching time. Another thing that you'll start hearing is like, they'll be like, you know, I didn't do anything. If maybe your conversation the first day was around like gym movements and not life movements, um, You know, same type of conversation with the glute med temnopathy. I've had patients come back in where they were climbing a ladder all day. They were doing some housework, they were up and down on a, you know, a ladder and they don't really bring that up when you're saying, when you're going through your subjective, you know, what did, what did you do? And they'll say, well, I, you know, I avoided squats for the time being and I didn't do any deadlifts, but I did your exercises. So I just don't know why, you know, things could have flared up. But then you dive a little deeper. Oh, what did your weekend look like? And they're like, Oh, you know, I had a, I had a bunch of yard work to do. I was up on the, up on the house doing gutters and it was up and down standing on that ladder. And that position of the ladder has them essentially loading that glute, glute tendinopathy all day long, a ton of time under tension. And so now all of a sudden you're saying, okay, well now we need to pull back on that. Or over the course of this next week, you don't have any more yard work to do. So now let's go after this plan that we had in place. Okay, so subjective exam on days two and three or visits two and three when they come back in are vitally, vitally important to be able to really take a deep dive. Like that conversation may take an additional 10, 15 minutes if they are not moving in the direction because you want to be as curious as possible because you already did your due diligence on the initial exam. CONTROL EVERY VARIABLE BEFORE YOU CHANGE YOUR PLAN So don't immediately assume that you're in the wrong and have that patient conversation of what did exactly your day look like? What have you been doing to try and self manage this thing? And you know, what have you done in the gym? You've also can talk to people, they have no real understanding. I've had patients where they go to the gym and they did a rope climb, sandbag carry, Ski erg workout because they felt like it wasn't a shoulder heavy Exercises they were avoiding their shoulder because everything they thought sandbag was mostly back, you know Skis like core type of thing and rope climbs you're using your legs to pull yourself up. So you're not really pulling I And again, it's just one of those things where you have to educate those people significantly on like, look, I know you don't feel like it is, but the reality is you're using a ton of that shoulder, especially the posterior, your cuff on all of those exercises. And you are not really avoiding any of those aggravating factors. So be a little bit more explicit on your, what movements could potentially be aggravating. That's also when you learn the type of human you have in front of you and how much you need to give them reins or really pull back on those reins. Most of the time I try to err on the side of giving people a little bit more leeway. I don't ever like to tell people there's nothing that they can't do. It's just a matter of like how much and the volume and intensity and those type of things. Visits two and three is when you actually learn that person and how much reins you can give them. And you might need to start controlling more variables as a therapist for them, okay? And so that might be the time where you say, hey, this movement is out. I need you to really pay attention to when you're standing and when you're sitting and where that hip is in space. I need you to completely avoid this particular set of movements for these next two weeks to make sure we can calm symptoms down. That's when you learn if that person has an actual like throttle on them or not a self throttle Can they actually? Determine on their own what they can push through and what they can't and if you can determine that they come in and they are worse and they did a bunch of stuff that you would say, man, that was pretty reckless given the thing that you were dealing with. Now you as a therapist and the expert in the field can say, you know what, this is out, this is out, this is out. I need to make sure I'm controlling every variable in your life right now until this thing gets a little bit more calmed down. Okay. And that's where you need to put your foot down every once in a while with a few patients and say, Nope, that's not happening this week. You're taking this time off or you are going and doing more cardio based exercises or you are doing XYZ, not a, hey, I want you to pay attention to this and that. This could aggravate it or could not, but give them leeway and they come back in and it's worse. and you're like, man, that was pretty reckless. Now, as a therapist, you're saying, nope, we're doing this, this, and this. This is a temporary thing, but in order to get this under control, now I'm telling you what you're doing and what you're not doing, okay? Because that is your expertise now on the line. If you give them a bunch of leeway, and they come back in and they're worse, and you don't ever have that conversation of, you know what, nope, this needs to happen this way, then they just assume physical therapy doesn't work for them, right? Well, it's not physical therapy. It's not what you've chosen. It's all the other variables that you don't have control over. So you need to start having a little bit more control as much as you possibly can. You can't control everything, but as much as you possibly can on what's going on there. This is also the time where you ask about food, sleep, nutrition, and stress, okay? Hey, over these last three, four days, how did your sleep look? Were you getting good sleep over these last three days? What does your nutrition look like? Is it as you typically do or did it change at all? Did you go to any parties? Did you go to anything outside of the norm? Are you having any type of particular high stress environment right now? Do you have a deadline at your work that you're trying to get done? Is your kid sick? Is whatever the case may be, all again, factors in that subjective exam that need to be dove into if things aren't going well. Okay? These are all just making sure that you are on the right track and aren't abandoning ship too early. The other thing is if they come in and they're worse, you also want to be like, give them confidence in saying, Based on what we found the first time and based on the exercises that we gave and this thing that you did over the weekend or whatever the case may be, I can actually give you more confidence that we are on the right track. We just need to dial that in a little bit closer. We either need to cut the exercises that I gave you in half, like let's say all those variables have been controlled and they're still coming in like, man, I'm just really flared up. Well, then that was your fault on giving them a little bit more, not reading that the irritability quite as well. And that happens. I've done that plenty of times. That needs to be like, Oh, okay, cool. You know what? We're going to cut those exercises in half, or we're going to pull one of them totally out. That one was a little bit more than I think you were ready for. We'll bring it back in and maybe a week or two, but over this next week, now all of a sudden we need to just dial that one exercise in and make sure that that's not aggravating and your tissues can tolerate that. If everything else has been pretty clear and there wasn't anything out of the norm that you weren't expecting, then you just overdosed their tissue a little bit. Great. You know what? Sorry that you were a little bit feeling rough the last couple days, but I know that if we pull this back, we should be in pretty good shape moving forward. Okay. All of those things need to happen before in your brain you say, oh I messed up, we treated the wrong thing, and we need to fully switch gears and go to our second hypothesis. Until you have controlled all the variables, you have asked all of the questions related to nutrition, sleep, stress, plus what they did in their non-gym, just daily life, Have they done your exercises? You need to have all of that information, and it needs to be in your brain, like pretty much, hey, everything is pretty close to exactly as I would expect it, before you'd say, I think we should recheck this exam, and might go after that second hypothesis on our list. So that's the big thing, is trust your instincts first, whatever you found, if you did a really good initial exam, whatever you found, When they come in that second, third, fourth visit on those subjective exam, when they come in, make sure you're super curious. Go after all of those variables, figure out all of those variables. Once that's all been controlled and they're still not going as you would expect, that then is the only time where you would start to switch that hypothesis list. So overall, Be curious on make sure that that second, third, fourth visit, that subjective exam is is very stout and make sure that you are really doing a good job on understanding that person in front of you. Where's their headspace at? Are they able to tolerate what you've given them? Do they know how to pull back on exercises if they need to? Or do you need to be the one that says nope, you're pulling back on this thing you have you know, shown me that you don't have that ability. So for the next couple of weeks, I'm your boss on, you know, what you can and can't do. Always making sure that it's a temporary thing. SUMMARY Okay. So that's when things don't go as planned, right? Make sure that that subjective exam on the second through fourth visit is super dialed in and you know that you can, uh, have a good solid impact and still give your patient the confidence that they need moving forward. And it's not a, um, you know, hope, just hoping for the best and throwing things at it and, and hoping it sticks. And now your brain is all over the place. Okay, looking forward, extremity management. If you want, there's a couple seats left in Bellingham, Washington, May 18th and 19th, and then we got two courses running on June 1st and 2nd, one in Texas and one in, oh man, I just lost it. I believe it is. in Wisconsin. All right, Texas, Wisconsin, June 1st and 2nd. So jump on both of those. There are courses, there are seats open on both of them. So check us out. Find Mark Lindsay or myself on the road with extremity management and we will see you tomorrow. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 29, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the concept of "fitness freedom" as it relates to helping patients & clients embrace the ability to "choose your hard" in customizing rehab & fitness exercises. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. INTRODUCTION Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan and I am thrilled to be here with you all this morning. I am here in my Airbnb in Carson City, just coming off of the ice sampler and Wow, what a weekend we've had. We have had so much fun learning from all the different divisions here at ICE and learning from all the different instructors. And let's be honest, having a blast, having a blast with each other. It has just been an incredible weekend that we are still running high from. Today's topic is fitness freedom. And it really is fitting for today in reflection of this weekend, just because the 150 people that have been all together this weekend, of course, we're all different fitness abilities, right? We all have our different fitness goals. WHAT IS FITNESS FREEDOM? And as I was thinking about this topic that is fitness freedom, which comes from our street parking friends, Miranda and Julian Alcraz. As I was thinking about this concept of fitness freedom, to discuss with you all this morning. It was beautiful how really the last two days here at ICE, it was just laid out perfectly. And so I wanna talk with you all a little bit about what fitness freedom is, what it means, and where it came from, and how we can implement it in our lives, as well as our practices, ultimately for our communities all across the nation. So, as I mentioned, we just got off of Sampler, and over the past two days, we've had various divisions talking. We went through different labs, and when our pelvic division did the lab on bracing, Rachel said, choose your heart. We did pushups, and we worked on bracing within pushups. But for every single person, a variation of push-ups is going to be appropriate. For some people, we may need to do the push-ups on our knees. For other people, we may need to have weight on your back. I'm giggling because if you saw the reel at ICE, you saw Dave Finkelstein laying backwards on top of Zach Morgan as he was doing the pushups. So maybe your weighted pushups is a human. If you missed that little scene, watch the latest reel, because it was hilarious. But choose your hard. That was what Rachel told us. Choose your version of hard, because you're gonna get the best out of this lab if it is relatively difficult, Not too difficult to where you can't do it, of course, but also not so easy to where you can't get what we're needing out of this lab, which is a brace. We need to find that moderately difficult heart. Choose your heart. Then in extremity lab yesterday, we went through so many exercises for the shoulder and so many ways to improve our clients, ourselves, our overhead athletes shoulder capacity. And as we're going through these exercises, they said, pick your poison. They said, choose your own adventure. You choose the internal rotation option and you choose the external rotation option that works best for you. Choose your own adventure. The same concept. We're not gonna tell everybody to do the exact same thing because there's so many options here. Let's individualize it for that person let's let them have fitness freedom. The freedom to choose what is right for you and your body at this exact moment in time, which applies to your goals, which may be different than what you would have chosen a year ago and is probably going to be different than what you'll choose next year. Fitness freedom. Do what you need to do right now. And Mitch, at our group workout, running 150 people through a group workout, which did include barbells, and he said, I like to ask people, what is your seven minutes of burpee time? Reps, how many burpees can you get in seven minutes? It doesn't matter the score that you get. It matters that you know. He said, as we're working out today, it doesn't matter what your score is. It matters that you're here, that you're sweating, that you're working out alongside each other. That is what matters. That is fitness freedom. I did a different weight than the person next to me. We did a different, it's all freedom within and it's all fitness. We choose it differently based on our own goals, based on our own needs. Now this idea, this term, I did not coin, this term of fitness freedom, I use all the time. If you've been to our live courses at Pelvic, you've heard me say this, because as we're giving various exercises, various versions of squat and pull-ups, we say it's fitness freedom. Do what you need to do to make it hard for you, to make it easy for you. Maybe you need that, whatever that is, but you've probably heard me use their term fitness freedom. I'm going to read a quote from street parking from Miranda and Julian. because I think it just so beautifully describes not only their company and their vision and their values, but also something that I think you all will resonate with as well. They say, consistency is one of, if not the most important values here. Doing with fitness freedom, in parentheses, embracing the ability to customize and make the workouts for you. and more than nothing, getting rid of the all or nothing mentality. It is so beautiful. I've been doing for the last three months street parkings programming and when you sign up for their programming, you get their emails and I read almost every single one of their emails. Their wording to describe to people this fitness freedom, to describe to people how to get fit. And that is consistency before intensity. It is choose what you need to do for your fitness so that you will be consistent. Because we know that consistency is what drives changes in humans. Consistency is what allows for these individuals to make life changes. We're changing lives here, not back pain. We're changing lives here, not peed pants. What is it that will allow people to exercise, to feel the freedom to do what they need to do on a regular basis to ultimately change their lives? Let's help them find their freedom within that. It's a beautiful saying. We use it all the time. Live this, embrace this. As I've been doing this programming, I have really learned to understand exactly what they're talking about. They have four different versions of every single workout. You choose your heart. You choose your own adventure. Sometimes I'm working out at the clinic at Onward here in Hendersonville, and I don't have I don't have an echo bike. My echo bike is at home. So maybe for that portion of the workout, I'm running outside. Or maybe when I get home, I've got my echo bike and I've got a box, but I don't have barbells. So I'm gonna use the dumbbells. Use what you have. We're changing up the equipment. We're customizing it for ourselves. But the same can apply to that mindset. Maybe for my… pregnant mama who wants to exercise, who wants that fit pregnancy, but she's sick and she's low on energy. Maybe for her, that fitness freedom is just moving through without even touching any weight. We all know what ideal is. We all know where we want to go, but that's a goal. How do we reach those goals? We don't just start doing it. We don't just climb the mountain, right? We train to climb the mountain. Part of that training to climb the mountain, so to speak, is to just move your body through that workout for that individual. Don't even touch the weight. Have a no sweat day, where you're just moving through that exercise, but you're not even sweating. Any of these concepts to break that down, to allow them to feel The freedom to choose whatever it is, is such a beautiful thing. So many individuals do not have that freedom, or at least they don't know about it. They don't mentally have that freedom. They think that they have to do everything as hard as possible, or else it doesn't count. I have to do that RX way, or why even bother? They're saying to themselves. I have to do better than so-and-so. I always do better than them. And if I back off at all, they're going to beat me. Well, maybe for a time, that's okay. We would rather you show up and be consistent in your workouts than not show up at all and not do the effort, not do the work. Allow for that fitness freedom. If you come to ICE courses, you are definitely going to experience that fitness freedom. You're definitely going to experience that group workout at the end of every Saturday, every day one at ICE. We always do that group workout. You are allowed to customize that workout for you. You have that fitness freedom. We'll make suggestions, we'll make ideas, but at the end of the day, it's your workout, and we're just here to guide that. Embrace this, learn it for yourself, and ultimately teach your clients about that. Teach your clients to where they can, at the end of the day, take those baby steps all the way to reach their goals. SUMMARY Thank you all so much for being here and listening this morning. Just wanna do a quick little notification for you all who are listening live. Probably by the time you're listening to this on the podcast, next year's sampler will be sold out. So if you're listening live and you want to go to the sampler next year, which you want to go to the sampler next year, 91 people are already signed up. This just went live on the website, um, 24, 48 hours ago. 91 people are already signed up. We only have 59 tickets left. Today is Monday, April 29th and they will sell out today. So if you want those tickets, if you wanna enjoy this beautiful place that is Carson City right outside of Lake Tahoe, come join us, buy that ticket to where you can join us. Today marks day one of Pelvic Online Level 1 and Level 2 starting out. This is our very first cohort for Level 2 and we are amped to have so many people who are ready to provide this fitness freedom this fitness forward pelvic health to their communities in this level two. And we're of course excited about all of the folks who are joining us with the level one as well. Some people have taken the live course before, some people are brand new to pelvic, taking this online course to understand a little bit more about how they can help themselves maybe, their family members maybe, and their communities about pelvic health. So if you are interested in joining us, we've got some online courses coming up in a couple of months. They will sell out, they always do. Level one starts in January, level two starts in, I'm sorry, not January. Level one starts in July, and level two starts in August. So be sure to sign up for those, we would love to have you. And then lastly, if you want to join us in May or June for Pelvic Live, we are going to be in four different cities. We are gonna be in Kansas City, Missouri, Anchorage, Alaska, Highland, Michigan, and New York, New York. So we would love to have you join us for our live course as well. Thanks for joining me this morning. Enjoy your fitness freedom and hopefully we'll see you next year at Sampler. Take care. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 26, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the why behind the footwear recommendations they make and why minimalist footwear may not be the best choice for many fitness athletes to start with as well as how proper footwear can have an added benefit of improved strength, hypertrophy and fitness Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. GUILLERMO CONTRERAS Here we go. Good morning, fitness athlete crew. Good morning, PT on Ice Daily Show. Welcome to the PT on Ice Daily Show and the best day of the Fitness Athlete Division of the Institute of Clinical Excellence. Super happy to be with you here this Friday morning. fitness athlete footwear. And that's a little teaser there. Hopefully you get excited for that. Before I start jumping though, I want to say anybody headed to Reno, Nevada, in Reno, Nevada for the ice sampler, have an awesome time. Have an epic time. A little bit of FOMO not being able to be there, but hope you all have a wonderful time. Take so much out of that weekend. It's such a great weekend. So much to learn. So many to learn from. And I've done this topic in the past. I've talked about my shoe recommendations for fitness athletes, whether it be the Rad One Trainer, the Strike Movement Trainer, the Nano, the Metcon. I've gone deep dive almost too long into episodes with that in the past. And today's actually a more of a, let's call it a response, a response PT on this episode, discussing why we don't, or why I don't personally recommend barefoot in the fitness athlete, whether it's the level one or the live course, we get asked, hey, what are your thoughts on barefoot shoes? Or why aren't you recommending minimalist shoes to allow the foot and the ankle to naturally do what the foot and ankle should be able to do? And this is where we're going to dive into, right? This is the topic I'm discussing because we know there's different shoes out there, right? I have somewhere in front of me right here. This would be a minimalist shoe, right? This is a zero drop shoe. it allows the foot display so a really nice wide toe box. It allows the foot to move naturally, allows the ankle to move through a broad range of motion. Why is that foot, why is that shoe wear not something we recommend to the majority of fitness athletes? to explore that full, broad range of motion that we wanna see with squats, squat cleans, wall balls, air squats, you name it. Why is that? when we look at shoe wear, we know that there's aspects to it, right? There's the forefoot, there's the midfoot, there's the heel, and we have something called a heel drop. And the heel drop, essentially, I'm gonna grab another pair here, is the amount of drop a four millimeter heel drop from the back of the shoe to the front of the shoe. That means that when I put this shoe on, my heel is lifted up just a little bit, just about four millimeters difference. What that does for me as an athlete, when I am squatting, is that it gives something we like to coin a dorsiflexion buffer. on board so that when I squat, I have maybe a little bit more available ankle dorsiflexion range of motion for me to squat with. When we take that away, when we go into that minimalist where we have a flat, fully flat shoe, if I am limited at all in ankle mobility, ankle dorsiflexion, that shoe is not going to allow me to have as much anterior transition to that tibia. it's then going to reduce the depth with which I can get into my squat, or it's going to push me into some more funky motor patterns, what we call the immature squat pattern, where my shin moves forward, but then it stops, which means my hips can't go any further without me losing balance or falling backwards, which means my torso needs to dive much further forward, which leads typically to a significant increase in stress on the posterior We're going to increase the loading, uh, the, the, the, the torque on the hips and the posterior chain when we significantly limit that anterior translation of the tibia. We know that from research, right? We know that it's no longer recommended or should be recommended to teach to restrict amount of increased stress to the lumbar spine, the posterior chain, and the hips when we do that with a very minimal decrease in stress to the knee. If you look at the data from the research, it's about a 53% decrease in the knee. 1,000% increase in torque to the low back, hips, and posterior chain, right? That's a huge trade-off. Whereas if we allow that tibia to translate forward, that knee to move forward, it allows for a more upright torso, a more vertical descend into that squat, and improved motor pattern there. So all that to say, when we give minimalist footwear, and we don't know what the individual's mobility is like, or we do know, like, hey, I know this person has really stiff ankles, And what we see both anecdotally and pretty much everywhere is that the ankle is one of the most difficult joints in the body to create mobility. And it can take years to improve ankle dorsiflexion range of motion. If you don't believe me, you can talk to our COO, Alan Fredendahl, uh, who's been working on ankle dorsiflexion for darn near a decade now, probably. And he's, he's doing much, much better now, but it's, it's been a journey for him to try and improve his ankle dorsiflexion. that athlete's ability to sit deeper into that squat with that more mature vertical squat pattern. And when we're talking about CrossFit or fitness athletes, that means that we're limiting the squat, including the back squat, the front squat, the overhead squat, squat cleans, squat snatches, pistol squats, wall balls. There's all these movements where we want to have a vertical torso, a more upright torso when we're performing it or receiving And when we take away mobility from the ankle, we restrict that motion because we're saying you need to go barefoot at all times to really work on it. You need to work on your mobility. Okay, you're not gonna go to depth until you can have better ankle mobility. We are significantly reducing that athlete's ability. to improve, strengthen the knees, strengthen the hips, strengthen the trunk because they can't load that barbell as much. We're reducing fitness level because now they're doing less work in the same amount of time as maybe their counterparts in the same classes or following the same programming and such. So we use the shoe to allow for that dorsiflexion buffer to allow for a deeper squat. We also recommend TO Slide a pair of VersaLifts, of heel lifts underneath the insole, they sit in there. Now instead of a four millimeter, maybe they have more like, I believe VersaLifts are eight millimeter or so. So it'd be like a 12 millimeter, which is, it's pretty high up, right? But it gives so much more mobility in that ankle to allow them to sit deep into a squat with good mechanics, with good motor pattern, and really, really hit the deep ranges that are gonna allow them to train a greater amount of the glute max, a greater amount of their quad to a broader range of motion, right? powerful hip extender that most people don't realize only really gets targeted when we're hitting those deep ranges below parallel to the squat. Again, this is not me saying barefoot or minimalist shoes aren't for nobody, right? There are individuals who have fantastic mobility in their ankles, great mobility in their hips. By all means, if they want to wear a two millimeter heel drop like Vans or Chuck Taylors, or do you want to wear a New Balance Minimus or the, I think the Xero, X-E-R-O, whatever those are. Those are fine for those individuals if they have the adequate prerequisite mobility in their ankle, their hips to be able to perform these movements are really good quality patterns. But for those of us who might have a limitation in the hip or limitation in the ankle, we have should be recommended. right? The two I have right in front of me, right? The strength movement, his trainer, four millimeter heel drop. This is someone who maybe has pretty good hip mobility. Um, and they can make up for a little bit of lack in ankle mobility with that, but they still have more than like 10, 15 degrees of ankle dorsiflexion. Um, me personally, I have like 30, 35 degrees of ankle dorsiflexion. I have decent hips. These work really, really well for me. These are my favorite training shoe for They fit more true to size than they used to. This has, uh, the rad one trainer, um, has a seven millimeter heel drop. Uh, and it is much larger. It's different. The heel is really good for lifting. It's good for Metcons. I have a lot of people at our gym who love these shoes. Uh, really high recommend these for those who maybe need a little bit more ankle dorsiflexion buffer or limited in their ankle mobility because of that. And one I don't have with me right now, if you have more of Um, and you don't like your toes display a whole lot, uh, tier T Y R their tier one trainer has a nine millimeter heel drop. So the biggest heel drop and they just standard training shoe that you can find. And that is the one I recommend to my individuals who like, Hey, I have horrible ankle mobility. Um, I always struggle to hit squatting full depth without my either my ankles kicking in or my going up on my toes. What do you recommend? Um, that's uh that's tier one trainer um excuse me first ones are called oh i'm sorry these are the uh strike movement haze trainer strike movement haze trainer so there is a strike movement right there uh strike movement without any vowels in the movement um so the haze trainer uh good quality shoe really really solid uh great for med cons i love them for weight lifting as well um and again nice and like a wider toe box not too wide but not too narrow at all either so really comfortable i love these for So hopefully that answers your question. And if you're looking for the evidence, right? Like, oh, well, like you gotta be able to use your feet. You gotta be able to use your ankles. In 2022, a study from the Journal of Strength and Conditioning Research came out on the effects of footwear and biomechanics of the loaded back squat to exhaustion in skilled lifters. So these are people who are already lifting, who probably already have really good mechanics and strength and everything on board. And they made one group lift barefoot or minimalist as barefoot style shoes. One group had to lift in like heel elevated shoes. And what they found was there's no difference more in like a novice athlete or beginner athlete or maybe people who maybe don't have that same mobility but in these skilled lifters people have been doing it for a while there was no significant difference in that either shoe reduced joint loading or improved joint range of motion for them they already had the adequates on board so the reason I even always emphasize, more than anything else, in the level one, in the live course, when people ask about shoe wear, about are we going to restrict someone from squatting until they have adequate ankle mobility, do we give them a shoe like this, is this okay, or do we give them a minimalist shoe right away, and if they can't do it, do we let them do it? It's always and, not for. I'm going to recommend something like a Rad1, and if they need it, a Rad1 with a heel insert, a VersaLift in there, while they work on ankle mobility, while they work on their hip strength, to work on their squat, to continue being a part, a participant in their CrossFit class, in their group fitness class, without needing to worry about scaling every single time, without needing to worry about modifying every movement every single time, and then they are also going to continue working on their ankle mobility diligently to get to a point where maybe they can take that heel insert out and they feel really comfortable here, and they can move to something like this, and then they can move to minimalistic. That is their end goal. It's always and, not, or with this type of If you want to learn more, if you want to ask this person live and really have a debate with me one-on-one, we have courses coming up where you can meet us on the road, where you can talk all things shoe. Like I love talking shoes. I love talking footwear, worn them, almost all of them. Love doing it. SUMMARY But we have courses coming up. Our CMFA online level one just sold out. So if you've been looking to take an online level one course with Fitness Athlete, we are not having another one until fall of 2024, but you can sign up for that now. So if you want to register for that now, this course always sells out. We always sell out before we start the course. We have a course in the fall. You can sign up now. You can wait until the summer to sign up whenever you want to. Our next level one one if you've taken the live course and you just have the level two to finish up your CMFA cert or if you just want to continue down the path of that CMFA cert we have CMFA level two starting up in September uh on to a year. So again, if you're looking to get that certification, if you're looking to learn more about Olympic weightlifting, programming, modification, even some business type things, check out the level two CMFA course on September 3rd. That one also always sells out before it starts. So if you're looking to take that, sign up sooner rather than later. If you want to hit us up on the road, you're looking where we're at. CMFA Live is going to be on May 18th and 19th in two different locations. Proctor, Minnesota. I believe Joe Hnisko will be leading that one up in Proctor, Minnesota. And then that same weekend, I'll be hanging out with Mitch Babcock in Bozeman, Montana. That is, again, the weekend of May 18th and 19th. And that's all we have right now in May. And then June, on June 8th and 9th, you can hang out with the barbell physio, Zach Long, in Raleigh, North Carolina. And then on June 22nd and 23rd, we have the first ever annual Fitness Athlete Summit. You're going to see every single faculty and TA and every member of the fitness athlete crew. You have Mitch, Zach, Joe, myself, Kelly, Jenna, Tucker. We're all going to be coming together in Fenton, Michigan at CrossFit Fenton for an epic weekend, more fitness and fun and sweating and learning than any course you've ever done in your career. So we would love to see you at the Fitness Athlete Summit on June 22nd and 23rd. I believe it's about 45 minutes, an hour, something like that away from Detroit. null: So quick flight in. You can also SPEAKER_00: to fly into Flint, I believe, which is a shorter, even shorter drive from there. But we would love to see you there and have you join us for the Fitness Athlete Summit in June of, June 22nd and 23rd. Gang, thanks so much for tuning in this morning. Have a wonderful weekend. Again, if you are at Sampler, have an absolute blast. Enjoy yourself for me as well. And we will catch you on Monday for the PTNX Daily Show. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 25, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the history of non-compete agreements, relevance of non-competes to PTs, and recent law changes banning non-competes. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Good morning. If you're listening on YouTube, Instagram, the podcast, we're happy to have you. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions here on Leadership Thursday. We're going to talk about non-compete agreements today. But first things first, Leadership Thursday also means that it is Gut Check Thursday. So, Gut Check Thursday this week will be the Ignite Workout from our friends over at Forging Youth Resilience. FIRE, we team up with them every year. They support kids learning CrossFit, using CrossFit to help themselves with mental health, and other things they have going on in their life. So this year, they are doing the Ignite workout in the month of May for Mental Health Awareness Month. And we're going to do this workout this weekend at the Ice Sampler here in Carson City, Nevada. And so the workout, what is it? It is a two-part workout. It has a conditioning piece and it has a weightlifting piece. So it starts with an 18-minute running clock for the whole workout. So start at 18-minute clock and then work your way through 21, 15, 9. Thrusters at 95 for the guys, 65 for the ladies. Lateral burpees over the bar and then ab mat sit-ups. And then in whatever time you have left in that 18-minute window, you're going to max a complex of a power clean and a hang squat clean which must be performed unbroken. So cycling that power clean back down to the hip and then moving through a hang squat clean for a max load. Now this year at The Sampler we're going to do this in teams of three where three folks each do the workout at the same time. They have a combined time and then they have a combined load on their weight lifting piece. And what we're asking folks to do at the sampler, and we're asking you all to do as well if you hit this workout, is to consider donation to FIRE in whatever amount, one cent, 50 cents, one dollar, for every second you are slower, and every pound you are less on the complex than the team that FIRE has assembled of CrossFit Games athletes. So EZ Muhammad, Noah Olsen, and Sam Dancer have teamed up to represent FIRE. And the challenge to all of us is to try our best to beat them. And so we ask you all to consider donation in the seconds you are slower, pounds you are less on your lift. And then ICE will donate $1 per second and $1 per pound to any team whether you're here at The Sampler this weekend on Sunday or whether you're doing it at home in a team of three, we will donate $1 per second that you are faster and $1 per pound that you are heavier on your complex than that team of CrossFit Games athletes. So a little challenge flag for you all. If that is your team and you are not here at The Sampler, we would love to see a full video posted somewhere, shared with us, and then we'll make a donation on behalf of your team to fire. So that is the Ignite Workout. We're super pumped about that. Today on Leadership Thursday, what are we talking about? We're talking about non-compete agreements. So most of us are somewhat familiar with these. Some of us are unfortunately very familiar with these. We may have a non-compete looming over our head that we're worried about. So my goal today is to talk about the history of non-competes, the purpose of non-competes, and then talk about some recent changes to non-compete agreements that are really in our favor on the employee side of the equation. WHY NON-COMPETES? So first things first, when and why did these begin? These have been around for a while. These are becoming more prevalent in healthcare certainly, but these are primarily designed to limit the ability of somebody to leave a job and take not only their experience, but maybe knowledge of technology or systems to a competing company. So that is why they were created. So you might say, well, that seems like a pretty good reason. But in reality, what happened is that non-competes just became so prevalent that pretty much every person at every job, no matter what they were doing at that position, ended up being asked to sign a non-compete agreement. And what we've seen and what the government has done a lot of research on over the years is, is this good or bad for workers? And is it good or bad for the American economy in general? And what they have found over the years is that it is very bad for the economy. Why? Two reasons. It suppresses wages and it increases worker dissatisfaction. So obviously if you're working at a position and you're asking for a raise and you're not getting a raise, you're asking for a bonus, you're not getting a bonus, you're asking for a promotion, you're not getting a promotion, The answer when you have a non-compete agreement has always been too bad. You can't leave anyways, right? So we have no reason to help you further your career along. And now you can imagine how that part influences worker dissatisfaction of feeling like you are stuck, feeling like you have no mobility in your career, feeling like if you leave you might end up with a lawsuit, you might end up in a really bad position both personally and professionally. And the thing to know about non-competes is they are not in effect everywhere. There are some states that have never allowed them, and there are some states over the past couple years that have begun to ban them, either across the state or for specific workers. So a good example, California and New York, a couple other states have completely banned them. And then a lot of other states, about 25 states in total, have restrictions on who they can be applied to. And they can't be applied to specific professions or people making under a certain amount of money. And the whole idea is we cannot control the ability of people to have upward mobility in their career. That's obviously bad for the individual, but it's also bad overall for the economy. People who make less money, spend less money. People who make less money, pay less taxes. So the government is very interested in seeing what happens when non-competes are in effect and when they're not in effect. Your thoughts on California notwithstanding. California is a great example of what happens when non-competes are not allowed. They have been banned in California for a very long period of time. And you can imagine an area like Silicon Valley where all of our technology is essentially created and invented would simply not exist with non-competes because people would not be able to leave and have upward mobility in their career to join a different software company or something like that if they had non-competes in effect. And because non-competes are banned in California, we see higher than usual income for workers in California. Yes, unfortunately that's offset by cost of living because California has a really nice climate and everybody wants to live there. But that is the reason why wages are higher on average. And thinking about world economies, The United States is number one. We have about 25% of all the world's economic output happening just in our country. But not too far behind is the state of California itself. So if we look at largest economies in the world, United States is number one, China is number two, Japan is number three, Germany is number four, and actually the individual state of California is number five. And part of that is favorable worker laws like having non-competes banned. So that is the history of non-competes. RELEVANCE OF NON-COMPETE AGREEMENTS TO PT Why have these never really been appropriate for us as physical therapists and for healthcare workers in general? As physical therapists, we are not really using a lot of proprietary software or technology or systems that we could leave a position and move to a different employer and really have, you know, inside secrets. We can all agree there are really not a lot of inside secrets and technology and stuff like that inside of physical therapy that would offer a competitive advantage. The primary reason employers are upset when PTs leave is that they're now generating revenue for somebody else and not for them anymore. And when we think about what does it take to become a postgraduate professional, especially a healthcare provider, a physician, a physical therapist, a dentist, whatever, it takes a lot of time and it takes a lot of money. And non-competes for healthcare providers have never historically stood up in court anyways to begin with because it is so limiting on our career mobility to say that you cannot work for another physical therapy organization. You cannot create your own physical therapy company for five years within 50 miles of your current employer. All those restrictions that we see in non-compete agreements make it very, very difficult to continue to work. in physical therapy in general, let alone close to where you currently live. Some of them are so restrictive, folks either leave physical therapy entirely, or they have to essentially move very far, potentially out of state, to get around their non-compete agreement. And knowing that they're not held up in court, they're primarily used as a scare tactic of People don't want to be in court. They don't want to be sued. They don't want to potentially lose their license. So even if they've been told, don't worry about that non-compete, they worry about it. In our brick by brick course, our practice management course, this is one of the biggest concerns with people starting the course of, hey, I don't want to start my own business yet. I signed this non-compete for two years, three years, five years. We have met people who are working in fast food, who are waiting tables as physical therapists because they are so scared to leave a position as a physical therapist and work somewhere else. that they decide to just at least temporarily leave physical therapy entirely, which is devastating. That is a significant reduction in the income you could make as a physical therapist if you decide to wait tables or if you decide I have to move out of state to continue to work. And so they have never historically held up in court and they have primarily been used as a scare tactic, especially for physical therapists. NATIONWIDE BAN ON NON-COMPETE AGREEMENTS ISSUED APRIL 23rd, 2024 So, the history of non-competes, the relevance of non-competes to physical therapy, what has happened recently as of this week that is a great change. On Tuesday, the Federal Trade Commission, the FTC, announced that non-competes were banned nationwide. And so they have been watching this issue for a while. They have been doing a lot of research on this issue for a while, and they have decided it's in the best interest of the American people and the American economy to ban non-compete agreements everywhere. So as of that issuing of that rule on Tuesday, April 23rd, 2024, Any current non-compete, so if you're sitting here right now and you're listening to me talk and you have signed a non-compete, it is invalid. It cannot legally be held up in court ever. And you cannot be asked to sign a non-compete moving forward. There are some exceptions here, but they largely don't apply to us as physical therapists. The one exception is that you can still be asked to sign a non-compete if you're a C-suite level executive who has ownership stake in the company that you work for and you make more than $151,174 a year. So some of you, depending on where you live, you might make more than that. However, unless you're a C-suite level executive who has ownership stake in the company you work for, then still you are exempt from being asked to sign a non-compete. So where do we think this will go? Well, we're not quite sure. Any party, public or private, has 120 days to challenge this rule. In August, it will become permanent, but we have about four months where private companies could sue and say, this is not allowed, you can't tell us what we can do with our employees. Public organizations such as state governments at the state government level can sue, and then other governmental organizations can sue. Because the Federal Trade Commission is an executive branch of the government, or at least an arm of the executive branch, the president also has the power to shut this down. Congress has the power to change this by passing a law about it. And then any individual organization, public or private, can elevate this to the level of the Supreme Court for the judicial branch to weigh in. So all three branches of government have chances, one way or another, to weigh on this issue. and either cement it, certainly if it's drafted into law by Congress, it becomes a much more solid rule, but if we don't see it challenged, then this will become permanent. And we really like this here at ICE. Again, in our brick-by-brick course teaching people to open their own practices and how to manage their own practice, this is a large concern. Over at Onward Physical Therapy, starting new clinics, starting cash-based physical therapy across the country, it's also an issue of people do not want to leave their current position and start their own business for fear of what might happen to them legally. So this was a great rule and that we hope this stays in effect and that nobody challenges it over the next four months. We'll be watching this issue closely because it's near and dear to our heart. SUMMARY As much as we love PT 2.0, we think part of PT 2.0 is also being able to run your practice really well or consider opening your own practice and not being limited by things like non-compete. So we're excited about this here at ICE. We hope you're excited too, especially again, if you're sitting here listening and thinking, oh wow, I have signed one. I've been worried about one. It's cool that it doesn't count anymore. So that's where we stand right now. And then we'll see what happens over the summer, what organizations challenge this, hopefully none, but we'll see how it goes. So non-competes, what's the history of them? Largely used to try to keep a competitive edge in business, but what we see happen is really just obviously very personal negative effects on workers, but also an effect on our economy in general. that they're not really relevant to physical therapists to begin with. They're primarily used as a scare tactic, but the good news leaving today's episode is that as of right now, they're not valid anymore. You can't be asked to sign one. If you had signed one, it's unenforceable and it cannot be legally upheld in court, but we're watching to see what develops over the next couple of months. So, that's PTN Ice for Leadership Thursday. I hope you get a chance to hit that Ignite workout. If you have time over this weekend, grab some friends and go for it. If you're gonna be coming to the Ice Sampler, we're looking forward to seeing you very, very soon. Have a great Thursday, have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 24, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses helping patients better understand their osteoporosis diagnosis, including learning to read a DEXA scan. Dustin also shares tips on discussing prognosis with patients as well as using the data supporting their osteoporosis diagnosis to inform your treatment choices & plan of care development. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane, an online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. DUSTIN JONES What's up team? Dustin Jones here. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Today we're talking about osteoporosis diagnosis, prognosis, and treatment. This is a big topic that so many of the folks, older adults that we work with, they will receive this diagnosis or have this discussed with them. And a lot of times it's not given a lot of context or they don't have full understanding of what this really means for them and what they can do about it. Most importantly, what they can do about it. All right, so let's get into this. OSTEOPOROSIS: DIAGNOSIS We'll start with the diagnosis piece, just really defining what is osteoporosis and then spend a little bit more time on the prognosis side of things and the treatment because I feel like that's where we have a lot of opportunity to really serve our folks well. So osteoporosis, we're going to review, go all the way back to your formal training when you learn some of these numbers. that we may have forgotten, all right? So when someone is, when that conversation of bone mineral density starts to come into play, usually it's for postmenopausal women or males over 50 years old, start to look at bone mineral density. And the way that we can measure, objectively measure bone mineral density is through a DEXA scan. You'll see that D-X-A or D-E-X-A, that's Dual Energy X-Ray Absorbed Geometry or DEXA. This is the reason why everyone calls it that. So you're basically looking at bone mineral density. And if for individuals that are over that kind of 65 year range, you're going to get a score. That score is going to be a T score. And so we're taking the measurement of the minerals in the bone in a certain area and comparing that to same sex and race norms for a younger population. So we're comparing it to a younger cohort, and that's where you'll get those T-scores. And so based on those T-scores, you will get maybe something from 0 to negative 1, and that is considered to be normal and healthy. Then that negative 1 to negative 2.5 is that osteopenic range or osteopenia which means the bones are a little bit weaker but not full-blown osteoporosis just yet and then below negative 2.5 and below they will receive that osteoporosis diagnosis. Typically, along with the DEXA scan, a physician is doing a FRAX screen. This measures the 10-year risk of having a fracture. There's some different lifestyle questions and it'll basically spit out a percentage of likelihood that that individual is going to have a fracture within the next 10 years. And so those two pieces of information really formulate the, or someone giving a diagnosis, but then also the treatment that follows. And then based on those T-score readings, as well as the FRAC score, the pathways are typically, there's gonna be some pharmacology involved, right? Whether we're preventing bone resorption or really encouraging more bone formation and remodeling. And then they're typically going to give some blanket generic recommendation of exercise of weight bearing exercise. All right. Now, the tough part about this diagnosis, it can come from a whole host of different providers. So you can see primary care physicians, you know, kind of leading the charge of, you know, looking into bone mineral density. Internists can as well. Orthopedic physicians can as well. And so there will be different doctors that will be kind of looking into bone mineral density. And then they will often refer out to someone like an endocrinologist, for example, for further treatment and so there's a lot of people kind of involved talking about this and what at least I have seen is that this has been a topic that has been brought up and a lot of fear has been revolving around this topic but not a ton of guidance of what it really means day to day to really influence bone mineral density beyond taking that pill and you know quote-unquote weight-bearing activities. I've just worked with so many people that did not understand that diagnosis and what it actually meant. So just understand that. I'm not saying that always happens, but in a lot of the folks that I work with, that is typically the case. OSTEOPOROSIS: DIAGNOSIS So they're given this diagnosis and now let's talk about the prognosis. In particular, what I want to speak to is the opportunity to really dive in to the DEXA scan that our patients receive. And I'm not saying it is our place to kind of give a medical prognosis per se. Well, I guess when I'm saying prognosis is what can they expect going forward and to give them context of that diagnosis. So I'm mainly working the context of fitness now at Stronger Life in Lexington, Kentucky, and it's a gym for folks only over 55. And we're about four years old now, and so over the past four years, we've had a lot of members that have had at least a couple DEXA scans at this point. And so I'll put a field out for folks to send me some of their DEXA scans, and this is something that, these are conversations I'll typically have with folks anyway, once they get their DEXA scan. This is something I want you all to do. I want you to ask some of your folks that have osteoporosis on their, you know, their chart, their diagnosis list. Say, Hey, can I see your DEXA scan? Or, you know, if you're in a medical system, look up their DEXA scan, because it's really interesting. And you start to look at a lot of these reports and you'll have some of them that are more kind of narrative based, um, that, you know, are basically just several paragraphs kind of outlining, um, you know, what to expect, what they found, something more along the lines of, a bunch of words if you're not watching I'm just holding up some of these DEXA scans but more narrative but then a lot of them will actually have graphs of T-scores when they had that DEXA scan and where. So the most common areas are going to be the lumbar spine, the neck of both femurs, bilateral femurs, and then they'll kind of zoom out a little bit and look at the total hip as well. And so get those DEXA scans and look at some of those numbers. And when you start to look, what you're often going to find is variation amongst the different sites. So you can have individuals that may have that negative below negative 2.5, negative 2.5 or below, let's say at the neck of the left femur, for example. And then the neck of the right femur may be negative 1.7, osteopenic. The lumbar spine may be negative 1.5, for example, osteopenic. And so technically that person has osteoporosis on the left, on the left side, right? The right and the lumbar spine does not have osteoporosis, osteopenic, still a concern, right? But not as bad as that left side. That message is often missed by many of our patients. Now, I believe they're getting that message, you know, when they are getting these reports and having conversations with some of the physicians, but they're probably getting all kinds of recommendations. They're getting that diagnosed and all kinds of things that, you know, we only may only hear half of what is actually being said. But a lot of folks I work with, they will receive that diagnosis of osteoporosis that in reality is only in their lumbar spine, for example. and they will take that and own it as if every single bone in their body is brittle and about to combust under any type of pressure or load. They embrace that diagnosis as it's this global systemic osteoporosis. Every single bone I have is tremendously weak without acknowledging that there's some variability in different areas of the body. That piece of information for folks can be really eye-opening and very empowering. Oh my gosh, are you saying that I only really have this in this particular area of my body and not everywhere else? That's a sense of relief for a lot of folks. A lot of folks will take this diagnosis and view it as almost like a death sentence. everything. I am so weak. I'm so fragile. I need to be very careful. I'm going to break something, any bone I need to be very, very concerned about. Right. And that's not necessarily what's happening. It's usually in kind of one, maybe two areas that are a concern, particularly folks that are initially receiving these DEXA scans. And the cool thing about where I'm at now, working with folks for over four years, this individual, she's had a DEXA scan every two years. She was on a negative slope, negative three in 2017, negative 3.1 in 2019, negative 3.4 in 2022, and her most recent scan a couple months ago was negative 2.8. This is at her lumbar spine. and when you are able to give context to the diagnosis but then also be able to see over time you'll be able to spot trends and then hopefully be able to potentially reverse trends or slow down trends and we're seeing this at Stronger Life and I know many of y'all don't have the luxury of working with folks consistently you know three times a week over the course of several years but man if we can apply some of the interventions I'm going to talk about here in a second over the course of years you can have a significant influence in a lot of these DEXA scan readings and we're definitely seeing that and you can too. But I think that conversation, the prognosis, them understanding the diagnosis, where in particular that may be, that they understand every single bone in my body is not going to combust under pressure. This particular area may be more concerned, but I'm doing okay in these other areas. It's really good for them to hear that and that can be a more empowering message. OSTEOPOROSIS: TREATMENT Now the most important thing I think is that we take the information from this DEXA scan and then we use it in our plans of care. And so if I have someone that has maybe normal osteopenic in terms of the DEXA scan in their bilateral femurs, neck of their femurs, but then they're kind of borderline osteoporosis in their lumbar spine, for example, as a physical therapist, That gives me something that I can focus on, that I can give targeted interventions to give specific forces and stressors to that area in a very progressive manner, keep in mind, to stimulate a change in that bone mineral density or increase the odds that we can see change in their bone mineral density. So we take that information, use it for our plan of care. Some folks, you may be focused, all right, this left hip, let's load up this left hip a little bit more, do some unilateral stuff, staggered stance type things, not neglecting the other side per se, but if there's a big difference, we may want to give preference to one side or the other. If it's a spine, lots of loaded carries, deadlifts, those types of things where we're getting that axial compression, getting those forces through the spine. We can give target interventions. that's gonna encourage those bones to remodel, to get stronger, or potentially slow down, decline. So we take that information and take it into our intervention piece. Now for the intervention piece, you know, this is a 15, 20 minute podcast. We have a whole week on this in our NYA Level 2 course. But what you need to know is there are three things that are really, really important if osteoporosis is on board. One is balance training. This doesn't directly impact bone mineral density, but if we're able to improve people's balance capacity, I would even go as far to say their fall capacity as well. Do they know how to land? Do they have the balance capacity to even prevent the fall? That whole conversation of falls prevention and falls preparedness that we speak to, particularly in our live course, is really helpful for these individuals. Because if we can prevent a fall or even teach people how to fall in a more efficient or safer manner, you can potentially prevent an injurious fall or an osteoporotic-related fracture. So that's the first thing. Second thing is progressive resistance training. Bones really like progressive resistance training, where we're working up to relatively higher percentages of a one rep max, 70, 80, 85%. We're not going to come out the gate hitting that, but it'll take some time. But there's some really promising studies showing that, man, if people are able to regularly train at those higher intensities, they get really strong. They improve in a lot of the functional outcome measures that we care a lot about, but also their bone mineral density as well. Lyftmore trial is a great example of one group that's been able to show that. And then probably one of the more neglected things that we can definitely implement that can be intimidating for a lot of folks, but I found a lot very empowering for patients once they're able to do these things, and that is impact training. Weight-bearing as well. Loading the bones, but really thinking about the rate of loading. Progressive resistance training puts a ton of force, a bunch of load through that skeletal system that gets really good results. But bone can also respond really well to rapid loading. So think like plyometrics, stomping, heel stomps. step-ups, maybe a plyometric push-up, for example, or a quick bearing of weight through the upper extremities, something along those lines, where we're getting those increased ground reaction forces, we're getting those impact that can give the bones a signal to remodel. You take balance training, you take falls preparedness, sprinkle in some progressive resistance training, and then sprinkle in some of that impact training, and you stretch that out over years, And I will put my money that you're going to see some solid results when your patient comes back and says, Oh my gosh, Alan, look at my DEXA scan I just got. Remember the previous year, about a couple of years ago is like right when we started working together. And then man, I just had this DEXA scan and I've reversed my osteoporosis. We've seen that. Not to say it's going to happen every time, but people have the capacity to change and we often don't perceive that with this particular diagnosis. It is not a death sentence. There's a lot we can do. So understand the diagnosis, but then also understand that prognosis and give your patients context. Get that DEXA scan, look at it, analyze it. It's going to give you a lot of helpful information that they may not have comprehended and it can ease their mind of a lot of concern and worry, but it can also give them, something that they know they can do. And we can take that information and give a targeted intervention to a particular area that may be more troublesome than others. But man, if we combine that balance training, falls preparedness, progressive resistance training, and impact training with folks over a long duration of time, we can see some really significant results. All right, y'all. I appreciate y'all taking the time to listen. Let me know if you have any thoughts, questions, or your experiences working with folks. I do want to make sure I'm not saying everyone's going to get better. Everyone's going to improve their bone metal density. That is not the case. But man, if we can try without causing more harm, I think that's a good thing to pursue. And oftentimes, we can see some improvement. SUMMARY Before I go, I do want to mention our MMOA courses. I already mentioned that level 2 where we talk a lot about osteoporosis. Our online level 1 course is starting May 15th. Our level 2 course is starting May 16th. These are both 8 weeks long, about 2 hours a week, so you'll get 16 CEUs for PT, OT. and we equip you all to be the go-to clinician to best serve older adults in your community. It's likely gonna make you a very, very busy clinician serving these folks. And then our live course, we're gonna be in Bismarck, North Dakota, in Richmond, Virginia on May 18th and 19th. I'm gonna be in Scottsdale, Arizona, the beginning of June 1st and 2nd, and then we'll be in Spring, Texas, June 8th and 9th. We'd love to see y'all on the road or see y'all online. Y'all have a lovely rest of your Wednesday and go check out those Texas games. See y'all! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 23, 2024

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses details surrounding velocity changes and fatigue in both metabolic and cardiovascular systems when loading the spine. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION I NTRODUCTION Thanks for watching! Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account. BRIAN MELROSE All right, good morning, PT on Ice Daily Show. My name is Brian Melrose, teaching both cervical and lumbar courses in the spine division, and just here to kind of round out another clinical Tuesday, talking about loading the lumbar spine in a comprehensive program. Today, the aspects that I want to talk about is kind of loading the spine at different speeds and different fatigue levels. If you can do those two last things, I think you've really built a comprehensive loading program for either your patients or your athletes that you're working with. So a couple of weeks ago, you know, we've talked about all things at this point, barbell isometrics. Last time we were talking about leveraging different planes of motion. And not just sticking in the sagittal plane, loading into kind of side bend into rotation. And so if you miss those episodes, check those out, because all those rules still apply. But the last thing that we need to talk about is different speeds and fatigue levels. And so where this thought process really comes from, is kind of, you know, again, I was sitting at extremity, and I was thinking about loading the rotator cuff. And again, we can't just sit down here, we got to get in different positions, we have to load with variable resistances at different speeds. And I thought to myself, why would the spine be any different. And so that's really where I started messing with some of these things in the clinic. And so If we want to start leveraging some of those concepts for the back, we have to take something like the deadlift, and then start loading folks at different variable speeds, as well as fatigue levels. So just like last time, I made a partnered post here, it should be on our Instagram, it'll be in the reels. Again, that kind of outlines everything that I'm going to talk about for the next couple minutes. There's gonna be a lot of exercises I mentioned. And so again, there's visuals there if you want to check those out after listening to the podcast. WHY SPEED? And so when it comes to speed, the first question is, is like, why? Like, why would it matter? And that really comes down to something as simple as different muscle fiber types. We have type one and type two fibers, and those do different things. And so if you're only doing something like power lifting and lifting heavier loads, at lower speeds, you're going to really leverage type two type fibers. If you're moving lighter speeds quickly, again, you're going to be more oxidative, you're going to challenge different energy systems, and you're going to utilize a different kind of muscle fiber type. So if we want our comprehensive loading program to include both of those, you got to have lighter loads, you also got to have heavy loads to train both of those systems and move those kind of weights at different speeds. And so when I think about loading the lumbar spine on a spectrum, there's really a lot of different speeds that we can mess with. The first one you would have to kind of really begin with would be the barbell isometric where the barbell or the weight really isn't moving at all. And so we talked about some of the nuances of that weeks ago, but you can get that barbell underneath those J cups and have a very consistent pull with max effort without any movement. And so the first speed would be no speed. And you can set that at different kind of heights for something like the deadlift. Things really begin there and they can then swing the direction of normal movement. So looking at something like the deadlift, you could do something like a touch and go rep where the barbell is touching the ground and then you're almost using that momentum of hitting the ground and that reaction to pull the barbell back up. And so it's a faster movement and therefore typically a lighter load. We can compare that to something like a heavier deadlift where you're maybe again slowly getting that barbell all the way to the top of the rep. And a lot of athletes use different things to look at speed as a parameter. And so a lot of the powerlifting athletes that I end up working with use a barbell accelerometer. It's a thing that kind of sits on the ground, it's got a cord, it attaches right to the barbell. And as it's lifted from the ground, the device allows you to kind of record how fast you actually pulled it. And this can be a great way to use an objective measure to look at someone's kind of difficulty level. Are you programming it properly? Are they working in the right range? We love using things like reps in reserve, RIR, or RPE, Raiders Perceived Exertion. And we know that those subjective measures are actually pretty good at helping us vary load for our patients. But something objective can also help as well. And so those barbell accelerometers, I'm sure they have a bunch of cute apps that do it too, can really be a helpful thing in the clinic to kind of dial in your speed when you're working with those different athletes. The only other concepts I want to kind of throw out there would be leveraging different speeds with the concentric and eccentric portions of a lift. And so for the deadlift, again, as you're pulling that concentrically from the ground, you could do a fast pull up, and then a nice, slow, controlled lowering. You could also change that. You could do a slow, gradual pull up, and then a fast drop towards the ground, where either you come to a rested point right before the barbell hits the ground, or actually contact the ground. And so that's leveraging speeds within the lift to, again, challenge different muscle groups in different systems at those different speeds. The last thing is kind of what I call a reactive speed drill. And so, again, in my post, if you check that out, it'll have a band just looped around the barbell that's gonna accelerate the barbell down towards the ground each time I pull it. And so that can, again, really change your ability to slowly, eccentrically control a lift. A really cool way to, again, just leverage speed in a different position. Now, if you have access to chains, that's another thing you can put on the barbell. As those chains come off the ground, it increases the weight. So again, typically in the easier part of the lift, you're getting a little bit more load. As that barbell comes back to the ground and those chains kind of pile up, that load is removed. And so both banded or chain work would fall into kind of this reactive speed zone. And I think that's the last speed parameter that we need to kind of consider when we're thinking about challenging someone's system. So that's speed for something like the deadlift. TRAINING THE SPINE UNDER FATIGUE The other thing that I really want to talk about today is fatigue levels. And there's really two big buckets that that falls into. The first kind of fatigue bucket that you would want to consider is looking at somebody's kind of movement and taking something like the deadlift, which is primarily a sagittal plane movement, a hinging movement. And you wanted to really tax that entire muscular system, those same synergistic muscles that are doing that movement, and you just want to bury them, you're going to give them two or three exercises that are kind of varying the speed, the load, but they're all taxing that same muscle group. And so kind of the metabolic failure that I'm describing in this bucket, is one that's a little bit more energy specific. I mean, I want you thinking about how can I tax out that creatine phosphate system that's going to be the primary one used for the first 30 to 60 seconds of an exercise. And then it kind of switch it over to like Krebs glycolytic. all the way on up to oxidative. And so for leveraging different barbell speeds and loads, you can also again, give them that same stimulus to tax that muscular system. And so you could take something like the deadlift, have them rep some of those out, Then have them go to, again, a hinging pattern with a medicine ball slam. So same muscle groups working, again, different speed. And then last, put them on something like the reverse hyper, where, again, they're going to kind of tax the same muscle groups. They're all different exercises, but you are bringing that muscular system, that energy system, to complete an absolute failure. And so that would kind of be a position-specific failure scenario. The other big failure kind of bucket that we can push our folks into, and really I think we need to push all of our folks into, would be a little bit more of cardiovascular fatigue. And this can be something, again, that's nuanced all the way down to you're doing it with Doris or Betty, where maybe they're pumping some reps out on the new step, doing a reverse Tabata, and then going and lifting the kettlebell off an elevated step, on up to our higher end athletes, where they might be crushing something on the rower for a period of time, jacking their heart rate up, and then kind of transferring to the barbell. In either one of those scenarios, we want to tax the cardiovascular system. And so now I'm talking about fatiguing that, really the heart and the lungs. Can you keep up and continue to lift when you're absolutely gassed cardiovascularly? And so for more of a lifting athlete, this would look like, again, the last kind of swipe on that reel that I posted would be starting with something like the deadlift, And then maybe having them do something like a kettlebell swing, where they're jacking their heart rate up and moving a little bit more quickly, still a familiar hinging movement. But again, with a little bit more speed, a little bit more cardiovascular demand on board, and then having them for a third exercise, pump a bunch of reps out on the rower. So I like jacking the resistance up to like eight to 10, having them do about 30 seconds to 60 seconds, and then cycling those exercises. And really by round three or four, they are going to be absolutely smoked from that cardiovascular demand, those faster movements with the kettlebell, and it's not just going to be a simple deadlifting, hinging routine anymore. And so those would be the final concepts that I think we really need to consider when we're building somebody a robust strengthening program for the spine. You're nuancing these all the way down for some of our lower level folks, and then really challenging some of our higher level folks that might already be deadlifting, squatting, doing some of these movements a couple times a week. Now you got some different lenses to kind of either add or alter the lift, looking at different speeds, isometric, concentric, eccentric, touch and goes, heavier stuff where you're looking at a barbell accelerometer, all the way up to reactive things with a band or chains. That speed also fatiguing a particular muscle group, a specific position, a certain synergy of muscles, or the cardiovascular system. you can hit all of these different parameters and give your folks a nice robust back program to keep with. Again, I think the chances of them having future injury or issues significantly decreases. So just some food for thought. I hope this was helpful. I hope you guys have an awesome Tuesday. SUMMARY I just want to touch briefly on a couple courses we have coming up. There's only a couple spots left. May 18th and 19th. I'll be in Casper, Wyoming teaching cervical So if you want to learn how to twist some necks, we'll be doing that on Casper The next cervical course we have on the books is in Kent Washington on June 29th and 30th again You'll be stuck with me for that one for lumbar. We got two coming up here. We got Zach out in Chandler, North Carolina and on May 18th and 19th, and then we got Jordan up in Victory, New York on that same weekend. Those will both be lumbar courses. Again, if you guys are looking to get out to any of those, we go over everything comprehensively, the whole process, and then give you some manual therapy techniques on the weekend. So, hope to see some of you guys at those courses. I hope this information was helpful. Have a great Tuesday. I will see you guys next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 22, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses ideas for further treatment for an individual experiencing vaginismus. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everybody, Alan here. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at sign up to receive a one month free grace period on your new Jane account. APRIL DOMINICKGood morning, everyone, and welcome to Pelvic Monday on the PT on Ice Daily Show. My name is April Dominick. I'm here to talk to you today about pain in the vag, a case study. This case study was brought to us by some of our students in our level one pelvic cohort, and they just had some questions about a case on vaginismus and where to go since they were feeling a little bit stuck. So I wanted to hop on here and provide some in-depth guidance on how to continue with what they have already started for their treatment. Particularly, they are interested in how to improve their patient's pelvic floor hypertonicity, as that's where they're feeling a little stuck. So here are some details of the case that the treating therapists have already shared with us. The subject is a 19-year-old female who's diagnosed with vaginismus. Her aggravating factors are history of difficulty and pelvic pain with insertion of a tampon. She more recently was on her menstrual cycle, got a chance to try putting the tampon in. and had another failed attempt. She also has reported pain at her inner thighs after horseback riding, and she is an avid horseback rider. Easing factors so far, the therapist had provided the patient with adductor stretching, strengthening, foam rolling, and that seems to have eased the adductor pain, not necessarily helped with her pelvic floor situation just yet. And from a physical activity standpoint, I don't know much, but again, she is an avid horseback rider. And she also reported history of sexual trauma from a horse camp instructor who is now in jail. And thankfully she is currently working with a trauma therapist as well. In terms of objective findings, again, they found some tightness and pain with adductor palpation. as well as when attempting the internal pelvic floor exam, they were limited by the patient reporting pain. Current treatment, they have done some dilator work that has improved since the start of PT. So a few weeks ago, the dilator itself was shooting out upon insertion, and now the patient is able to maintain a dilator inside the vaginal canal for a few minutes. And if you all are unfamiliar with what a dilator is, it is essentially a phallic-like structure, that can be inserted into the vaginal canal. I like to call it a space holder for the vagina. And there are different variations of it. And some of them have a longer length while others are wider. And so it allows someone to be able to progressively overload the vaginal space or the vaginal canal. And after horseback riding, the general adductor exercises that the therapist provided have helped, again, reduced the patient's adductor discomfort. So their biggest question, again, is how do we address the pelvic floor hypertendency? It doesn't seem to be that we are making progress with this. So initial thoughts. First off, the therapists are doing just wonderfully with the direction of treatment. I love that they zoomed out from that pelvic space and addressed structures that indirectly impact the pelvic floor. And I love that they did attempt an internal exam, but again, didn't find that to be helpful given that the pain was present and the patient needed to stop the exam. I also appreciate that they talked about any previous trauma, as that is extremely important in this case in particular, and that they asked about, hey, are you getting help for this? And yes, the patient is again seeing a trauma therapist. So I'll discuss some of the considerations that I am thinking about, and I wanna talk about some things like working from the outside in, with external manual therapy of the pelvic floor, of the hips, as well as mobility and active strengthening that I would suggest as well, and some thoughts on, hey, what is going on with her nervous system and working together with the trauma therapist. So let's start with the internal external pelvic floor work first. Given that pain was a limiting factor in the internal pelvic floor muscle exam, That's a sign to me that the patient is not currently ready for or would benefit from continued internal exam attempts at this time. As she works with her trauma therapist from the inside out, she can simultaneously work with her physical therapist to treat the outside in. And what do I mean by that? External work on the pelvic floor, that can be simply a visual exam. And the vulva, no palpation, just guiding the individual on how to relax the pelvic floor. This is your pelvic floor. Using mirror feedback or even imagery work, like imagining that she, the patient, is inserting something into the vaginal canal and see if she responds better just from that imagery versus any sort of palpation. And then gentle, moving on towards a gentle external pelvic floor soft tissue mobilization. So techniques like sustained pressure or contract relax on the superficial pelvic floor muscles, like the bulbospongiosis, ischiocavernosis, and near the outer labia, as well as near the perineum. And also tackling the obturator internus, given that it is a hip rotator. So the hip, the obturator internus shares some fascia with the levator ani, and if we can work on the obturator internus externally, then it's very possible that we can just help decrease some of that upregulation in the pelvic floor, no matter where we are tackling the pelvic floor. Another piece is working on hey, can I do some cupping in that posterior pelvic floor region? I've been known to cup that area. And for some of my clients who have just a lot of tension and pain in that pelvic floor region, I will again offload the backside of the pelvic floor. in hopes to also decrease some of that hypertonicity in the anterior side or near that vaginal opening. So I pair the cupping with some child's pose or some quadruped rocking just to get some gentle movement, active movement in as well. And then if there is some progress with those techniques, but then we're running into a roadblock again, and maybe we're still not ready for any sort of internal work, then considering some dry needling plus electrical stimulation, maybe with some neuromodulation to the pelvic floor, and that's gonna directly tap into the cortex, create a nice chemical pump to the pelvic floor, and really help downregulate. Now, if this will work the best, if the patient has really responded well to dry needling in the past and is game to have it done in that region, it can be extremely beneficial. And then after doing all those manual therapy interventions, what are some things that she can do herself? She can do some self palpation externally with diaphragmatic breathing and some pelvic drops or pelvic lengthening to release some of that tension. I want to suggest that she try using her own digit, her own finger, to do some external self palpation. while she gradually moves towards internal insertion of her own digit into the vaginal canal. As this can be often more approachable and less painful for someone who has a history of trauma, for them to do it themselves, rather than inserting something external like a tampon or a dilator, or having someone else do the insertion. This way, if she's using her own finger, then she's remaining in control. Then having the client follow up on self-palpation with the dilator practice. It sounds like this person was already doing some dilator practice. So having her try it in varied positions of comfort, coupled with the diaphragmatic breathing. And then in terms of when someone is ready to trial vaginal insertion, I generally prefer them to be able to insert an object that's the same size or larger to what they're wanting to insert. In this case, having the individual aim for comfortably tolerating a dilator that is the same size or larger than a tampon is a great rule of thumb for test-retest with that tampon insertion. Traditionally, many individuals insert a tampon seated or maybe in a mini squat over the toilet. While this client is building up her confidence in getting those positions and doing this in public, I believe that she can try some more comfortable positions for tampon insertion like semi-reclined, maybe having her legs supported by walls or a pillow in her own home. Again, not traditional, but a great place to start.So attacking the hip from the joint side of things. We can do some manual therapy in the sense of doing some joint mobility. The therapist can do some joint mobilizations. And then that can be followed up by the client getting in some active hip mobility exercises. Gotta love the seated hip 90-90s. or seated banded hip IR and ER, banded hip capsule mobilizations, and I really love the long axis distraction just to get some nice general chemical pumping blood flow to that area to address chemically induced stiffness. Then we have hip mobility via muscle. Given that the adductor's origin is the ischiocubic ramus, I like to say the adductors are the long driveway to the pelvic floor. Dry needling plus e-stem for the adductors to reduce tone and increase blood flow is a beautiful option. Only always follow whatever kind of manual therapy to the adductors with standing banded and loaded lateral lunge sliders, sumo deadlifts or Copenhagen variations. We love the holds for 45 seconds. times five rounds for those Copenhagans, just to really tap into the analgesics from an isometric hold perspective. Also of note, if we're continuing the house analogy, and the adductors are the driveway, I like to think about the abdominals as the chimney. So the abdominals, if they are showing signs of hypertonicity and gripping, then we wanna do some of those same techniques, soft tissue manual therapy, to the abdominals followed by stretching and loading of that area. And then the nervous system, given that the individual has that history of trauma, we have to treat her from a holistic standpoint. Addressing that elevated centrally sensitized nervous system by ramping up the parasympathetic side. So doing vagus nerve stimulation exercises to increase calm, What are those examples of? Having her chew her food at least 10 times. This taps right into the vagus nerve. Humming, gargling, having her do one to three physiologic sighs. And that is two inhales followed by one long exhale. It sounds like this. So making sure that first inhale is longer than the second. or having her create a mantra like, I'm in control of my body right here, right now. Doing any of those vagus nerve stimulation exercises before and during her attempts to insert a finger, a dilator or a tampon in. This is going to really help address that tenacity. And then a time expectation. How long have you been working together? If it's only been a few sessions or if the client has dealt with vaginosis for a long time, rest assured it can take time for that physical side to catch up with the emotional or vice versa. especially given that trauma link and reminding her, hey, progress may not be linear, but here's what you've already improved on and showing her what she's made some progress with in terms of a couple of weeks ago, you weren't even able to have that dilator remain in the vaginal canal. And then I love that she's seeing a trauma therapist. This is so vital in this scenario and asking the patient, hey, can you tell me what you all talk about in your sessions? Or are you okay with me contacting your therapist so that we can do some integrative work? So I can bring in maybe some things that you all are talking about and we can practice that from the physical space. So given I don't have all the details, I'd also be curious of, hey, has she been able to insert a tampon in pain-free previously? And if so, we can lean on those positive instances that she does have the capacity to do so. And then I'd also be curious about some of the previous hip, low back, abdominal surgeries or injuries that she's had. Does she have any associated bowel, bladder? issues, urinary urgency, difficulty completely emptying, as these may be conditions that contribute to that pelvic floor holding tension. And then if she's sexually active, understanding what that means and what that experience is like for her. So hopefully those tips help y'all with the case or if you're someone who has someone like this on your caseload. To summarize, when we're treating someone with vaginismus, we really wanna lean into treating from the outside in, with external pelvic or abdominal or hip manual therapy, whether that's soft tissue, joint mobilization, cupping, dry needling, plus stem, all followed by some active mobility and stretching as well. And know with some of these patients, you may never get to the internal exam, and that is totally okay. The internal pelvic floor exam. Remember, the adductors are the driveway to the pelvic floor. The abdominals are the chimneys, so down-regulating those structures and then eventually loading that is going to be helpful. And then tapping into the nervous system via the vagus nerve just before and during insertion attempts in positions of comfort. Timing can have a huge impact on healing trajectory, and working side-by-side with their mental health or trauma-informed provider to reiterate concepts of the mind and body connection. Okay, so if you all want to learn more about some of those external techniques I was discussing, like the external pelvic floor exam, or if you do want to learn more about the internal exam, our next live courses are Kearney, Missouri, May 18th and 19th, and we have a double hitter of a weekend, June 1st and 2nd, with one course going down in Anchorage, Alaska, and the other in Highland, Michigan. So definitely sign up for those courses, or if you're interested in our online courses, we have two available. Head over to btonice.com and hop in. Thank y'all so much for listening, and I'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 19, 2024

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses utilizing hill running as a gait drill for injured runners, explaining the changes in running mechanics between running flat, uphill, and downhill. Megan also explains when and why to recommend uphill or downhill running Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. MEGAN PEACH I think both YouTube and Instagram are both live. Miracles. Good morning. Happy Friday. This is your PT on ICE Daily Show, and I'll be your host today. My name is Megan Peach, along with the Institute of Clinical Excellence, bring you this topic today of incorporating hills into your gait retraining toolbox. I am one of the lead faculty for our endurance division here at Institute of Clinical Excellence. and I teach both the live and the online versions of Rehab of the Injured Runner. So I'm super excited about this topic today. Let's get into it. So we have a lot of different tools in our gait retraining toolbox that we might use to keep injured runners running or return injured runners to a running program if they've had to take some time off. CHANGES IN RUNNING MECHANICS WITH UPHILL RUNNINGOne of the tools that we don't often use or that maybe we don't often think about as much of the others like cadence training or forward trunk flexion or maybe quiet running is incorporating hills into their current running program as a gait training tool to keep that injured runner running. And before we talk about specific injuries, I want to talk a little bit about the differences between running mechanics when we're running either uphill or downhill as compared to running over a level surface or a level ground. So when we're running uphill, a couple of things happen in terms of the sagittal plane gait mechanics that are different from running over ground on a level surface. One of those things is that our stride length So the distance from where the foot strikes the ground to a vertical line straight down from the center of mass, that's our stride length, that often will decrease when we are running uphill. And what goes along with that is also an increase in knee flexion at initial contact. So when we're running uphill, our knee flexion tends to be more than when we are running over a level surface. and it tends to be a little bit less in comparison. Also, another change that we typically see is a decrease in the angle of inclination from the foot to the ground when we're running uphill. And so what that means is that, or what that looks like, is that a runner running on a level surface who has a rear foot or a heel strike might look like they have less of a rear foot or a heel strike when they're running uphill. So maybe they look like they have a midfoot strike or they may even have a forefoot strike. It's going to be very, very dependent on the runner and that certainly doesn't happen in every single runner. We don't necessarily see a strike pattern change in every runner when they start to run uphill, but certainly that can happen and it does in many, many runners when we go from running on a level surface to uphill. So that's the third change. And then the other change that we commonly see in that sagittal plane is an increase in forward trunk flexion. So from going from a level surface to running uphill, we will often see that runner shift their trunk forward. And what that does is take a little bit of work off of the knee and transfer it to the hip. And so the glutes end up doing a little bit more work. The quads end up doing a little bit less work when we're running uphill. That has some advantages. but potentially some disadvantages as well, depending on the runner. So then when we talk about running downhill, all of those biomechanics changes that we saw, or that I talked about running uphill, are the opposite when we're running downhill. CHANGES IN RUNNING MECHANICS WITH DOWNHILL RUNNING So going from a level surface to running downhill, we often see that stride length increase. And so a runner will go from maybe landing with a little bit of knee flexion to nearly a straight knee at contact when they go from running on a level surface to running downhill. So we also see the knee flexion decrease or the knee extension increase depending on how you want to describe and look at that. What we'll also see is an increase in angle of initial angle of inclination at initial contact at the foot and ankle in relation to the ground. And so somebody who was a midfoot or a heel striker or a rear foot striker running on level surface is just going to shift that impact a little bit more posteriorly toward the heel. And it's going to be relative to how they hit the ground when they are on a level surface. So a midfoot striker may look more like a heel striker, or a rear foot striker may look more like a heel striker, depending on how they started out. Again, not in every single runner, but certainly there is that trend. The other thing we see with running downhill is a change in trunk position. And what we see when they're running downhill is more of an upright trunk posture. And even occasionally, we can see that runner almost lean backwards. And this happens for a couple of reasons. One, they're just trying to maintain their balance. It's a different body position running downhill versus running either uphill or over level ground, and so they're just trying to maintain their balance. And another, they're trying to control their speed. So often when a runner leans forward when they're running downhill, that can almost feel like they're gaining speed and it's a little bit uncontrolled, especially if that runner is more of a novice runner or just not used to running downhill. And so they'll lean back in an effort to just control their position and control their speed when running downhill. that has some obvious disadvantages, as it will increase the load on the knee and the lower extremity and decrease the load on the hip musculature. UTILIZING UPHILL OR DOWNHILL RUNNING FOR THE INJURED RUNNER So, in talking about specific injuries and running mechanics in an uphill or downhill, we want to take into consideration where those specific injuries are and what types of tissue we want to offload. So starting with patellofemoral pain, super common running related injury. It's one that a runner can typically continue running through, at least in some capacity, as long as there are some shifts and adjustments in their training program. They may not be able to do the same amount of mileage, but they certainly can, in most cases, continue running. So when we consider offloading the patellofemoral joint, We typically use gait retraining drills like cadence retraining or increasing the step frequency. So we reduce the stride length, increase the knee flexion angle at initial contact. We might also use something like a forward trunk flexion drill to shift that load from the knee more approximately to more of the hip. And those tend to work very, very well for people with patella femoral pain. I personally treat a lot of trail runners and so they're generally not running on a level surface and they're generally running uphill or downhill and that's just the terrain that they're running on. And so often when we're using other drills like cadence or like trunk control, then we're expecting that they're going to run on a level surface. And so if we have a drill like running uphill, they're very, very much appreciative of being able to incorporate their normal terrain into their current running training program while they rehab that injury. And so with runners with patella femoral pain, we will often incorporate running uphill. Now I know it sounds a little bit crazy and runners always give me a little bit of a weird look, but because of the biomechanics that go into running uphill, namely the reduction in stride length, the increase in knee flexion angle at initial contact, and the forward trunk flexion, all take a little bit of that load off of the patellofemoral joint and shift it up the chain, so it shifts to the hip, and they're often able to tolerate running uphill quite well, even in comparison to running over a level surface. It is important that you remind them that they need to walk downhill, and that's really important so that we don't actually increase the load on that patellofemoral joint. Now, when I talk about incorporating uphill running to an injured runners training program, I am not talking about incorporating this giant steep slope that I expect them to run up. I'm talking about a very low grade, like a three percent grade, which is generally what's cited in the literature as something that the authors or the researchers are looking into as does this create biomechanical changes. And even a low grade like 3% is enough to create some of those favorable biomechanic changes that are going to make a difference in that runner's ability to tolerate that running load. And a 3% grade is enough to reduce that patellofemoral joint stress by about 25%, and that's per step. And so when we think about that cumulatively over many, many, potentially thousands of steps, that's a lot of load reduction on a single joint that is going to allow that runner to continue running as they rehab that injured tissue. So moving down the chain and thinking about Achilles tendinopathy, very different injury, obviously, different types of structures, different types of tissue injured. And we think about the biomechanics of hill training. And when we think about biomechanics of running uphill, like I mentioned, we have that reduction in angle of inclination as one hits the ground or as one impacts going uphill. that reduction of angle of inclination or the shift toward landing on a midfoot or a forefoot is going to also result in an increase in load or stress on that posterior lower leg musculature. So the gastroc soleus complex, as well as the Achilles tendon and some of the forefoot structures. And so with an injured runner, with Achilles tendinopathy, they're actually going to accumulate more stress while running uphill than they would running on a level surface or downhill. So much so, in fact, it's about a 25% increase in stress on the Achilles tendon while running uphill as compared to that level ground. And so with a runner with Achilles tendinopathy, we actually want to discourage them from running uphill. We do not want them running uphill. obviously while they're still symptomatic later on in the program. That might be something that we incorporate as they're able to tolerate more and more load, but certainly not while they're still symptomatic. And so when an injured runner with Achilles tendinopathy, we actually want to encourage running downhill because of some of those biomechanical changes, those runners are going to tolerate downhill running much, much better than maybe even overground running. And often in those, Runners with Achilles tendinopathy, they've stopped running for a period of time in an effort to rest the injured tissue and resolve the symptoms, they're not always sure how to get back to running. And so downhill running can be a good start with less load on that injured tissue than overground or level running or uphill running. Certainly we want to incorporate those later on as they tolerate more and more load. Okay, so the last one I want to talk about and It's been 12 minutes already and I haven't talked about bone stress injuries, so it's probably, it's a little unusual, probably a record. I do want to talk about tibial bone stress injuries. And so with bone stress, it's a little different than other types of soft tissue stress because with bone stress, we get stress from a couple of different inputs. One is an external input, meaning the ground reaction forces. Two are the internal inputs, which comes from the muscles that are attached to that specific bone. So in this case of the tibia, the gastroxilia is complex. And both of those external and internal inputs are going to have an effect on the amount of stress that that bone is accumulating. The internal load or the internal stress being much, much more of a contributing factor to bone stress than the external ground reaction forces. Although it does contribute a little, so it still needs to be considered. Okay, so when we run uphill, we know that there is going to be an increased load on that gastrocnemius complex. And so therefore, there's going to be a significantly increased load as well on the tibia because of that internal load from the gastrocnemius complex. When we run downhill, then we see an increase in ground reaction forces, which is also going to increase the load on the tibia. So we can talk about uphill or downhill, but they're both essentially going to increase the load on the tibia specifically. And so while somebody, although they will likely have some time off of running after they've had a diagnosis of a bone stress injury, while they are returning to running, we want them to run on level ground. We do not want them to incorporate any hills up or down early on in their program until we are absolutely sure they are tolerating level ground running without any symptoms or exacerbation of symptoms. And then we can start to incorporate the downhills, which are going to be less problematic and less provocative than the uphills because that internal load with the uphills and the gastroc soleus is going to contribute much more stress and load to that tibial bone than the downhills with the increased ground reaction forces. Okay, so a couple of other things to add. One is that if you are working with novice runners, hills often have to be trained. So they're not intuitive in terms of how we can most efficiently run downhills, uphills a little bit more so, but certainly not downhills. And because of some of those maladaptive mechanics that I talked about with running downhill, specifically like the upright trunk posture and the increase in the stride length or the over striding, those we tend to just do when running downhill if we're not trained how to run downhill. So if it's in your toolbox and you know how to kind of instruct or coach a runner to have better mechanics running downhill, meaning lean into the hill just a little bit. You don't have to have so much forward trunk flexion that it's making you uncomfortable, but lean into it just a little bit, or to maybe just be conscious of not extending the trunk posture or having a very rigid upright trunk posture. And then maintaining the stride length. So trying not to reach out as one goes down can really help to reduce some of that stress on the patella femoral joint, and the lower extremity as well. And so training or coaching a runner to be able to run downhill can also have really positive benefits in their ability to tolerate some of those hills, especially if they either currently are injured or have that running related history, especially if it's something like a patella femoral pain. And then the other thing to mention with using uphill and downhill as gait retraining tools is that The biomechanical changes are not independent of changes in stride frequency or our cadence or changes in speed. And so just like any other gateway training drill that we might use, so cadence for example, it's really, really important that we maintain some of the other variables that go into running. So speed for example if somebody's running on a treadmill and we manipulate their cadence we're really really sure to maintain that speed otherwise we may be changing too much at one time or we may not be getting the desired effect that we want from that gait retraining tool if we are changing more than one variable. So if you are recommending like an uphill run for example try to maintain some of those other variables specifically like stride frequency or cadence and speed. So obviously easier said than done, much easier on a treadmill than it is outdoors like on a trail, but just something to be aware of. Okay, so to recap, running uphill or downhill can be a really effective tool for runners with specific injuries, such as patella femoral pain or Achilles tendinopathy, that we can definitely put into our running gait retraining toolbox. As long as we keep some of those biomechanics in mind, and as long as we understand how uphill or downhill running can shift some of that load from one structure to another, And then also taking into consideration that there are instances when we do want runners to run on a flat surface, for example, in tibial bone stress injuries, when they are returning to run, it's really important to keep them on that flat surface so that they are not inducing excessive stress on that injured or healing tissue. SUMMARY All right. So before I let you go today, I do want to mention a couple of upcoming courses. We have, let's see, Rehab of the Injured Runner Online. We are just about to start a new cohort. It is in May, the very beginning of May, so you've got a couple of weeks to sign up, but it's filling up. Sign up now. We have just revamped Rehab of the Injured Runner Online for 2024 and so far it's been really, really fun. We've had a lot of great engagement from current participants and previous participants. in our courses this year. Great questions. It's been really fun so far. So make sure you get into that if that's something you've been meaning to do. We also have Rehab of the Injured Runner live. We have June in Wisconsin and then we have September in Maryland and then Certainly the bike fit course is part of our endurance division and so we have a course this weekend in North Carolina. We've got one in May, mid-May in Minnesota and then up with our friends in Bellingham, Washington in June. All right, so that's it for me today. Hopefully you can add in hill training, uphills and downhills into your toolbox for rehabbing injured runners and just hit the ground running with that and use it right away. That's my goal for you for today. Feel free to ask any questions and hope you have a great Friday. All right, have a great weekend as well. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 18, 2024

Dr. Ellen Csepe // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ELLEN CSEPEGood morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients. MOOD & OBESITY ARE RELATED So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity. BINGE EATING AS THE MOST COMMON EATING DISORDER Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job. THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity. SUMMARY So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 17, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how to incorporate geriatric treatment principles into practice to address pelvic floor concerns with older adults. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily show. My name is Christina Prevett. You saw me on Monday. I am one of your division leads for both the geriatric and the pelvic health division and you guys got stuck with me twice. If you saw the episode on Monday, you can definitely see that my voice is better. So I don't have the same sickness. So hopefully my voice will be a little bit more tolerable for today's podcast. Today we're gonna be talking about how fitness-forward geriatric clinicians do pelvic well. And one of the things that I often will get asked about is, Christina, it seems really weird that you're in both the geriatric space and the pelvic health space speaking to pregnancy and postpartum. How the heck are these two things connected? And they are a lot more similar than you think, especially when it comes to the quality of our care. What I mean by that is that we are not as fitness forward as we need to be in both the geriatric and in the pelvic health spaces. And there is a significant amount of under dosage that happens in both places. And in our older adult course, we talk a lot about this fitness forward mindset and we try and do the ultimate reframe, right? We worry about the cost or risk of loading people and our thoughts are, what is the risk if we don't? And What is the risk if our person gets a little bit weaker or they have an exacerbation of congestive heart failure and now they're five pounds heavier and they were barely getting up from a chair or using their hands when they didn't have that five pounds? We ask, you know, if they have low bone mineral density and we don't give them the resiliency to reactive step when they have a perturbation, what is the risk when they fall of having a fracture versus somebody else? And that reframe is potent, right? Because it eliminates a lot of the fear and it gets us having a sense, or at least it does for me, a sense of urgency with respect to getting individuals moving. When I see individuals in pelvic health, a big part of my clinical practice right now is postmenopausal females. who are struggling with incontinence or other type of pelvic health conditions, and have underlying muscular weakness or muscular reserve issues. And when I step back and I zoom out and I see that the geriatric space, we tend to underdose. In the pelvic health space, we tend to underdose. My goodness, when you slam those two things together, we see that the bias is to keep people on the table doing Kegels, or we don't even offer them pelvic health services because we assume that leaking and incontinence is a part of aging. and it's something that they have to deal with and it's part of being postmenopausal and have had babies 50 years ago and therefore we're not going to address it. Today I want to talk to some of the literature that says that we actually need to prioritize that fitness more. When we look at aging physiology of the reproductive system, we see that as men and women transition through menopause or andropause, right? Menopause blunting of female sex hormones, andro blunting, but not removal of the male sex hormones, AKA testosterone, that we see a rise in pelvic floor dysfunction. For females, there are one in four individuals are struggling with pelvic floor dysfunction that increases with age. For males, significant increases in pelvic floor dysfunction happen because many of our younger or middle-aged men, not all, but the rates of pelvic floor dysfunction are much lower and they start to increase with age, right? So pelvic floor dysfunction is talked about a lot more in the female space because it's more common. It is definitely more common as we get older. And when we are thinking about incontinence, we are thinking about different types, right? We have stress incontinence, that is more of a mechanical issue where inner abdominal pressure in the belly is exceeding the ceiling pressure of our pelvic floor to be able to close our holes, our urethra and our anal sphincter. And if we don't have enough of that capacity to close those sphincters off, then we pee or poop or pass wind when we don't mean to. Urge incontinence is that we get the urge to go to the bathroom and then we don't have the capacity or we have a very sudden behavioral intervention where I have to go to the bathroom and I have to go right now. I get the urge, I can't defer that urge, I have to go right now. That's very largely outside of any pathology in the kidney or the urethra that it's largely we're seeing behavioral issues. The other camp that we need to really speak to in the geriatric space is functional incontinence. So functional incontinence is that individuals are getting the urge to go to the bathroom or when they have to toilet, there is either a functional capacity issue where they physically cannot make it to the bathroom, or there's a cognitive issue where they get the urge, but because of some changes to cognition, They either do not act on that urge or they lack insight to have that toileting behavior. When you are working in acute care, we see a lot of this functional incontinence happen in combination with the burdens on our healthcare system, right? We see that individuals have to go to the bathroom, they're waiting a really long time because of our staff shortages, and then we're giving individuals periwicks or external catheters or internal indwelling catheters to prevent any incontinence issues from happening that are a consequence of them being sick. Okay, so when I think about stress incontinence and functional incontinence with aging, super common, a lot of times this is an issue of muscular reserve. If your body is one rep max living, where the demands of your day are at or exceeding your one rep max, your pelvic floor is a set of muscles that is acting no differently, right? If your entire body is experiencing weakness, then your pelvic floor is experiencing weakness too. And what that means is that yes, we want to be very focused in the pelvic floor. We have excellent evidence for pelvic floor muscle training across the age continuum, including older age. And we have to recognize that by increasing the functional capacity of the system, we are going to improve a person's pelvic floor symptoms, which means that you do not have to be a specialist in pelvic health in order to make a significant contribution to a person's incontinence. And this to me lights my soul on fire because incontinence is one of the leading causes of institutionalization in our older adults. It is one of the main reasons. Urinary incontinence, cognition, mobility disability, right? Those are the top three reasons why individuals can no longer be independent in their home. And when I think about the role of PT and OT, the PT OT dream team and rehab in general, we target two out of three of those issues, right? And every single person can target the urinary incontinence piece. And so the first huge message that I want to have with this podcast is that one, every clinician is a geriatric clinician because we are not going to ignore a group of muscles and just say that this is not our scope and we don't know how to handle it because we know how to work with muscles. Two, if you have a person with frailty or sarcopenia on your caseload, we need to screen for pelvic floor dysfunctions because if we are seeing outputs of weakness in the musculoskeletal system in the person that we are working with, we have a higher likelihood that we are going to see something happen with incontinence. And this is extremely important considering that incontinence is a main reason or a big driver for individuals needing institutionalized care or increased help in the home. decreased likelihood that they can age in place. And then let's talk about how we put this fitness forward pelvic approach in, whether you are a pelvic health clinician or not. Okay, when we look at the evidence of pelvic floor dysfunction in an aging population, there's a couple of things that we see. One is that individuals with higher amounts of sedentary behavior are at increased risk for pelvic floor dysfunction at age match. So when you compare a cohort of individuals at the age of 70 or 75, those that are more sedentary are more likely to have incontinence than those that are not. So by getting individuals moving around more, you are going to reduce their risk for urinary incontinence. That is number one. Number two is that individuals who are physically active have reduced rates of significant pelvic floor dysfunction compared to those that don't. And so individuals over the age of 65 who are more active are less likely to have pelvic floor dysfunction. Speaking to the musculoskeletal reserve component of pelvic floor dysfunction and aging. Number three is that for individuals with pelvic organ prolapse, those that are weaker or more sedentary, have higher amounts of sarcopenia and frailty, are more likely to experience subjective symptoms of prolapse. So subjective symptoms of prolapse are feelings like your bladder is coming out, that you feel like there is a ball in the opening of your vagina, or that there are symptoms of bother as if there is a heaviness or a dragging sensation around your pelvis. And this is one that I wanna kind of focus on. So when it comes to pelvic organ prolapse, the combination of an increase in objective range of motion of the vaginal walls in combination with a subjective complaint of bother is the way that we create the diagnosis for pelvic organ prolapse. Objective range of motion changes to the vagina are a sign of aging, right? So we are going to see an increase in vaginal range of motion. We have wrinkles on our skin. We have wrinkles in our pelvis. That is one of our wrinkles. The subjective signs of bother, though, have a discordance between the amount of range of motion that people see and the subjective reports of symptom thresholds in that person. This is true across the lifespan where some people can have a high amount of range of motion and not experience bother or any symptoms at all can be completely asymptomatic and other individuals can have a little bit of range of motion change and experience a high symptom burden. So that range of motion change is like a disc bulge on an MRI, right? We cannot just hold onto that objective range. We have to do that with subjective complaints. What we are seeing is that those with more weakness have higher rates of bother. And this is where I really want to hit on the fitness forward approach. Because if you are a person who is one rep max living, imagine the strain on your pelvis when you are doing a one rep max lift versus you are doing something that is 10 to 15% effort, right? What are you more likely to do when you're one rep maxing? You're more likely to hold your breath, your inner abdominal pressure in your belly comes out. We see a lot more people who are bearing down or straining when it comes to that activity and that repetitive straining can be a risk factor for subjective complaints of prolapse. So if I have an older adult who is 100 max living, then they are straining with activities of daily living, right? They are straining every time they need to exert themselves around their house, which means that they are more likely to experience some of those subjective complaints of something falling out, right? That is a barrier to us being able to load people. So what the heck do we do about it? First, we acknowledge that that straining can be contributing to how a person is feeling within their body, feeling within their pelvis as they go about their day, okay? That's the first thing. The second thing is that we can acknowledge what our body is supposed to do under strain. A lot of our older adults don't realize that they are pushing down into their pelvis when they are doing strainful tasks. Is that even a word? I don't even know. Straining tasks, I guess, is a better way of saying that, across their day. So the way that I will reduce that strain on their pelvis, if they are experiencing these symptoms, is one, I will get them to acknowledge or understand that the pelvic floor should be contracting, not bearing down on effortful tasks. That might mean that I'm gonna ask them to do a tiny Kegel before they stand up. That means that I may ask them to exhale as they are standing up while we are working on getting them stronger so that we reduce the strain on their system and reduce their bothersome symptoms. And the third thing is that I focus on getting them stronger so that they do not strain their pelvis throughout the day. So if I think about how taxing it is on my body when I'm straining, for a person who has had pelvic floor dysfunction, I have had two vaginal births, I understand what that means, but also a person that has a good musculoskeletal reserve, my older adults are edging into that straining a lot faster. than my individuals without that reduction in deficits. So if you are a person who's working in home health, if you are a person who's working in hospital, if you're a person who's working in long-term care or skilled nursing, they are going to oftentimes be straining down, right? And that's why individuals are farting when they get up from a chair. That is your sign that they are bearing down as they are getting up, which means that they are straining on their pelvis, and that may be a risk factor for their symptoms. add in constipation, which is much more common with our individuals in their 70s and 80s because of a combination of decreased drive for hydration, decreases in gut motility, side effects of their medications, and potentially dietary changes, that constipation that straining, that reduction in musculoskeletal reserve is kind of like this trifecta of risk factors for that pelvic burden. That pelvic burden is a huge barrier to our physical activity, right? 50% of individuals with pelvic floor dysfunction reported as a barrier or a reason to stop being physically active. And so if you are having a person who is resistant, maybe let's ask and really deep dive into why, right? So when we are thinking about our fitness forward geriatric clinicians, where I want to finish off this podcast is know that you are already doing pelvic well. Because if you are getting a person to be less sedentary, get them doing movement snacks throughout the day, if you are encouraging physical activity and exercise in your people, and you are teaching proper movement mechanics, including and avoiding of bearing down, when individuals are doing activities of daily living, you know how to teach the brace, which we get you to do in our MMA live with our plank lab, right? That's the foundations of bracing. You are doing pelvic health well, right? Because we see so many of our older adults are struggling with pelvic floor dysfunction and their musculoskeletal reserve is contributing to that risk. If you are stuck with me for MMA Live, you know I end up on a soapbox about pelvic health because it's so, so important that a deconditioned person is a deconditioned pelvic floor and our older adults do not get the care that they need in conservative management of a muscle group that is absolutely within our wheelhouse. And that is also why if you are in MMA level two, we do an entire week on conservative management for the non-internal pelvic floor physical therapist on pelvic floor dysfunction, because it is a huge part and it is not just do Kegels. It is so much more than that. And everybody who is listening to this can get on board and be positively contributing to some of the improvement of those symptoms. And when I think last kind of point to make with saying that you are all doing pelvic well, is that by adding in the screens, increasing the muscular reserve of the system, and speaking a little bit to straining and breathing, I clear up so much pelvic floor dysfunction almost immediately in my practice. It's like my geriatric PT magic trick, right? If I have a person who is having wind or anal incontinence every time they sit up from a chair because their abs are too weak and they're bearing down and holding their breath every time they sit up from a reclined position, then When I teach them to breathe out as they do that, tell them not to bear down and get their abs a little bit stronger, it clears it up almost every time. And it's embarrassing for people, right? They don't want to engage in certain activities because they're afraid, or they pretend that it doesn't happen because it happens to them so often that they just don't acknowledge it anymore, even if they feel it. Oh my gosh, 20 minutes in. Gosh, sorry, Alan. So if you wanna learn and get the rants on the reproductive system, make sure to jump into MMA Live. We are this weekend up in Hendersonville, Tennessee. Julie's up there in Hendersonville and Dustin is in Aspinwall, Pennsylvania. We are going to have incredible groups. They're looking pretty good. The next courses for MMA, because we have sampler, and we have a long weekend. I am up in Bismarck, North Dakota, the 18th, 19th of May, and Jeff Musgrave is in Richmond, Virginia, same weekend. So you either have the chance this weekend to get into MMOA Live or middle of May is your next opportunities. And if you really want to hear me rant and rave about pelvic floor dysfunction, you guys have made it to the end of this podcast. Our level two is starting middle of May, but today's April, I'm losing track of time. And the level one is our prerequisite for that. We are going all the way to the ICE app for all of our MMA courses, starting our next cohort. We are super excited about that. And let me know if you guys have any other questions, because I love blending the Jerry and pelvic worlds together. Thank you so much, Andrea. All right, have a great day, everyone, and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 16, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey reviews the anatomy of the latissimus dorsi muscle, its relevance to overhead movement, and discusses two ways to begin to improve long-term functional mobility. Lindsey also provides a rehabilitation every minute on the minute (rEMOM) program to begin to use for an HEP for patients who need to improve their own lat mobility. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PTonICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. LINDSEY HUGHEY PT on Ice daily show. How are you? I am Dr. Lindsay Hughey from our extremity division, here with you today on a clinical Tuesday to share some pearls of how we'll get after our LAT mobility. So I first wanna just briefly unpack the function of the LAT, so a little anatomy review, and then I wanna discuss two ways to really get after mobility access, demo those two ways, and then suggest them in a rehab EMOM sequence for you all, so you can directly use it yourselves, or use it with your patients in the clinic. A lot of our overhead athletes, our weightlifters, our crossfitters, maybe even just our stiff shoulders need more access to lat mobility. REVIEW OF THE LATS So let's first just review what is the lat and where is it? Well, the latissimus dorsi is responsible for internal rotation of the arm, arm adduction, arm extension, and it even assists in respiration. in both inhalation and exhalation. It spans quite a big area of our extrinsic superficial back muscles. So we have a vertebral part that goes from our spinous processes and converges into the thoracolumbar fascia, goes all the way down to our iliac crest. There are even connections into that inferior angle of the scapula, and then even 9 through 12 ribs. So it spans quite a bit of area. The reason we review all of those areas is when you're doing your mobility work, you really want to make sure you hit all of those and make sure to challenge them. TWO WAYS TO ADDRESS LAT MOBILITY So I'm going to show you how we can do two versions, a way where we fix the arms overhead and move the body away to traction the lats from below. And then I'm going to review how you can fix from below and then move lats from above. What we won't do this morning, though, is just a static hold stretch. So before I review these two with you, I want you to know that purposely these two moves are so effective because in the first we're going to use a hold relax technique. So we're going to actually use isometric contraction, hold, and then lengthen tissue longer. And what we see with our ISOs, as long as you hold it at least six to seven seconds, I'm gonna make you all push to 10, but we see this increase in neural drive and we get those Golgi tendon organs to chill out and make that agonist, the deltoid relax so that we can actually gain more lat access. The second exercise, we're gonna actually go after eccentric training. So the reason we choose eccentrics as we see constant and ongoing research links to improve strength and length and even greater cortical excitability when we train in eccentric fashion versus just like a static hold or even doing concentric work for our lats. So without further ado, let me show you these two exercises. So number one, we're going to fix from above by putting our elbows on a surface. I'm going to show you on a bench here today, but it could be a bar. It could be a foam roller, whatever feels good for your body. It could even be the counter or a wall surface. So we're going to put our elbows in like a goalpost position, and then we're going to fix our arms here. And we're going to lean our hips back, but we're going to actively contract our arms down for a hold of 10 seconds, then relax and push our hips away. So we get this tractional effect from below. So it'll look like this. So elbows down, and we're going to push into the object while we push our head down. And we're going to push down for 10 seconds. and then access greater length. So you'll notice that I push my hips back and away as I gain access to new length, but that key piece is activate for 10 seconds into the surface, pushing down, and then move away. To fully maximize this particular movement, we're also going to tie our breath work, because remember I said function of lats is helpful in inhalation and exhalation, And then we have links directly to those ribs. So we're going to pair our breath with this. So we'll do it one more time, but this time we're going to link that isometric hold with an inhalation. And then on our exhalation, we're going to move away. So it looks like so we're going to go hold for 10 seconds, pushing down and then exhale and push the body away. And then we would do another rep pushing down 10 seconds. Inhale. And then exhale. For those that are just listening to this this morning, I do suggest watching the video so you get the visual. But we would repeat that for at least five to six reps. I'm going to show you how we'll do that in a rehab EMOM. But we really want to get at least a six to seven second hold of that isometric where we're pushing down before we lengthen. The key parts here being tie breathwork with it. And then don't forget to access more length and maintain it. So that next isometric hold where you're pushing down in the hold relax sequence should be in that newer length. The second exercise we are going to review today is eccentric training. So we are going, I'm going to lay in either hook lying position or you can put your legs up to put further tension on the thoracolumbar fascia. My palms are going to face toward the ceiling and I'm going to slowly lower a bar. Right now I just have a PVC pipe with a plate on it and I'm going to slowly lower eccentrically. I want the slowly lower to be three to four seconds and then a hold for three seconds at the bottom. And you'll repeat this with a goal of eight to 20 reps or what in extremity management we would call our rehab dose. Keys being that eccentric slowly lowering on the way down and the hold at the bottom. So we want about three to four seconds in each of those parts. Don't care as much about that concentric raising portion. Appreciate this eccentric could be done with dumbbells as well or kettlebells. I love starting with a PVC pipe and just a five pound change plate for those that are new to lat access. So we have two things that we've reviewed so far. We are going to do Number one, our ISO hold, where we get into a position where our lats are on tension and you push and drive the elbows down for 10 seconds. And then after that 10 seconds of inhalation and pushing down, you'll exhale and lengthen those lats into a new mobility access area. The second one is that eccentric overhead with the either Dow or PVC pipe and weight. Just these two things done. MAKE MOBILITY EFFICIENT: THE rEMOM So if you do each of these for a minute and you do three rounds, you have yourself a very efficient six minute rehab EMOM to attack lap mobility access. Nothing gets more bang for the buck when you combine both of these and you'll get relaxation. Start subbing your static hold stretches that either you're doing or that you're doing for your patients and really get the neuromuscular system on board to see change more rapidly. From a frequency perspective, at least two to three days a week is something I would recommend for my patients to get after and even using it as like a precursor before they do some overhead work because we know what will solidify this even more is then to actually load it and do some functional meaningful thing. SUMMARY If you want to learn more about how to even test if your patient has lat mobility tightness, if you want to dive a little bit more into dosage and the rationale behind eccentrics and why we don't use static stretches in our course at extremity management, Mark, Cody, and I and our extremity team would love to see you on the road. Um, and literally we have courses all throughout this year, almost every month in May, May 18th, 19th, I'll be in Bellingham, Washington, and our director of marketing say will be with me. So if you want to join us, that is sure to be a blast. And then June 1st and 2nd, we have two offerings, one in Wisconsin and then one in Texas. So check us out on ptlnice.com. if you want to learn more about how we think and treat the lats. Thanks for tuning in with me today. And if you're listening, be sure to watch the video later. Take care, everybody. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 15, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of physical therapy in the male fertility space. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account. CHRISTINA PREVETT Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in both our pelvic health and our older adult division. I'm going to apologize in advance if I sound a little hoarse. I am not feeling well, but that doesn't mean that we aren't going to be able to have an incredible episode here on the podcast. So today I wanted to dive in a little bit on male fertility. So last podcast episode that I did several weeks ago, I was talking about our role as physical therapists or individuals in the rehab space in fertility. That conversation circled very much around female fertility and around ethical considerations for fertility. We're gonna continue that conversation. We are gonna launch off of that conversation into our male fertility and male fertility related factors. So I feel like when we are talking about individuals who are struggling with fertility related concerns, a lot of our conversation centers around the female pelvis. And that makes a lot of sense because individuals who are struggling with fertility, it's oftentimes, we are hearing about assisted reproductive technologies like IVF and IUI that are largely interventions that are done for females. And so if couples are dealing with infertility, the female is oftentimes doing different interventions to allow for more successful rates of conception or implantation in the uterus based on a variety of factors. What I think is important for us to recognize, though, is that 30 to 50% of couples who are going through infertility have male-related infertility factors. Let me repeat, between 30 and 50% of couples seeking help for fertility-related concerns have a male-related factor in their journey. And I think this is really relevant for us to be starting to have conversations about because so much of our education has focused on the female pelvis and our males really don't know a lot of things that relate to their fertility. So there was a cross-sectional survey that was published asking males of reproductive age about their fertility. 55% of them, 54% could not identify factors that positively influenced male fertility. So we have a role to play sometimes when we are working with individuals. This is probably not an area of practice where individuals are going to be all of the time marketing their services in male fertility, but I think it's important that we talk about the male aspect of infertility as well. When we are talking about male related concerns, we have sexual response concerns and then we have sperm related concerns. When it comes to the sexual response related concern is that in order for conception to happen, an erection has to be able to be developed and maintained in order for that erection to lead to ejaculation in order for sperm to meet the egg. That sexual response needs to happen. If you are struggling with erectile dysfunction, if you are struggling with pain with ejaculation or testicular pain with sexual activity, those are going to be big barriers to a person being able to successfully have penetrative intercourse. We have a huge role to play in helping with erectile dysfunction and with individuals who are experiencing pain. And in our level two course, we go into a lot of these pain syndromes that focus around the male pelvis. And so the first thing is clearing some of those conditions. Secondly is we talk a lot about the sexual response being not just a mechanical property where you want to have sex, you get that sex response, and ejaculation occurs. There are a lot of bio-psychosocial factors that go into a person's sexual desire, their libido, and issues related to their want for that type of intimacy. We have a book called Come As You Are that is focused on the female pelvis and the female sexual response, but we don't have as many of the same type of resources for males who are struggling with the same thing, right? Like if you are really stressed out, if you are not sleeping well, new parents who are like in the thick of postpartum, that doesn't just affect are females, that can affect our males as well. If they are struggling with mood disorders like depression or anxiety, that can have huge side effects on their libido and their desire for sexual activity. If they are on certain medications, it can have influences on their sexual desire. And so having conversations about the biopsychosocial factors of the sexual response are also important. So when we are thinking about the bucket of sexual response for males, our role comes into helping individuals with erectile dysfunction, if that's something that we have cleared that may be in our wheelhouse around hypertonicities or different type of pelvic pain issues that are leading to that response. A lot of erectile dysfunction is a vascular response and individuals with erectile dysfunction are at higher risk for cardiovascular disease. So there's a health promotion component there. And then we're also going to have a lot of education around libido. If it is the physical act of penetrative intercourse that is a stumbling block for a couple who is dealing with infertility. We see this all the time in our female pelvis with those with vestibulodynia or other dyspareunias or pelvic pain syndromes. This can also be true for our male pelvis, which can create a barrier for individuals being able to have sex at the right time. Okay, so that's kind of our male response piece. The second is on the sperm itself. And so when we are thinking about the male sperm meeting in the fallopian tube and being able to successfully have a conception moment that happens, we have to think that there has to be enough sperm and the sperm has to have good motility or movement, which is related to its shape in order for it to make the long road to the fallopian tube. I mentioned in my female fertility podcast that it's interesting with some of our health promotion because female pelvises have all of the eggs that they are going to have in their entire life by the time they are born. They do not develop more eggs. Eggs mature across cycles. That is not true for the male side of the physiology. For females, that means that health promotion is related to their entire lifespan. For males, that is 74 days. So the maturation cycle of the sperm is 74 days. What that means is the acts that you take, the health promotion incidences that you take when you are trying to conceive, what is really important is those 74 days are approximately three months prior to conception. So if you are a couple who is trying to conceive, your health promotion factors for the male in the three months prior to trying to conceive matter, okay? They matter. So when it comes to our sperm volume and motility, what we are seeing is that there is a large influence on motility for reactive oxygen species and low-grade inflammation. And you all are probably thinking, well, that's good news because that means that our health promotion factors are going to be very relevant in male fertility. And you would be correct. OK, so when we're looking at the magnitude of improvement in fertility for those that start taking on more lifestyle related factors, health promoting factors, it is significantly more beneficial for men who are trying to get pregnant or get their partner pregnant than it is for females because females it's the accumulated reactive oxygen species of their entire life up to this point where it's still going to be beneficial but the magnitude is not going to be the same as the 74 day cycle of the male sperm. What that means is that we have several modifiable risk factors that we can be educating on when it comes to our fertility. So heat stress, use of a sauna, is one modifiable factor that seems to degrade sperm quality. Another one is alcohol use. Alcohol use can negatively impact sperm and sperm-related factors, and it should be avoided or minimized for individuals, for the male partner, for the female partner too, but specific to the male when we are trying to conceive. Steroid use and use of testosterone replacement therapy is a big cause of male-related infertility. It is not everybody who is on TRT, but in our male pelvis, right, the exogenous hormones shut down some of our spermogenesis type of physiological pathways and our body or the male body isn't producing sperm because there is an exogenous hormone that is coming in that says we're good. Okay, we're good. So individuals who are on exogenous steroids, so this is kind of our athletes. Pardon me, sorry. They're on TRT. We're seeing a lot of individuals who are topping up their T to be on the higher end of physiological normal. That may be a big contributing factor for them for their infertility. So asking about any supplements or any medical interventions that individuals are doing to top up their testosterone is a big factor. Smoking is another male related factor that can influence fertility. Smoking creates an increase in reactive oxygen species. creates chronic low-grade inflammation, this makes a lot of sense. The other one is obesity. Adipose tissue is low-grade inflammation tissue and can contribute to the burden of low-grade inflammation on the body. So a lot of these like heat stress saunas, alcohol use, TRT, smoking, and obesity are things that we can counsel on. Another very big influencing factor is a person's exercise. So sedentary behavior is linked to lower fertility rates and those who are physically active in the three months leading up to their fertility journey, starting, trying to conceive, have a higher rate of fertility. So the influence here though is a little bit nuanced from what we're seeing in the literature. So individuals who are active going into their conception journey. It doesn't seem for those who are not struggling with infertility to influence how fast a person gets pregnant, but it influences if there is going to be a male factor fertility issue. That makes a lot of sense because it's two people, right? We're going to only be able to optimize the person that we are working with. being physically active, going into your conception is a good thing to do. Especially most of our evidence, you guys are not surprised based on where my research is, like a lot of this is in aerobics, so we're trying to build up some of our resistance training literature. So being physically active, being less sedentary is good. The only flip side of that is for individuals who are really active. Okay, so for our highly, highly active, especially endurance, especially cyclists. Okay, so when we are working with individuals who are very highly active, especially our endurance trained individuals, we are seeing an influence on sperm motility for those who are cycling for more than five hours. And what that is, is the closeness of the testicles to the body when you're on a bike that is putting the seat close to the body, because the heat can influence the sperm and sperm quality. It's also some of the impact, mechanical impacts of the bike seat. We see that there are higher rates of erectile dysfunction and pudendal neuralgia, which can influence sexual response in our high-level cyclists. And we are recognizing that individuals who are in the endurance space, our male endurance athletes, are at risk for RITS, relative energy deficiency in sport. Our female athletes are much more sensitive to underfueling and that low fuel and energy availability and its impact on their physiology, but our males are not immune. And our endurance male athletes, in particular, appear to have a higher incidence of underfueling than we are recognizing. And so Exercise in general is very good for fertility. For those who are on the very high volume side of the spectrum, we may be counseling on type of exercise, fueling, and volume, and clearing for any types of sexual dysfunctions that may influence a person's conception. SUMMARY All right, I hope you found that helpful. I found this literature to be so fascinating. When I think about fertility and the male cycle, I just kept thinking, this really feels like a vital sign for health for our males, right? Like when I'm thinking about the sperm quality, reactive oxygen species load, like it almost feels like an HPA1C for health of the entire body. We use HbA1c to get a good idea of blood sugar responses over the last three months. We can get almost like an inflammatory load response for males in the previous 74 days with sperm analysis. Now, we're not going to go and get pupils to have a sperm analysis every couple of months to take a look at their health, but I think it is fascinating to see how sperm-related parameters can really give us some insights into the overall health of the male that we're working with. All right, if you are interested in learning all things about fertility, we dive into fertility management in our level two course across a variety of weeks. So we talk about fertility and influences for fertility. We talk about fertility related conditions that lead to infertility, and we talk about assisted reproductive technologies and the influence of different fitness forward modalities on ART technology. So if you are interested, our next level two, you have had to have taken our level one online course to get into that is in August. I have just been in Texas last weekend. It was so fun. You guys were so great. I'm so thankful for you all. Around learning about all things pelvic this weekend if you were looking to get into our live course Our next course is May 18th 19th in Kearney, Missouri Then I'm gonna be in Highland, Michigan June 1st and 2nd Alexis is gonna be up in Anchorage, Alaska and then June 8th 9th. I have a back-to-back I'm in Mineola, New York. So I'm at Garden City CrossFit close to New York City and I would love to hang out with you guys. We had so much fun at dinner. We were talking all things Pelvic health and we just had a great time. So if you're interested in any of those courses OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 12, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses incidence of knee injury in functional fitness, common types of knee injuries seen in this space, and how to begin to treat knee pain for the fitness athlete. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. ALAN FREDENDALL All right. Good morning, everybody. Good morning, Instagram. Good morning, YouTube. Good morning to those of you on the podcast. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. My name is Alan. Happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and our division leader in the fitness athlete division and practice management divisions. It is Fitness Athlete Friday. We would say that means it's the best darn day of the week. And here on Fitness Athlete Friday, we talk all things for folks who are recreationally active. So those patients and athletes active in CrossFit, functional fitness, running, endurance sports, whatever, that person who is getting up every day and getting in their daily movement, we're here to help you help them. So today we're going to be talking about knee pain in the fitness athlete. And in the context of today, we're going to be talking about specifically those folks who are probably squatting on a regular basis. So CrossFit and functional fitness athletes, folks who are maybe squatting, squatting heavier, higher volume on a more frequent basis than maybe some of our endurance athletes. INCIDENCE & TYPES OF KNEE INJURIES IN FUNCTIONAL FITNESS So I want to talk about what types of injuries do we see in the knee in this space, describe a little bit about those injuries, and then discuss the beginning stage of how to begin to treat some of those conditions. So first things first, What do we see with knee pain in the fitness athlete population in general? The great news is over the past decade or so, we have got a lot of great high-quality research out of the CrossFit and functional fitness space about what regions of the body are injured most frequently, and then kind of what conditions follow those injury diagnoses. So we should know that in the fitness athlete, we primarily see shoulder as the most injured region. About 45% of injuries are from the shoulder. Really close behind that is the low back about 35% and then really musculoskeletal injury kind of falls off after shoulder and low back. Specifically today talking about the knee we see about 15% of injuries are related to the knee. Beyond that we have elbow, wrist and hand, ankle and foot, that sort of thing. So primarily shoulder and low back and then a real sprinkle of the knee. With those knee injuries, we're not seeing really major traumatic injuries. It's very rare, probably never in your gym, anecdotally, have you seen somebody fracture their leg, fracture their patella, tear their ACL, get hit by a vehicle, fall off a thing. That usually doesn't happen in the space of the gym. Primarily what we see in the fitness athlete population, folks who are doing a lot of impact, a lot of squatting, is that we see a lot of patellar tendinopathy and we see a lot of what we maybe would describe as a meniscus issue but really something that we could just generalize as medial knee pain. So now breaking down those two major conditions patellar tendinopathy and meniscus or medial knee pain first things first I would tell you if you haven't yet taken our extremity management course with Lindsay Huey, Mark Gallant or Cody Gingrich I would recommend you get to that course as soon as possible. That course is a really great complement to our fitness athlete courses as far as being able to recognize and diagnose and stage a tendinopathy, diagnose an extremity condition, but also treat it and learn a lot of progressions and regressions to treat those injuries. Specifically, they spend a lot of time the entire afternoon on Saturday addressing the knee in a lot of detail. So make sure you're really comfortable with these conditions. if you hear words like patellar tendinopathy or meniscal care and you think, quad sets? I don't know. PATELLAR TENDINOPATHY & MENISCAL CONDITIONS So talking about patellar tendinopathy, what do we know in overuse condition? who is that person in the gym that we maybe need to be aware of, or questions in our subjective exam with that person that would let us know this person may be in that bucket. Somebody brand new to squatting, think of somebody in their 40s or 50s, sedentary, maybe their entire life, that's not out of the realm of possibility these days, who is now jumping into CrossFit, jumping into Orange Theory, jumping into F45, being expected to squat at higher volume and higher loads than obviously they ever have in their life. Folks who maybe are not new to this space but are maybe incurring and encountering a higher level of squatting volume than normal may also fall into this bucket. There are also movement patterns that tend to show up in these folks. I like to stage these as two different movement patterns. The first is what I'll call the close enough squat depth pattern, right? That person who is getting to maybe just above or just at parallel. what do we know about that range of motion in the squat we actually know that's when force on the knee is at its highest that above that point at about 45 to 60 degrees or less of knee flexion and then below 90 degrees of knee flexion we know we have a deloading effect at the knee so those folks who are trying to squat to full depth but are in just that close enough bucket are putting a lot of mechanical force on their knee that they could get rid of if they either squatted more shallow, which is not ideal, or ideally squatted a little bit deeper. The second group of movement pattern folks who fall into overloading their knee is that back and down squat pattern person. So that person who does not break at the hips and knees at the same time. So as we instruct the squat, we like to tell people, imagine there's a rope around your hips and your knees and they're pulling in opposite directions at the same time. That means your hips should flex and your knees should flex. And ideally with a relatively vertical torso, you sit down, sit straight down into that squat pattern. The down and back folks tend to initiate their squat with a hinge, and then to get to depth at the last moment, bottom out that squat and drive all of that force into the anterior knee to hit depth. This is kind of how powerlifters tend to squat, especially with a low bar back squat. But folks who just have not grooved out the motor pattern of the squat yet, when they hinge back and then sit down to finish the depth, the knee again is taking up a lot of force that really we could clean up with some coaching and cueing, right? Maybe we could elevate that person's heels, give them a corrective to hold a plate in front of them, but otherwise encourage a more vertical torso and a more sit straight down squat pattern that distributes force equally between the hips, knees and ankles in their squat pattern instead of at the moment of truth, putting all the force in the knee as they try to hit depth. So that's the patellar tendinopathy bucket. What about the meniscus, the medial knee pain bucket? These are folks who are encountering a lot of impact in rotation. So we do see this a lot in the functional fitness space, right? We do running. We might not go run marathons, but we do a lot of workouts with 200, 400, 800 meter runs. We do a lot of box jumping to train triple extension. We do a lot of double unders for model structural cardio work. And we have begun to introduce shuttle runs, at least in the CrossFit space, to be able to run indoors during the winter in a competition environment where maybe we don't have access to run outside or we don't have the treadmills to be able to run inside on a machine. With shuttle runs comes not only the impact of running, but now a turning rotation moment. not too dissimilar from catching a box jump in the bottom of your squat with your double unders or with running in general. Also in this group are folks who might be new to squatting full depth or otherwise increasing their squat volume, right? No different than the patellar tendinopathy bucket that they are now encountering extra volume. So understanding who that person is is really important and that's where knowing that this person is a functional fitness athlete knowing if they are new to this or not, if they're returning after a break, if they've never done something like this in their life. Uncovering all of that in the subjective history is really important because it's going to give you a better idea of where your treatment might take you. TREATING KNEE PAIN IN THE FITNESS ATHLETE So let's talk about that treatment. What should be our priorities in treatment? With our functional fitness athletes, we're demanding full range of motion at every joint whenever possible. That means one of our primary goals should be if we find an asymmetry, a lack of range of motion, particularly in knee extension and knee flexion, we need to restore that as soon as possible. Again, I'll point you towards our extremity management course. I'll point you towards our fitness athlete live course to learn techniques to self-mobilize to load to restore that full range of motion. But as we're restoring that full range of motion, respecting the irritability of the patient, we need to begin to strengthen in whatever available range of motion we have. These folks do not need more volume, right? They're coming to you with an overuse, a repetitive use injury already. Giving them a 20-minute AMRAP or a 30-minute AMRAP and having them do hundreds of squats or lunges in the scope of their PT session is just adding insult to injury, especially if we are thinking that this is a patellar tendinopathy case, for example. These folks need strength, they need capacity and resilience in those structures, so that they can continue to not only stay in the gym, but perform in the gym, ideally, beyond the point at which they got injured, right? We don't wanna just return somebody to the exact moment at which they got injured. Ideally, once we clear them fully, hey, you don't need to do your PT exercises anymore, they are a stronger person than when they first began rehab with us. So we need to strengthen that full range of motion of the whole knee. Now PT school has closely associated in our brains that the knee means quadriceps and that's it, right? It's all over the research. It's all over knee extension machines and really, really focused on making sure that we have really, really strong quads, which is not a bad place to start, especially if that person is missing some knee extension, right? Some, some traction banded straight leg raises can do a lot to both begin to restrengthen quadriceps, but also restore knee extension. but we can't just stop at the quadriceps. We need to strengthen the whole knee, right? All four muscle groups of the leg that attach to the knee. So we also need to make sure we're targeting our hip abductors, our hip AD ductors. We need to target, yes, the quadriceps, but we also, especially if we're thinking this is a rotational-based injury, if we are thinking this is medial knee pain, call it meniscus, call it whatever, we really need to focus on the hamstrings because why hamstrings flexed and rotate the knee. They are pulling the knee into medial or lateral rotation in a movement like running. Ideally, hopefully, they're firing pretty much in sync so that we don't have a lot of rotation in our knee. We're primarily going through flexion extension, but our knee does have the capacity to rotate, obviously, and it's primarily driven by our hamstrings pulling the knee into flexion and in rotation. What is the problem with hamstring strengthening? The problem with hamstring strengthening is that in most functional fitness environments, we don't primarily isolate and train the hamstring. We certainly do a lot of deadlifts, we do a lot of kettlebell swings, that sort of thing, but if you think about the range of motion from the knee and the hip in motions like deadlift, kettlebell swing, it is not full range of motion of the hip and or knee, which means we're not strengthening the hamstring through its full range of motion. Yes, you'll feel a little maybe glute, high hamstring burn on high volume deadlifts or kettlebell swings, but you are not getting that deep behind the knee stimulus that you are with things like Nordic curls or even just isolated knee flexion on a knee flexion machine or banded knee flexion or anything like that. So understanding that the hamstrings flex and rotate the knee is really important to kind of finishing the drill on a really comprehensive knee strengthening program. Understanding that biceps femoris is responsible for knee flexion, but also yes, lateral knee rotation, and that semimembranosus and tendinosis are responsible for flexion and medial knee rotation. So particularly with those medial knee pain bucket folks, we wanna get into semimembranosus, semitendinosus, maybe with our hands, with needles, with cups, whatever, try to restore both that flexion and rotary component of the knee, and then get out in the gym and really strengthen those hamstrings on top of, yes, the quadriceps, the hip abductors, and the hip adductors. TIME UNDER TENSION IS KEY The key with strengthening the knee, again, is time under tension. The folks you're working with are already doing higher volume, higher repetition, relatively moderate to higher load training for the knee in a Metcon style workout. So adding in more air squats at high volume or light wall balls or thrusters or goblet squats is really just doing the same thing that they're already doing in the gym, which led them to be sitting on your table in the first place. So just giving them more of that isn't necessarily a prescription. When we have students at Health HQ, they're so excited to have people out in the gym moving, folks who are interested in taking care of their health and fitness, and they love to jump up to that whiteboard and write out, Remom 24, Amrap 30. We have to go, wait, stop, stop. That's not appropriate for this patient, right? This patient is already dealing with the consequences of too much volume. We need to back their volume down, especially in physical therapy, and focus on time and attention. So be careful that we're not actually exacerbating or at least prolonging the healing time of that patient's condition because our volume in PT, our volume for our home program is too high. Slow it down, less reps, less sets, more time under tension. Depending on the patient's irritability will let you determine how much tension you can apply both in the clinic, in the gym, and for homework. When someone's really irritable, I'm thinking maybe isometrics, and I'm thinking something like a reverse Tabata. 8 rounds, 10 seconds of work, 20 seconds of rest. There are apps out there. I personally like GymNext. It is a timer. It has a Tabata built in, EMOM, AMRAP for time built in. It can connect to a Bluetooth clock that the company sells, but you can also just use it as a standalone app and play it through a Bluetooth speaker or just through your phone speaker for your patient to hear. So reverse Tabata, eight rounds, 10 seconds of work, 20 seconds of rest, that gets us 80 seconds time under tension. That's a pretty good start, especially if we're doing it isometrically and the patient is really, really, really irritable. Now, as symptoms calm down, as function begins to improve, as tolerance to loading begins to improve, we want to increase that time under tension dose, especially if we're convinced that this is a tendinopathy based condition. So I like to move next to 10 sets of 10 seconds of work. I'll usually do 10 seconds on, 20 to 30 seconds off for 10 sets. That bumps the needle about 20%. That gets me 100 seconds time under tension. Then, when that patient appears ready, we'll probably progress to a Tabata. That's 160 seconds, right? It's the opposite of a reverse Tabata, a full Tabata. 8 rounds, 20 seconds of work. 10 seconds of rest. So the inverse of a reverse that gives us 160 seconds. So now we're close to pushing three minutes time under tension through that structure. At this point, you're probably away from isometric exercise, but if you're not great, keep rocking the isometric exercise for more attention. And then really for me, kind of the hallmark that someone is getting close to the end of their plan of care is when we can do isotonic movement, we can do five sets of five, and we can do some really gnarly tempo right think about a slant board goblet squat right so he was really elevated a lot of focus on tension through that anterior knee and that medial knee structure three seconds down hold the bottom and as deep of a squat as you can show me three seconds and then three seconds standing concentrically out of that squat. That's nine seconds per rep, five reps per set, five sets. That gives us 45 seconds time under tension per set. That gives us 225 seconds across the five sets. That is what the tendinopathy research tells us we need to be hitting as a benchmark for our time under tension. So understanding, depending on that patient's irritability, depending on how long this condition has been going on, that person may not be able to walk into the clinic and do a slant board, heels elevated, goblet squat, five sets of five at 3-3-3-1 tempo. That might be a lot, right? Certainly probably going to make them sore, but it might aggravate their condition. So understand how we can regress and progress, time and retention is needed. And then make sure as well that we're doing that for every structure of the knee. Again, that we're hitting the medial knee, the lateral knee, the anterior knee and the posterior knee, particularly doing things for the hamstrings like Nordic curls, curls on the rower, furniture slide curls, anything to really target the hamstrings as they insert at the knee as they flex and rotate the knee. and not just strengthening mid-range of the hamstrings and mid-range of the quadriceps. SUMMARY So knee pain in the fitness athlete. How frequent? About 15% of all injuries, so relatively low compared to all the other injuries that this population encounters. Primarily, folks, patellar tendinopathy, meniscus, medial knee. Why? Overuse, either a sudden spike in volume from a more competitive athlete or a new athlete, or someone who is maybe doing extra stuff outside of the gym, extra running, extra squatting, whatever. Folks to watch squat when they're with you, are they the close enough depth person? Do maybe they need some help in their ankles or hips to hit better depth and take load off the knee? Are they the back and down squat person? Do they primarily squat with a hinge and then bottom out through the knee to hit depth? That is a person that can benefit from sequencing their squat pattern a little bit better, especially if they do have a goal to be a functional fitness athlete. They need to be able to show a relatively vertical torso squat, a high bar back squat, a front squat, a thruster, a clean, that sort of thing. With our treatment, make sure that we're working as soon as possible to restore full range of motion of both extension and flexion. We need full knee flexion to squat. We want full knee extension for impact. We want to strengthen the whole knee, not just the quadriceps. Hit the hip abductors, hit the AD ductors, and particularly full range of motion hamstring work, not just things like deadlifts and kettlebell swings. They're already doing partial range of motion hamstring strengthening in the gym. And then remember, it's not about volume. It's not about coming into PT and doing 500 air squats. They can definitely do that. It's probably going to exacerbate their symptoms. What we're focused on with our strengthening with their home program is time under tension. Start with the reverse Tabata. 10 seconds on, 20 seconds off, eight rounds. 80 seconds time under tension. Move to 10 sets of 10 on, 20 to 30 off. That's 100 seconds. Move through a full Tabata. Now 160 seconds, 8 rounds, 20 on, 10 off. And then the gold standard is can we do 5 sets of 5 of a movement at 3 seconds eccentric, 3 seconds isometric, 3 seconds concentric. Can we get to that 225 second time under tension benchmark? So I hope this was helpful. I'd love to hear questions you all have, throw them here on Instagram, shoot us an email, shoot us a message over on the ice physio app. Some courses coming your way from the fitness athlete real quick before I let you go. Our next cohort of fitness athlete level one online starts April 29th. That course is already almost sold out and it does not start for three more weeks. So if you've been looking to get into that class, that class has sold out every cohort since 2017. This next class will not be the exception, I promise you. So if you've been on the fence, get off the fence. If you've already taken that course, your chance at level two online to work towards your certification in the clinical management fitness athlete begins September 2nd. And then some live courses coming your way. Mitch Babcock will be down in Oklahoma City this weekend, April 13th and 14th, if you want to join him. He'll be back on the road again, May 18th and 19th out in Bozeman, Montana. And in that same weekend, Joe Hanesko will be up in Proctor, Minnesota, which is in the Duluth, Minnesota area. That will also be the weekend of May 18th and 19th. So hope this was helpful. Hope you all have a wonderful Friday. Have a fantastic weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 11, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses three fundamentals to working with individuals new to a fitness routine who encounter their first injury: avoid medical imaging, stay in the gym & modify around the injury, and be goal-driven to maintain motivation to continue to create a fitness habit. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JEFF MOOREAlright crew, what's up? Welcome back to the P.T. on Ice Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and always thrilled to be here on a Leadership Thursday, which is always a Gut Check Thursday. So first things first, let's hit the workout. Gut Check Thursday this week is going to be a bit of a partner WOD. So we've got four times, relatively simple. It's going to be 100 deadlifts, 100 power cleans, 100 power snatches. The weight is going to be 225-155 on the deadlifts, 135-105 on the power cleans, and then 95-65 on those power snatches. Essentially, you're going to decrease load with each movement, but obviously increasing complexity, and maybe more importantly, increasing grip fatigue. I'm looking at that workout thinking, boy, that's a lot of pulling on that barbell, but it's in teams of two, so break it up however you want, maybe five, maybe 10 reps on some of those things, and then pass it over to your partner, bang all of that out for time, and then post it so we can see how you did. Tag Ice Physio, hashtag Ice Train. I'm gonna do this at three o'clock with Say over at CrossFit Endure, our marketing director. We're gonna challenge this workout. I will make sure to post my time. so you have something to try and smash later on today or tomorrow whenever you have a chance to get to the workout. So that is Gut Check Thursday. Let's move on to the episode. THE ROAD TO FITNESS RUNS THROUGH MUSCULOSKELETAL PAIN We are talking about the fact that their life is in your hands. It sounds a little dramatic. I don't think it is, okay? We're gonna start off with the fact that whether we like it or not, we have to acknowledge it's true and that is the fact that the road to fitness runs through musculoskeletal pain. The road to fitness runs through musculoskeletal pain. We don't have to like that to acknowledge the reality of that. Meaning, if you're gonna take somebody who's relatively sedentary, is not on the path yet, and you're gonna bring them all the way to fitness, right? So through wellness, all the way to fitness, that journey, requires a lot of loading, and a lot of challenging, and a lot of recovering, and a lot of programming, and a lot of strain, and stress, and rebuilding, and remodeling. It is a journey, right, that involves a lot of stress to the organism, right, to be able to get it to adapt, to get to a point where you achieve fitness. You don't get there, first of all, quickly, and second of all, without ever experiencing any kind of symptoms, right? That's a lot of stress to the system. You're going to have some bumps and bruises and strains. I'm not talking about major injuries, but you're going to be working through some stuff, right? How we manage that stuff, especially acutely. And when I say we, I mean the entire team, right? Coaches, trainers, physios, chiros, fitness forward physicians, right? Everybody who these individuals are beginning to trust to guide them along this journey, how we all swoop in and manage the acute response to someone developing symptoms is going to dictate whether or not they stay on the path. And from our perspective, if they stay on the path, is a huge variable in the quality of their life. MANAGING THE INITIAL RESPONSE TO ACUTE INJURY DICTATES LONG-TERM OUTCOMES So when I say life is in your hands, what I mean is managing the initial response to someone's acute injury onset dictates probably the longevity, probably the level of thriving, probably the health span. That's why I'm saying life is in your hands because the way you respond to this will dictate those things. And those things really are the quality of this person's life. So let me tell you the three things specifically. that when someone develops symptoms in the gym, that our response kind of hangs in the balance whether or not this person continues along this path that we believe drives so many of the important metrics of the quality of someone's existence. Okay, so if an athlete develops symptoms, right, you're not going to get into a case study of how or why. It happens all the time. Somebody tweaks something, they develop symptoms. Here's the three things. AVOID MEDICAL IMAGING Number one, they avoid medical imaging, advanced medical imaging. If we want this person to stay on the path to fitness and they've recently developed symptoms, the number one most important thing is that they avoid advanced medical imaging, okay? We now know the problem, right? That most asymptomatic people have abnormal findings on imaging that can be really scary and knock someone off the path. I am not gonna get in to the myriad of studies here. Nobody reasonably well-read is gonna push back on this podcast and say that isn't true, right? We have now known for well over a decade, you think back to 2012 when the American Journal of Sports Medicine, right, took that cohort of folks, average age of 38. How many had abnormalities in their hips, asymptomatic people? 73%. How many had labral tears? 69%. No hip pain whatsoever, asymptomatic people. You think about that classic Brzezinski article, right? Not article, but systematic review paper. Took a bunch of different publications, bundled them all together, looked at the data, what did we see? Your average asymptomatic person, meaning no low back pain whatsoever, in their 50s. 80% disc degeneration, 60% disc bulges. We now know the average asymptomatic person has all of these findings on their imaging that can be concerning. This is why we focus on tissue health, not tissue shape. What we now all acknowledge is that your connective tissue changes over time in your face, inside your body, your spine, your labrum, right? It changes over time. It doesn't tend to correlate well to symptoms. The problem is if someone just got hurt, If they just started experiencing pain and they're nervous, right? And they're vulnerable and they get that image and they see something that looks kind of scary, it sticks with them. It bumps them off the path. They have a hard time letting it go. They say, well, yeah, I might be able to get healthier, but I saw that cartilage. It was torn. We're not going to fix that unless we go in there and fix that, right? And they get extremely fixated on this. They begin to lose confidence. in the rehab or strength and conditioning process. It really, really sticks. What we know is when that person develops symptoms, we could have sent the other 10 people in that class to get an image and we would have seen the same stuff, but it doesn't matter. We can say that until we're blue in the face. We have said that until we're blue in the face. When the person's injured, when they feel vulnerable, when they're in pain, when they're in that decision-making process and they get that image and they see something that looks scary and maybe somebody in the medical industrialized complex made it sound scary, Those things make it very, very difficult to keep that person on the path. So getting them to avoid that unnecessary image is a massive part of the acute triage process if we want to keep this person moving towards fitness. Now, it always is worth saying, But certainly there are some times when they should get an image. Of course there are. And that is why physios, chiros, physicians, I'm challenging you all to make sure you're available to these gym owners and these coaches that when something does happen, you've got that direct access training and license where you can come in and make that tough call. And it's a tough call on either side. Because if you do send them, we're risking this thought virus we're talking about here. If you don't send them and they needed it, you're possibly putting that person at significant risk. So don't make gym owners make that call. Don't make coaches make that call. This is what you're trained for. Get in there and make that call. And make sure that the gym owners know you're available that day for a quick consult to get that person's mind off of that possibility when that's appropriate, which usually it is, or doing the appropriate triage if it's necessary. Get that part accomplished, okay? Alright, number one, if you want to keep them on the path, avoid advanced medical imaging unless it's absolutely necessary. Have somebody qualified to make that tough call so that you can get over that hurdle quickly and efficiently. DON'T LEAVE THE GYM; USE THE GYM Number two, if you don't want them to fall off the path, You've got to convince them they don't need to leave the gym, they need to use the gym. People when injured, when in pain, are going to make a very broad assumption that they shouldn't be in the gym. It's the first thing they're going to say, right? They're going to go to put that membership on hold. Your job on the same day of injury is to help them realize that everything they need is actually in that gym. All the tools to rehab the injury that occurred are right there in that gym. The ability to regress the skill that maybe they were inefficient with is why they wound up straining something. are right in that jam. You can regress everything and build a better foundation so next time you get up to that PR or that new movement, you're more ready for it, you're doing it more efficiently, and you've done the accessory work so that you're not stressing different structures at an unnecessary rate, and now you're having a lot more success with these movements. All of those abilities, whether it's to rehab the area, to work on the skill that you struggled with, to build a better foundation, Those tools only exist in the gym. The number one place you should be after injury is in the gym. So don't let them leave, right? So help them understand that you might not do exactly what you just did, you will in a few months, but everything around here is what we're gonna use to make sure you can if you want to. Helping them realize, whoa, whoa, whoa, whoa, you don't need to be leaving the gym, you're gonna use this place, right? That's a critical part of the acute triage process. GET OBSESSED WITH GOALS And finally, number three, Get them obsessed with new goals or at least new angles at the same ones. What I mean by this? is that motivation is fleeting, especially in people that don't have well-formed habits yet, right? Something, some confluence of factors happened in their life where all of a sudden they became someone who goes to the gym, okay? That is a pretty fragile ecosystem early on. We know how tough habit formation is, you're learning new skills. Motivation can be fleeting and fragile. You gotta shift it, don't lose it. shift it, don't lose it. Get inside that person's brain quickly and figure out why they were coming to the gym and show them that they can achieve that while working around the injured area. If that person says, well, I'm here because I've been listening to so many podcasts and it sounds like Cardiorespiratory fitness is a massive predictor of longevity and healthspan and decreasing all-cause mortality. All the things, right? Like, I'm in, but I hurt my knee. So now I can't do the bike and run, etc. So I'm going to call it quits for a bit. You sure are not going to do that. You are going to be on the ski erg, right? Because those things don't involve high or low to those areas, but we can still challenge your cardiorespiratory fitness. We are going to get them obsessed with a different goal, right? If they had a gymnastics goal and right now their shoulders tweaked, we're going to help them realize there's nine other similar goals that don't involve that area that we have a very specific program to move towards. And we're going to get them obsessed with getting that goal. And then we're going to swoop right back around and get on the same path and grab the other one. We're just going to show them. There are so many amazing things that we can do in here. to keep chasing your original goal, add on new goals, work around the injuries, and still achieve everything you set out to do, we understand that motivation is fleeting and fragile. We are going to help them take that motivation they've got right now, and we're going to shift it a little bit. We are not going to let them lose it. And you've got to be convincing in that acute phase, because they're going to make some heavy-handed decisions with all that emotional energy, with pain on board, and you've got to be there to guide that process. SUMMARY Team… Whether people choose to chase fitness during their lives is going to be a huge predictor of the quality of their lives. As they chase fitness, they are going to have soreness. They are going to tweak things. We are not going to load the system for years and years and never bump into any of this stuff. How we as a support system come alongside that person in that acute emotional time when they're having pain is going to dictate if they stay on the path. If we can get them to avoid advanced medical imaging when unnecessary, if we can get them to stay in the gym and use it versus leaving it, and if we can take that motivation they have and shift it as opposed to getting rid of it, we can get this person staying on the path. and we can change the entire rest of their lives, their family's lives, everybody they interact with, their life is in your hands. Be a great resource. Think about those three things in that acute management phase. I hope it helps, team. Thanks for being here on Leadership Thursday. As far as courses coming up, We've got a bunch of them. Ice Sampler is coming up at the end of this month in just a couple weeks in Carson City. We're actually going to put a limited amount of tickets on sale for 2025 because we know this event is hard to get into. It sold out in one day last year so we're trying to make tickets available at different times to give folks an opportunity to be a part of the event in 2025. But before then, we've got a bunch of courses. We had 12 last weekend. I think we have another dozen coming up over the next weekend or two before Sampler. So get on PTNICE.com, check those out. A lot of online courses start on April 29th, which is only a few weeks away, and some of them only have a handful of seats. So get over to the website, check it out, have an awesome Thursday, do gut check. We'll see you next week, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 10, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer takes listeners through a case study, showcasing how therapists dig deeper into patient goals in order to create meaningful treatment sessions that improve patient function. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JULIE BRAUERGood morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division and I'm going to be talking to you all this morning about make it meaningful, load it, dose it. So what is that? Make it meaningful, load it, dose it is the exercise prescription formula that the older division uses. So those of you who have taken our online course or our live course, you have heard this, you have learned about it. So what we're going to do this morning is I'm going to take you through how to apply this formula specifically for the goal of a patient who wants to return to gardening. So we're going to go through a little bit of a case study here. So to dive a little deeper into exactly what's coming up, I'm going to take you through how to dig deeper into the goal of when someone tells you I want to be able to garden on my own. We're going to dig deeper there and talk about why it's important And then I'm going to show you how you can take that goal and break it down into its functional movement parts, because that is going to give you all the exercises that you will be using throughout your plan of care. Using this formula is going to be able to give you all a way to create meaningful, effective, and efficient exercise programs for your patients. So we'll dig into the goal, we'll break it down into its movement parts. Then when I see you all again in a couple weeks, I will have my wireless mic by then and I'm going to go out into my garage and I'm going to show you what some of these exercises look like and give you some scaling options and how we would load it and dose it for intensity. DIG DEEP INTO GOALS TO FIND THE "WHY" Okay, so let's start from the beginning. We have to dig deep with every single patient when they give us a goal. We got to dig deep for the details. Why? Two main things. First, we want to know, in particular for this case study, when this patient says, I want to be able to garden, we want to know why. We want to know why gardening is important. What about gardening is this individual most excited about? We want to know the emotional why, because that's going to get us our buy-in. Next, we want to know details down to the nitty-gritty, exactly what this activity looks like. I want to know what this gardening task looks like from start to finish, because once you visualize it, you're going to recreate it. That is going to give you all of the exercises that you're going to ever have to do with this patient throughout your plan of care. It's the easy button. So when I say dig deeper to get to the emotional why, this is what I mean. It sounds something like this. So patient, let's call her Dolores. All right, we'll call her Dolores. Dolores tells you, I want a garden on my own and you're going to say, Dolores, tell me more about that. What about gardening is so important to you? I would love to hear more. When you are asking Dolores about her goal, you are giving her eye contact. This is not the time to open up your laptop and do any typing. You give her your undivided attention for these first few minutes while you are asking her about gardening and why it's important. Dolores, what about gardening brings you joy? What are you most excited about with gardening? This is where you can say, I love gardening. I grew up with a garden. My mom would, we would plant catnip and we would make our cats go crazy. I mean, literally this is true for me. This is what I've told my patients when they've told me they want to get back to a gardening task. Relate to your patient, right? Make that connection. When you do that, you're allowing the patient to give you more of a story behind why it's important. So Dolores is going to tell you something like this is true for a patient I recently had. My granddaughter is getting to an age where she likes to garden with her mom and I want to be able to garden with her as well and I want to be able to go outside and garden with my granddaughter and feel confident doing that. Boom, there's your emotional why. You have to dig deep enough to get to that point. Why? Because superficial goals, if you were to just leave it at, I wanna be able to garden, I wanna get stronger to be able to go outside. If you leave it at that superficial goal point, you lack the emotional connection. And Jeff Moore did a podcast, I cannot remember what it's called, but he says, and it stuck with me, this is probably a year ago, Superficial goals lack emotional connection, and emotional connection is what motivates your patient. Emotional connection is what's going to motivate your patient. So you find that emotional why, now your patient's connected to you, they believe you give a damn, you feel connected to them, you've got that therapeutic alliance, you both are invested and locked in. Okay, Moving on, the next details that you want are the nitty gritty details of what that gardening task looks like. So this is what it sounds like. I will say, Dolores, I want to visualize what this gardening looks like. Can you tell me exactly what it looks like from start to finish, from the very beginning to the end and everything in between? I want to be able to visualize it. as Dolores is walking you through all of the functional demands that she has to be able to do in order to fulfill this goal. I am using my whiteboard and I am writing this down. Now I know this was reversed for you all. I'm going to take a picture of this and put it in the comment on this post, but I am writing down every single thing she says. All right. So I have a whiteboard at the top. I'm going to put her name. Maybe I'll say this is, uh, Dolores, Dolores gets a garden strong, something like that. Those little details can make it much more meaningful to your patient. Little special things that you can add in. CREATE TREATMENTS THAT PROGRESS PATIENT GOALS So I have her name at the top and then as she is telling me what she has to do, I write it down. So she will say something like, I need to be able to push the door open on my own to get from inside to outside. So I'm writing that down. And then in parentheses, I'm putting what type of exercise exactly mimics that activity. So if she says, I need to be able to push the door open to go from inside to outside, To me, my fitness forward brain is what does that look like? Oh, a sled push. Awesome. So I write down push door open and then in parentheses I put sled push. Then she tells me, all right, and then I got to walk over grass and I have some stepping stones and I have some gravel. So she told me she has to walk over variable terrain. So then in parentheses, what am I putting down? Okay. So that's stepping on and over obstacles. Then she tells me, then I'm going to have to pick up some stuff and carry it around. So I got to pick up some tools. I got to pick up my mulch. My fitness forward brain goes, okay, what looks exactly like that? Pick up and carry. Well, I know that that's going to be a deadlift and that's going to be a loaded carry. Then Dolores says, then I'm going to have to get down on my knees and do some things on the ground. I'm going to have to get up and off the ground quite a few times. My fitness for brain says, what is that? Well, that's going to be a lot of floor transfer, part practice and full practice. Then she says, I got to pull weeds as well. It's, you know, usually like, Oh, well it's, it's not the best part of the job, but it has to be done. I want my garden to look really nice. I need to be able to pull weeds. So I'm thinking, what does pull weeds look like? My fitness for my fitness for brain says that's going to be quadruped position and I'm going to do some quadruped rowing. Okay. I'm trying to make it look exactly like that functional activity. You're catching on here, right? You're understanding what I'm doing. I am taking everything she's saying and I'm turning it into what the exercise is going to be. That looks exactly like that activity. And then the last thing she says is, and I need to do all of that and I don't want to fall over. So when I hear that, I know that I have to add in some perturbations. So I'm going to be giving her some external perturbations that are going to force her to take that reactive step. So I can train that. So I can train her dynamic balance. So now that I have that entire list, I am going to teach it back to her. I am going to say, Dolores, I was writing down everything you were telling me, all the pieces and parts that are important in order for you to accomplish this goal. Is this correct? And I'm going to go through and I'm going to say, Dolores, what I heard, what you told me is you need to push the door open. You need to walk over grass and gravel. You need to pick up and carry some stuff. You got to get down on your knees. You got to pull some weeds and you want to be able to do all of that without tipping over. Dolores is going to sit back and be like, wow, this person was actually listening to me. You have just improved that therapeutic alliance even more because you have heard her well. So now you have this entire bank of exercises. This is what you're going to pull from. Now that, I mean that was sit one, two, three, four, five, six. Those are six different movements there. That list could be less than six. It could be way more than six. So then you're going to think, okay, well, what's the next step here? I have all of these movements. What do I do with them? ASSESS,DON'T GUESS THE PATIENT'S ABILITY TO PERFORM FUNCTIONAL TASKS Next, you want to assess Dolores, how she goes through the motions of these functional movements. So when you are in an outpatient clinic, you got to recreate it in your clinic. If you're in a home health setting, this is easy peasy. You say to Dolores, all right, we're going to go through and I'm going to have you show me exactly what this looks like. All right. Something that I like to do when I, before I do this assessment to watch what this looks like is I will ask Dolores, I will ask my patients, What about all of those movements? Which of those do you feel like you can do really well? What are you really strong at when it comes to all those different pieces and parts that make up gardening? And then I will ask her, which of those movements are you fearful of? Which of those do you feel like that you don't really have the strength to do yet? I want to know her perception of her own abilities. And because as I'm assessing her, I'm looking at a lot, this is going to help me dial in exactly what I should pay attention to. I want to know the things that she's really strong at and see if she is actually strong at those. And I want to know the things that she's fearful of and see if she actually struggles with those pieces and parts. So after I asked her that, I kind of put a little asterisk sign into which of those movements are her strong movements and her weaker movements based on her perception. And then it's assessment time. So again, in the home setting, I am having her do the thing. I am not helping her. It's very similar. If you work in inpatient rehab, you just do the assessment, a FIM care tool. You're not helping them. You're simply watching how they do it. This is not the time. to assist and teach and coach, you are simply watching. In the clinic, this is where you want to set this environment up. You want to mimic and recreate this activity. BUY FUNCTIONAL EQUIPMENT, NOT BARBELLS So this may ruffle a few feathers, but as opposed to say you have budget and you have some money to spend at your clinic to buy equipment, I'm going to give you a potentially not popular opinion. Maybe instead of buying that barbell first for your clinic, if you're working with older adults, what if you bought functional activities that older adults actually use and that are not intimidating to them and directly relate to the goals they're trying to achieve? So what if you bought a laundry basket? What if you bought a bag of mulch? What if you bought some gardening tools? What if you brought in a, um, some laundry detergent, some pots, some pans, dog food, things that older adults are lifting and carrying and using at home pretty consistently. I would rather have those things at my disposal to use right away when I introduce loading to an older adult versus rely on jumping straight to the barbell where someone can be incredibly intimidated by that. This is not a or situation. This is an and. However, I have learned over time that I'm going to get more people to buy in if I have those functional activities those functional objects that people use at home that's going to get me more buy-in than saying all right you have to pick up uh and carry tools from um when you go out and garden well let's go do it with this barbell That's a lot harder of a sell. So here's your call to action. Spend that extra clinic money or just take stuff from your home that you don't use. You know, don't throw it away or go to a garage sale or a thrift store, whatever it is, and get this stuff and bring it into your clinic. All right, so you're going to set this all up in the clinic. You're going to assess, you're watching to see her quality. You're watching to see how long it takes her. I mean, this really is becoming an outcome measure for me. this is going to become like a benchmark workout. Okay. So think about it that way. This is, this is much more than an assessment. I'm going to use and recreate this, uh, call it a meaningful obstacle course that looks exactly like her gardening task. And I'm going to run it again and again and again. So I can track her progress and how well she's able to do this activity. So from them, I have recreated, the functional activity. I am assessing how well she does. I'm taking notes. I'm looking at the things she's strong at, the things she's weak at. After we're done, we're sitting down and we're recapping. Are the things that she thought she was strong at and weak at, did that match with how she actually performed? And we have a discussion there. From there, again, I'm looking at this list and now I'm talking to Dolores and I'm saying, Dolores, Based on what we just saw and what you just felt, these are the few activities, and you're looking for three to four here, three to four. These are the three to four activities that we are gonna focus on next session. And what are you gonna do? You are going to create an EMOM or an AMRAP with those few functional activities that you together have determined are the most important and you're going to find a way to load it up, whether that's adding physical load or cognitive load, and you're going to find a way to appropriately dose it so that you know you are at an appropriate intensity to drive adaptation. SUMMARY Okay, so that is how we go from taking a goal, digging deep to get to the emotional why, going through breaking down that meaningful goal into its functional movement parts. All right, that is the hardest part. It's the most important part. When I see you on a couple weeks, I will use this same exact case study and I'm going to take all of these exercises and I am going to show you ways to scale this up, scale it down, dose it, add some load, whether that's physical load or cognitive load. The idea here is we want to make our sessions and our AMRAPs, our EMOMs and the workouts harder than what the demand is that she actually has to do to reach that goal. Because if she is able to do her gardening tasks with load on her, with cognitive load on her, adding in intensity, then gardening with her granddaughter is going to feel easy. And that is the goal. All right, guys, that's all I got for you. I will post a screenshot of this list. So if you all have a patient whose goal is to garden at any point the rest of the week, you have a nice list of exercises that would probably be very relatable and meaningful for them. To end things out, I will let you guys know what we have coming up in the Older Adult Division in terms of courses. For the rest of the month, we will be on the road in Washington, Tennessee, and Pennsylvania. And then both of our online courses, Level 1 and Level 2, are starting in the month of May. We would love to see you on the road or online. PTI Nice is where all that lives. If you have any questions, any comments about anything we talked about today, hit me up. Would love to jam on anything with you all. Have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 9, 2024

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses using isometric exercises for more than just pain relief including newer research emerging that isometric exercise does cause structural adaptation. Mark also discusses key points important for successful dosage of isometric exercise in the clinic. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Janex. MARK GALLANT All right, what is up PT on Ice crew? We got Instagram, we got YouTube. I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey. Cody Gingrich coming at you here on Clinical Tuesday. What I want to talk about this morning is isometrics beyond the pain. So isometrics are obviously a muscle contraction type that have been around since the beginning of time, really. Since humans have existed, we've had to hold things and carry things isometrically. And the popularity of isometric exercises has come up and gone down and come up and gone down as fitness trends and rehab trends always tend to change and the last decade we've been in a period where isometrics have been on the up for the last 10 years and a lot of that has been because of the research of Ebony Rio out of Australia where in 2015 she took a group of volleyball players and figured out that if we hold long hold heavy isometrics we get both cortical pain inhibition and a subjective decrease in pain. Well, that study has been looked at a handful of times over the last nine years since then. And sometimes it shakes out just as ebony Rio found in 2015, 2016. And other times we see that it does not have the same wonderful, incredible pain reducing results that we're all hoping for. And really the reason for this is pain is wildly complex. So if you do the same study that Ebony Rio did with her volleyball players, five sets, 45 seconds, 70% of their one rep max for a two minute rest, and the group of people ate something different for breakfast that day, if they did not get as good of sleep as the other group, if they are incredibly stressed, if their soccer coach yelled at them, a million different things could have possibly happened that are going to impact that person's symptoms overall. So despite pain being multivariable and very complex and maybe not being the 100%, isometrics not being a great, they're still great, not being a 100% reducer of pain every time like we saw in that Ebony Rio study, we've talked about on this podcast. ISOMETRICS ALLOW FOR THE CONTROL OF MULTIPLE VARIABLES The reason we're still gonna use them is the isometrics control for so many of the variables that are challenging when someone is injured or early on in their rehab process. It controls, you can control the volume easily, five sets of 45 seconds or four sets of 30 seconds. You can control the position. Is the shoulder flex? Is the shoulder down at neutral? You can control the amplitude of motion. So isometric, there is no amplitude. It is, it's exactly still. You can control the load easily overall. That load's not going to change as they're doing the motion. and you control the speed really well because it's isometric. So there is no speed once that object gets into the position or the joint gets into that position. ISOMETRICS: TREAT THE DONUT & THE HOLE Beyond those things, there's more exciting research that has been coming out that gives us even more reason to keep isometrics in our rehab plan, especially when it seems that the tendon and ligament are involved in that person's pathology or the injury. Out of Keith Barr's lab at UC Davis, California, they are now showing that it seems, with isometric, that we can indeed adapt tendon and ligament tissue and lay down new collagen. So classically, we always thought that the catchphrase, treat the donut, not the hole. Treat the donut, not the hole. So what we believed was that you were adapting all the healthy tissues around the degenerative or injured area so that that person can get back to their activities and you're not gonna be as concerned of healing or building back up the degenerative area. And we believed it could, it was possibly, that it was not even possible potentially. And what Keith Barr's lab is now showing, that it does seem that with long hold heavy isometrics, that we can lay down new collagen in these areas potentially. Now this is all new and exciting research, so if it doesn't shake out perfect, we'll adapt with the times. Keith Barr's lab is exciting because what they are able to do that other labs can't is they are able to engineer tendons. So they create a bunch of tendons and ligaments that they can test in all sorts of wild ways because they're literally manufacturing them. Once they get something that's cool or seems beneficial, then they move that same technique or same intervention onto rat or mice studies. Once it looks positive in the rats or mice, then they move it to a human trial. So they're doing this three-tiered system where they're getting a ton of volume from the engineered tendons and trying all sorts of crazy things. Then they move it to rat and mice. And then once they really feel confident, they can move this into human studies. And what they have been showing is through the processes of stress shielding and stress relaxation, that it does seem that we can lay down new collagen and adapt these tendons. ISOMETRICS & STRESS SHIELDING What stress shielding is, it is the ability for your healthy, non-injured tissues to take on a majority of the stress to protect the unhealthy or injured area of a tendon or ligament. So it's a wonderful protective mechanism for back when we were foraging for food or hunting or having to outrun predators, that the healthy part of the tissue would take on more of the loads so that you could keep moving to either get food or stay away from them. This is a great process to keep us alive, not a great process for adapting tissues. What we really want instead of that stress shielding is some stress relaxation where the healthy injured or the healthy uninjured part of the tissue starts to relax a little bit so that we get some load or some stress into the injured area. When we get that stress into the injured area of the tissue, it's gonna create a cascading signal to the nervous system that says, hey, we need to lay down new collagen, we need to adapt to be able to remodel this tissue area. The easiest way to explain this is an analogy that Keith Barr commonly gives of two individuals playing tug-of-war together. So you've got two teams of two playing tug-of-war, they're relatively evenly matched. Let's say for this case that it's Mitch Babcock and I. So for those of you who don't know Mitch Babcock, he's an OG instructor for our management of the fitness athlete. Mitch is over six feet tall, over 200 pounds, big strapping muscular guy. I am 5'7", 165 pounds. If Mitch and I are on the same tug-of-war team, early on he is going to carry a majority of that load for the team. He's going to take on most of that stress because he's such a robust human. If the other team is evenly matched, at some point during that tug of war, Mitch is going to either fatigue out or he's going to have to start to relax a little bit to start to conserve his energy. At that point, I am going to have to take on some higher portion of the stress or load. Once I start to take on that higher stress or load, my nervous system is going to start talking, going like, If this is the type of thing we're going to start getting into, we're going to have to adapt. It's the same with our ligaments and tendons. As that healthy area starts to relax or fatigue, then what we're going to see is that the injured or unhealthy areas have to take on a load. And then again, that's going to start that cascade of the nervous system to remodel and adapt those tissues. What we're seeing is that there's a few things that need to be true for this to happen. It has to be long enough duration. So that has to be held long enough, the load, so that it gives the opportunity for the unhealthy, for the healthy tissue, excuse me, and robust area to start to relax a little bit. So long enough load where the healthy areas of tissues begin to relax. It has to be a heavy enough load to create some sort of stimulus. If the person feels like it's easy and they're not having to put out a lot of effort, it's very likely that the healthy portions of the tissue are carrying all the load And it also seems to work best when that tissue is at length. So when those tendons or ligaments are at their most lengthened position, so extended elbow, dorsiflex ankle for the Achilles, bent knee for the patellar tendon, that tends to be where it works out best. KEYS FOR DOSING ISOMETRICS APPROPRIATELY Now, there's some keys to this depending on how robust the human in front of you is. The more robust that individual, the longer the heavier and the closer to length that we need to perform those holds. So if the person is healthy, you may need to go beyond a four sets of 30 seconds. So four sets of 30 seconds tends to be this minimum amount of time that has been shown to create this stress relaxation. If you've got that really robust person, if you've got the Mitch Babcock, they may need to hold five sets for 45 seconds. Now there does seem to be a ceiling of about 10 minutes of tendon loading, seems to be this area of diminished return. So if you go beyond 10 minutes, then you need to wait six to eight hours to reload that tendon. Somewhere between four sets in 30 seconds, five sets of 45 seconds, adjusting that depending on how robust that individual it is. It has to be heavy enough again to where that person feels an effort. So if you've got someone who's deconditioned, they have not done as much exercise recently, you can create this stress relaxation with relatively light loads. If you've got the Mitch Babcock that's been lifting weights since he was 12 years old, you're going to have to load that tissue a bit heavier to create that adaptation. It has to be a high effort load. And then the final piece is we see now that tendons and ligaments tend to adapt better from an actual structural standpoint if they're held at length. So again, for the elbow, is it extended? For the Achilles, is it dorsiflexed? For the knee, for the patellar tendon, is the knee flexed? Obviously, if someone is symptomatic, it's going to be more challenging for them to get in these positions. What we do in this case is we get them to the most length that they can tolerate for that four sets of 30 or five sets of 45. And then as time goes on, we progress them to a more lengthened position overall. If you all have been following ice for a while, a couple years ago, Joe Hanksco did a wonderful virtual ice on medial elbow tendinopathy. And one of the key exercises he looked at was wide grip biceps curls to help out those medial elbows. And if we look at this, it's a wonderful exercise for exactly what we're talking about for medial epicondalgia because when you're in that wide grip bicep curl, you are holding that during the max eccentric portion, that elbow is at a ton of length, they're in a relative wrist flexion, it's gonna be a lot of stress to that medial elbow. You can take that same exercise, do it isometrically, four sets, 30 seconds, and it becomes a wonderful thing to adapt the medial elbow, ligaments, tendons, and tissues overall. Last thing that we wanna talk about is anti-inflammatories block stress relaxation. So if that person takes anti-inflammatories early on, everything we discussed the last 10 minutes becomes much more challenging. When there's inflammation in the area of the tendon, it creates a natural stress relaxation where the healthy portions of the tendon are not gonna be able to take as much stress and load, and you're gonna get a little bit more stress and load to the injured or unhealthy area. So if that person takes an anti-inflammatory early on, they're not gonna get that benefit of being able to take less load, less strain, and get some adaptation to the injured area of the tendon. So if folks can, we tell them to use natural processes. Use your cardio to pump inflammation out of the area. Use eating healthier foods that are not going to block the entire inflammatory process. They're just going to decrease some of the inflammation and still allow for that stress relaxation. So overall, if we're trying to adapt tendons, to lay down new collagen, to remodel those tissues, We want it long load, four sets of 30 seconds, five sets of 45 seconds. We want it heavy enough to overcome that stress shielding. So it's a high effort lift and we want it at length of that tissue. So again, if it's the elbow extended, the ankle, dorsiflex, the knee, if it's that patellar tendon bent, whatever the deepest amount of, of length of that tissue that we can, that's where we want to go. Hope this helps. We're gonna come back on here in a few weeks and talk about isometrics for adapting muscle output in the central nervous system. Hope to see you all on the road. Head on over to the ICE app or the ICE website. We have a ton of offerings coming up for extremity management all over the company. My next one, I'll be in Dallas, Texas in June. Hope to see you all there. Message us, comments, love to chat more about this. Hope you all have a great Tuesday. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 8, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses pelvic floor screens such as the PFD-SENTINEL and introduces a new pelvic floor screening resource coming soon to the ICE Physio App! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. RACHEL MOOREGood morning, PT on ICE Daily Show. I am getting lunched on YouTube and Instagram and we are good to go. All right, what's up? My name is Dr. Rachel Moore. I am here this morning to talk to you guys about screening for pelvic floor dysfunction especially if you are somebody who is maybe not familiar with the pelvic floor space or this is an entirely new space for you or you're somebody who is like identifying or classifying as a orthopedic PT and you're like I don't know anything about the pelvis. I want to clear things up with you guys and put together or we did put together a resource for you guys that is a pelvic floor screen that you're going to be able to access through the Ice Physio app under the resources section. So you'll be able to get that off of the app, download it, either have it in your intake forms, in your paperwork so that you can use that as people are coming in and kind of have an indicator of if this would be a person who would benefit from a referral for pelvic floor PT. Where this all came from, we've been asked at our courses before for just kind of an easy, quick, general screen. A lot of us use kind of a different option. So there was some people had a couple options that they were using. Other people were using different things. So what we did is we took all of these resources. We compiled them together and we really leaned into the research and what we have out there for pelvic floor screening. So we're going to chat a little bit about what that screen is and how we kind of adapted it or modified it for this really quick, easy, downloadable version that you can pull up and have as an 11 question fast screen for your patients. So This whole screen kind of is based around or adapted from a study that was published in the British Journal of Sports Medicine in December 2022. So the screen is called the PFD Sentinel Screen, S-E-N-T-I-N-E-L. What this was was a Delphi study and they basically polled professionals that are experts in this space. So they had PTs, they had urogynecologists, they had just different healthcare providers, physical medicine and rehab providers that all had either been in this space seeing patients or been in this space researching these topics. And what they did is they polled these providers to kind of come up with a consensus. Because prior to this, there really wasn't a validated published screen in any evidence. that we could really lean into for patients that would benefit from pelvic floor physical therapy. And so they created this screen kind of as a way to have a resource specifically for sports medicine providers, and this was really kind of leaning into sports medicine PTs, like orthopedic PTs, or sports medicine doctors that were already seeing female athletes, and they're kind of range or definition of female athletes was like super broad. So across all ages, across all sports, across all profession levels, whether it was amateur athletes or professional athletes, they came up with this screen based on this Delphi questionnaire, not questionnaire, but survey. And so what they landed on were five main pelvic floor dysfunction symptoms, and then 28 risk factors for pelvic floor dysfunction. So with that, in order to be included on this screen, they had to have over 67% of the consensus of the group. And this went through two rounds. So it was like 43 and 37 were the two rounds of number of professionals. So of those two rounds, 67% or higher had to agree that they felt that these were indicators for potential pelvic floor dysfunction screens. So with this screen, there was this top section of score A, which was five main pelvic floor dysfunction symptoms. So this was things like leaking urine, urinary urgency, leaking gas and stool. And with these five, if they answered yes to any one of these, then they recommend an automatic referral to a pelvic floor specialist. Doesn't necessarily specify PT, but could be a urogynecologist or somebody that specializes in treating the pelvic floor. From there, there was 28 risk factors that they delineated. With these 28 risk factors, they either landed in the categories of score B or score C. If they were score B, that means that they had greater than 14 of these risk factors. These risk factors were pretty broad. I actually really loved the things that they included. So this was things like whether or not somebody's in menopause, if they've been diagnosed with hypermobility or connective tissue disorder, if they have a family history of urinary incontinence or a family history of pelvic organ prolapse, their BMI being under or over a certain range. So they really took a lot into account here under the risk factors. And if they had a score of greater than 14 for those risk factors, then they fell under a score B, and that would be a recommended referral to a pelvic floor PT or pelvic floor specialist. So score A, for sure, send them. Score B, we recommend you get this checked out. And then score C was less than 14. So if they didn't have more than 14 of these risk factors, Then it was just monitor, kind of keep an eye on them and see how they do. And when they made this screen, they made it as a kind of touch point to repeat. So maybe you start this at the beginning of the season, and then as they begin off season, you start or you re-screen this. So this is kind of an easy ongoing screen to see how things are changing as these athletes are evolving potentially, whether they're in off season or in season. Or if, again, we're thinking about just our general population, maybe once a year when they're coming in or once every six months when they're coming in, we're doing this really quick and easy screen to determine if they would benefit from a referral for pelvic floor PT. One thing to kind of note about this is it was specifically created for female athletes. Again, broad term for athletes here, but specifically created for females. So no males were included in this when they were breaking down the rationale for when somebody would benefit for a referral for PT. And so we don't really have a good resource of when our males need to be referred to PT just yet. Maybe that's something that'll be coming out in the research soon. And then also just note that this hasn't been like validated by any further research yet. This is kind of the kickstart point of, Hey, we've got this group of experts that have come together. We don't really have a lot of information in this space. Let's come up with something so that we can then push this out there and see how it flows. So, Love it. It's really awesome. PFT Sentinel is really in-depth. It has a lot of really great risk factors on there. When we were putting together our screen, our thought process was a little bit different. It was a little bit more leaning in towards something quick and easy that, like I said, we can put in our intake forms and just have people check things off. You could really even use this as marketing. So I actually do use a pelvic floor screen on the backside of my flyers. So on the front side, I have all of my business information. I've got a QR code for people to book a session pretty easily. And then on the back is the pelvic floor screen printed on it. So as people are setting these out, it's got our business logo on the top, set it on a counter at the chiropractor's office or at the gym or whatever, and they can pick up the screen and read through it. and it says at the top if you say yes to one of these following questions, you might benefit from Pelvic Floor PT. So, great option for marketing, great option just to have as part of your intake form in your paperwork. If you are not a Pelvic Floor PT and you're not really sure who you should be sending to Pelvic Floor PT, it's also a really great resource to have on hand. So, diving into our specific screen, what we really focused in on were what we felt were kind of the heavy hitters for recommendations for pelvic floor PT, and then maybe some of the things that doesn't necessarily jump out at somebody that's not in this space. So, some of the more obvious ones would be like experienced urinary leakage, urinary urgency or frequency, issues with remaining continent or holding in gas or stool, sensations or feelings of heaviness or seeing something bulging at vaginal opening and then really leaning into the pain side pain or discomfort and we really kept this grog because we've seen pelvic floor dysfunction show up as hip pain, we've seen it show up as low back pain, we've seen it show up as groin pain, and so we really wanted to kind of catch a broad range here, especially if you are the orthopedic PT who's maybe been seeing somebody for their hip and you're doing all the right things and you're like, I'm crushing this, but they're just not 100% better, maybe that would be the time to kick them over to a pelvic floor PT if you're not doing pelvic floor. and see if there's some contribution from the pelvic floor to that issue. Childbirth, whether it is a vaginal or a cesarean delivery, both of these situations we feel weren't a referral to pelvic floor PT, just to really kind of recalibrate and get things on the same page again. Being in menopause or perimenopause, A, from the education standpoint, there is so much education that we can provide to this population. but also just kind of staying ahead of any problems or symptoms that may arise as they're progressing into this low estrogen state. And then having a history of relative energy deficiency in sport. And this is something where we might need to lean into our providers to do some education. If somebody doesn't know what that is, really knowing if somebody's had irregular cycles, if they have these chronic injuries, or one week you're seeing them for their knee, the next month it's for their shoulder, the next month it's for their back, these signs of these chronic kind of nagging injuries would be a thing to hone in on that maybe they're potentially in this relative energy deficiency in sport state. We've got a lot of really great information out there, lots of podcast episodes about reds that we've done as the pelvic division. So if you're unsure about that, definitely go to YouTube and type that in the search bar and pull that up so you can learn a little bit more about that topic and really be able to screen that a little bit better. But again, we came up with this resource. I hope you guys love it. I hope it's helpful. We've been asked for it at our pelvic courses. I've been asked for it at our other courses that I've attended just as a participant. OrthoPTs that are like, I'm not really sure what I'm supposed to do. Can you please come up with a resource that we know how to screen? So we're really excited about this resource. It's going to be on the ICE app. So keep an eye out. In the app, we'll also blast it out on the pelvic newsletter. So if you're not signed up for the pelvic newsletter, go ahead and get signed up for that. And same thing with hump day hustling as well. Sign up for that. That way you know exactly when it gets posted, exactly when it goes live, and when you can download it to have it as part of your screens. SUMMARY If you are somebody who wants to be in the pelvic floor space but maybe isn't in the pelvic floor space yet or you want to learn more about pelvic floor pt then jump into one of our courses We've got so many live courses coming up. Christina and I are actually teaching in Spring, Texas this weekend at my home gym. I'm so excited. We still have openings there if you want to come hang with us. But lots of offerings for our live course coming up, as well as our L1 coming up again. And then our L2 is sold out for this upcoming cohort, but we do still have spots open. in our fall cohort so head to the website figure out where you can jump into a pelvic course if you're interested in learning more about pelvic floor pt and how to treat these women If you're not really sure how to treat these women or who should be referred out, head to the resources link. You're going to see this resource posted in just a bit. And then we are excited for you guys to have it out there. Use it for marketing if you are a pelvic PT and let us know how it goes. Thanks for joining in. I appreciate it. I hope you guys have a great day. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 5, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses three factors to consider when transitioning from biking indoors on a trainer back to riding outdoors: equipment, road/weather conditions, and controlling training volume on the road. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. JASON LUNDEN Good morning. Happy Friday, everyone. Welcome to another edition of PT on Ice. My name is Jason Lunden. I am the lead for our endurance athlete division, which entails rehab of endurance athletes, including our professional bike fitting course and both our online and live versions of the rehabilitation of the injured runner. So today I am going to be talking about a very timely topic, transitioning back onto the road after training all winter indoors for especially those of us in the northern climates. And here in Montana, we are definitely seeing our transition back to spring and everyone's getting back out onto the road. after being on the trainer for the past four to six months. So I just wanted to give some tips for either yourself or your clients on how to make that transition as smoothly as possible and not interrupt their training cycle. So we're going to cover three things, equipment, conditions, and then the actual mechanics and transitioning of back on the bike in terms of volume. EQUIPMENT So first thing being equipment. Obviously, when you're on a trainer, you're not really all that concerned about, you know, are your brakes working? Is your headset working, et cetera? Do you have like your kit already with a spare tube and… Spare tube and… Pump etc. So first and foremost Making sure that you're checking that your headset is indeed tight. So that is going to be the top bolt where the handlebars go into the steer tube and Way to check that tightness is depressing the front brake and rocking the back the bike back and forth and you shouldn't feel any clunking at all. If you do feel clunking you need to tighten the headset. Things can get loose over time so it's an important thing to do. So loosening the two screws on the sides and then tightening the top down and then tightening the screws on the sides back too. And then also making sure brake wear and everything are okay as well. Because typically in the spring, you're going to be encountering wetter conditions. So it's really important that your brakes are working and to avoid any catastrophic, traumatic injuries. And then probably lastly is just making sure that you do have the supplies with you if you do break down. Again, typically at the end of the season, when transitioning back indoors, We always think that we're going to get those new CO2 cartridges, replace the used ones that are in our pack that we used already, as well as making sure that that spare tube is still working and adequate. So making sure that you're kind of restocking your kit or at least reassessing your kit for while you're out on the road, as well as making sure you got those tire level levers with that too. ROAD CONDITIONS Number two is conditions. Uh, obviously biking outdoors, there are a lot more environmental conditions and biking indoors. Uh, and that's really important to, to take account of. So again, in the spring, we're typically going to be dealing with some wetter weather, uh, some cooler temperatures, uh, especially for us, uh, working folks, uh, working athletes. We're going to be having to try to fit our rides in around our work schedule. So typically in the early morning. um, or after work where temperatures are already going to be cooling down. And so making sure that you, you are, you or your patient are dressing and layering appropriately. Uh, as if you're, if you are riding in cold weather, um, it can get cold really quickly because of the wind resistance and all of that. Um, and your muscles can get cold, which, uh, you know, anecdotally, I think a lot of us think, well, you know, we're more likely to actually strain or have injuries in the cold with not being warmed up and there's actually some very limited evidence on that but there is some evidence on that in looking at exercises in different temperatures and the incidence or likelihood of increasing the incidence of tendon strain or muscle strain. And anecdotally, this is the time of the season when I really the only time I see cyclists coming in with quadriceps tendinopathy or tendinitis, more acute. And I think there is a correlation with the colder weather and just not muscles being warmed up as well as maybe not quite being acclimated to the volume that they want to do. in the style of riding that they want to do. So just tucking that in the back of your head and just making sure that you're prepared for that. CONTROLLING ROAD VOLUME And then lastly, looking at how you're going to approach your volume in your training with transitioning outdoors. Training indoors is really efficient, especially you know, more recently with our direct drive trainers that can add resistance and simulate hills, et cetera. But we're still very, it's very easy and more comfortable to have your hands up on the flats of the bars and not all the way out on the hoods or in the drops. And I think a lot of us have the tendency to ride in that position of comfort. Either if you're watching the virtual screen of racing on Zwift, or you're watching a show, just being in more comfort even with putting that effort out. So realizing that your body may not be adapted to being in the drops or being on the hoods for a long time, as well as the increased instability of being on the road where you're having to balance more. So not maybe necessarily having the core stability strength for that as well. So ideally before transitioning into back onto the road for the month prior, making sure you are getting time in the drops on the hoods, making sure you're getting time where you're getting efforts standing up on the bike, and then doing an assessment of your core and spinal extensor strength to make sure you can sustain those positions. And then even with that, when you're transitioning back onto the road with your training, Have those first rides be just shake out rides, totally, um, just going out for, for fun rides, not really, uh, equating that into your training and keeping the volume on the lower side. One to make sure your equipment's working, uh, to, you know, the, the conditions are going to be more variable. And then three, just to, to be able to have a smoother transition back onto the road because of the. wide variety in terrain, conditions with the wind, and again, that instability and maybe being in slightly different positions and having slightly different mechanics while you're out on the road. And then after a week or two of that, well, two weeks of that, then diving back into your training plan with that. So while you're doing those shakeout rides, continuing your actual training indoors. It's easy to get excited when it's nice out. I've certainly been a culprit of it, too, where, you know, we're just stacking rides back-to-back days when it's nice out, especially here in Montana, in the mountains, where the weather can be changing rapidly, and we're getting to really try to take advantage of those nice days and getting in as much as we can. set ourselves up for success and pumping the brakes a little bit and just having those rides be enjoyable a little bit a little bit lower volume before really getting after it back to our training to prevent injury. So just some practical advice for you on again transitioning from the trainer back onto the road things to consider Double checking your equipment, making sure that's functioning well, especially the headset and the brakes, and that your emergency kit is dialed. Two, preparing for the weather, mainly in terms of layering so that those muscles, you don't get too cold, perhaps increasing the likelihood of a strain or a tendinopathy. And then three, just going easy with that volume back out onto the road and having those first few rides just be shakeout rides just for fun not really training rides. SUMMARY So hopefully that's that's helpful for you and you are getting back outside onto the road or if you've been in the south you've been on the road all along and you know If you're interested in treating endurance athletes, please join us for one of our offerings. We're really starting to ramp up here with professional bike fit certification. Matt Keister and I will be in Asheville, North Carolina, April 19th and 20th. We still have some spots for that. This should be a great time. It's the only time that we have both lead faculty at the same course for the year. And then I'll be in Minneapolis in the middle of May. Matt will be in Denver in June. For Rehab of the Injured Runner Live, we only have two offerings so far for 2024 until Megan Peach gets back from Austria later in the fall. Uh, first offering will be in Milwaukee the first weekend in June that is filling up. So, uh, if you have an inkling to, to, to join us there, uh, sign up sooner than later. And then second offering will be in Maryland in September. Uh, we're getting some signups there too. So hope to see you at a course. And then next, um, online cohort for rehabilitation of the injured runner is May 7th. Uh, everyone have a great weekend. Get outside, do something fun, get out on your bike if you can, or get out running. See ya. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 4, 2024

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses five different ways to work on correcting lateral shifts in patients demonstrating low back pain with radiculopathy, including standing, sidelying, and prone variations. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. JORDAN BERRY All right, what is up? PT on Ice Daily Show. This is Dr. Jordan Berry, lead faculty for cervical management and lumbar spine management, as well as our T and D content over all the spine division. I've got Jenna here with me today from the fitness athlete division, and we're talking lateral shifts again. So a few weeks back, we talked about the lateral shift and how we have to be able to pick that up in order to oftentimes move forward with the planned care. So when someone comes in that has really severe back and back related leg symptoms, oftentimes the lateral shift is the number one thing that you have to be able to pick up. and clear up, because if you don't, you're not oftentimes going to be able to work into this agile plane and start resolving those symptoms. So a few weeks back, we talked about the main ways from an objective and a subjective standpoint that we could pick up on the lateral shift. Today, we're going to change gears and talk about actually correcting it. So a few ways during our treatments that we can correct the lateral shift. Now, by far, the most common is the standing variation. or we're shifting the person that we'll talk about in just a second. But oftentimes the irritability is too high to allow for that. So we can't use that variation. We have to go to something in a non-weight-bearing position. So we'll talk about a few ways based on irritability that we can regress the standing lateral shift correction to be able to match that person's irritability and move forward during the plan of care, okay? CORRECTING THE LATERAL SHIFT IN STANDING So I'll have Jenna stand for just a second. and we'll demo as if she has symptoms on let's say the left side. Okay, so oftentimes we turn the camera just a bit here. If we have symptoms on the left side, almost always, 90 plus percent of the time, the shift is gonna be away from the side of symptoms. So we're gonna assume today that the shift is away from the side of symptoms. And Jenna would then, if she has symptoms on the left side here, right, would be shifted away from those symptoms. So for the standing variation, I would be standing on the opposite side of symptoms. So I would be in a staggered stance here, right? She's going to have arms either across like this or at least up away from her hip so that I can get around her hip. And I'm going to have my head on the backside of her shoulder blade with my arms wrapped around the very top of the hip. And so we're right here. And then I'm going to shift over and load towards this side of symptoms, right? So she's avoiding that side. And I'm wrapped around shifting towards the side of symptoms, okay? So we covered that technique in a lot of detail during our lumbar spine management weekend course, so we're not gonna spend a lot of time on the standing variation right now. But what I do wanna do is show you a few non-weight-bearing variations, because if you go to test that out, and the irritability's high, and that person either starts to peripheralize or pain increases, we have to have a variation in a non-weight-bearing position that is a little bit less vigorous that we're gonna start from. CORRECTING THE LATERAL SHIFT: SIDELYING Okay, so immediately if that's not working, my first regression here is in the sideline position. So now we're going to have Ginego on the table here. And I'm actually, I'm going to change sides for the video, but it'll be easier to see here. So Jenna is lying on her side, and we're going to say that the side that's up on the table, in this case, the right side, is the side of symptoms. And so for their side-lying technique, we're going to do a side-lying lateral glide. Again, during our lumbar spine management weekend course, we cover this in depth and we typically refer to it as a way to improve range of motion and mobility, just generally speaking in the stiff back. But it's a great technique for a lateral glide or a lateral shift correction as well. And so the way that we set up is I'm facing the bottom corner of the table and I have my contact hand that weaves through Jenna's arm here. and right around my hypothenar eminence rests along the paraspinal right here that's on the top. So I'm just hooking my hand in, facing the bottom corner of the table, and I just drop my weight down here. So again, we're saying that the top leg here is the side of symptoms, and we are gliding down towards the table or away from the symptoms if you want to think of it like that. And oftentimes that, because we're not in the weight-bearing position that we were in standing, the patient will be able to tolerate that much better. CORRECTING THE LATERAL SHIFT: PRONE Now, what if they can't tolerate the side-lying version or they're peripheralizing or not seeing the changes that you would expect? Well, we could then go to a prone variation. And so appreciate for that last technique, right? I was standing above the side of symptoms and we were gliding away from the symptoms. So we're doing the exact same thing in this prone position now. I'm going to bring the camera slightly closer here. And the same idea here in the prone position. So we're going to say that the side that I'm standing on right now, right, the side towards me or closest to me is the side of symptoms. In this case, it would be Jenna's right side. So instead of having my hand fully on dropping down into the lateral glide, I'm still going to glide laterally or away from the symptoms here. But I've got my thumb pads here together. and they're on the side of the spinous process that the symptoms are on. So again, for those listening and for those watching, just to make sure we're on the same page, if we have right-sided symptoms, the pads of my thumbs are on the side of the spinous process on the right side. And I am just gently gliding away. This is the exact same thing as the sideline lateral glide. It's just a less aggressive version. So again, my thumbs are together like this on the side of the spinous process where the symptoms are and I'm gliding away. And oftentimes just that very, very gentle, soft mobilization is enough to start to get some centralization. Okay, but what if we can't tolerate that, right? What if, for example, the actual spinous process or the area in the low back is too sensitive to actually be able to put contact or pressure on the spinous process? So then we could do the exact same thing, only now we're contacting the torso and the hip. So our contact hands are above and below the lumbar spine. So with the exact same setup that we had, again, the side of symptoms or the right side, the side that's closest to me, I'm going to have one hand on the right glute, right to the glute on the side of symptoms. And then I'm going to have my other hand on the torso on the opposite side. and I'm pushing the glute away and pulling with the torso towards me. So again, it's the exact same thing that we're doing the previous two techniques in the lateral glide. We're just not contacting the actual lumbar spine now. So we push away with the glute and pull towards with the torso here. Push away at the glute and pull towards on the torso. And now we can do the exact same mobilization in the lumbar spine without actually having to contact the lumbar spine. CORRECTING THE LATERAL SHIFT: BELTED MOBILIZATION OK, I've got one more. So this is my my go to if someone cannot tolerate any of those other variations. It's very, very rare that someone would not be able to tolerate one of the ones that we just went over. But I want you to have a technique in your arsenal where if the person really isn't tolerating anything at all, where you're going right at that area where they're having to cross that leg over on the table that's painful. I want to give you a version that is completely passive on the patient's end where we're actually going to use a belt around the person to lift the hips. So for the setup here, the painful side now is actually down. So this is the opposite of that first version that we showed. So we move the camera so we can see here. Jenna's painful side would be down towards the table. And what I'm going to do is take a belt here, mobilization belt, you could use a gait belt, and I'm going to wrap it underneath Jenna's hips. So we're going to weave this through. And I'm just making a loop with the belt. And so what I can do now is actually get on the table. I'm going to be up above the person and I can lift Jenna's hips up while she's completely passive and does nothing. And what that's doing is the exact same thing as what we were doing with the lateral glide, right? When the painful side was up and we were gliding down. Well, now the painful side's down and we're the ones that are pulling up. So I would be on the table above pulling on the belt. here. And Jenna can stay completely relaxed. She doesn't have to do anything at all. And I can do a lateral glide with the painful side down. Again, very rare that I would ever have to go to that technique, but it does happen and it's nice to have that in your arsenal. SUMMARY So those are five ways, five of my most used ways to correct a lateral shift in the clinic. The one that we're probably all familiar with, again, is the standing variation. That's the one that you see in most courses. That's the one that you see in most textbooks. And it's a great technique when it works, right? It's a great technique when the irritability allows for that weight bearing position to be used. But plenty of times in the clinic, the person's not going to tolerate a weight bearing or a loaded shift correction. So we have to go to a non loaded or non weight bearing position. I love the lateral glide that we started with. You can also go prone and do that really small, gentle lateral glide with the pads of your thumbs on the side of the spinous process. We could also go above and below the area if it's too hot to actually get your hands in there and contact it. You could go one hand on the glute, one hand on the torso, push and pull to do the exact same loading to the lumbar spine. Or you could go painful side down, belt around, lift the hips up. All right. Well, those are five variations. Hopefully that helps you out in the clinic with managing some of these folks with back and back related leg symptoms. If you're going to be at a cervical spine or lumbar spine management course in the future, we will see you there. Have a great day in the clinic. Thank you, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 3, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave as he discusses three key steps to keeping older adults moving while injured: symptoms, guardrails, and modifications. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account. JEFF MUSGRAVE Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday, so it is all things geriatrics. Happy to be here with you for a PT on Ice Daily Show brought to you by the Institute of Clinical Excellence. So, team, I had a really interesting scenario. One of the things that I do is I'm an owner and a coach in Stronger Life and it's fitness for people 55 and up. We had a member who had missed a couple weeks trying to go through the diagnostic process for some reactive arthritis. And actually, still, that's just a working diagnosis. About four weeks now, currently, since diagnosis. But after a couple weeks, she reached out and was like, hey, I really want to get back in the gym. It's good for me physically. It's good for me mentally. This is a member that's been with us for about four years, very dedicated to her fitness, showing up, doing what she can. Each day has gotten really strong and didn't want to lose her fitness. So here she is in the medical system advocating for herself Which is sad that during this process, you know this this PT first Idea that we're trying this mission that we'd like to see come to fruition if we're not there yet. Okay, so she's had her blood work, she's had x-rays, all these things are done, she's getting no intervention, no formal PT, and she's begging, can I go back to the gym? And we're like, absolutely. Now, are her providers and her medical team on board with this? Not quite, but that's okay, because we're going to take good care of her. So, oftentimes we find ourselves on the other end of this scenario, right, where we are trying to figure out If we've got someone we're treating for some type of injury, an older adult, and they are going to group fitness, how can we set them up for success? 3 STEPS TO CONTINUING TO MOVE WHILE INJURED: SYMPTOMS, GUARDRAILS, AND MODIFICATIONS Particularly, we know when we're working with older adults, it's all about this game of building reserve and maintaining resiliency. We know we want our older adults to be as strong as possible. We want to put as much distance between minimal ability to function on a daily level and their fitness. We want to build as much margin, build as much reserve as possible, so when illness or injury comes knocking, because we know it's going to happen eventually, right? We want them to be able to fight back. I want to outline a few things that we do at Stronger Life that I think are just a good guideline if you're a treating physician and you want your patient to be able to go into group fitness. A lot of these things you're probably already doing, but just thinking through this lens, we know that the game is vital. We've got to keep people moving. We're trying to get people as fit as possible and keep them that way as long as possible. So I'm going to say, by and large, we believe keeping people moving is paramount. That is what we have to do. We have got to get and keep people moving despite their injuries. With our formal physical or occupational therapy interventions and or in the gym, fitness, Most of the time we can keep them moving if we can set them up for success. So I've got three steps that I think will be very beneficial. The same thing that I used for this Stronger Life member, and that is symptoms, guardrails, modifications. Symptoms, guardrails, modifications. SYMPTOMS I'm going to set the stage just a little bit more for this patient. So when we're thinking about this specific scenario, it was reactive arthritis in the knee as a working diagnosis. This member had been nearly non-weight bearing to partial weight bearing limited range of motion, painful loading of the knee. So focused on the knee here. And at this point, two weeks of symptoms, no better. We wanted to dig into her symptoms. So she gave us a heads up she was gonna be coming in, which is nice, we don't always get that on the fitness side of things, but you're gonna have that information as a treating clinician. So things we want to know, obviously just like during the diagnostic process, if we're thinking about what do we need to know about their symptoms going into some type of movement practice or group fitness, or maybe group fitness are already engaged in. We wanna know their ags. We wanna know what's making these symptoms worse. Is it the range of motion? Is it the pain? Is it the volume, the number of repetitions? Is it power-based movements that are exacerbating their symptoms? And this is all information you're gonna know about your patient that you're treating already. So we wanna know that. and set those baselines. So if you're treating the patient, you probably already know the symptoms. Step one, check. We know for this specific case scenario, it was painful range of motion past about 30 degrees. 30 degrees of knee flexion is about all we could get. Weight bearing Sometimes not exacerbating symptoms, sometimes it was. So the member was walking in on a cane and was very leery of weight bearing. So the things I knew about this member coming in is they've had chronic knee pain for a long time. Their baseline, she's telling me, is a five out of 10. It was a nine out of 10. She was in the ER on pain medication. Two weeks later, she's weight-bearing, ass-tolerated, on a cane, about 30 degrees of knee flexion. Loading the joint through range is painful, okay? So that's kind of the information I knew coming in. Dug in just a little bit right before class. GUARDRAILS And then we need to set some guardrails. So now that we know the ags, we also want to know the irritability. How irritable are these symptoms? If we flare this up, is she going to go into non-weight-bearing status? And is this going to affect her activities of daily living the rest of the day? or is she going to have a little increase and then as she rests symptoms are going to come back down. It wasn't, her symptoms in this scenario were not like once they're spurred on she's dealing with these for days. So I put her in the low irritability category. Symptoms had been severe but they have been stable. So I wasn't really too worried about her Causing any symptoms in class but wanted to have some some options to take her out of weight-bearing make sure we're limiting her range of motion because we had identified those were the things that were exacerbating her symptoms, so That was the symptom baseline irritability, I would say low and then some guardrails and So for her, we let her push into the discomfort and set some guardrails. Hey, if your pain gets five out of 10s your baseline, if you hit a seven out of 10 or above, we need to make some changes. You need to pull me over, we'll cut the range of motion, or we can reduce weight bearing. MODIFICATIONS And then the last thing that we need to do is we need to give her some modifications. So we knew it was range of motion, and weight-bearing positions. So those are the two things we're looking at first. So I'm going to give you the exact workout we did and then we'll walk through symptoms, guardrails, modifications, and how we went through this. So the workout was a station-based workout where it started with weighted step ups. Okay, you can see how that could be a problem. Then we had sumo deadlift high pulls, which were weight bearing. We had some time on the rower. We had a three position balance movement. So it was dynamic balance with a water tube. And the last thing was spending some time on the ski. Heard different movements with her to work on modification. So she was weight-bearing with the cane, she was not able to do much more than a few steps, so we knew adding weight wasn't going to work. So we got to the weighted step-ups, I had her try it just with a couple inches, cut the range of motion, cut the load, still uncomfortable. I took her over for a wall sit, wall sit didn't work either. Okay, so cut the range of motion, cut the load, still too painful. So what did I end up doing? I ended up replacing the movement. And this is the last thing we want to do, right? We want to stick to the body group to get the desired stimulus from I had misjudged a little bit. She was a little more irritable than I thought, couldn't tolerate a static position to work the lower extremities, couldn't handle the reduced range of motion or the reduced load. So instead of replacing it, she ended up doing a seated Russian twist, okay, working on some core work, taking her knees completely out of weight bearing for that movement. Next movement, we got sumo deadlift high pull. Since I knew she couldn't tolerate much load plus, like body weight plus resistance, I went ahead and put her on a box to do a sumo deadlift. So she's still, she's in a seated position, has a dumbbell in each hand. She's driving from her feet, giving us this nice high pull motion. So she's still working her legs, her hips, her core. We're able to maintain the stimulus on that one, which was great. She was able to tolerate that. The next movement was the rower. So on the rower, I knew that her range of motion, she had about 30 degrees. That's all we could work with. Rower, pretty friendly place for people, especially with reactive knee arthritis. So she can control the range of motion and it's limited resistance, right? We've taken gravity out of the picture here. So what I did is I had her put her feet on the floor of the rower and just drive through her feet and cut the range of motion. And she was able to tolerate that really well and actually saw progress during this workout from the beginning of the workout to the end of the workout with her getting more and more range of motion. She actually said that time on the rower made her knee feel really good. So that was good. So we modified the rower. Then we've got this dynamic balance movement where you're starting on one leg, quick step, and then standing on the other. So there's a dynamic component, there's a power piece, there's a single leg support piece, and we know weight bearing on both legs is okay. Single leg is kind of out of the picture. So we had her work on some weight shifting, holding a little bit of load and she was okay with that, which kind of surprised me. And actually as the workout went on, she ended up doing a little bit of single leg support and weight shifting until she was on one leg and then the other. So that was a replacement. So that dynamic power-based movement ended up being more like weight shifting side to side. I gave her the option to close her eyes to make it a little more challenging and the surface she was on was dynamic. So that was the modification there. When it came to the ski, knowing how much weight bearing was in there, she's walking from station to station, I had her do the ski from a seated position. So arms length away, the setup is still very similar for the ski, reaching up nice and tall, pulling to the hips. So she's still getting a cardiovascular stimulus, she's still working overhead pulling, so we're able to maintain the stimulus. So that is the process that I went through, looking at her reactive knee arthritis, trying to figure out what she could tolerate, cutting the range of motion, cutting weight bearing, but she got a great workout. Her fitness is better because of it. She's worked really hard to maintain and build that reserve and resiliency, and we're able to go through and give her a great modification, something that's meaningful and helpful, trying to stick with maintaining the stimulus as much as possible, what direction, what muscle groups, and then last case scenario on modification, sometimes we just have to replace it. What's something valuable you can do, even if it's not the same muscle group, not the same position? So oftentimes when I'm, I gave you kind of the scenario I did this with for this patient in particular, knowing weight bearing and range of motion was limited and producing symptoms. But when you're thinking about just in general, oftentimes cutting the range of motion, cutting the load, those two can help. If those don't help, you can still maintain the stimulus from going from a dynamic, to a static position. So say it was push-ups, for example, are painful, can we do a static plank? Tristatic, so cut the range of motion, cut the load, take them a little bit more out of the weight bearing position, and then tristatic. If you can't do a static with reduced range of motion, reduced load, then it's time to start thinking about replacing that with another upper extremity movement. But if you're in a scenario where you've got to make a decision quickly, or you're trying to arm your patient to make these modifications in a group class, just have them see if there's anything else they can modify going in. So the reality is this patient is still in the diagnostic process. There has not been any solid diagnosis for her, no clear prognosis, still getting no intervention. She's been coming to group classes for two weeks. Her pain is better. Symptoms are reduced. Range of motion is improved. She's walking without the cane all while awaiting her one-on-one intervention and a diagnosis. So during this time she's been able to improve her fitness, improve her range of motion, improve her weight-bearing tolerance, and the other benefit that she brought up, which we've not discussed yet, is just the mental and emotional piece. we have to remember for older adults, maybe they're seeing us for a pain or a problem, if we can keep them moving in the group setting, we can equip them with the guardrails, we know what causes their symptoms, we know what we need to modify, because we're already working around them, we just need to give them modifications they can use once they get into the group fitness environment. And she's getting better, even though she's had no formal intervention yet, which I love. But the other piece is the social isolation piece. For our patients, a lot of our older adults are socially isolated. That changes our health outcomes, team. Friends save lives. And keeping our older adults connected with their social networks is crucial to treat the whole patient. And she said mentally and physically, she has felt a lot better. And if you've done any studies, looked at any of the studies for chronic pain, We know that keeping people moving and some of these mental emotional factors can be huge in the experience of pain. The things we want to do to set our older adults up for success, to keep them moving in the group environment as much as possible, to maintain that reserve, to maintain those social connections, is we've got to know their symptoms. We've got to know their ags. We've got to know what makes their symptoms worse, their symptom irritability. After we know their symptoms, it's guardrails. If this, then that. If your symptoms get to, in this scenario, was a seven out of 10, then we need to cut the range of motion, cut the load, or we need to take you out of weight bearing. And then the last piece is to be set with those modifications just like we outlined. We knew for this client, the range of motion, the load was the issue. So those are the things that we changed. And if those two things don't work, then we completely replace it. But the more we can get and keep people moving, The more we can help them maintain their fitness and their social connections, ultimately, the better their outcomes are gonna be in our clinic. So, I hope that was helpful. Real life scenario, patients getting better, no formal PT, symptoms, guardrails, modifications. Team, I hope that was helpful. I would love to hear your thoughts on that. If you have any other strategies you like to use to modify around symptoms, in particular to equip your patients for the group training environment, I would love to hear about those. SUMMARY If you are interested in coming to check out us for more mmoa content we have got our mmoa level one eight week online course level one is happening may 15th if you've already had level one you're looking for level two it's going to be may 16th We've got our live course is gonna be in Raleigh, North Carolina, Urbana, Illinois. We're gonna be in Burlington, New Jersey, and we're gonna be, I'm gonna be in New Orleans, Louisiana this weekend. Team, the live courses are a lot of blast. If you've not been to one, you should come check us out. The weekend after, if you're on the West Coast, I'll be in Bellingham, Washington. Would love to see y'all in the live course. If you get a chance, love to hear your thoughts on this topic, on this case study, keeping people moving in group fitness despite their injuries and symptoms. Have a great day team. We'll catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 2, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the gap between social media and actual clinical practice, seeking real mentorship from real clinicians treating in the clinic instead of social media influencers, and the importance of having a healthy sense of humility regarding manual therapy treatments. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTIONHey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account. ZAC MORGANGood morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty here with the cervical and lumbar spine management, teaching both of those courses on the weekends. And if you have not had those courses, both of them involve a decent amount of manual therapy. So we enjoy kind of teaching manual therapy, doing manual therapy on one another those weekends and kind of reframing how you might frame that manual therapy intervention with your clients. in the hopes of maybe creating a little less dependence on manual therapy and instead a lot of independence in our patients and kind of pushing them towards a more fitness-forward lifestyle. For those of you that have been to the courses, you know that's a big deal to us here at ICE and we love doing that. And this morning's podcast is titled Manual Therapy Misconceptions because I think this is definitely an area in the manual therapy world, physical therapy specifically, where I see a lot of disconnect between what happens in the clinic and then what happens on social media. So I want to start out by talking about over the last several years of spending a lot of time on the weekend, you know, teaching manual therapy techniques, fielding questions in those settings, as well as spending a lot of time in the clinic treating a lot of clients with acute back pain, with acute neck pain, with persistent back pain, with persistent neck pain. I see a lot of misconceptions and at our clinic we spend a lot of time training younger clinicians and bringing through students and then also on the weekends working with a lot of seasoned clinicians And I just see that social media has had an influence on our profession's willingness to use manual therapy and our understanding of everything. And so I think that's what today's podcast is about, is sort of how that has been influenced and maybe just reframing some of our thoughts around it. THE GAP BETWEEN SOCIAL MEDIA & REAL CLINICAL PRACTICE There's one thing that's for sure. If you spend a lot of time on social media and specifically follow a lot of the conversation that happens in our profession, you'll see a huge gap between what a lot of people say out there on social media and what actually clients want and what drives people to seek out physical therapy. So there's a huge gap there. And that's where I want to kind of start is with the social media conundrum. Obviously, social media platforms have become such a popular way for us to get new clients, for us to educate the public, and for us to educate one another within the profession. But there is a conundrum here. And the conundrum is that all of the platforms, really regardless of which one you spend time on, they are built specifically for the reason to drive engagement. The goal of those apps is to keep you on them for longer. That's why they exist. So within that, the content that typically keeps people's eyes on it for longer is generally framed more contrarian or more negative, that tends to drive engagement more frequently. So if you post something negative or if you point out something negative, often you will see a lot more engagement, a lot more comments, a lot more likes, a lot more just overall view of that content. And I think that this can cause a lot of issues in clinicians and has caused a lot of issues and I've seen it firsthand and that's a huge issue in our profession. So I kind of want to talk a little bit about those issues specifically and then what we might do to sort of reconcile them. SOCIAL MEDIA DRIVES CLINICAL CONFUSION So the biggest issues that I see and this is really regardless of whether it's a younger clinician or somebody who's a little bit more of a seasoned veteran What we see is when people spend a lot of time kind of intaking some of that negative information from social media, it drives a lot of clinical confusion. People are confused about what they should do with their patients. It drives ethical challenges. Some of these posts call into question how ethical manual therapy is, and it makes people feel like maybe it's a little unethical for us to be doing hands-on care. And they definitely often drive further away from expert opinion. So when I say expert opinion, I mean things like our clinical practice guidelines. So you think about what that is, like how those are formed, and it's really the foremost experts in our profession getting together, synthesizing all the data that exists, synthesizing clinical experience as well, and then making evidence-based recommendations. To get a clinical practice guideline published, it requires a lot of work, a lot of experts to communicate with one another and develop expert opinion. And here's what we think. This is a grade of A, this is a grade of B, and so on. To get a social media post out requires nothing other than an internet connection and a device that can do it. sometimes we're reading these opinions from non-experts and those non-experts could wind up being very loud and have a large platform and that doesn't always equate to someone that actually spends a lot of time in the clinic. So I think this is where some of that confusion can come into our practice, whether again, whether you're a younger clinician or someone that's more seasoned, it's kind of who we're choosing to listen to because of who's the loudest on social media and that being where we get most of our information. "MANUAL THERAPY DOESN'T WORK" So the narrative specifically, the misconception specifically that I'm addressing in today's episode is this manual therapy doesn't work narrative. So a lot of people have that feeling that manual therapy doesn't work and there are certainly studies that have challenged the efficacy of manual therapy and you see those studies get talked about a lot on social media again because they're negative and they drive engagement. But that narrative is one that I have heard often be challenged either on the weekend or in the clinic where people are just confused about whether or not manual therapy works. And that's a huge disconnect between clinicians that you talk to that do treat a lot of these issues. Those clinicians typically feel strongly that it does work and again our experts If you look in the clinical practice guidelines for back pain, for instance, you're going to see that really regardless of the presentation, there's some expert opinion that we should use manual therapy, that it should be used almost regardless of acuity or stage. Manual therapy might be something that should be included in back pain. And that's not just profession-specific. A lot of clinical practice guidelines make those suggestions, but ours certainly do. The updated ones from 2021 from Stephen George and colleagues make a lot of recommendations surrounding manual therapy. So I think that disconnect is driving a lot of clinical confusion for us. The reason this podcast kind of came up in my head, the topic, really came to me when I was looking through the recent JOSPT and there was a systematic review from, forgive me if I butcher the name here, but I think it's Ruzick et al, and this was just a couple of weeks ago that this one was published. You might have seen it in Hump Day Hustling, our newsletter. But essentially, it was a systematic review. It was done over at Bellin College. So the DSC program and the fellowship there at Bellin went in and they did a systematic review, kind of analyzing the literature, looking at manual therapy for low back pain. The question they were trying to answer was, are the methods in these manual therapy studies, the way they're described, are they repeatable? So in other words, if you read these studies, and you're an independent researcher outside of the group that just did that study, could you read through that and then actually replicate the findings? And the way they were looking at that is, are the methods described well enough for us to replicate the interventions? The answer was no. There was poor reporting in manual therapy intervention studies, and that limits the reproducibility of those findings. This is a big issue because one of the major tenets of science is that it needs to be replicable. You need to be able to check your work. If you're not able to do that, I would call into question whether or not it actually is science. At the end of the day, science has to be described well enough that an independent researcher could then come in and replicate the interventions to see if they can replicate the findings. If you then get a lot of data pointing in one direction, we start to say, you know what, I think there's some merit here. But if the methods aren't described well enough that we could even replicate them, you have to call into question whether or not that's actually science. And I guess my point here is a lot of these conclusions that are drawn on social media posts are of an independent study where maybe the methods aren't even described well enough to where you could apply them to the clinical cases you're seeing. And so we're drawing a huge conclusion that manual therapy doesn't work Meanwhile, the studies aren't even replicable. I think this is a massive issue. There's a huge disconnect there. And so I don't just want to point out the issue, I also want to talk to you briefly about what we might could do going forward, given that the studies don't guide us that well, given that they're not super replicable, and given that we can't draw those big conclusions off of non-replicable studies. And so let's address those problems. CLEAR UP CLINICAL CONFUSION WITH ACTUAL MENTORSHIP I think that the confusion here can be sured up by seeking mentorship. expert opinion and just time around expert practitioners. So what you will find often when you're actually seeing those people treat in the clinic, when you're working alongside of those people, is they're not confused about whether or not manual therapy works. They often have some type of a framework that they're bringing forward to the patient and they feel confident that they can often help patients because of their skill set. So I think we, as a profession, need to lean more on the empirical side of the scenario, given that our data is a bit confounded by lack of replicability. So what I mean by empirical is things you can witness, things you can see. The test-retest model, actually spending time around clinicians that utilize that and frame it positively for patients. That's what I think we should be seeking out as our evidence-based practice right now, because I think a lot of our actual evidence is challenging. That is the short-term solution. In the short-term, I would suggest if you're a younger clinician or a seasoned clinician who has some disconnects surrounding manual therapy, seek out mentors that have an understanding of manual therapy, who see a lot of back pain, who have busy schedules, busy caseloads full of patients with back pain looking to get better and see how they handle those scenarios. I think that is a much better route than seeing social media posts and drawing a huge conclusion from those posts. Meanwhile, the evidence that they're analyzing isn't that great. RESEARCH METHODS MUST IMPROVE The second thing would be a more long-term solution, and this is more speaking to the research going forward. We have to improve the methodology. That's what that systematic review from JOSPT That's what they suggested, and I couldn't agree more. In the future, our methodology has to improve. We have to get better at describing our techniques so that we can, over time, whittle down what is the most effective. But the problem is, that doesn't help you today. When you go see that patient that comes to see you with five days of low back pain, and they're really looking to feel better quickly, and they're starting to lose a lot of functional capacity because they're not doing much, because their back hurts so much, and you're confused about whether or not you should use manual therapy, long-term improvement of methods won't help you. You need to fix the short-term problem and get some understanding by spending time around clinicians that are used to seeing that and that can help you move that patient forward. And again, our practice guidelines are pretty clear here. they make a lot of suggestions surrounding utilizing manual therapy. And most of my colleagues that also treat a lot of back pain, that's basically my whole caseload is back pain and neck pain, occasionally shoulders, hips, knees, but a ton of back pain and neck pain. and I utilize a lot of manual therapy. And I don't feel bad about that. I feel like framed in the right way, it's so helpful to help that person reduce their concern and improve their activity. I agree that there are some ways you could frame it that might challenge someone's belief system in their body, but just don't do that. Just frame it correctly. And so that's my call to action. Seek credible mentors, contribute by pushing our profession forward with the use of these techniques that patients are going to seek out and they're going to get regardless of whether they see you or someone else. So let's be good at it so that they do seek us and then reframe the methods in future studies so that that way we can actually get good scientific data moving forward and understand what works and what doesn't. SUMMARY Team, in summary, I think a lot of clinical confusion comes down to a mismatch of understanding the quality of the information you're receiving. Social media has made it very easy to get your opinion out there, and often there will be opinions coming from folks who may or may not even be experts, who may or may not even be treating in that region, and challenging your belief system on whether or not an intervention works. And I see that confusion manifest as confused young clinicians who have a challenging time deciding whether or not they should utilize manual therapy. Spoken from someone who treats a lot of those problems and who has spent a lot of time around experts who also treat those problems, I've been very lucky to get a lot of time on board with experts. there's not that much confusion on the other side of the coin. So I think that mismatch of where you're getting the information from is huge. So my call to action is let's improve our manual therapy skill set. If that's what you're looking to do and this message is resonating with you at all, I'm going to tell you about a handful of upcoming courses because this is huge for us at ICE. This is why we don't hire people who aren't clinicians. It's really important to us that at ICE, when we bring forward a message to you, you're getting that message from people who actually are in the treatment room. They're behind the walls. actually trying to eradicate these problems over time. UPCOMING COURSES If you're looking for that in the cervical spine, May 18th and 19th, Casper, Wyoming, that one's filling up fast. So if you're in that area and you need a spot there, Casper, Wyoming only has a few seats left, make sure you jump into that. At the end of June, the 29th and 30th, will be in Kent, Washington. And then in July, the 13th and 14th, Charlotte, North Carolina. So a handful of options there for neck. If you're looking for low back, this weekend we've got two course offerings. If you want a last minute ticket, you can certainly jump into one of those. Carson City, Nevada, and then right here where I'm at in Hendersonville, Tennessee. Still seats left in both of those. And then next weekend, April 13th and 14th, near Boston in Braintree, oh I'm sorry, yeah, in Minnesota. I think I've got that down wrong. I think it's Braintree, Massachusetts and that's actually over in the Boston area. So if you're looking for either one of those and you're liking these narratives for reframing manual therapy, jump in with us. We're excited to bring forward some different ways of framing manual therapy. Thanks, that's all I've got for you team. We'd love to hear some interaction here in the comments throughout the day. Keep an eye on the thread. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Apr 1, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses the kipping pull-up as well as modifications to maintain kipping for pregnant athletes & reintroducing kipping sooner for postpartum athletes. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTROHey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account. JESSICA GINGERICH Good morning! Sorry for the late start. Welcome to the PT on Ice Daily Show. My name is Dr. Jessica Gingrich, and I am on faculty with the Pelvic Division here at ICE. My goal for today is going to be expanding on my last podcast that was about gymnastics during pregnancy, and really during the postpartum phase as well. So just a quick review of what defines gymnastics. It is a broad term that encompasses many movements and is utilized in many different sports like gymnastics, cheerleading, yoga, trampoline, and also CrossFit. So today I'm going to expand on the kipping pull-up rather than just a strict pull-up. WHAT IS KIPPING? Kipping is the act of using momentum to help drive certain movements. So we will see this on the rig, on the rings, and even during some handstand movements. So during pull-ups on the rig or the rings, kipping is using your lats and your core to drive into a hollow position, so that looks like a C, and then pulling into an arch position, which would be the opposite range of motion. This taxes the core through active muscle contraction, as well as putting the anterior core on a stretch. We often see coning and doming during the hollow or arch position as it stresses the anterior core during both movements. We see this during pregnancy and postpartum, but we also see this in other populations as well. Now, this is often communicated as something that is bad or dangerous, especially in the pregnant and postpartum women. And just remember, we want to help redefine that language as more of preparedness versus dangerous. Is your client prepared from a musculoskeletal standpoint to perform said movement. This is a less aggressive way of communicating. And remember, we don't want to induce fear around movement ever, but especially in this already vulnerable population of people. WHY IS CONING & DOMING WITH KIPPING SEENAS DANGEROUS? Now, let's unpack why coning and doming is seen as dangerous. So this was based on what we didn't know. a recommendation that came about because we didn't have research, so we erred on the side of caution, especially in the pregnant and postpartum world. We now know that coning is going to happen, and this is because of a mismanagement of pressure in that core canister. Mismanagement of pressure does not only happen in pregnancy and postpartum. It happens in all populations. We see coning and doming, and we use those words interchangeably by the way, in all populations like men, babies, and nulliparous women. That is just someone who has not given birth. Now, with this mismanagement of pressure, there are ways to optimize core recruitment to decrease objective coning or doming and increase co-contraction of the obliques, transverse abdominis, and rectus abdominis. However, you will see that many of your clients don't really care. They don't really take our advice on how to optimize their core. So will they hurt themselves? The short answer is no, they're not going to hurt themselves. Depending on overall core strength and preparedness of a particular task, they may be more susceptible to injury, but we're not scared of injury, right? We know how to rehab injury. What we don't want is to create fear around movement. So how do we negate this? ELIMINATE FEAR AROUND KIPPING So first and foremost, we eliminate fear. So, this can be difficult as mom, grandma, a random dude at the gym, friends, and really most commonly what we are starting to see now with Instagram is the fitness influencer that doesn't know the research. Telling your client that they shouldn't do certain movements. We train their core before, during, and after pregnancy. This includes more than just dead bugs, bird dogs, supine TA contractions, et cetera. Furthermore, we show them modifications in the gym to keep them on the rig and closely mimicking the stimulus of the workout when it comes to kipping pull-ups. The biggest point to make is your client maintains points of performance. This could be during any core movement, but specifically, kipping pull-ups is going to be, are they able to maintain the hollow position? If they are able to maintain that, then we let them go. Do your kipping pull-ups, whether you're coning or you're not. So the points of performance are going to be scapular depression and opposed to your pelvic tilt or that hollow position. This can be maintained. Can this be maintained throughout the pole? If they cannot maintain that, A, they're not going to hurt themselves if they continue. However, if you are educating around core optimizing strategies, then we modify. Modifications can look like feet supported kipping pull-ups, so that could be on the ground with a rack chin or with a box. Single foot supported kipping pull-ups, same thing, most of the time is done on a box so that other leg can hang off the box. Or they can further regress to feet supported strict pull-ups, known as the rack chin. There is always an option to decrease reps or rounds while we are choosing to modify that mimics the stimulus as well. When we choose a foot supported option, we are maintaining the kipping movement throughout a period of time rather than eliminating it. So we are saying, try this to maintain your pulling strength rather than eliminating it completely. This way they have more time or I guess less time between when they come off the rig during pregnancy and get back to it in that postpartum time. So to recap, change your language in the clinic, deal hope not fear. Bring attention to social media and how really we can't trust everything that we see and this may be showing your clients who to unfollow or who to mute in real time in the clinic. You should do the same thing for yourself and also report misinformation. So just like your client is going to be influenced by things that they see, so will you. The human body is resilient, and it does not stop being resilient once they become pregnant. Help your clients understand that. They will move with less fear, and they will come to you if they're unsure, or if they're having pain or symptoms. And so therefore, you're gonna be keeping them in the gym. And we want that, right? We want them to come to someone who is gonna encourage exercise throughout the lifespan, and that includes pregnancy and postpartum. Use modifications as necessary or if your client wants to. Remember that it may not be, they may want to use a modification because they feel better doing it. That's okay as well. Train their core in all positions and all ranges and prepare them for what life is. Prepare them for beyond what life is going to throw at them. Now, as always, we're gonna end with some courses. So if you head over to PTOnIce.com to check out our upcoming courses. In our live course, we dive into pull-ups, we dive into rig work and gymnastics. So if this is something that you wanna better your skills at, head over to PTOnIce.com to sign up. I hope you guys enjoy the rest of your week and I will see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 29, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses the concept of kipping in 2024. After 128 years of kipping movements in Olympic gymnastics, we still have high levels of contention over the use of kipping in recreational fitness despite poor evidence to support or refute the safety or efficacy of these movements. What evidence do we have, and what can we do in the gym and the clinic regarding kipping? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLGood morning, PT on ICE Daily Show. Happy Friday morning. Hope your day is off to a great start. Welcome to the PT on ICE Daily Show. My name is Alan. Happy to be your host here today on Fitness Athlete Friday. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member here in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We would argue it's the best darn day of the week. We talk all things Friday related to that person who is recreationally active. The CrossFitter, the Boot Camper, the Olympic Weightlifter, the Powerlifter, the endurance athlete, running, rowing, biking, swimming, whatever, that person that's getting after it on a daily basis, how to address that person's needs and concerns and be up to date on the research in this space. THE STATE OF KIPPING IN 2024 So today we're going to talk about kipping, a sometimes usually, it's fair to say, usually contentious topic. related specifically to the CrossFit space, but now as more and more functional fitness gyms open that are doing CrossFit style exercise, we see that even folks who would not say or know that they're even doing CrossFit style exercise are doing kipping movements. So I want to have a discussion. on where we're at in both the public facing, the clinician facing aspects of kipping, what kipping is, and really, what is our goal, especially when we have our clinician hat on? What is our goal when we're looking at kipping and considering Is Kipping safe? Is Kipping dangerous? Is Kipping right for this athlete? So let's start and talk about Kipping. So if you don't know what it is, or if maybe you have athletes or patients who don't know what it is, the public facing side of searching for things related to Kipping can be really gnarly, right? If you just type Kipping into Google, you get a real bunch of crazy stuff. What do you get? You get endless videos on kipping pull-ups specifically, but also a bunch of articles on why kipping is dangerous, why it's cheating. My favorite Google search is the top two results are in direct contention with each other, right? The top result for kipping is an article from Men's Health. Why swinging around at CrossFit isn't for everyone right so a little bit a little bit of a mean article a little bit condescending of an article But then the next article is from our very own Zach long the barbell physio the truth about kipping pull-ups right a lot of research on kipping a lot of practical information on kipping and a lot of the stuff that we're going to talk about today that is public facing, but in a very educational manner. So you see a lot of stuff. It can be very confusing for our patients and athletes because they're being given this message of, Hey, if I'm already doing this, here is really an endless wealth of human knowledge on how to get better at these, how to improve my performance. But also I'm seeing articles from people who tell me that this is dangerous. that this is cheating. This is actually reducing the effect of exercise on my body. It could be making me weaker. All of these different essentially thought viruses are going around simultaneously. RESEARCH ON KIPPING IS NON-EXISTENT So stepping back away from what's public facing, the social media content, the blog articles, what else is available on Kipping? Not a lot. If we're being really honest and we go way back in history to the start of modern gymnastics, we know that it started in 1896, so 128 years ago. Across that 128 years, we have watched the sport of gymnastics develop We see gymnasts use kipping on their hands, on the mat, up on the bars and rings, doing things like muscle ups and handstands, and using a lot of kipping to do so. But across that 128 years, we really still only have one research article that is relatively recent in that big span of time. that even discusses anything related to kipping. It's an article that we share in our Fitness Athlete Level 1 course by DiNuzio and colleagues. It's a randomized controlled trial back from 2019 in the Journal of Sports and Biomechanics. and it's titled The Kinematic Differences Between Strict and Kipping Pull-Ups. So a very basic article looking at subjects who performed a set of five strict and then five kipping pull-ups and just looking at what are the differences in the muscular activation patterns between folks performing the five strict pull-ups and between folks performing the five kipping pull-ups. And what we already know to be true was found in the research that we see a little bit less activation of shoulder muscles and bicep muscles and a little bit more activation of quads and of core muscles when we look at the difference between when somebody begins to kip their pull-ups or when somebody does strict pull-ups. And that's it. That's it. That's all the research we have, right? When you kip, you offload your shoulders and your arms a little bit, and the force is taken up a little bit more by your lower extremities and your core. And that's all the research we have on kipping. We have no research that it's dangerous. We also have no research that it's safe. We really have almost no research in this space, and we need to be cognizant of that. We have absolutely no research related to injury. of how many strict pull-ups can we do before we should kip. What level of strict pull-ups makes our shoulders safer from kipping pull-ups? What is the limit of kipping pull-ups volume-wise that we'd want to see somebody perform? Some sort of structured progression towards performing kipping pull-ups. We have absolutely no research on that. We need to be aware of that. And we also need to realize that's probably unlikely to ever happen. If you think about the recruitment for a study that would evaluate some of those concepts, it would look totally insane and be unethical, right? Let's take different groups of people, let's randomize them, and let's see, based on strict pull-up capacity, who does a certain amount or a progressive amount of kipping pull-ups, and then let's see how long it takes for someone to develop an injury, if ever, and then crunch that data and come up with some sort of Conclusion that we'd all love to hear, or at least be interested in seeing, of how many strict pull-ups is enough, how many strict handstand push-ups is enough, before we begin to create and allow, quote-unquote allow, kipping in our athletes. So we need to know the public facing space is out of control with this, can be very confusing to our patients and athletes, but the clinician facing, the research side, there is almost no information and there's probably not likely going to ever be something change here in a really substantial manner. WHAT IS KIPPING? So what do we do in the absence of research? Step back and better understand what kipping is. Kipping is just momentum creation and transfer. If you have taken fitness athlete level one in the past couple years, you know that we talk about this in week four when we talk about metabolic conditioning. We talk about why are we doing kipping? Why are we doing things the way we're doing them in the functional fitness gym, in the CrossFit gym? Well, we're primarily doing them to get our heart rate up, right? We're primarily exercising for power output. to create a cardiovascular response. That's why we're primarily going to CrossFit. Yes, we lift some heavy weights every now and again. And yes, we do some lower intensity, maybe zone two, zone three, steady state cardio from time to time. But primarily, we take a couple exercises, we smash them together in an AMRAP or rounds for time or an EMOM. and we're doing them in a manner that facilitates our heart rate getting up ideally into zone four and maybe if we're not careful, maybe sometimes a little bit of zone five. So when we talk about kipping, we're just doing it for momentum transfer. It's allowing us to do more work in the same or less amount of time. so that we can keep that heart rate elevated. You all can imagine that it would take a very long time to do a workout with 100 pull-ups if you did them all as strict pull-ups. We just had a great workout last weekend at Extremity Management up in Victor, New York. We had some pull-ups, or should I say pool-ups, as Lindsey Huey would pronounce it, programmed in the workout, and the folks that kip their pull-ups or butterfly their pull-ups got a lot more work done in that workout than the folks who just did strict pull-ups. So kipping is just momentum creation and transfer. I think it's important to understand we so intensely and closely begin to associate kipping just with gymnastics, specifically vertical pulling gymnastics, pull ups, and toes to bar and muscle ups and that sort of thing, that we forget that as humans, we kip almost everything in our life, right? I am standing still right now, if I begin to walk, I'm going to begin to use global flexion to global extension patterns, to propel myself forward. If I want to transition from a walk into a run, that is going to become even more intense. I'm going to begin to use more of my core, more of my shoulders, more of my glutes to produce a flexion to extension, back to flexion moment that generates momentum. If you don't think humans should kip, I want you to jump into a pool and not use your shoulders, core, or hips to swim. What you'll find is that kipping is very functional to daily life. If we begin to disassociate kipping from being up on the pull-up bar, on the pull-up bar, we recognize that we kip almost everything, right? It's a very functional thing. We kip to go from walking, from standing to walking and from walking to running. We kip when we stand up from a couch. We kip when we're swimming in the pool, or the pool, I should say. And we need to understand as well, some part of this, of why we don't just do strict gymnastics, why we don't just do strict weightlifting, is that it really limits our top end performance, right? Imagine if you watch the Olympics, and gymnastics was strict work only, right? Only the very strongest people would be able to do that stuff, and they wouldn't be able to do a lot of it, right? We would watch somebody come out on the floor, we would cheer for them, This is this is Steve from Belarus. Hey, Steve. And he does like maybe three strict muscle ups, right? He's not swinging around on the bars anymore. We don't really care about his landing, because he can't generate momentum to swing around to land. Imagine if Olympic weightlifting did not allow momentum and people just performed a deadlift to a strict high pull to a strict press, it would limit top end performance, we would not see people clean and jerking 500 pounds, we would not see people snatching 300, 400 pounds. So that momentum generation is a very functional part of being a human being and of performing these functional movements. And we can't take that away from people. Because even if for nothing else, it would become really boring, right? So not only is it functional, at some level, it's kind of fun to do. And it's fun to move along that progression from Okay, I can do some strict pull ups. Okay, I can do some kipping pull ups. Cool. Now I'm working on muscle ups, so on and so forth. WHAT IS THE GOAL WITH KIPPING? So what is the goal? If we put our clinician hat back on and we think, what is the goal with our athletes? Really the kind of the question we're answering in our mind, and when we ask questions like, how many strict pull-ups is enough? What we're really asking is, what level of strength in the shoulder begins to be protective of injury? And the answer we don't wanna hear is that it depends. And what does it depend on? It depends on that athlete's history, right? Somebody who has been performing a lot of strength training for a very long time that comes into a CrossFit gym or a gym where they might be doing kipping movements, that person has a lot less concern for the momentum on the shoulder or the momentum on any other joint in the body, right? We could say the same thing about runners, right? That person comes in with a higher what we call training age and therefore less worry about the capacity of that person's body as we begin to produce and create momentum with it. So the answer is, it depends. We can't say one strict pull up is enough. Five is the minimum. 13. Is five safer than one? Is 13 safer than five? It depends on that athlete. It depends on their training age. If they have never done any sort of vertical pulling, exercise, then we're just a little bit more concerned, right? We want to see that person begin to develop that strength. We'd love to see that person get one strict pull-up. We'd like to see them continue working on it. The answer, at least in our gym and the way that we coach, is that you should always be working on your strict gymnastics. You should always be doing strict pull-ups. You should always be doing strict handstand push-ups. We had a workout just last week with a bunch of strict pull-ups, and I coached it, and I was very, very adamant. Do not kip these. Do not use a band to kip these. I want a strict pulling stimulus today. If you can't do strict pull-ups, here are the scales that are going to help you get a strict pull-up. We're not going to bypass the strict training stimulus just to be able to go faster. If you can't go faster with strict work, we need to scale and work on that strict work. The other thing is, anecdotally, if you work with these athletes in a gym or you work with them on the patient side as a clinician, having a super high strict pull-up capacity does not guarantee high quality kipping pull-ups. That person who comes in who's been doing lat pull-downs and strict pull-ups for 30 years They can do a ton of pull-ups, but their kip probably needs a lot of work. What we see is opponents of kipping don't kip, and so they don't interact with individuals who do kip. And so we begin to develop this false belief that being able to do 10-strick pull-ups guarantees large, high-quality sets of kipping or butterfly pull-ups, which is completely unfounded. We all know that athlete who can jump up on the bar and do 10 or 15 or 20 strict pull-ups in a set, and then we ask them to, hey, try kipping those, and you're like, oh, God, what's happening, right? You are just swinging around on the bar. So just having the strength doesn't necessarily guarantee the technique that's going to lead to efficiency in that movement. So the truest answer is we always have to be working on both. When it's time to do strict work, strict pull-ups, strict handstands, whatever, we need to be doing those strict or finding a scale that allows us to progress to strict, and when it's time to allow momentum, kipping pull-ups, kipping, handstand push-ups, toes-to-bar, whatever, we need to find maybe also scales there, even if the person has the strength to do them in an ugly fashion, that allows the development of the technique, so the person that can do 10-strip pull-ups is somebody that goes on to be able to perform very large sets of high-quality kipping or butterfly pull-ups or toes-to-bar or muscle-ups or whatever. So once someone has demonstrated that they really have that functional shoulder strength, we need to recognize that they're naturally going to increase the volume of vertical pulling, and it's slowly going to ideally increase over time. And at that point, we're really dealing with an issue of volume management, we're no longer dealing with an issue of foundational shoulder strength, that person has the capacity to do strict work. Now we just need to carefully watch that person's volume, making sure that when they begin to develop kipping pull ups, they can do sets of five, they don't decide to help themselves to a workout where maybe they're doing 150 pull ups in a workout or 200 pull ups in a way that Volume is now the concern for the shoulder and not necessarily the foundational strength. SUMMARY So where's kipping at in 2024? The same place that has been for 128 years. There is a lot of public facing information out there that is confusing to our athletes and patients of how to get better. how to work on these for performance, how these can improve your performance in the gym, but also an equal amount of information on why these are dangerous or deadly or detrimental to your fitness progress. So understand the concerns that your athletes and patients are going to have when it comes to the KIP. Know that on the clinician facing side there is almost no research for or against kipping. We have just one article that looks at muscular activation patterns between strict pull-ups and kipping pull-ups and shows that when we kip we reduce the demand on the shoulder a little bit and increase the demand on the lower extremities in the core. Understand really fundamentally what we're looking at with kipping. We're just looking at momentum transfer and that we do this in a wide variety of movement patterns away from the gymnastics bar in the gym. Yes, we can kip pull-ups and toes to bar muscle-ups and handstand push-ups, but we also kip when we stand up. We kip when we transition from walking to running and jumping in the pool and swimming and so on and so forth. What is our goal? Our goal is always the pursuit of as much vertical pulling strength as we can get. So when things like strict pull-ups show up, things like strict handstand push-ups show up for vertical pressing, we need to make sure that we're working on strict work and not bypassing the foundational strict work with kipping just because we can't do the strict work. What's the answer to how many strict pull-ups is enough? Two answers. Strict work does not guarantee performance, efficiency, safety with kipping, but also you can never be strong enough. So always continue to work on strict pull-ups, even once you develop kipping pull-ups. And even once you believe that your kipping pull-ups or butterfly pull-ups or toes-to-bar or whatever are in high capacity and high quality, you're still working on that fundamental strengthening of the shoulder because we know Strengthening is protective of injury. And understand that once someone develops the strength work and begins to kip, we're not really dealing with a volume management issue. We're dealing with maybe the future potential development of a tendinopathy, not necessarily a lack of functional shoulder strength once that person can do a couple of strict pull-ups. So I hope this was helpful. I know it's a very contentious area across the functional fitness space. Happy to take any questions, comments or concerns you all have thrown here on Instagram courses coming your way from the fitness athlete division. Our next level one online course starts April 29. Our level two online course starts September 2. and then we have a couple of live courses coming your way before summer kicks off. Mitch will be down in Oklahoma City on April 13th and 14th. Joe will be up in Proctor, Minnesota on May 18th and 19th. That same weekend, Mitch will be out in Bozeman, Montana. The weekend of June 8th and 9th, Zach Long will be down in Raleigh, North Carolina. And then the weekend of June 21st through the 23rd is a really special weekend. It's our Fitness Athlete Live Summit here in Fenton, Michigan. We'll have all of our lead instructors and teaching assistants here. So Zach will be here, Mitch, myself, Joe, we'll have Kelly, we'll have Guillermo. We'll have all the fitness athlete crew here for a special offering of Fitness Athlete Live at CrossFit Fenton. So I hope this episode was helpful for you all. I hope you have a fantastic Friday. Have a wonderful Easter weekend if you're celebrating Easter. We'll see you all next time. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 28, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses pursuing mentorship with individuals who are not too far removed from your current situation so that they can best understand your needs & optimize a path to facilitate your growth. Jeff argues that often, individuals seek mentorship from those so far removed that they can no longer understand what it is like to be in that situation or the steps needed to continue to see growth. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MOOREAll right crew, what's up? Welcome back to the PT on ICE Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of ICE and always thrilled to be here on a Leadership Thursday, which of course is a Gut Check Thursday. The open is over. We are back in business with Gut Check Thursday and we've got a doozy. We've got every two minutes, you're going to do 15 calories on the bike, and then you're going to do as many thrusters as possible in the remainder of that two minute time period. at the weights of 135 for the gents and 95 for the gals. Then you're going to keep repeating that, right? Every two minutes you've got to get your 15-12 cal on the bike done before you start knocking out thrusters. The workout is over at 30 thrusters. I just did this the other day. I finished in the 7th round, 13 minutes and change. It's rough. There's not a lot of rest by not a lot I mean none. Think about scaling that weight if you're not getting over 5 reps in those first rounds. If you don't feel that's doable, maybe knock a few pounds off or you might be there. for a while because that bike only chews up more time as you get more fatigued. So give that a bit of thought. It's a wonderful workout. Make sure you tag us, Ice Fisio, Ice Train. Love watching you do all these workouts and sharing them across our social media platforms. Team, welcome to Gut Check Thursday. Welcome to Gut Check Thursday and welcome to Leadership Thursday. where I want to share a huge hack on mentorship that I think is so underappreciated. So the title of today's episode is Optimization via Degrees of Separation. Speaking of mentorship, and the hack that I want to share with you is how to recognize who you should learn from and who you should be teaching. An area that is incredibly plagued by low intention. The organization of that is not something people give a ton of thought to. It's plagued by low intention and one very common mistake. A COMMON MISTAKE OF MENTORSHIP: FOLLOWING THE LEADER So let's open with that common mistake. The common mistake in this, in the space is that most people think they want to learn from the star player or the leader of the organization or the person who they recognized that brought their attention to that area. They think they want to learn from that key person. You almost never do. Who you, you might want to work in their system, right? Like that absolutely makes sense. You might want to move towards their position. That totally makes sense. But who you want to learn from is very rarely that individual. You want to find someone who can over deliver for you and it will almost never be that person. The principle that we're talking about in today's episode is that you can talk across a river, you can yell across a lake, but you can't hear each other across the ocean. What I mean by that is the farther apart you are in knowledge and experience, the less effective the mentoring relationship. Now, the classic example here is when somebody says, oh, I had this great physics teacher, right? They were brilliant, but they couldn't relate to us. They couldn't teach as well as entry-level students, okay? This is not because of their intelligence. Generally, that's what it's blamed on, right? This person was too smart to be able to relate to us. That's almost never the case, right? SEPARATION FROM LEARNING PREVENTS SOLID MENTORSHIP It's because of separation. So many kinds of separation that make it more like an ocean than a river. Examples of that separation are the amount of knowledge this person has. That is not so much speaking to their intelligence, but they have simply accumulated a tremendous amount of knowledge over so many years that they can't understand anymore what it's like to look at a new concept in the absence of having that knowledge. because they have so much and they've had it for so long. They can't remember what it was like not to have it and what trying to learn a new concept feels like in the absence of it. They simply cannot put themselves back in that position. They can't relate to your phase of life. They can't remember what it was like when their other parts of their life beyond the professional stuff looked and felt like yours does because theirs looks nothing like that anymore. Other responsibilities. These people, that physics professor for example, is thinking about their research. They're thinking about building their team right well above and beyond the classroom. There's other areas that not only have some of their attention but arguably probably have more of their attention because as they've gained seniority that is where their unique role is probably most dependent upon. So that's what they're thinking about all the time. It's where a lot of their focus is. But when you add in all of these degrees of separation, the amount of knowledge, the phase of life, all these other responsibilities, that's what creates the ocean. And getting across that for a quality mentorship relationship is simply impossible. I can give you a personal example of this. My most effective phase of teaching physical therapists how to get better at physical therapy was when I was in the clinic about 25 hours a week. That was the sweet spot. I remember being in that sweet spot. I was one degree of separation. away from the people I was teaching. Yet, I had enough time out of clinic that I could mold and form my course and put good intention into the content That was the sweet spot. I was just removed enough from full-time clinic that I could really craft the message, but I was in it enough and I was still in phase of life enough that I totally understood exactly what these people needed to hear and what was going to have the greatest impact. When my role in the company shifted, my ability to teach clinical content noticeably declined. Oh that's better that's better because it just they had all the antidotes you could feel the fact that they just faced the same problem it was so much more relatable all the small changes in the profession they were in in and are in lockstep with and you could just feel the real. And that made it come across so much more applicable and so much more relatable. So I noticed as I began to move away and get a bit more separation, my ability to relate and be effective was significantly altered. This should guide you. This principle should guide who you look to for mentorship and who you look to mentor. You want the person who was where you are two to three years ago. That's the sweet spot. When you get in this organization you're excited about, you do not want to learn from the most veteran, clinician, person, team member. REACH UP THE LADDER BY ONE RUNG You want to learn very specifically from the person who was where you currently are two to three years ago. That's the sweet spot. So don't get enamored on trying to maybe look at it as reaching up, right? And try to make that relationship. You really want to reach up, but just one ladder rung, because that's going to be the river. That's going to be the most effective communication mentorship relationship. Now, similarly, you want to teach people who are only two to three years behind you. who are in situations that you very recently were in. So give that some really serious thought, right? Is there somebody you're currently teaching leading that really you should be passing that off to somebody who's a bit more closely connected to where all of those different components in that person's life are existing? Have you been hanging on to some relationships too long, or does the system need to be reshuffled where you're a bit more intentional about that time domain when you're looking at these mentoring relationships? This is not, by the way, just true in professional or clinical practice, right? It's true literally everywhere. Think about it in the gym. The athlete who just learned muscle ups is often the most effective person at helping you get your first one. Why? Because when you ask the person who knocks out 12 to 15 unbroken without thinking about it, that last part's the problem. They don't have to think about it, right? So it's very hard because they kind of say things like, I don't know, man, I just do it, right? Now don't mishear me. There are some amazing experienced coaches that have a truly unique ability to still break it down for you. But there is something to be said that once it gets so natural, once it requires so little thought, it's a bit tough to instruct somebody who is just learning their very first one. It is so true in music, right? When you're learning the guitar, somebody who just mastered their scales is an amazing person to show you how to sit and how to hold the guitar, the fundamentals. Because again, the person who has true virtuosity is going to say things like, dude, I don't know, man. I just kind of feel it out, right? I can play it by ear. Well, cool. I can't. So right now I need somebody who can understand what it's like to not be able to. EVALUATE YOUR MENTORSHIP SYSTEMS ON A DEEPER LEVEL My call to action for all of you on Leadership Thursday is to begin to evaluate your mentorship systems using the one degree of separation rule. You want people teaching people who were where the learner is just a couple years ago. When you go into a system, don't think it's awesome to learn from the person who's been around the longest. Think it's awesome to learn from the person who most recently solved your specific problem. And that person was where you are two to three years ago. Change these mentorship relationships from a time domain and you will drastically alter their efficiency. Give it some thought team. We are off for Easter weekend and then we are coming back with 13 live courses next weekend. all over the map. Actually the next couple weekends we've got about a dozen or more courses on tons of spots to check out PT on Ice live classes. Go to PTOnIce.com. You'll see them all right there. April 6th, 7th, the following week. Tons of options. Wherever you are, we probably are. Jump into all the fun team. Have an awesome Thursday. We'll see you next week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 26, 2024

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses loading the lumbar spine in all planes as part of a judicious rehab plan, including anti-flexion, anti-rotation, and anti-sidebending exercises. Brian shares a progression sequence beginning with plank-based loading that advances to using external resistance, and culminates in intentionally loading the spine in suboptimal positions. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION BRIAN MELROSEAll right. Good morning, PT on Ice Daily Show. My name is Brian Melrose. I'm one of the lead faculty in the spine division, teaching both cervical and lumbar courses. I'm really stoked to be back here on a clinical Tuesday to talk about loading the lumbar spine in multiple planes. And where that really comes from is I was back in Windsor, Colorado. I was at the extremity management course. And I was listening to Lindsey Hughey talk about loading the rotator cuff. She was kind of discussing the idea of loading in different positions, loading in different speeds, and varying loads. And as I'm sitting there and I'm kind of marinating on the idea of loading in different planes and speeds, I thought to myself, why would the lumbar spine be any different? And what if we approached kind of loading the spine through that lens? SPINE RESILIENCE IS MULTI-PLANAR And so when you begin to think about how to make a comprehensive exercise program for individuals where you're building resiliency in the spine, we have to consider that multi-planar approach. So something that would stress the spine into flexion, something that would stress the spine into extension, something for side bend, and then something for rotation. And so a full comprehensive exercise program would look like at least four exercises. And after that course, that's really when I started messing with this concept in the clinic. And it's been really helpful for a couple different populations. Number one is individuals that have had more chronic pain and you're just trying to introduce exercise overall. I think jumping to things like, you know, the deadlift or a squat with a barbell can be a bit much for them. And so it's a great way to start with some exercises and kind of progress them towards using weights and resistance. The other place where this is helpful, though, is when irritability is high. If you've been to any of our courses, we talk about how your interventions need to mirror the patient's irritability. When the irritability is high, it may not be appropriate to have them using external resistance. It may not be appropriate for them to be loading at heavier loads. And so usually I like to start things, again, in a multi-planar sense with body weight and then move more towards dynamic movements. And the last population, where I think this concept helps a lot, is for individuals that are higher-end athletes, or folks that are already kind of squatting or deadlifting multiple times a week. I know for me, that's a big issue with my powerlifting patient population and other skilled Olympic lifters and crossfitters. When they come into the clinic with back pain and I want to offer them some exercises that make their spine more resilient, they're already loading the spine with the deadlift and with the squat a couple of times a week, my window of opportunity really begins to shrink just in terms of the type of exercises I can do with them. And so really, I think that's where we have to identify kind of like a smaller lane in which we're going to intervene and bring some new stress to the spine. And so for a lot of my power lifters, I like them to begin to consider loading into planes of side bend, like so frontal plane, transverse plane, looking at side bend and looking at rotatory movements. And so if we can kind of extrapolate this idea, then I want to kind of shift towards talking about what those exercises actually look like. And so I really like to begin, folks, in this space with doing a series of planks. And so I'm going to talk through a lot of different exercises in the next couple of minutes here, 12 in total, four, four, and four, and kind of describe how and when each of those are advantageous. But if you're looking for what those exercises look like together, go ahead and head out to just our Instagram page and there's a nice reel on there where you'll see all these exercises kind of grouped together. So where do we start? Well, you know, if you've been to an ice course, you know that we want to eventually get to loading a little bit. It doesn't have to be a barbell, but something with some resistance. PHASE ONE: PLANK-BASED LOADING And so usually the first phase of this for me, level one is going to be more plank based. And so I'm thinking of getting the athlete or the patient in a position that's pretty optimal for them in terms of it being a neutral spine, them just being able to maintain that position and not have heavy loads on board. And so level one typically starts for anti-flexion. I like doing a Chinese plank. And so typically you're just going to elevate your heels and your shoulders on boxes or chairs of equal height to be benches in the gym. You can even place a dumbbell over the hips, which is going to introduce a little bit more of a flexion stress. as gravity kind of pulls the athlete down. They can do a longer hold here. It's a little bit like an isometric. Again, if irritability is high, this is a great place to start if they can't hinge over and grab a kettlebell or grab a barbell for a deadlift. So anti-flexion, the Chinese plank. For anti-extension, what we like here is getting a pull-up assistance band looped over the J-hooks of typically the squat rack. And I have the athlete kind of slide underneath that band and place it right over the lumbar spine. In a normal plank position, that's then gonna pull the lumbar spine down towards the floor into an extended position. And so they're gonna resist that. And so we get a nice anti-extension exercise. For side bend, all you're gonna have that person do is just flip over to their side, still underneath the band, and they're just gonna scoot it down from the lumbar spine down to the iliac crest. In this position, again, now the band is pulling the hips down towards the floor and they're resisting that, so it's an anti-side bend stress. The athlete or patient would have to get both sides there. Last is anti-rotation and I love defaulting to the nice old classic payloft press. I like loading this up pretty heavy with those bigger pull-up assistance bands. Loop it around the rig, get your feet nice and narrow and it's a great way to just start to kind of get an athlete or again a patient that isn't doing a ton of loading in the spine familiar with some of the muscles and some of the stabilization positions that they'll be seeing later on in the plan of care. And so again, as rudimentary as it is, I love the payoff to partner with some of these plank exercises. And again, neutral spine location, a little bit of body weight, a little bit of band stress. This is a great way to kind of initiate things for a lot of our folks in the clinic. PHASE TWO: LAYERING IN EXTERNAL RESISTANCE Level two is really where I like to kind of again, take it up a notch. We're now going to keep the spine in an optimal position, still hanging out again in a neutral brace spine, but we're going to add some external resistance. And I think this is a big step for a lot of our folks. Again, we can't leave them at bands and body weight. We have to progress them to getting their tissues stronger. And the only way we're going to force that adaptation is if we begin to load. And so again, I think this is a good step. Even when irritability starts coming down, we can begin to load in this area. So our first anti-flexion exercise in this level two is gonna be just a kettlebell deadlift. And so for our individuals that are a little bit, you know, getting more inexperienced in the weight room, it's a great way to get their hands on some weights, get them comfortable with some movement patterns, and again, stress the spine into a more flexed position. For higher-end athletes, they may not be able to tolerate the barbell at this stage as they kind of rehab an injury. And so the kettlebell allows them to get in the gym, do a little bit of work in a familiar sport-specific spot, and get the job done. So love the kettlebell deadlift for our anti-flexion exercise. For anti-extension, I want to kind of get a little bit more vertical. And so for my Olympic weightlifting athletes, I want to start working and challenging the spine for overhead positions. And so anti-extension for level two is going to be a tall kneeling overhead press with the band where the band is kind of fixed behind the athlete. And so as they come up all the way overhead, the band will pull them into extension and they're going to have to stay nice and braced. So again, we got flexion, we got extension. For side bend level two, we're going to go with a heavy kettlebell suitcase carry or march. And this is the one where I think we kind of underdose and don't load up nearly enough. And so for this exercise, I have them get a big kettlebell, stand as tall as they can. We don't want to lean. We don't want it to look like we're holding a heavy weight. And that may be enough of a stimulus for those athletes. They can feel the opposite side, again, stabilize. If they can progress towards doing a standing march or even a step up, a suitcase walk, those are all great ways to, again, challenge the spine in that side bend position. Last is rotation. And again, if you've been to an ice course, you know that we love the bird dog row. I think people underestimate how difficult this exercise is. And so again, if you're looking to see what that one looks like, head over to the Instagram post, but you're going to assume a bird dog position on top of the bench. The bottom hand is going to reach down and hold the weight. Usually start folks somewhere around 20 to 35 pounds, and then progress them all the way up to a good 40, 50 pounds here. If the athlete is in that position, as they lower, that's gonna put a lot of rotatory force through the spine, and so we begin to, again, stabilize in an anti-rotation position. If your athletes are looking pretty good with this one, the only add-on I got here is do a faster drop. If you try that, you get this big rotatory moment, and the athlete is gonna have to really work on stabilizing the low back. And so level two looks just that way. Kettlebell deadlift, tall kneeling extension overhead with a band, we got the bird dog row, and then last we have that kettlebell march is typically what it ends up at. For a lot of our folks, this may be enough of a stimulus to get them again loading their spine and moving in optimal planes, but the job is not done yet. PHASE THREE: LOADING THE SPINE IN SUBOPTIMAL POSITIONS The last piece is I think we have to begin to load the spine in suboptimal positions. So maybe we reduce load for that consideration, but when people tend to agitate or irritate their back, it's sometimes doing lifting, but a lot of times it's doing those everyday things. It's reaching underneath the hood of the car, reaching into the back seat. bending to put your child in the car seat. Whatever it is, you're probably not in a perfect neutral spine position most of the time. And when we work with our patients on getting them confident and comfortable loading the spine, I don't want to create this idea of fragility outside of neutral. And so I think if we're going to get our folks all the way to the finish line on this one, our last piece has to be a challenging level three, four group of exercises to challenge in all planes, but have folks start moving through a range of motion with load on board. That's how we get full resiliency. And so the last group of four exercises here, is going to be starting with an anti flexion movement. But this time, there's going to be a little bit of flexion on board. So the spine stays straight with a kettlebell swing, but we're hinging at the hips quite a bit. And every time that heavier kettlebell comes down, there's a pretty good flexion moment. And so I love to integrate this for a lot of my athletes that deadlift and even squat regularly, but aren't doing more of a dynamic, volumized stress to the back. A lot of my powerlifters, you give them a kettlebell and they get smoked in about 10 reps. So females go heavy, 53. Males, 70 if that's appropriate. If not, we'll drop those down to 35 and 53. But a good kettlebell swing can really challenge the spine in that flexion position. For extension, I love the Reverse Hyper. Jordan did a great reel a couple weeks ago, kind of breaking down the value of the Reverse Hyper, as well as different ways to modify it for different athletes. We have one of those Westside Barbell Reverse Hypers in the clinic. And again, this is my go-to for loading the spine into a more extended position. It pendulums down, but then as the athlete kicks up, we're not just going to neutral, we're going all the way into extension and really challenging the tissues in a new position. So we got flexion, we got extension. What about rotation in this group? Well, I like the barbell rotation. So typically it's going to be set up kind of more like a landmine position with the athlete standing tall. You can put a plate on there. I usually like starting folks anywhere from 10 to 25 pounds and work them up to 45 and they're just going to rotate from hip Again, if you haven't seen that one before, check out the Instagram post. There's a good demo of that. And this can really begin to challenge the back in some different spots, right? We're rotating up and down. You're getting a little bit of hip shifting. The obliques are starting to work. This is a very challenging exercise for a lot of our athletes. The last thing would be doing side bend. And I don't have a good name for this exercise, so I just call it kettlebell smiles. But you're going to have the athlete get back in that suitcase hold position, and they're just going to dip from one side all the way to the other with load on board. If you haven't tried this one before, again, it's going to feel a bit funky, but it really challenges the lumbar spine throughout the range of motion of side bend. And so typically, if you've got an athlete, again, towards level three, you've really given them that gift of fitness that we always talk about. At that point, I think they have a good, robust program where they have a group of exercises that challenges the lumbar spine in all planes. If things get irritable, they can always default back to level one. They can have a nice steady training stimulus once a week with level two in terms of some resistance on board, but staying in an optimal position. And then once a week, maybe they dance up and begin to load the spine in some of these ranges of motion. And I think if we can give all of our patients that have lumbar spine pain and are looking to get a stronger back, these kind of group of exercises, they tend to just progress much, much better than someone that's only doing deadlifting. The deadlift will always be king in terms of exercise, but our patients that get these groups of exercises, we give them that window that they're missing and we can get a lot more resiliency in the spine. So check out that Instagram post for more details. Um, hopefully this was helpful. Um, I'm going to keep piggybacking on this concept and do probably another podcast in a couple of weeks here. I'm talking about considerations for loading everything from volume and dosage to working at different speeds and even considering fatigue. Cause I think that's where I want most of our patients that have had either chronic or ongoing back symptoms to be resilient is when they're gassed. Because that's when things get a little bit sloppy. So we'll be getting those topics in the future. I hope you guys all have a wonderful Tuesday morning. Thanks for joining us. We got a couple courses coming up in the next couple weeks here. We got cervical out in Carson City, Nevada. Zach Morgan will be out in Hendersonville at his home turf. So check those things out. And again, I hope you have a great morning. Thanks for joining. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 25, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to close the pelvic floor knowledge gap through education in the community, prior to an individual needing formal pelvic PT. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION APRIL DOMINICKGood morning, PT on Ice. My name is April Dominick. I am Ice Pelvic Faculty and your host this morning. Let's chat about how PTs can close the knowledge gap when it comes to basic pelvic floor education in the community. Essentially, I'm presenting a case for how we can use a prehab framework to educate individuals prior to the onset of pelvic floor dysfunction, or them requiring formal PT. What really gets my knickers in a knot is how uneducated we are as a society about our bodies. It blows my mind, all of the incredible systems that are happening in our body, like breathing, pumping blood to muscles and organs, filtering through nutrients to store stool and urine. All that's happening in the background right now while you're listening attentively to me on this podcast. All is fine and dandy with those processes until one day it's not. Until one day you're listening to your friend who is a singer and she tells you that her pessary, the device that she inserts into her vagina to support her bladder, fell out on stage. while she was singing her solo for her opera. But she's never heard of the pelvic floor muscles or pelvic floor muscle training, which can also support her bladder. Or the baseball coach who's two years post-prostatectomy and now struggles going to work because he leaks pee when he's yelling out plays to the players. or when he's demonstrating a new sprinting strategy to the team. Does he know that just because he doesn't have a uterus, he also has a pelvic floor too? An entire group of muscles that he can voluntarily control to help him not leak when he's yelling or when he's running. We are undereducated about our bodies. There is a massive gap in knowledge when it comes to the pelvic floor and treatment options or associated risk factors with pelvic floor dysfunction. This gap in knowledge could be the difference between someone getting surgery or avoiding it due to prior knowledge and doing conservative care instead. Zooming out on a larger scale, I got to thinking, what role do we as PTs have in teaching individuals in our communities about the pelvic floor and any related pressure management systems before they reach the point of needing to come into our office for formal PT or surgery? Given that the rates of pelvic floor dysfunction rise with age, there's so much power to potentially reduce function, such as urinary leakage, simply through pelvic floor education at any age, at any stage in life. So that parents feel comfortable educating their kids in this space. So that grandma Betty can advocate for herself and ask for specific treatment options for painful intercourse that she learned at a talk at her community rec center. And so that Sam feels empowered to talk to their coach about leaking and lifting. One issue that's related to pelvic floor dysfunction is intra-abdominal pressure, or IAP. It's defined as steady state pressure that's concealed within the abdominal cavity, and it's created from the interaction between the abdominal wall and the viscera. It tends to fluctuate with our respiration phase and the abdominal wall resistance. the pelvic floor muscles are essential for the maintenance of this intra-abdominal pressure, as they lock shields with other muscles in the core canister, like the diaphragm, the abdominals, all to support this dynamic pressure system. If you think about it, life is a series of fluctuations in intra-abdominal pressure that affects all humans. One minute, the pressure may rise with a sudden sneeze or jumping, or it may lower to a different level when standing up from sitting, and then it may swing back up if someone is on the toilet pooping. So the ability to manage those pressure changes will differ depending on the human, depending on their relative capacity and knowledge and understanding of this pressure system. It doesn't matter whether they're a young gymnast, an older adult with low energy reserve, or a two-year-old potty training, or a yogi mom of three kids. All of those individuals are subject to changes in IAP, no matter their age or stage of life. The input IAP is the same for all of us, but we have this really beautiful ability to turn it into different outputs. We could use that IEP to manage lifting a grand kid overhead. We could use it to laugh at April's podcast this morning, to score a goal or to nail a note in a song without a pessary falling out. Education on interabdominal pressure management as it relates to pelvic floor dysfunction is not a major focus in performance, in athletics, or in life's education either. So I propose it's time for an intervention or a PT prevention intervention, if you will, So let me use the example of urinary leakage or urinary incontinence, aka UI. I'll use that as an example for pelvic floor dysfunction. UI can arise in the presence of poor intra-abdominal pressure management. A staggering 50% of female adolescent lifters leak when they are doing their sport. And that leakage, can be a barrier to entry or a barrier to continue with exercise or their sport, as well as a distractor during training and competitions. Taking it one step further, the lack of knowledge of the pelvic floor contributes to inadequate management of IAP, as say someone's lifting a heavy barbell. This lack of knowledge influences the development for pelvic floor dysfunction for some. A 2018 observational study by Cardoso and colleagues aimed to determine the prevalence of UI, urinary incontinence, in female athletes practicing high-impact sports. They also wanted to know what's the association of UI with knowledge, attitude, and practice. In their study, they found that 70% of their athletes reported UI, and none of them told their trainer about this dysfunction, and none of them sought PT care. Talk about a missed opportunity. Participants were also unaware of the positive association between high-impact sports and the development of UI. The authors found that an individual had a 2.7 times more chance to develop UI if they practice their sport for more than eight years. And this piece of information is key not only for the short term, but also for the longterm in someone doing athletics for that long. However, there was one saving grace. And that saving grace to the development of pelvic floor dysfunction was adequate knowledge of urinary incontinence. So in the study, if an individual had adequate knowledge of the occurrence of urinary incontinence in sport, then they had a 57% lower chance of developing UI. 57% chance of lowering the development of UI if they had adequate knowledge and that's just education alone. What a huge difference that can make. So in the conclusion, the authors, they called for a greater dissemination of knowledge and preventative practices for UI in sports in order to decrease the prevalence of urinary incontinence and increase adherence of young athletes to sports practice. So many individuals, some of us included, avoid talking about urinary incontinence with teachers or coaches due to shame and embarrassment, coupled with a lack of knowledge about the condition and treatment options that are available. Instead, individuals will suffer in silence. They'll spend a ton of money on protective pads, they'll restrict hydration, and some will even avoid exercise altogether. Y'all, this, this is a coaching problem. This is a teaching problem, this lack of knowledge about pelvic floor dysfunction. When the athletes in the Cardoso study were asked about whether trainers should discuss the topic of urinary incontinence, a majority agreed that the trainer should encourage prevention. But how? How can they do that if trainers or coaches aren't even educated on pelvic floor dysfunction? Research supports positive effects of education alone when it comes to improving pelvic floor outcomes. So what's needed? I believe education is needed at the community level. PTs have a unique role in teaching about the pelvic floor and intra-abdominal pressure management that could be directed either to trainers or to fine arts teachers like vocal coaches or to athletic coaches or even to the athletes themselves. This could potentially allow for the reduction of instances of pelvic floor dysfunction, as well as maybe some PRs because now they understand, oh, I have this whole group of muscles to help me, or more efficient performances where the person, the singer, the theater major isn't fatigued because they know how to optimally utilize their IAP system. Athletes and performers are not the only individuals, though, who deserve this basic pelvic floor education. The general population does, too, as it relates to their IAP management with daily functions like we talked about before, lifting the grandkid, running, sneezing, we need more pelvic floor community workshops and in services at music or dance classes in the community, in collegiate team meetings, or silver sneaker programs. These programs could potentially reduce urinary incontinence and pelvic floor dysfunction at any age or stage to allow for improved quality of life and a shame-free environment in which folks are encouraged to discuss pelvic floor dysfunction with their teachers, their providers, their friends. Furthermore, PTs can also educate on an instance that may come up, which may signal, hey, I think pelvic floor PT would be more dialed in and you could get some gold standard pelvic floor muscle training because this general education didn't work. So in a 2018 systematic review, Fonte et al and colleagues identified five risk factors for lack of pelvic floor knowledge. Number one, educational level. Number two, access to information. Number three, socioeconomic status. Number four, age. And number five, race. So community talks could focus on these populations in order to narrow the knowledge gap. I urge you to consider the role of educating your community, whether it's the grandma buddies, the baseball bends with the prostatectomy, as well as performers and athletes at any age on the pelvic floor, particularly as it relates to management of the intra-abdominal pressure, something that we all experience changes in moment to moment. SUMMARY So if you're looking for more opportunities on how to optimize your pelvic, your client's pelvic floor or folks in your community through breathing and bracing strategies, check out our upcoming live courses. We've got two I'll talk about. One is April 6th and 7th in Windsor, Colorado. That's gonna be with Alexis Morgan and myself. Come on out and learn with us. Another opportunity is the following weekend, April 13th and 14th, and that's gonna be with Christina Prevett and Rachel Moore down in Houston, Texas, my home state. And our next available 8-week online cohorts that aren't sold out yet, but you can still sign up for, are Level 1, it starts April 29th, and then Level 2, that one starts August 19th. Head to PTOnIce.com to sign up for those courses. Thank you all so much for listening, and I will see you all next time! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 25, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras dives into all things split squats and shares its utility for improving lower extremity strength asymmetry. Also discussed: progressions for the most novice up to the most advanced of athletes and clients in the clinic and gym Whether for the quads, glutes, hamstrings, the split squat is one of the exercises we "love to hate" most Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION GUILLERMO CONTRERASHere we go, gang. Thank you so much. Sorry for the little bit of a delay. Had some technical difficulties all morning for myself dealing with some stuff here on the back end. But happy to be with you here on the PT on ICE Daily Show on the best day of the week, Fitness Athlete Friday, the day where we talk all things fitness athlete, loading progressions, getting strong, getting fit, all the good stuff. We are today talking about split squat science. And it's more of the applicability of the science of the split squat more than going into the deep, deep nitty gritty about the split squat. And the reason for this topic today is many times in the courses of the fitness athlete, whether it be the L1, L2, or even in the live courses, when we are breaking down movements like the back squat, like the front squat, movements that we tend to use in the CrossFit realm more than anything else, movements that we really preferentially push towards to get maximum loading of bony tissue for bony adaptations, muscle tissue for strength gains. The squat is how we're going to do it. However, when we're breaking down the movement pattern for the individuals in our courses, or the individuals in front of us, or our athletes and clients, many times we're going to see some deficits. We're going to see some asymmetries, whether one leg is just not pushing as much as the other, one leg caves in, whether one quad or hamstring or glute or whatever it may be is more developed than the other due to a previous history of injury. as well as also just when someone tends to shift and put more weight into one side versus the other. There can be a myriad of reasons for it. We don't know what's going on. That's why we want to assess things and not just assume anything. But once we get through that assessment phase, Bam! That's when we can see the benefits of some single leg work to improve leg strength deficiencies or asymmetries. And this topic is brought on by a recent study in 2023 that came out looking at leg strength asymmetry in basketball players. So strength asymmetries as well as the ability to kind of change direction quickly. And what they did in that study is they found that a three-to-one non-dominant-to-dominant strength training program was optimal, I could say, or they worked really, really well to improve that asymmetry in one leg versus the other. And one of the movements that they used in order to load individuals as well as kind of uncover where the weaknesses were was the loaded Bulgarian split squat. For those unfamiliar with the Bulgarian split squat, I am simply in a lunge position here. I'm away from a surface I can put my foot on behind me. So I step up as I'm going to do a lunge. My foot goes up on a bench or a box or something elevated behind me. I then hold a barbell or dumbbells or kettlebells, whatever it may be, on my back. And I simply go down, tap the knee, and then drive back up. It's a fantastic movement for doing unilateral loading of the quad, hamstring, glute, And depending on your foot position, you can actually preferentially load one tissue over the other. For example, if I want to really hit that quad for an athlete who really needs it, and they have adequate ankle mobility to be able to do this, what we do is we narrow that step so we don't make it as far of a step out, and we encourage that athlete to really dive straight down into that split squat with that knee going over that toe just slightly more, and then drive back up. You will feel a massive quad pump when you are through a set with a slightly more narrow stance. If you want to preferentially hit the glute hamstring, we go a little bit further, and we allow that individual to bring their torso, to tilt their torso forward a little bit more. So as they go down, their torso can tip forward, thinking like a low bar back squat or something like that, and you get a lot more of a stretch pulled on the glute and the hamstring, as opposed to that really upright torso. You're thinking when you would use that further one for more glute hamstring, high hamstring strains, really getting that deep end range of hip flexion towards the bottom there, your quadripatellar tendinopathy for that more narrow stance, we're trying to load that up and build strength there. In the study, they used 65, 75, and 85% of 100 max, and they were doing I believe 10, eight, and six reps at that heavy weight for that single leg. With that said, right now we're really familiar with the Bulgarian split squat, and if you've done it before, you know that you hate it, like you love to hate it. It feels awful to do, it's difficult, but it's a really, really beneficial movement, really beneficial strength exercise. Truth is, the majority of our clients, if we're dealing in general population, not just fitness athletes, we wanna be able to use this same exercise, but we wanna be able to bring it down to the lowest common denominator. SCALING THE SPLIT SQUAT How can I scale this movement down to the easiest form and make it even harder than that Bulgarian split squat we just did? And that's where we're gonna go here. First and foremost is just a standard split squat. Have the individual stand in place, one foot forward, one foot back, have them drop that knee down, tap, and then back up. It's as simple as that. For my older adults, when I'm working with them, and they struggle with even getting to that point, I will stack, what are those, Eric's mats, Eric's pads, whatever it is, or handstand push-up mats, or sorry, ab mats, under their knee, and have them just get a target, right? That way they know every time they go down and tap their knee on that pad, they come right back up. And then we can progress that by removing layers of weight. Can we take one away, have them go a little deeper, take one away, have them go a little deeper, and progress that further and further. Once they are comfortable with that, can we now increase that split squat range of motion even more? If they're tapping the ground with their knee and coming back up, can we now create a deficit? Because we know with the squat we want that below parallel depth. But with a split squat, we are never hitting that below parallel depth. It could be death too, depending on how tired your legs are. So for here, we bring elevation into the game. Can we have someone stand on two elevated surfaces in that same split squat stance? Can they then drop down below parallel in a deficit and then come back up? Same movement pattern, but just increasing that range of motion. Really nice progression for increasing load and stress onto the legs. You're also gonna get a little bit more of that high hamstring, that glute, because of the sheer depth of that, even that adductor. So if you have someone with an adductor strain, which I've had a handful of those in my time, that's a really good one to try and get someone a little more comfortable with that big depth, under less load, and try and get a little bit of stress onto that adductor magnus. We can have a front foot elevated split squat, where we're just focusing on the depth in that front leg, really tight anterior hips, rectus all the way down to the knee, front foot elevated, drop down, less stress on that back knee, more range of motion on that front leg, and then driving back up. Probably going to be in this kind of partial squat, partial bent knee at the top, unless they push themselves all the way back, kind of dealer's choice, however you want to load that up for the individual. from that, from that deficit, we then continue just loading these things, right? We're loading these people throughout these different variations. And then we get to the point where now we have their foot elevated on a solid surface, a stable surface, a bench, a box, something behind them, going down, going back up. And I mentioned stable because there's a variation we can do that changes it up a lot that I've had a lot of success with where we use a band on either some pins or J cups, and we have that individual put their foot up across that band. Now, that band is just supporting that back leg, but they can't push down into that band to stand up, because if they do, typically they'll lose balance, or they'll hit the ground and they'll know they're doing it wrong, or they realize, I've been putting a lot of work through that back leg. So having that unstable surface, that band behind them to rest their foot on, and then doing that single leg squat, which I just butchered there, boom, And boom, it shows how much more you have to work through that front leg when you have your foot on a band, something that's not gonna allow you to push through. So a really, really good progression, really difficult progression is to put that band on something where they can no longer support themselves through that back leg. And the most difficult variation I would recommend that we do in the clinic, with our athletes, with our clients, with anyone who's appropriate for it, is something known as a shrimp squat. A shrimp squat is simply a single leg squat. However, we are not using that back leg anywhere at all. So we can usually get some support with the hands if needed on a surface, so kind of up right here. I then pick up my back leg, I go down, I let the knee tap, and then I come back up using just that front leg. We take away the ability to push through that back leg at all, to support through that back leg at all, and then all of a sudden that front leg has to work that much harder. All of these can be used to work on strength balancing symmetries. The ones I recommend the most for my athletes, for the clients I work with, are the rear foot elevated split squat with support, because of the fact that we can actually load those really, really heavy. when we add a lot of instability, right, when I add the banded one or the shrimp squat, we can't really load that up in the same way as we can that rear foot elevated split squat, which is why that Bulgarian split squat is king. That's why you see it in CrossFit gyms, why you see it in bodybuilding spheres, why physique competitors and the Brett Contreras clients of the world are doing heavy Bulgarian split squats, because they can load it up and really pump the glutes, pump the quads and get the legs really big and strong. It would be, Wrong with me not to mention it, because we see it a lot more in the mainstream now, is that ATG split squat, in which an individual has something like a slam board. Here we have one from VersaLifts, the V-Stack from VersaLifts. We place that foot on top of the box or any sort of incline. You can even do like a 25 or a 10 pound plate. I keep that back leg straight. I drive my front knee forward. I place almost all of my weight on that front leg, getting as much anterior displacement of that tibia as I can, and then I drive back up. This has been made really popular online. You see it a lot in like the ATG, or like the knee rehab, or the ankle rehab, or apparently it heals everything. And it's a very good movement. It works really well for hip mobility. You think about the fact the leg is really straight, driving to that end range of hip extension there, that deep knee flexion position where you're exploring that full, broad range of motion of deep knee bend. But again, it's a hard movement, it's a more advanced movement. You can elevate the slant a little bit to make it less intense on the knee. And again, it's hard to start loading that when you have to get really comfortable with it before you load it. So for me, that split squat, that Bulgarian split squat is my go-to. But that standard split squat, just in place, a little bit of elevation where maybe you're just doing a two or four inch elevation behind them just to kind of encourage a little bit more load through that front leg. and then keeping in mind where is my foot, where is my torso, because that is going to change what we are loading when you're performing it. So there is your, let's call it split squat bro science progressions from the ground to a deficit to a rear foot elevated. to an unstable rear foot elevated, to a shrimp squat or a pistol squat you could even do as well, but all the single leg things that you can do with your clients to help fight and work on some of these symmetries they may be dealing with in their legs that are affecting their squats, front squats, back squats, overhead squats, cleans, snatches, you name it. If there's a squatting pattern in it, there could be some issues. SUMMARY If you wanna learn more, if you wanna see these live, and actually if you wanna practice these in person, we have a number of live courses coming up. Number one, this very weekend, so you're probably already headed to it if you're not already headed to it. We're in Meridian, Idaho this weekend, March 23rd and 24th. In April, we got two courses, one in Renton, Washington, and the other in Midwest City, Oklahoma. Both of those are on April 13th and 14th. And then in May, we are in Proctor, Minnesota and Bozeman, Montana. And both of those are on the same weekend as well, May, 18th and 19th. So this weekend, March 23rd, 24th, head to the course, sign up right now, I don't even know if you can at this point, for a boat for Meridian, Idaho in April, April 13th, 14th, and Renton, Washington, and Midwest City, Oklahoma. And then May 18th and 19th, we're in Proctor, Minnesota and Bozeman, Montana, both on the same weekend. head to ptiknice.com, check out those courses, sign up. We hope to see you on the road. If you're looking to take an online course, CMFA Level 1, where we learn all things squat, back squat, front squat, deadlift, push press, strict press, pull up, kipping pull up, overhead squat, how to program, how to do EMOMs, and what a METCON means, the science behind METCONs. That is Level 1. We hope to see you there. Next cohort starts April 29th. We are finishing up the current cohort right now. Super great group, hope to see you online there. And then level two. If you're looking to finish up the CMFA cert, or if you just want to learn a little bit more into programming, Olympic weightlifting, high level gymnastics, that is not kicking off until September 3rd. So two cohorts a year getting through one. I think they just finished one. They're just finishing one right now. And then the other cohort will be in September of this year. So what is that? May, June, July, August, about five and a half months away or so. No, five months away. Can't do math. Five months away from today. Gang, thank you so much for putting up with me. Thanks for being on the call with me. Hopefully you practiced some of those split squats today. Hopefully one of those was new to you. You're like, oh, holy cow, I never thought about that, never worked on that. But try it with your athletes. Try it with yourself. Make sure you practice these, play with these to know what they feel like so that your clients know what to expect because you know what it feels like as well. Have a wonderful weekend. Thanks for tuning in. Big weekend for Wisconsin basketball, Wisconsin Badgers and Marquette both playing in the tournament. So make sure to turn those guys on for me as well. Take care, gang. Have a wonderful weekend. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 21, 2024

Dr. Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the relationship between value & price, how to arrive at a potential price, avoiding assuming the value that patients perceive from our services, and understanding that not all physical therapy is created equal. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLAll right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Fitness, Athlete, and Practice Management divisions. We're here, Leadership Thursday, talking all things clinic ownership, management, personal development here on Thursdays. Leadership Thursday also means it is Gut Check Thursday. Gut Check Thursday is back, the CrossFit Open is over. We have kind of a You're going to row 2,000 meters or 1,600 meters on the rower. That time domain is normally around the same time domain as a one mile run, about a seven to maybe 10 minute effort. But of course, we're going to make it a little bit more difficult. Every two minutes, but not the start of the workout, you're going to stop and do two rounds of three wall walks. six hang power cleans at 115.75 and then 12 ab mat sit-ups. The challenge there is when that clock beeps on the two minutes to get off, race through those wall walks unbroken, race through those hang power cleans unbroken, move through the sit-ups very fast, trying to get that work done in ideally a minute so that you have a minute or possibly even more to jump on that rower and chip away 200, 250, maybe 300 meters at a time. Extend that normal 7 to 10 minute 2k 1600 meter row out to maybe a 15 to 20 minute workout. Scale appropriately. Make sure your wall walk option you can do unbroken. Make sure your hang power clean option you can do unbroken. Make sure your sit-up option you can do unbroken. You don't want to have to stop and rest anywhere in there, or you're taking away from your time to do the real work of the workout, which is to move the distance on that rowing machine. So be careful you don't trap yourself where you're just doing wall walks, hang power cleans, and sit-ups, and you never actually get back to the rower. Scale that appropriately so that you have at least a minute, maybe a little bit more, each round back on the rower to chip away at that distance. VALUE VS. PRICE So today, sorry, Leadership Thursday, what are we talking about? We're talking about value and price. So we had an interesting conversation. The last cohort of our Brick by Brick Practice Management course just ended a couple of weeks ago. And one of the big themes of that course is folks deciding, especially those folks who may decide to be 100% cash-based, how do I know how to price my services? A lot of folks don't know where to start. A lot of folks look to maybe competitors in the area. They look to maybe national clinics that have different prices listed online to try to get an idea of what they should price their physical therapy visits at. And insurance providers are very similar of what is good payment for physical therapy quote-unquote good and so I want to talk today about Discussing what is value? Discussing what is price? Discussing how they can sometimes be the same but how usually especially if we're doing it, right? They are very different and some tips and tricks for you out there on to hopefully understand that the services we offer, at least as we teach them here at ICE, are probably much more valuable than what your competition is offering, and therefore worth a lot more when you're considering charging your rates, especially if you're going to be a cash-based physical therapist. WHAT IS PRICE? So understanding price is maybe the best and easiest way to start. If we talk about what is literally the definition of price, it is the arrival at the amount of money we'd like to make after we've accounted for the expenses of whatever it is we're selling. The physical cost, the expenses of making a thing to sell it, or the costs that go into what we might price a service for. So understanding that we're in the service industry, our expenses might not be as high as maybe a company that sells furniture or cars or something like that, but that our services do have a cost. We do need to pay ourselves or pay those individuals who work with us. And we also need to account, we do have some supply costs. We have to pay for power and heating and cooling and internet and needles and linen and all the sort of stuff that goes into keeping a physical therapy clinic running. And that comes at a cost. And so factoring in cost of expense, otherwise better understanding, especially on a patient by patient basis, What does it actually cost you to see that patient? So if you're already in practice, having an idea of what that number is, is really, really important because it lets us better come to an educated arrival on what our price could be. At the end of the day, though, we need to recognize that that is really just a guess. It is yes, assuming costs. Yes, it is assuming what we need to pay ourselves or pay someone else. and then having some sort of idea of ideal profit, but that it is a guess at what the perceived value of what we're offering is to our patients, to our customers for the sake of argument today. A calculation of ideal potential profit. How can we better understand the value that we're offering people? THE SWOT ANALYSIS I highly recommend, if you've never done it, even if you don't think that you would ever own your own practice or manage a practice or anything like that, I recommend that you do a little thought experiment called a SWOT analysis. S-W-O-T SWOT. Strengths, weaknesses, opportunities, and threats. This can be very in-depth, this can be very short, it's kind of an experiment that it's what you make of it, but sitting down and thinking what are the strengths of myself if I'm an individual practice owner, what are the strengths of my clinic if I have maybe one clinic with multiple providers, maybe multiple clinics with many providers, What are our strengths? What services can we offer? What are the strengths of the clinicians that I have on staff? What are the strengths of essentially the value of the product that we can offer? The inverse of that, what are the weaknesses? What are areas maybe of practice that we don't have somebody who could treat it? Maybe we don't have anybody who could work with pregnant and postpartum patients. Maybe we don't have somebody that's very keen on treating the vestibular system, treating folks maybe with falling or dizziness or balance issues. Maybe we don't have anybody who's comfortable working with older adults, youth athletes, so on and so forth. So understanding where are the weaknesses in your practice. And then O is the opportunities. What opportunities are there, not only in shoring up those weaknesses, but what opportunities exist outside of our clinic? Do we live in a town that's really big on running, right? Maybe we live out in Asheville, North Carolina, or we live in Johnson City, Tennessee, and we have a big mountain bike or trail running population. Are we able to target that population? If not, we know that's a weakness, yes, for a clinic, but also an opportunity to provide value to a new pool of potential patients. And then threats. Threats can be, yes, direct competition, but threats can also be external things. We can label things like inflation under threats. We can label higher than normal cost of commercial real estate under threats. But going through that SWOT analysis and saying, do I have any chinks in my armor? If yes, then I know the value of what I'm offering is probably a little bit lower than I'd like it to be. If I go through this analysis and I think, gosh, especially compared to the competition, I think we're doing really well. Then now you have an idea of actually I think what we offer here is more valuable than the competition. And that will overall let you better arrive at how to price your services. TAKING A GUESS AT PRICE And at the end of the day, when we're thinking about price, I love what our CEO here at ICE, Jeff Moore, says of thinking about what you need to charge per hour is really working in reverse. A question of what does it take to make a certain amount of money for a year, whatever that is for you or your clinicians or both, to treat five to eight patients per day, three to five days per week, 48 to 50 weeks per year, right? Having two to four weeks off for vacation, seeing maybe 30 to 40 patients one-on-one. What volume do you need to treat at and what do you need to charge as far as your price goes to achieve the amount of money that you would like to make each year? And now we need to understand, back to the threats portion of the SWOT analysis, that there are always going to be forces we can't control that are going to affect that, right? If we live in a really big city and with a really high cost of living, then we know we're either going to need to be happy taking less money home, or that we're going to need to charge maybe more than we're sure is going to be an appropriate price to offset some of those expenses. So at the end of the day, setting a price but not being so locked into it that it can't go up, ideally it won't go down, you won't continually lower your price over time, Ideally, your price will continue to increase as more folks find your services valuable, but at the end of the day, picking a price and starting there and then seeing how expenses, seeing how external threats, market forces, inflation, that sort of thing, change your price over time. And if you're doing it right, and this is maybe a personal belief, I don't have research to support this, but if you're doing it right, if people truly find your services valuable, you should find yourself slowly getting busier over time such that you can begin to charge more because you will end up in a position where you have more people that want to see you than you have time to see. And of course, that's where we can discuss growing beyond yourself into multiple clinicians, but that is a really good point to be at. It's not great to start with a full caseload and need to slowly decrease your price to try to hang on to it over time. It's a race to the bottom and that never ends well regardless of what industry that you're working in. So that's a conversation on price. WHAT IS VALUE? Talking about value, I love the quote by George Westinghouse. If you don't know the story of George Westinghouse, his company eventually defeated Thomas Edison in the race to electrify America, essentially in the late 1880s. He said, the value of something isn't what someone's willing to pay, but what it contributes, right? And that kind of says that the customer drives the bus on value. We can certainly set our price, But the folks who are buying our service, paying for physical therapy, buying our widgets, whatever, they ultimately dictate the value that they perceive from what we're offering and that that's going to be different from person to person. Some folks are going to find more or less value even if our price is flat and never changes. And we need to accept that just like we need to accept that price is never permanent. There's no business that's selling stuff for the same amount of money 50 years ago as they were today, for example, except maybe Costco with their $1.50 hot dog. But for most businesses, things tend to get more expensive over time to adjust for inflation and that sort of thing. So value is kind of in the eye of the beholder. A lot like price is not really a fixed thing for us on the other side of the equation. DO NOT ASSUME PATIENT'S VALUES In most businesses, and I think especially in physical therapy, we do way too much assuming about how our customers, our patients, our clients, what have you, perceive the value of our services. We see a lot in brick by brick. We see a lot on social media. We see a lot of conversations. that I'm worried about charging too much. I'm worried that my patients won't find value with the price that I'm charging. We are assuming way too much about how much money people have to spend, but also again, that value is this fluctuating thing. and that folks place different levels of value on different products and services in their life in ways that are, yes, in line with the price, but sometimes that are not in line with the price, right? A good example is cell phones. Almost every human being on the planet has a cell phone. In the United States, 94% of all Americans have at least one cell phone that connects to high-speed internet. In particular, they have a smartphone. What does that tell us? At least as Americans, we highly value having a smartphone, right? We're willing to pay $1,000 to $2,000 out of pocket to initially buy it. We're willing to spend $100 or $200 a month on the subscription so that that cell phone has access to the cellular network and can text and email and look at apps and all that sort of stuff. So there's a high value on something like a cell phone. What we're really talking about in the conversation between price and value is that we need to show folks the value of physical therapy such that they don't even consider the price of what it is. Of yes, of course, if we try to charge $1,000 a visit, we're probably not gonna get too many takers, but also we shouldn't feel like we need to undercut our competition and perform visits for $50 or take insurance payments for $40 because we're uncomfortable asking for too much money. Again, do not assume what your patient values. If they find your services valuable, trust me, they will find a way to pay for what you're charging, just like they find a way to pay for their cell phone and all the other stuff in their life that they truly find value at, even if they think, gosh, that's high. If their perceived value is high enough, they will find a way to pay for it. I think of myself as an example, across the week, most days I work about 16 hours, most weeks I work seven days a week, and most months I work most weeks. On average, I make about $28 an hour across everything that I do. An incorrect assumption is that an hour of my time then is therefore worth exactly $28. And that is a misunderstanding between the relationship between price and value. There are hours of my time that you cannot pay me a million dollars to take that hour away from me, right? You cannot offer me $28 to not exercise an hour a day. You cannot offer me $28 to skip the mornings that I have with my son where I get to get him out of bed and get him ready for school or the days where I get to pick him up and bring him home and play with him and put him to bed. That has a value on it that really has no price that can be associated with it and I hold on to those hours very, very much. Likewise, when I myself am injured and need physical therapy, I place a high value on the physical therapy that I obtain because I find that it helps me a lot, right? The manual therapy helps me a lot. The guided home exercise program helps me a lot. I tore my meniscus two weeks ago tomorrow, just finished a workout. I'm back to lunging. I'm back to light impact. I'm back to light squatting in just two weeks. An injury that might put some folks out for three, six months might cause them to seek surgery. I'm already modifying around it and slowly getting back to full activity, probably realistically within a month. That has an extreme level of value that I would argue is more than the cost of what I pay for the physical therapy with the price that it holds. So do not assume what folks value, how much they value things, or that relationship between value and price. Because it's not always exactly equal, even though in our heads we tend to think value equals price, that is simply not the case. WHAT IS THE VALUE OF TIME WITH A HIGH-QUALITY HEALTHCARE PROVIDER? I will challenge you before we sign off for today to really step back and ask yourself the question, especially if you're in this scenario right now where you're thinking, what should I charge for my services? Should I increase my price? What are people around me charging? What is the value of a high quality healthcare provider? who can keep you from otherwise consuming tens of thousands of dollars and hours and hours of your time otherwise in the healthcare system to usually ultimately not get any better than you were doing nothing on your own. I would argue the value there is really high. The value is high to the patient. The value is high to the healthcare system in general as well. And the question then becomes, what is ethical? What is too much? What is too cheap? What is an ethical amount of money to be paid? And the answer to that, unfortunately, that we don't want to hear is that it depends. Well, what does it depend on? It depends on the perceived value of the patient for our services. Sure, you can charge $500 for an hour of physical therapy, but that probably needs to come with a really high quality level of care. That's probably more concierge care, direct access to your provider at all times, evening visits, weekend visits, visits at the office, visits at the home, whatever. That's kind of a more high caliber level service versus what is the value of a visit of physical therapy that costs $33. Well, we might assume that's so cheap, it might not be really valuable, but at the end of the day, we don't know that either, do we? There are a lot of folks accepting insurances that pay almost nothing who are providing high quality care, or at least trying to, in a way that their patients perceive value. So don't assume what the value of our care is, and certainly never assume the value of the care a competitor is providing until you know what they are offering their patients. that we can say, wow, they're charging $500. The default assumption there might be it's really high quality of care. It must be. It's $500, right? The natural association in our brain is higher price equals higher value. but that is not always the case. There are a lot of people charging a lot of money cash for patients to walk in and lay in a circle on treatment tables and just get dry needles for an hour. And I would argue that's probably not really valuable care to the long-term health and fitness of that patient. Yet they are charging and receiving that money, which again kind of shows us the asymmetry between price and value. If those patients perceive value, they will find a way to pay that amount of money, and that is true for you as well. So at the end of the day, don't shortchange yourself. Don't set your prices just because it's what somebody else is charging. Don't set them lower. Don't set them a little bit higher. Step back and ask yourself, What is an ethical payment for an hour of my time given the value that at least I believe I'm providing to my patients? Set that price and then adjust fire as needed later on. We say here at ICE, ready, fire, aim, right? Set it up, lock in the price, see what happens. Your patients will determine your value. Do not assume it for them. Do not assume someone does not have the money or cannot find the money to come see you once a month for a cash-based physical therapy treatment. Again, if those patients truly find value, they will find a way to come pay you. So price versus value. They're not always related. Sometimes they are, but usually not. We often see an asymmetry where the value that folks perceive can often be significantly higher than the price they're paying. We hear that a lot in physical therapy. I would have paid double what I paid. This was such great service, you erased a decade of back pain, I'm back to playing with my grandkids, I'm back to walking without a walker, whatever. We hear all of those things in the clinic. We hear that folks are significantly happier with the value they receive from our services than the price they were charged, so keep that in the back of your mind. What price is sustainable? What price is sustainable for you to believe that you're making enough money to do the work that you're doing? And what price is sustainable for your patients? Demographics, socioeconomics, market forces, inflation, commercial real estate, all those things that are really out of our control do play a factor in our price. What price targets your ideal customer the best? Do you want to provide a high level of elite concierge service? If so, you can probably charge a little bit more as long as you're comfortable knowing that that patient is probably going to demand a lot more out of you than if you charged less. Again, keeping in mind at least your perceived value of what you're providing to somebody, what price is ethical? I guarantee you an ethical price is not the $43 flat rate payment from an insurance that's an HMO that requires a 30 minute authorization before you can treat that patient. I don't know what an ethical amount of money on average across the United States is for a physical therapy visit, but I know it's not that for sure. And then what is a fair market value for a similar service? Again, do not assume the value that your competitors are providing until you know exactly how they treat and the value that they at least are attempting to provide to their patients. It's easy to look on someone's website and see what they're charging and just make your price $5 more or $5 less, but that doesn't really understand the whole picture of the value they're providing, the value you're hoping to provide, and what the difference between those two services might be. I think of it a lot of getting a haircut, right? Yes, I can get a $10 haircut at Bo Rick's or Fantastic Sam's or whatever. My hair is not going to look the greatest. What is the price at a barbershop? It's a little bit more. What is the price at a high-end salon? It's a little bit more. And what am I getting along the way? Well, with those services, quality tends to go up and the value tends to go up, right? The haircut tends to be a little bit better. You tend to get a little bit more time with the person providing the service as you go up each tier. And that can be the case in business, but it's not always. SUMMARY So remember, Price isn't firm. It can change. You're the one responsible for changing it and do not assume the value of what you're providing. Let your patience dictate that. If you set a price and you have a full caseload and you have a two or three month waitlist, guess what? Your price is probably too cheap compared to the value that your patients are perceiving, and you're okay to bump that price up at the beginning of the year. So don't assume that. Don't assume people can't or won't find the money to come see you if you truly believe in the value of the product you're providing. If you want to learn more about this stuff, our next cohort of Brick by Brick starts April 2nd. We take you all the way through from having no idea how to run a business to finishing the course in eight weeks, having all of the legal documentation you need to formally start a business, to have a better idea if you're going to take insurance, take cash, take a mix of both, and to be able to open your doors potentially at the end of that eight-week class. So we'd love to have you. More information at PeteDenise.com. That's it for me. Have a wonderful Thursday. Enjoy Gut Check Thursday. I'm going to be out in Rochester, New York this weekend watching Lindsey Huey teach extremity management. So I'm going to be at that course. I'm looking forward to hanging out with you. And I imagine we'll probably hit Gut Check at lunch on Saturday or Sunday. So have a great Thursday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 20, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Dustin Jones as discusses the gap between someone given a diagnosis and then a prognosis. Whether it's a matter of seconds or decades, we'll discuss the huge opportunity in that gap to impact our patients as well as practical takeaways. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONESGood morning, folks. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division. Today, we are going to be talking about minding the gap between diagnosis and prognosis. Mind the gap between diagnosis and prognosis. I'm going to share a personal story of some experiences I've had lately as a patient within the healthcare system. And I've experienced what many of our patients are experiencing as well, and that is that gap between receiving a diagnosis and then potentially, sometimes not even, right, receiving a prognosis of what that diagnosis actually means. This is an area that we spend most of our time in with the folks that we serve, and I think this is a huge opportunity to serve these folks well and potentially do some damage control and kind of rewrite a narrative that's going on in their head. So this Mind the Gap phrase, it originates from the United Kingdom. So if you ever go on any public transit, you're in a subway, for example, and you've got kind of the train platform and the train pulls up on kind of the curve of that train platform, it's going to say, mind the gap, basically beware, right? Beware of the gap between this platform and the train. And this, this phrase, you know, is a cautionary tale, right? That you are being careful. And I feel like that, cautionary perspective, it needs to be applied to when we give something a name, aka a medical diagnosis, and then the prognosis. That we need to mine that gap, that space in between giving someone a diagnosis and when they're giving the prognosis of that particular situation. I'll share my story. If you're watching this, you see an obnoxiously large bandage on my forehead. I have recently had a spot on my on my temple that was a little curious, right? So I went to the dermatologist to get it checked out. I haven't been to a dermatologist in, man, probably 20 years at this point. I don't get regular checkups or anything along those lines. But I went, they saw the same spot. They say, hey, let's take a biopsy of this and see what this is. All right, cool. So they take a biopsy, about five days to get results. And in that five day period, you got all this stuff running through your head, right? What could this be? Could this be some super gnarly, Skin cancer, for example, is this gonna be something serious or is it is it, you know Just something to not worry about. I don't know. I'm in that five-day period then I get the call from the office This is a call that I've been waiting on for about, you know Five days solid days now and I get a call and the individual that called me was I would say Roughly kind of 22 24 year old pray fresh out of undergrad working as kind of the billing clerk within this dermatology practice. And she calls me and says, hello, is this Mr. Jones? I said, yes, this is him. All right, thank you. It's good to talk to you. I wanted to give you your lab results and just kind of tell you the next steps going forward. So with that area on your temple, well, you have, you know, basal cell carcinoma. So you got skin cancer there. and we're gonna schedule a Mohs surgery to take that out. And then you've got a dysplastic nevus, I'm probably butchering the pronunciation of that, on your scalp and we're gonna excise that as well. When would you like to schedule these procedures? Literally, that's all this person said. And so I want you to put yourselves in the shoes of someone that may at some point have learned about the different types of skin cancer and which ones are more concerning than others. But in that moment, you may not remember, right? You're giving this diagnosis of cancer and a procedure that you have had some patients, right, that have had a Mohs surgery before. Very straightforward procedure where they basically just shave off skin and then assess if they got all the cancerous cells. And they just continue to do that until they find no cancerous cells. A lot of our patients, especially if you work in geriatrics, you're used to these types of surgeries, but you may not necessarily understand what it really means, right? And then, you know, the seven-syllable diagnosis for the other lesion, and it's gonna get excised, you know, just all these words. And just imagine what can happen, what runs through your mind in that situation. And it was fascinating for me because this was all laid out on me. without any context, without any prognosis, no understanding in the moment of what this actually meant. and they were trying to schedule a procedure. And I asked to speak to someone to kind of give me an idea of what this means. And it took about three minutes to get a PA on the phone to kind of give me an idea of what this actually meant, right? Basal cell carcinoma, very, it's the least aggressive out of any of the skin cancers. You take that out, you don't have to worry about it. We'll just follow up with regular skin checks. Not a big deal whatsoever. all this other piece that you have, it's basically just a mold that we're not necessarily sure if it could turn into something gnarly, so we're just gonna take it out just to be sure. That was not given to me, but that three minute gap, the stories that I told myself were fascinating. I was thinking about my life insurance policy. What are my kids gonna do if I'm not gonna be on this planet for much longer? What's Megan, my wife, gonna do? Just thinking about all the ripples that come with that getting that diagnosis and just realizing, you know, your mortality in that very short period of time. So I would say overall, this is, I would say a relatively minor interaction, right? Everything's all good. I had this Mohs surgery yesterday. It's bandaged up. You know, I've got a nice little scar. It's going to be fine, right? But think about what this is like for so many of our patients. When they go to that doctor's visit, that specialist, and they get that diagnosis, And sometimes it is hours, days, weeks, months, and even decades before they get that prognosis of what it actually means to have that name, that diagnosis on your medical chart. This is where we typically operate, right? This is where we are typically interacting with individuals. and this can be a very, very scary place for folks. It has huge implications in their day-to-day life. So let's go through some common examples that we're gonna see where we are kind of in the midst of the gap between that diagnosis and prognosis. Two of the most common ones that I've experienced working with older adults is degenerative joint disease and then osteoporosis. So degenerative joint disease, you know, you have someone that may have some back pain, whatever, maybe knee pain. They go and get the image, right? and they see the image report, especially nowadays with your access to MyChart, for example, where you can see a full-blown report without full context, right? You're reading, you know, radiologist's report verbatim, and you see degenerative joint disease. And oftentimes, how often are these folks actually given context of what that actually means? How often are they told? You know what? At this stage of the game, this is actually considered to be normal. If we were to take a hundred pictures of a hundred people, right, at least 75 of those individuals are going to have the same findings, right? But not all those people are going to be in pain. So yes, you have this on your image, but it's not necessarily abnormal or something to be that concerned about. How many folks are hearing that when they see that diagnosis on that report, right? so often is left untouched, unnoticed, unaddressed, and they can have this perspective that their joints are just absolutely disintegrating day by day by day. And you stretch that out over years and decades. Think about how they can learn to perceive their joints, their body, their ability to adapt, their ability to improve. Do they have a positive or negative perception of the days ahead, right? Oftentimes, it's going to contribute to a negative perception that it's just downhill from here. That is something that we can clear up. We can show, hey, we know you had this diagnosis. This is actually considered to be a relatively normal part of aging that a lot of folks have this on their imaging and they're doing awesome. They're doing things. similar to what you want to be able to do, I know that you can get to that point and I can help you get there, right? So DJD is one. The next one is osteoporosis. This is more common in the realm that I'm working in. I'm working in the context of fitness right now at Stronger Life in Lexington. So it's a gym for folks over 55 and we have so many folks that come to us that have a diagnosis of osteoporosis. And oftentimes that diagnosis is given based on a number of a certain area of the body that may be demonstrating low bone mineral density. And I always ask folks when they have that diagnosis, do you have your DEXA scans? Has anyone gone over your DEXA scan with you? And nine times out of 10, they say, no, no one's ever really walked me through this DEXA scan and what it actually means. So I had them bring it in. And when you talk through a DEXA scan, you'll see that they will run their bone marrow density at different parts of their body. And so you could, you know, have those numbers ran at, you know, their bilateral femurs, for example, the lumbar spine, thoracic spine. And so if someone shows below negative 2.5, for example, on that DEXA scan, in one of those areas, they're gonna be giving this diagnosis of osteoporosis. And oftentimes when you're looking at that DEXA scan, it may only be one one place it may be osteoporosis like a negative 2.6 in the right neck of the femur and then the left femur may be in an osteopenic range it may be kind of under that negative 2.5 maybe negative 2.3 negative 2.2 that's a different story right that when they are given that diagnosis of osteoporosis nine times out of ten they perceive that every bone in their body is brittle and is going to self-combust under any load, right? And that is just not the case whatsoever. Usually it's in a certain area that is a little more troublesome than others and we can give target interventions to build that area up and to show noticeable changes in that DEXA scan if we can work with these people over a longer period of time. And so osteoporosis diagnosis is another one. They're often not given what that prognosis actually means, and often not, they are given a message of hope that they can actually do something about this beyond taking a pill and crossing their fingers for that next DEXA scan for those numbers to change, right? There's a lot that we can do. So these are two of the dozens of situations that we often encounter, right, where people are given that diagnosis And then they may get a prognosis or they may not. And that is where we live. And I want us to just really consider and appreciate the negative implications of this. The fear, the lower physical activity. Increased fear will often encourage them to be more conservative with their physical activity because they're afraid to get hurt for example. We've had folks at Stronger Life that have gone to a doctor's visit and gotten a diagnosis, osteoporosis being one of the, I would say three, but one of them that if not given a clear prognosis and they will be scared to death and almost try to cancel their membership to say they can't exercise anymore. That this is a very, very delicate situation that we often find ourselves in. So now let's talk about what we can do about this, right? I think I like to think about this in three steps. Assess, inform, and advise. Assess, inform, and advise. When you're doing your chart review, when you're doing that evaluation, you see some of these diagnoses. Congestive heart failure is another one. The different categories of congestive heart failure, some are more serious than others, right? But man, that term alone will scare you to death, right? Assess what diagnosis do they may have and what's their knowledge of that? I would include surgeries in that as well. Knee replacements. Total hips, right? Assess their knowledge and perception of that particular diagnosis. Do they have an accurate perception of what it means to have osteoporosis? Do they have an accurate perception of what it means to have a total knee replacement and the implications that that actually has on your life after? Right? Because so many folks think they can't do X, Y, and Z and that's just not the case. We're learning that day in and day out with these folks challenging a lot of these perceptions. So assess. once you assess and you can inform. I feel like this is where this is something that I wish we would not have to do, right? I don't want to have to feel like I need to clear up someone given a medical diagnosis without an accurate prognosis, but sometimes we have to. But I think we do need to be very careful here that we don't kind of overstep our boundaries and really speak to this person's situation in the sense of where we probably don't have any right to do that, right? So this is where I'd like to speak in generalities. I don't, I'm not going to pull up someone's, you know, imaging and assess it myself per se and say, Oh, this is, you know, okay, this blah, blah, blah, and compare it to others. Like that, that's not my job. Right. But I can say I've had folks that have had that diagnosis that have responded really well to this treatment. I've had folks that had that diagnosis and they were able to do X, Y, and Z. We can inform them of what can happen with some of these diagnoses, but I would want to respect our medical colleagues there, so hear me out on that. So we assess and then we inform, all right? This is where, particularly with osteoporosis, this is where I will get their DEXA scan, And I will just say, hey, this area, this is where you have osteoporosis. This area over here, this is actually osteopenic. It's a little bit stronger, a little bit more dense than this area over here. Give them context and inform them of that particular diagnosis when we can, right? And then last but not least, we advise. What can they do about it? What can they do about it? We need to give them control to give them the ability to rewrite the script, to develop some of that self-efficacy of the confidence that they can do something about that diagnosis that they've been given. And that's going to look different for each person, right? But there's so much that we can do, especially with DJD, with osteoporosis, with congestive heart failure. These are not, not death sentences. They are not death sentences. There are a lot of things that we can do as clinicians to help maybe improve their situation, and ultimately, a lot of times, to prevent further decline. There's a lot that we can do with a lot of these 10-syllable, very scary medical diagnoses. So, we assess where they're at, their perception of their diagnosis and perception of their prognosis. Is it accurate, right? Then we inform them. We want to try and make it more accurate and realistic based on the evidence, but based also on what you've seen as well in your clinical practice, and then we want to advise. When we're able to do that with someone that has not been given a clear prognosis or context of their diagnosis, man, you've really given their life back. You've answered so many difficult questions they've been wrestling with for sometimes hours, but sometimes decades, and you can really change their life as a result of some of these conversations. All right, thank you all for listening so far. I appreciate y'all. Before I log off here, I want to mention a few of our MLA live courses coming up. So this is an awesome two-day, very practical weekend where we dive into a lot of exercise, application, prescription, but also a lot of these nuanced conversations about kind of the softer skills of implementing that fitness-forward approach in the context of geriatrics, where we may talk about diagnosis and prognosis and how we can bake that into an exercise regimen to get people to really push themselves at a level they probably haven't done before. SUMMARY Awesome weekend. So, I want you to check out, if you're around Madison, Wisconsin, we're going to be in your neck of the woods March 23rd, that weekend. Then April 5th and 6th, we've got four MOA Lives across the country going on at the same time. I'll be in Urbana, Illinois. We have one in Raleigh, North Carolina, Burlington, New Jersey, and then Gretna, Louisiana, just outside of New Orleans. All right, there's tons of other MLive courses across the country going on through the spring, summer, fall, so be sure to check on there if none of those are close to you, but we're grateful for y'all listening and watching wherever you consume this podcast. Y'all crush the rest of your Wednesday, and we'll see you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 19, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity lead faculty Cody Gingerich explores the concept of "entertaining" patients by constantly introducing new & exciting exercises. Cody challenges listeners that just because they are bored, their patient may not be bored with PT, especially if they're seeing demonstrable progress with their rehab. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CODY GINGERICHAll right, good morning everybody. My name is Cody Gingrich and I am one of the lead faculty in our extremity division. The big thing I want to come on and talk about today, it's going to be the title of today is called Are You Not Entertained? And really what today's conversation is going to be around is a bit of a blend between a couple of the lectures that we have in both of our extremity management division and then some of our spine division in our build a bike conversation. So if you've ever taken a course through the spine division we always talk about building the bike and then in extremity division the conversation is around dosage. Okay so the title of today called are you not entertained is really I want to focus in on are we as physical therapists, is our job to entertain our patients or is it to get them better, right? HELPING PATIENTS RECOVER VS. ENTERTAINING PATIENTS And so what we want to talk about is really our job is to get people better. We want people to improve health-wise, we want to improve their pain and all of those things, right? But where we see that tend to get a little bit lost in translation is when with our exercise dosage. Okay. We have so many, so many exercises at our disposal in physical therapy. We see things on Instagram, we see things all over the place. Right. And that leads to so many things swirling in our brain about like, Oh, let's do this exercise. Plus this exercise, plus this exercise, plus this exercise. Okay. And so what that does is that also clouds our judgment on what is actually bumping our patients forward. Okay. And when we talk about exercise dosage prescription, what that needs to be is a very methodical approach and then progressions over time. Of the same exercise, assuming that first exercise that you chose is showing benefit to your patient, right? And I think we veer from that too quickly, oftentimes. So let's take a shoulder pain, for instance, right? And we just give them a side, we've determined that it's coming from the posterior cuff and we really need to work on getting infraspinatus stronger, some of the teres group stronger, and that posterior shoulder really needs to build up some strength. So we start giving them side lying external rotation, okay? Now, is that the most fun exercise in the world? Potentially not, but we know that from EMG activity, that sideline external rotation is the best exercise that we could possibly give that person in front of us to build the capacity of their rotator cuff. And let's say up front, they can tolerate a two pound dumbbell for eight to seven to 10 reps somewhere in that neighborhood, which in extremity division, we would call that more in our rehab dosage. It falls in line with our rehab dosage and that's probably going to fall somewhere in there 70 to 80 percent of their one rep max shoulder external rotation. Now how does build the bike fall into that conversation? The building the bite comes the next visit when they show up and you have your subjective and objective asterisk signs. You have given them that one exercise and say, Hey, this is the best exercise for you. You need to do it seven to 10 reps, three sets, and you need to do that one time a day. You have a very specific rehab dosage laid out in front of them. and they come back in and your objective asterisk signs and subjectively, hey, they are sleeping better. They only woke up one time in the evening as opposed to three times. They were able to get through their workout, and they didn't have to stop or modify, or their pain was at a two out of 10 as opposed to a six out of 10. They were able to pick up their kid. Then, in your objective, they were able to raise their arm overhead, and they only had a very small window of a painful arc that was only a one or a two out of 10 as opposed to a five out of 10 the previous time. Now, your job at that point is saying, great, that exercise right there is working, We're going to go from a two pound dumbbell tip from that prescription to a three pound dumbbell. STAY FOCUSED ON WHAT IS WORKING That is not the time to decide, great, let me pull all of those other exercises that I have in the back of my brain that I've seen on Instagram and start giving them six to 10 different things or just like time to shift away. No, you have proven to that patient in front of you that that one thing that you gave them at the prescription and the dosage that you gave them was the right thing. Okay? So, Exercise and strength and conditioning principles tell us we need progressive overload. If you decide you wanted to get your back squat stronger, what is your back squat cycle look like? You are back squatting at least once, maybe twice a week, every week, and you add five pounds to that back squat and you do the exact same thing week over week. People don't get bored of that because they see progression. They see that they're getting stronger in that. IS YOUR PATIENT BORED OR ARE YOU? And I think we as physical therapists, I think sometimes it's us getting bored, not our patients. And we think that we, our job is to just be entertained or entertain them because we think the patients are getting bored of what they're doing. And so we need to give them the new fangled thing. Well, the reality becomes our patients are entertained by getting better and doing all of the things that they've told you that they haven't been able to do and now they can. Right. But, They will get bored and they will get frustrated if we don't also prove to them that they are getting better. It's not our patient's job to say, yes, I'm getting better. No, I'm not. Most of the time patients will feel they either have pain or they don't and you might get them that first time. Maybe they only could raise their arm to here and then the next time they're here and they're like, yeah, but it's still kind of bothering me. Your job then is to say, well, right, but last time you were able to get, you only were to hear, and now we're here. That's at least a 60 or 70% improvement. Now all of a sudden we're like, oh yeah, that is actually true. And I was able, I only woke up the one time last night. man, I am getting better. I need to keep doing that exercise. And you say, yeah, I wholeheartedly agree. But the thing is that seven to 10 reps for three sets now is getting too easy for you. So we need to bump that to the three pounder or the four pounder or whatever it is. Exactly the same thing, right? And that's where the patient gets entertained by seeing that they're getting stronger. improving all of their objective metrics that you're coming in to see, plus their subjective day-to-day life stuff. That's where the entertainment comes in. So don't get lost in the weeds of thinking, I need to give them the coolest brand new thing that I saw this week, right? Or I need to give them three, four, five different things. It is way, way, way more valuable for your patient, for you to know exactly right prescription, you've tested their one rep max, or you've tested a five rep max, or you have a very good understanding of their percentages of whatever movement that you're doing, that's going to challenge them appropriately, and that easily lets you determine whether or not that was the right prescription for them when they walked in, or that prescription needs to be adjusted. If they come in and they're a little bit worse, but it's the same symptoms, Great, that's not the wrong exercise still. That might be that you overdosed it up front and you can just pull that back. Maybe you handed them a five pound dumbbell and you said, okay, this is your exercise for the week. Maybe that needed to be a three pound dumbbell, not potentially a brand new exercise, right? And that's where the magic in rehab lives. Right? And that's where the entertainment factor comes in. Like you need to be entertained yourself because like I said, I think a lot of us as PTs, we're the ones that get bored before the actual patients do. Your entertainment needs to come from really figuring out the detailed prescription of what is going to be best for that patient, right? Use that as a puzzle each time they walk in and say, okay, well where, how can I dial this prescription in perfectly? And when they come in week over week, then you have to build that bike in front of them and say, okay, I'm proving to myself and to you that what I gave you previously worked and we can bump you forward with this same thing, but changing just the dosage. Don't go from, If you're trying to like, again, going back to that back squat, if you're trying to improve the back squat, how many different exercises can you do for your legs? You can do plenty. You can do back squat, you can do Bulgarian split squats, you can do hack squats, you can do leg press, you can do leg extensions, right? All of those things may get you stronger for sure. But if you want to improve your back squat, you are going to have to back squat and you're going to need to methodically and strategically bump that weight up time and time again. Once you feel like you have exhausted that thing and they come in and say, I have been getting better with this. You know, I followed exactly what you're doing. And this time, you know, we haven't seen as good of a bump. Maybe now we need to challenge that tissue in a different way, right? And that's when all of a sudden you can decide to switch exercises, okay? Find a new exercise, challenge the tissue in a different way, right? If that means that we need to go from really here and stop from this position here, maybe we raise it to a 90-90 here, or we do that wall slide that we talk about, that exercise is in the extremity management course, right? One of those two things, now we're challenging that through a little bit of a different range of motion. If we're doing a wall slide with a band, you start a light band, then you move to a medium band, then you move to a heavier band, right? And you dose that prescription the exact same way and we methodically take that approach to just adding resistance. REHAB EXERCISES DO NOT NEED TO ALWAYS BE DIFFERENT It does not need to be constantly shifting, constantly changing, constantly adjusting every single thing. that we're doing time and time again, right? So that's the big thing that I want to get on here and talk about that we see oftentimes throughout going around weekends is just that everyone wants all of the new things. And really they, it seems like the goal is trying to entertain our patients. We need to get our patients like they need to be able to like what they're doing. Absolutely. but they like when they get better. It's the same thing when people, this might be my own bias, but like if you're playing sports and everyone says like, Oh, I just, I want to be, I want to have fun. Well, you know what's really fun is when you're win, right? So like I have a lot more fun playing sports if I can also win at that sport. Right. And so that's the same thing. It's like, I might do some of the boring things because that's going to get me to win. which then therefore is fun. Same conversation here is like some of these boring activities or boring exercises, if you can prove to the patient that they're winning, now all of a sudden those boring exercises feel like fun because they can see the progress and they can see what's happening time and time again, week over week over week. And now they don't care about some monotony and some potential boring exercises if you have to prove that it is going in the right direction week over week over week. The second that you can't prove that to them, that's when all of a sudden compliance starts to dip. And once compliance starts to dip, now all of a sudden you're chasing yourself trying to figure out, well, what can I just do to get my patient to like do their exercises? Well, that's it. Prove to them that are getting better. Prove to yourself, right? Make sure every time they walk in, you're checking their subjective, you're checking their objective asterisk signs. So I want to challenge you this week, when your patients come in, give them the same exercises that if, assuming that things are getting better, don't abandon ship on that exercise. Add one pound, add the next band up, add three reps instead of it being a 10 rep, make it 13 or make it 12, same exact thing. at a set, right? These are the small details that we know bump people forward and actually progressively strength train. Okay, that's the podcast today. What I wanna talk about, are you not entertained, right? Entertain yourself by really dialing in that prescription dosage, right? Make sure that you have a good understanding and that's the fun part for you. It's like, well, last week we did 10, so this week we're gonna do 12, or it was two pounds or three pounds. That is the fun in rehab. Entertain your patients by proving to them that they're getting better, right? Using the dosage that you talk about and you're methodical over. Prove to them that they are getting better week over week over week. And now all of a sudden they're having a good time, right? Because they can do the things that they want to do. Catch us out on the road, extremity management. Myself, Mark, Lindsey, we're all over the country moving into the next couple weeks, so we appreciate you being on with me on this clinical Tuesday. Hope you all have a great day. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 18, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses what a pelvic floor exam looks like in light of updated practice patterns & research,. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION ALEXIS MORGAN Good morning. Welcome to the PT on Ice daily show. My name is Dr. Alexis Morgan. I am one of the faculty with the pelvic division and happy Monday. I'm excited to be here this morning to talk to you all about the 2024 version of the pelvic floor assessment. We've been through so many iterations as a profession of the pelvic floor assessment. And I want to just take a few minutes today to talk with you all about the 2024 version, the updated version, the modern way to assess the pelvic floor. Thanks for joining me. Let's jump right in. HISTORY OF THE PELVIC FLOOR EXAM So when we think about the history of the pelvic floor exam, this goes way back, all the way to Dr. Kegel. I've actually done some podcast episodes on the history, and if history's not your jam, don't worry, I won't bore you with the history details today. But our pelvic floor exam does go way back decades, closing in on 100 years now. And over the last several decades, of course, we've had a lot more research come out and a lot more evidence, a lot more understanding of these muscles that are at the base of the pelvic floor. And so with, of course, new updates, new pieces of understanding, we're still gathering information, but of course, as we change in the way that we understand a group of muscles, of course we're gonna change in the way that we assess them clinically, right? We see this so frequently when we look at the evidence on strength. So strength is not necessarily indicative of problems or lack thereof problems. Yet we are so often talking about assessing strength and obsessing about what manual muscle test grade is there. And yes, if you're not familiar, we do have a manual muscle testing score for the pelvic floor. but realize that that is such a small piece of the entire picture. And we're starting to see this in the evidence as just described, and there's several studies that are making us go, hmm, maybe it's not all about strength. But how do we then take that into our clinical practice? FOCUS ON RANGE OF MOTION & MUSCLE COORDINATION First and foremost, we ourselves need to back off of obsessing about strength, right? We need to really get a full understanding of the person in front of us and really gather that information and not just talk about strength, but talk about the entire picture. So, here's the updated version of the way that we do our assessments. First, we're going to test their range of motion. I'll dive into each of these details, but I want to give you all the overall picture first. So first, we do a range of motion assessment. Then we go into coordination. And after coordination, then we might go into a strength assessment. We might go into a palpation assessment. or we might go into a prolapse assessment, depending on how that person shows up in front of us. We may take it a few different directions, our assessment, but we're going to start with the range of motion and coordination assessment. Range of motion and coordination are important for all people. No matter what we are assessing, no matter what problem, no matter what genitalia we are looking at, all of the people that we are assessing with the pelvic floor, we need to start with range of motion and coordination. So what is the range of motion of the pelvic floor? What do you mean by coordination? Well, range of motion of the pelvic floor, you've heard us talk about this a lot here at ICE, is squeezing up, we call it squeezing into the attic, going up towards the head, going to baseline, and then going into the basement. So in our A-frame analogy, we've got the attic, the first floor, and the basement. So we need to assess all of these areas. That is the range of motion. There are going to be problems if somebody can't raise it up. There's also gonna be problems if they can't push their pelvic floor down. There's problems when the full range of motion does not exist. So we need to A, assess it, and then B, help them find their full range of motion. That's beyond the scope of this podcast. Come to our live course where we talk more about this. But that is range of motion assessment. Very important as it is first. Then we go into coordination. So coordination is me assessing your pelvic floor with certain coordinated movements or certain movements that you do in the day. And I'm assessing to see what does your pelvic floor do and is it coordinated with the core muscles? How does that function? So we might would look at a cough We would definitely look at a brace, especially if the individual is having issues with some type of bracing mechanic. And you may do it in a lot of other different positions. I have clinically assessed pelvic floor coordination for a yogi who is having difficulty with downward facing dog. Yes, we got into that position to assess the coordination of her pelvic floor. That was where her primary complaints were. That's where we need to do that assessment. It's not a strength assessment at that point. It's a coordination. What is she doing with her core and pelvic floor in the problematic position? That is coordination. With these two important pieces of the assessment, There's a lot of different ways in which you might assess. Range of motion, coordination. That could be assessed just visually. Just externally, I am looking at maybe the rectum, maybe the vagina, male or female. Whatever it is, I might be just looking externally. Or I might do an internal assessment. vaginal or rectal. I might would do it in standing, a standing assessment. There's a lot of ways in which we're going to match the assessment with the problems that the person presents to us with. We're going to match them, but realize that they're going to start with a range of motion assessment and coordination. Then of course we can dive into our other three options, that strength assessment, that palpation assessment, and the pelvic organ prolapse assessment. So it's important for you to know that All of these options that exist, you may not use all of them in a client. You may not use them all in one day. It may take you several months or weeks, depending on the person in front of you, to go through all of these assessment tools. That doesn't matter as much as what matters is that you're testing the problems that they're presenting with, and of course, that you're making progress along the way. So that strength assessment is important. It is a piece of the puzzle. Someone needs to be able to generate enough force in their pelvic floor to squeeze off their holes. That way they do not have problems of a lack of force. That is important. But only when we know that they're coordinated enough to squeeze their pelvic floor. Right? Because if they can squeeze it on their own, but whenever they're bracing, they're not squeezing it, it doesn't really matter to work on strength. It matters to work on coordination. You see where I'm getting at? So once they get that, those first pieces, the range of motion and coordination, then we move on to strength. WHAT NEXT AFTER RANGE OF MOTION & COORDINATION? So with that strength assessment, we might do that in supine, we might do that in standing, testing their strength, their ability to squeeze the pelvic floor. With the palpation assessment, and again, we go into all the details. I'm skimming the surface here. We go into all the details in our live course. When we are doing a palpation assessment, that is purely to reproduce their pain. You hear us at ICE all the time talking about, and no matter which course you're taking, when we are doing a palpation exam, we are trying to reproduce their main complaint that they're coming in to see us for. So, same is true in the pelvic floor muscles, each of the layers, left side and right side. Does this reproduce their problem? Their problem might be urgency. When I gotta go pee or poop, I've got to go. Let's see if pressing on some of these muscles causes that urgency. or round ligament pain or adductor pain or might even look or sound like what the patient may come in with is sciatica, right? Or radicular pain. All of those could be caused by the pelvic floor muscles in which you would find in that palpatory exam. So that palpation exam is important to rule out the pelvic floor as a potential root cause of some of their symptoms that they are experiencing. And then lastly is pelvic organ prolapse. So we may not do this pelvic organ prolapse assessment. There's a lot of podcasts where we're talking about our thoughts on POP or prolapse, and I will have to guide you to those. I'm not gonna take all of your time talking about that this morning either, but it is a piece of the exam that you might would add in. We might would add in the prolapse exam if the person is coming in with their main complaint saying the word prolapse. Saying that I've been diagnosed with prolapse. Discussing some concerns about prolapse. Similar to the obsession about the strength scores, we can also see an obsession about a prolapse grade. Something about these numbers gives us this black and white, this very clear picture in our heads, but it's not exactly the full clinical picture. So really, do the pelvic floor assessment. If you need to do the prolapse assessment, absolutely do that. And again, you can do that in supine. You can also do it in standing and apply that to that individual. But just remember that 50% of individuals assessed objectively are going to have some sign of dissent, aka some sign of prolapse, so we don't need to be freaked out about it. Rather, what we need to do is focus on their range of motion, focus on their coordination. Those two pieces are so incredibly fundamental and important for everyone to be able to utilize their pelvic floor effectively. Whether that is in preparation for birth, whether that is performance under the barbell, or trying to reduce pain with sex, Whatever the topic is that the individual is coming to us for, we're going to start with that range of motion assessment. We're going to go into that coordination and we might hang out there for a while and work on the goals of pulling pelvic floor up, pushing down, feeling all of those differences of the pelvic floor, and then coordinating it. Coordinating it with diaphragmatic breathing, with bracing, with whatever problem they have, matching it to that. That right there added with it the three options of the strength, the palpation, and the prolapse assessment, that is the updated version of the pelvic floor assessment. That is what aligns with how we understand, as of today, the pelvic floor function. It matches what we see in the newest literature all the time, which is maybe it's not all about strength. Maybe there's some other aspect. And when you look at these studies, we recognize that individuals are assessing this, but it's not really been discussed about in this way. This is what we're doing. This is how you create change. This is how you have some organization in your assessment. This is how you get the patient on board. You tell them we're gonna do range of motion. We're gonna do coordination. We're gonna see how you do with each of these. This is gonna look a lot like this problem that you're experiencing. We're gonna match that up and we're gonna talk about what optimal is. Really focusing in on what matters to them helps them stay focused. SUMMARY So use this, let me know what you think, and if you are so excited to see us maybe in Greenville, South Carolina this coming weekend at the live course, we're excited too. Or we've got several courses coming up in Colorado, in Missouri, in Alaska, In New York, we're all over the place this year. So look for a course that's near you or near somewhere that you would like to travel to. We would love to have you at our course. We also are discussing these topics in a little bit different ways in our Online Level 1 and our Online Level 2. Our first cohort of the Level 2 is actually sold out. Our second cohort of the season of the year is in August. It will sell out. If you are interested in joining us, you should go ahead and purchase that ticket. We'll be talking about all of these aspects of what we just discussed today in both of those courses. head on over to PTOnIce.com, check us out, we would love to have you join us in the courses. Have a wonderful day, a wonderful week, and let me know what you think about the new way of doing the pelvic floor assessment. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 15, 2024

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses research supporting the use of gait retraining for preventative rehab. She shares practical advice for coaching & cues to use with runners to improve their gait in a manner that has been shown to reduce likelihood of future injury. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION RACHEL SELINAAlright, good morning everyone and welcome back to the PT on Ice daily show. My name is Rachel Salina and I am a TA within our Endurance Athlete Division. So I help teach our Rehabilitation of the Injured Runner live and online courses. So hopefully today you are ready for a running topic because that's what we're going into. I will apologize now if it gets a tiny bit loud in a few minutes. I'm currently at our CrossFit gym, so we've got a group that's going to start doing 24.3 here in just a moment. So if you hear the music kick up a little bit in the background, that is what's going on. But otherwise, we'll keep this a bit brief into the point today. So we're going to talk about gait retraining and really addressing a question that comes up in our courses a lot. And that question is, do I address running mechanics if a runner isn't injured? So kind of asking that question, like, is there an ideal gait form, gait mechanics that we're trying to get to? Um, like if it's don't broke, don't fix it kind of thing. What do we do when someone is not injured? Should we still intervene? WHAT IS THE GOAL OF GAIT RETRAINING DURING INJURY? And I think first we need to break down a little bit what we're trying to do with gait retraining when someone is injured. So really what we're doing with most of our drills is we're taking a load that's overloading a particular structure, right? Say it's the knee. The knee is aggravated. running aggravates it. And we're going to use a drill to try and shift that load to a different structure, allowing the knee to have less load and therefore kind of recover and be able to tolerate the running. So all we're doing is shifting load from one structure to another. So we're not necessarily trying to make it perfect. We're just allowing that person to still be able to run because we've changed how their body has to absorb the forces of running. So for example, That same patient who's having maybe patellofemoral pain, we see that they land with an overstride, their foot is landing far in front of their center of mass. We might give that patient a forward leaning drill to try and bring the center of mass closer to where the foot is. By doing that, by getting that patient to lean forward more so than their preferred or kind of typical pattern, we decrease the stress at the patellofemoral joint, which is good. It decreases their pain. They're able to still run. But what we've done is we've shifted that load to the glutes and to the gastroxoleus. We've just moved the load. So that's the case where we'll use gait retraining. kind of in addressing injury shifting load. WHAT ABOUT GAIT RETRAINING FOR SOMEONE WITHOUT AN INJURY? But what about, like I said, if that runner's not injured, can we still use gait retraining in any form to either help that person run better, right? So we can talk about it from performance. That might be one time where we would use gait retraining in a non-injured runner. Or can we, do we have any evidence to show that we could use gait retraining to actually reduce the risk of injury. So that's where we're gonna talk a little bit more today. There's a really cool study that came out by Chan in 2018 and we dive into this some in our live course, but I really wanted to kind of deep dive today. So this study was looking at a group of non-injured runners and giving them a gait retraining drill. and then they followed these runners out over a year, which is a pretty long time to follow these runners, to see if there was any difference in the injury rates. So their only intervention, right, they were looking at addressing vertical loading to be able to reduce the vertical loading. So they had runners come in, okay, for eight sessions over two weeks, so four sessions each week. They increased their running time in that two week period from 15 minutes a session to 30 minutes a session. They gave the patients feedback, like they gave them visual feedback, which there's some systems we can use in a clinic to show like peak forces and rates. And we'll get into kind of how we can do this without having that visual. Anyways, they gave them lots of feedback initially. and then reduce that feedback over the eight sessions, which this is very typical of how you would see gait retraining carried out in a clinical setting or how we would like to prescribe it. So lots of feedback initially, kind of tapering that feedback off. And they actually didn't give them feedback in the last few sessions. And then they sent those runners off, right? That was just the first two weeks. And then followed them over a year. And they found, that the group that did the gait retraining had a 62% lower injury occurrence, which that's a huge deal to be able to, like that was the only intervention they did. They let the runners keep, you know, like their normal shoes, their normal running pace, speed, all that kind of thing. They just did the feedback. So given this is one study, but it's pretty hopeful or pretty helpful in thinking that if we can intervene and do some things to reduce the loading rate, we might be able to prevent some injuries. So like I said, in this study, they used like the, like they got visual feedback of their forces, but they also told the runners to run softer. And that's something that's very applicable to our runners that we can tell them to focus on, right? We can have them go, and spend those four or um sorry eight sessions on a treadmill inside like in a controlled setting trying to focus on making their gait um or their foot strikes softer and then send them out like they don't have to continue every single run to focus on that um but i think we can actually have an impact there um in how their body is having to accept load and hopefully be able to prevent some injuries. So like I said, I'll reference this study in the show notes if you want to read it all the way through. But again, a very promising way to start to look at still being able to provide something helpful to our runners when they're coming in, maybe from a performance or just a non-injury standpoint, we don't have to say like oh well you're not injured now so we don't do anything um but we also don't have to like pick apart every single tiny thing of their gait if not all of it um is something that we want to address so can we make them maybe run softer and then another instance where we can think of gait retraining from an injury perspective there was another study looking more at high school runners and again this was prospective as well so a bunch of runners that weren't injured, they measured their cadence and then followed them out. And the runners who had a cadence less than 164 steps per minute had a higher incidence that was associated with injury. Right, so that's another way where if someone comes in, they're not currently injured, maybe they don't have any complaints, they just want their gait looked at, they're curious what their gait looks at, they want to be able to do, like to run better or feel better running, we might be able to manipulate their cadence as well as a preventative type of intervention. So can they run softer? And can we make their cadence faster? So as I say, if you want to focus on two things for your non-injured runners that can be beneficial in the long term, that's where I would focus our attention. That's it. And some of these things are cues that you can very easily pick up when your runner is in the clinic for a gait analysis. If your runner is very loud, like you hear every foot strike really, really heavy, they might be someone that's good to give the cue to run softer and have them focus on that. If you measure their cadence and it's really low, like below that 164, have them start working on cadence retraining at 10% above that. These are some really simple, actionable ways to start helping your non-injured runners hopefully stay non-injured. All right, that's it today. Like I said, just want to keep it short and sweet. SUMMARY If you are interested in learning more about gait retraining, gait mechanics, gait analysis, we have two live courses scheduled for this year so far for Rehabilitation of the Injured Runner Live. Our first one is coming up in June, so that's June 1 and 2 in Milwaukee. And then we have September 7 and 8 out in Maryland. So we'd love to see you at one of those. If you can't make it live, Our next online cohort starts the beginning of June as well. So sweet. I hope you all have a great Friday. Get after 24.3 if that's your jam. Otherwise, get outside, go for a run, and we will see you soon. Bye. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 14, 2024

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey demonstrates a manual therapy technique to mobilize the knee joint to improve knee flexion. She also discusses dosing the mobilization as well as demonstrating a home exercise follow-up for patients. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION LINDSEY HUGHEYGood morning, PT on ICE Daily Show. How are you? I'm Dr. Lindsay Hughey from Extremity Management coming to you on a technique Thursday. This is my first technique Thursday, and I'm delighted to be with you today. I am going to show you a knee flexion gapping technique today. This is a technique that is really helpful for your folks with knee pain that are having any kind of mechanical knee sound. So maybe it's popping, maybe it's clicking, maybe it's even catching a little bit, or even just like crepitous sounds that maybe bother the patient. And they have some knee flexion deficits. So this gapping technique is one of our favorite in extremity management. So I'm going to show you on our demo model today is Paul. So first things first, we'll go over your position as the therapist, setting yourself up for good body mechanics. We'll chat a little bit about dosage. Then we'll actually talk about a follow-up mobilization to make this technique really effective. it happens what comes next. So this patient really needs to get after self-mobes to follow this up and for it to be its most efficacious in continuing to gain knee flexion and to reduce those mechanical knee sounds. POSITIONING & SET-UP So as the therapist, you are going to come alongside the patient. The table should be at about mid thigh height as the therapist. Your patient often will position themselves in the middle of the table. Tell them to scoot their hip to your hip. So go ahead and bring your hip to me, Paul, so that they're close, so that you get some really nice leverage here. The other thing is when you bend their knee into whatever flexion they have, their knee, the top of it, should sit about your chest height. If that's not the case, you might want to drop the table a little bit lower. So that will depend on therapist's torso side and then femur length of that patient. Next thing, you are going to come under that popliteal fossa with your elbow. And the patient's leg is just going to rest in your pubital fossa. So patient, you'll wait for them to just kind of relax. And then this hand is going to go somewhere along the tibia and fibula. in a cupped fashion, and then you're gonna sink in with your body. So it looks like so. So if I were to give you a little space here to see, my hand wraps around the tibia and fibula. And then I get back to that staggered PT stance, and I'm gonna lean in with my body and oscillate on off. I'm going to let Paul down for a second and do a little shadow mobilization body position. So I'm going to be staggered stance, midline is tight and active. That arm comes around, carries the limb, and we know we carry some big limbs here, right? If we're dealing with knee OA, meniscal injury, our big athlete legs, maybe they have some ACL stuff going on. Scoop here. Allow the leg to hang and then get that arm here and then it all becomes body. My body sinks so there's no break in the arms at all. This all stays tight and you'll oscillate. DOSING KNEE FLEXION MOBILIZATIONS Recommended dosage is 30 to 60-second oscillations, three to six reps, and then you'll retest that knee flexion. So we're looking for a change in either pain response, knee flexion, possibly even the mechanical sounds that they're having, but we try not to emphasize overall on the sound part. But we do want to do that test-retest. I'm going to show you one more time from the top, and then I'm going to show you the follow-up mobilization that we'll go to for this. So patient is close to you. I'm in staggered stance. I'm going to scoop that knee up, let it rest on my forearm so that I create a little gap in the knee joint. My hand is going to cup. I'm superior to medial and lateral malleolus. And then I'm just going to oscillate and sink for that 30 to 60 second oscillation. whatever the patient can tolerate, but really making sure I create that gap underneath the knee joint and sink in. And then you can get into progressive and more knee flexion. After that, we wanna follow up with a good mobilization. So right, we pretend we did those three to six reps, we've retested, he's feeling good. HOME EXERCISE FOLLOW-UP So now Paul needs the tools to own that autonomous access, right? To own the joint motion or range of motion that we just restored. So Paul, I'm gonna have you come sit on the floor and we're gonna actually use a band under his knee and a towel to create the gapping mechanism that my forearm created. So Paul's going to put that under, and then we're going to try to also get that band. So we'll put that in first. Beautiful. And then he's going to grab that lower tibia and fibula, lean back slightly. So lean on back, Paul, so that your foot's off the ground. And then he's going to oscillate his legs. So go ahead and lift your foot off the ground. And now he'll do that same, whatever oscillatory time, 30 to 60 seconds felt good. He can set a timer and he'll just kind of bounce on off. It should feel easy and feel very similar. And you can go ahead and relax to what we just did on the table. So again, try to match that dosage time. This technique is good for restoration of knee flexion, helping with pain, and kind of easing some of those mechanical joint sounds. It's one of our favorite go-tos for knee flexion restoration and extremity management. SUMMARY If you want to learn more from our team, from Mark and Cody, we would love to see you on the road. We are going to be in Spring, Texas this weekend, and then Aiken, South Carolina. Both of those locations have some spots left, so dive in. If you want to learn more about how we manage common knee conditions like knee OA, meniscal, patellofemoral pain syndrome, patellar tendinopathy, iliotibial band pain, we'd love to share what best practice looks like in that area. And we also cover the hip, ankle, foot, shoulder, elbow, wrist, hand, and best practices for dosage and tendinopathy. I will be on the road next weekend in Victor, New York. So if you'd love to join me, I would love to see you. And Alan will be there, our COO. So join us on the road. Check us out on ptonice.com. And if you're not on the app, we just launched our Ice Physio app. That is a wealth of connection. So join that as well. Have a happy rest of your Thursday. Thanks for joining me this morning. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 13, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Christina Prevett discusses 4 important reasons for older adults to lift heavy: improving strength outcomes quickly, reducing fear, improving confidence, and translating heavy lifting to real-life function. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our division leads in the modern management of the older adult division. Today I am going to talk about a question that I got from one of the physiotherapy students that I was working with last week. So last week I had the pleasure of going down to McMaster University to teach movement analysis. So basically to create the foundation of some of our big movements, including the squat, deadlift, press and pull. Talking to our students about all this normal movement variation and what that means for our foundational knowledge before before we kind of start building in these additional layers around aging and different diseases and all these types of things. And we started talking about exercise principles and we talked about you know that strength versus hypertrophy versus endurance And I made the argument, as you know, that we have within our older adult division, how we need to be less afraid to make our older adults lift heavy. And I love that this student was really like thinking through, and he said to me, well, does it really matter? Because we see that our people, if we use lightweights and high repetitions, they're going to get some hypertrophy as well, right? So then why do I need to do this if I can just get them doing three sets of 10 at the right intensity and they get better? And so I loved this question. You could tell that he was really thinking about the literature and trying to bring it into where he wants to go with his clinical practice. And I always love the challenge. I love having a meaningful conversation around our thought processes when it comes to certain principles that we are teaching. And this is no exception. So I thought that I would do a podcast episode on this around what we know in the literature, where we are going from a PT perspective and an OT perspective, rehab perspective in general, around this type of thought process. and then kind of take our four takeaways about why we do this within MMOA. So let's talk about the research first. So this student was not wrong in that if you take an individual who is not doing anything and you get them doing something, even low repetition work, at a moderate intensity, they will see initial improvements, right? They will. Stu Phillips group out of McMaster actually did a Bayesian network meta-analysis that was looking at the comparisons between high load and low load and high volume and low volume. And he showed that all groups did get a little bit better. especially with hypertrophy, which is building muscular bulk, that high load, low volume training is not necessary or sometimes maybe even ideal because of the amount of load that's required for muscles to get bigger if that is your goal. However, what we did see is that individuals got stronger faster when exposed to higher loads versus lower loads. NO TIME FOR A SLOW BURN And so this is our first principle that we really hold true to within MMA. We do not have time for the slow burn. When our older adults are one slip, trip, or stumble away from losing their independence, when it comes to their aging experience and where they want to be in the next five years, yes, they will get stronger a little bit with low load training, but they will get stronger faster by making them lift heavy. And so I have what I feel like an unbelievable amount of urgency when it comes to working with a lot of my older adults who are at this cusp of losing their independence. And I don't have a ton of visits with them. I want to get the biggest bang for my buck. But he was absolutely right in that what we used to consider really tangible buckets around like, you know, less than six is this and six to twelve is that and twelve to twenty is this. It's more blurry than that. And as rehab professionals, that's OK. We embrace the land of the gray. But where I'm going to prioritize the heavy lifting piece is because I know that they're going to get better faster. So that's number one. LIFTING HEAVY REDUCES FEAR OF LIFTING The second reason why we get individuals lifting heavy in rehab is because it reduces fear. So many of our older adults are afraid. They have been told by our medical system that they shouldn't lift more than 20 pounds, that they shouldn't do this, that they shouldn't do that. They're being told by their family members, oh mom, like let me get that for you. Like basically you are too old to lift this on your own, let me do it. And I'm not saying that this is coming across as something that is disrespectful. It's meant to be helpful, but over time and with reps, it creates a ton of fear. And so many of our older adults are afraid over a certain threshold and require graded exposure in order for individuals to feel okay and feel confident about going and approaching a load that was making them uncomfortable before. And what we know is that when individuals lack or have a high amount of fear or lack self-efficacy in a movement, they avoid that movement. And so if they are afraid to lift over a certain threshold, then that might mean that they have relinquished their independence with certain tasks around the home. And again, that can be a threat to their capacity to stay up to date with their activities of daily living, right? So number one is we get people to lift heavy because it gets them stronger faster. The number two is that it reduces fear. LIFTING HEAVY IMPROVES CONFIDENCE And two is very closely linked with number three, which is it increases confidence, right? I say to my older adults all the time, if you are lifting this 50 pound weight with me, you are never going to be afraid to lift something in your day-to-day life. And I hold true to that. I will say, you know, if you are able to lift a hundred pounds, then you know that that kitty litter that is 30 is something that you're going to be able to handle. And so exposing to supra physiological loads compared to what their activities of daily living are gives confidence. It reduces fear and subsequently increases confidence and self-efficacy. And that is a really important narrative for so many of our older adults where their interactions with our healthcare system make them afraid, make them feel fragile, and therefore make them lack confidence with their capacity to do activities of daily living. Now, I'm not saying that we are going to ignore risk, right? We're going to have individuals who have balance impairments or things like that that do make them have a risk for falls, slips, and trips. But a person with more physiological reserve with respect to musculoskeletal reserve kind of in the bank. is going to always do better with a fall than somebody who isn't, right? Because that sedentary behavior, that lack of musculoskeletal resiliency from the muscle, the tendon, and the bone is more likely to give you an injury as a consequence of a fall. So we want to take into account all of their other variables within their medical history, but we want to increase confidence when it comes to a lot of our tasks. So that's one, two, and three, right? So people get better faster if you get them to lift heavy weights versus low weights for high repetitions. It reduces fear. It increases confidence. PEOPLE LIFT HEAVIER IN REAL LIFE THAN THEY THINK THEY DO And my last one is that people lift heavier than we give them credit for in their day-to-day life, right? When we're handing them five-pound dumbbells or we're handing them pink three-pound dumbbells, they are lifting their 25-pound dog. They are bringing their 40 pound grandchild onto their lap. So they are doing a seated hip hinge with 40 pounds. They are making sure and doing a very forceful pull if their dog is pulling on their leash because they see a squirrel and their dog is 40 pounds. Like they are doing so much more in their activities of daily living. And if we are truly trying to do a rehab program that is work hardening and This is true not just for our outpatient community dwelling older adults, this is our home health older adults. This is our, you know, even the plate full of food that individuals are taking from their walker from their kitchen into their living room, that plate weighs two or three pounds. has a load to it. And so individuals lift so much more than they even think that they do. And I'm not like, when I think about my so many of my clients, like they forget how much load things are, or they like push a couch that's 50 pounds, and they don't think that they do a 50 pound, if I get them to a 50 pound sled push, they think that that's too much. I was like, you just told me you moved your couch. Like that is exactly what you did, right? So they lift so much more. And when they have more resiliency, the percentage of strain on their body with those tasks changes, right? So going back to that, can you lift a hundred pounds versus the 30 pounds of kitty litter, right? If they are working at 30%, that is a repeatable effort. If I got them to do a set of 10 at 30 pounds, yes, that would be a lower strain. But then if I gave them 35 or 40 pounds and they're afraid to lift it and they think that they can't lift that anymore, then they're topping out at 80% of what they believe their max capacity is to move that kitty litter. And that is a much harder reproducible task, even with some of the exposure and higher repetitions. than if they believed that they could lift 100 pounds and this was only a 30% effort. And it makes me really kind of think to even the state of our research and how much are we missing because of this inertia that we've created that this is the repetition range that we have always done so this is the repetition range that we are going to replicate and that is where we get into a lot of 3x10 repetitions right like we have always gone in that moderate intensity range and now we have this inertia in research as well where We have so much evidence that is accumulated in this area that our studies that are on the fringes in the 20 plus repetitions looking at muscular fatigue rates in our our rep ranges that are in the five minus or five or less ranges are so small that the bulk of our evidence is in the middle. And so then we think that this is where all of our exercise programs need to be. And I'm not against three by 10. I absolutely am not. But it is recognizing that there is a lot that can be done by exposing individuals to higher loads and then allowing their confidence to thrive. So where we go with this is not to say that our older adults don't gain anything from the three by ten repetitions. That's actually not true at all. And oftentimes what we will do is we will have individuals lifting heavier with us in a supervised setting where we can monitor irritability, especially when irritability is high. And then a lot of our at home repetitions are in that endurance hypertrophy range, because we bring the load down, we bring the intensity up to a moderate range with a less amount of load, load that tends to be more readily available in the home. And then we get this beautiful combination of getting that exposure to high loads, but also getting some of that hypertrophy resiliency in those higher repetition ranges. So where are we kind of going from here? One, we need so much more research that is comparing different types of exercise programs, right? When we are thinking about high load paradigms, so much, the bulk of the decisions that we make in rehab, and this is so true in our older adult divisions, and actually it's everywhere, but a lot of our health intervention research is comparing doing something to doing nothing. And they say that it's not doing nothing because they give a home exercise program, but then they don't tell us how often people actually did set a home exercise program that you gave them at the beginning of your 12 week intervention and then never checked in on them again until the end. And we are always going to see at least initial newbie gains when we compare doing something to doing nothing. It is a lot harder as a researcher to do doing moderate intensity to doing high intensity and making those comparisons, hence why we are using indirect Bayesia network meta-analyses to try and gain insights into some of those comparisons. Because it takes a lot longer for us to see differences between individuals who are doing nothing to doing something in both groups, but the intensity is slightly different, but still hitting thresholds for adaptation potentially. So we have so much work that we need to do in this space, but until then, I have the four reasons that our division uses and why we try and expose our individuals to intensity and know that the main biggest take home that you can see in your older adults, and that is important for driving physiological adaptation to resistance training at any rep range, is effort. Effort is the important part, and so often in MMOA Live, we see that people don't wait for effort to show up in our older adults. They don't wait for the grunts, they don't wait for the redness, they don't wait for the sweating across their brow. And that is always one of my markers of effort. And so when I have my people in the gym, and I would say that probably 70% of my time in rehab is spent in the gym, the rest of the 30% is education and manual therapy, they're sweating. they're working hard, their muscles are feeling tired. I always say I love the shakes. I get the shakes and some of the core work, you know, like those are the things that effortfulness across the lifespan that I am looking for. So how can you get some ideas around exercise prescription and effort? SUMMARY Well, I'm so glad that you asked. We start our next cohort of MMA level one this week, actually today. Today is the 13th. We have some big things coming at us. One is that our MMOA level one starts today. So if you were hoping to get in and dive into some of this research on exercise prescription, we have three weeks that focus on where our mindset is with respect to loading the older adult. And we also are seeing big changes around moving to an app. So if you guys have been seeing, jump into the iStudents group. We are going to be migrating over to Circle, so all of our courses are gonna be moving in that direction. So if you are interested in getting, thanks Taylor, we are going to be going in that direction. So if you guys are looking for where some of our slides and things from the courses are gonna live, they are going to be on the Circle app, which we are really excited for, that platform migration. All right, I hope you all are having a great week. We will see you all. If you are at our MMOA Digest, please get on there. Otherwise, we'll see you in a couple weeks. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 12, 2024

Dr. Brian Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose makes his debut on the Daily Show to discuss how to come alongside powerlifters, the differences between raw & equipped powerlifting, the sport-specific demands of powerlifting, and how to keep powerlifters competing. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION BRIAN MELROSEGood morning, PT on ICE Daily Show. My name is Brian Melrose. I'm one of the lead faculty in the spying division, teaching both cervical and lumbar courses. I'm stoked to be here on clinical Tuesday to talk about all things barbell isometric with a very particular population. That population that I want to talk about is with the power lifting athlete. And if you haven't had the chance to work with one of these guys before, then again, you don't know that when you lift 600 to 800 pounds of load, you tend to end up with some neck and some back pain. And so that's where this sport has crescendoed well with my clinical practice. And so I treat a lot of recreational, national, and even world-level powerlifters here in northern Colorado. And the story for me really begins about two years ago when Natalie Hanson walked into our clinic. And Natalie's a world-level powerlifter. She's won worlds multiple times and was in a new weight class and looking at returning to the sport. And so as I begin to work with her, as well as other powerlifting athletes, we can begin to understand, number one, why they have so much spine pain, but number two, how we can help them in the clinic to mitigate some of those symptoms, both leading up to competition and on competition day. COMMON SYMPTOMS OF THE POWERLIFTER And so the first thing I want to do is just provide a little bit of background as to why these folks end up running into some symptoms during competition. And so a typical powerlifting competition is going to consist of three different lifts. You get three attempts to get your highest lift total for the end cumulative sum. And so the powerlifting competition is always done in fleets or groups, and it begins with the squat. So everyone comes out going from the lowest weight to the highest weight, and they get three attempts to throw down the heaviest squat possible. After that, all of the athletes will transition to benching. Again, same style there. Three lifts to get the highest bench possible. And then they end the day with a deadlift. And to put this in context, right, in smaller events, like in Worlds, so last year I got the opportunity to go to Lithuania with Natalie and check out the World Competition. And there's only six other athletes that are throwing down similar weights. And so the entire competition takes about an hour and a half. So in 90 minutes, you are One rep max loads, again, either just below your one rep max or trying to hit the new PR. And so nine different lifts of, again, compound movements tends to really tax this system. And so both athletes are pretty gassed, usually by the time they get to the deadlift and then again at the end of the day. But when we begin to take a deeper look as a physical therapist at what's happening at the spine, we begin to see why things can kind of, again, become problematic. First, we have the squat, where again, there's a large compressive load through the spine. And then the athletes have to transition to benching. And if you've never watched powerlifting before, then you probably are unfamiliar with their unique benching position, which is extremely arched. And so the feet have to stay on the ground. The hips have to be in contact with the bench. all arch to end range, their end range in the lumbar spine. And what that allows them to do is typically decrease the distance the bar has to travel to their chest to complete the lift. It also helps pin the shoulder blades down. On the flip side, it makes it extremely difficult to maintain that arched position. The lumbar extensors are working incredibly hard to be able to maintain the hip contact down on the bench. And so they're in that lumbar extended position. The extensors are very shortened, but they have to be extremely active. All of the athletes, after benching, then have to switch gears and go out for the deadlift in an opposite position, where the lumbar spine is much more flexed, and those extensors have to then elongate. And so you can see why that can be challenging for a lot of those powerlifting athletes. But for someone like Natalie, it's even more challenging. And so Natalie, it's mostly because she has such a strong bench. So Natalie was just down in Austin, Texas a couple weeks ago and broke another world record. And because her bench is so high, she's typically one of the last people to go within that fleet. So she'll be the last person doing her third bench attempt. And then all the athletes switch gears, and they start doing the deadlifting. And so because of her geometry and history of back bend, she tends to be lower down in the pack when it comes to the deadlift. And so sometimes she has about 10 or 15 minutes to come off of the stage from the bench and then go ahead and switch gears and get ready for one of her first attempts warming up in the back with deadlifting and then coming out on stage and hitting a deadlift. And so for her in particular, that kind of, again, high bench, lower deadlift really decreases the time that her system can kind of switch. And so that's one of the reasons why we like using the barbell isometric. RAW VS. EQUIPPED POWERLIFTING But the other thing that I want to describe real quick is the difference between raw powerlifting, which I think a lot of us are imagining at this point, and what's called equipped powerlifting. And so raw powerlifting is a little bit more popular now, typically just done with a weight belt. Equipped powerlifting is what's done a little bit more historically. In equipped powerlifting, in the squat, you're allowed to use knee wraps as well as a squat suit. In the bench, you're allowed to use a benching shirt. And then in the deadlift, you can also rock a deadlift suit. And so these are single ply materials that are a little stretchy, but fairly rigid. And what they do is assist the athletes in some of the most difficult positions of the lift. And superficially, you might think, well, that probably makes things a lot easier for the athlete. And if they stayed at the same weights, that would be true. The thing is, though, is that these athletes tend to load the barbell way more aggressively and lift loads that physiologically they would not be able to do if they didn't have, again, the assistance of the equipment. And so the equipment becomes this other variable within competition or within the equation in the sense that they can They also have to almost fight the equipment to get into position. So with the bench, again, they're lowering down, have to balance the weight, and still have to touch their chest, but they're fighting the stretch of the shirt to get there. In the same way, when they end the day down in the deadlift, not only have they just taken those extensors from end range extension and activation of the bench, and now they're asking to kind of elongate for the deadlift, They have to fight the shirt to even get down and get into position. COMING ALONGSIDE POWERLIFTERS And so the answer to helping these athletes, either on competition day or in training, is really twofold. The first thing that we need to fix is, how can we get those tissues to be a little bit more pliable or extensible after benching in preparation for the deadlift? And so to do that, I'd like, again, referring to one of the things that we talk a lot about in our lumbar course, And we're talking about repeated motions, particularly folks that are recovering from a derangement and are reintroducing flexion. When we reintroduce flexion, we tend to start in non-weight bearing. And I do the same thing for my powerlifting athletes mid-competition. I like them to lay flat on the ground, on their back, and pretty much just rock their knees to their chest. postural tone, we already decreased some of the activation in those muscles. And then as the athlete brings their knees up, again, usually about 20 repetitions or about a minute, they flex the lumbar spine from the bottom up. So instead of reaching forward, they're kind of, again, coming at it a different way. And so usually that can help relax some of those muscles. Next, is what we typically like here. So again, looping a band behind the back, getting it down here, and then sticking in the first 50% of the range to begin to get a little bit more motion at the joint, as well as some muscular activation. Last, we end up going to the Jefferson Curl. So now in a weight-bearing position with a lighter load, but segmentally flexing that athlete all the way down to end range, and then coming back. And so what that can do is, again, take those tissues from a very guarded, shortened position, and gradually tease them in the right direction. In a powerlifting competition, especially for someone who's stacked like Natalie, that might be three or four minutes that we have. In the clinic, we can leverage things like manipulation, dry needling to mitigate those symptoms. But in the competition, it's going to be much more movement-based. BARBELL RACK PULLS TO PRIME THE DEADLIFT So now that we have the tissues relaxed, the next question becomes is how do we prepare them for the deadlift? And again, these athletes warm up a lot backstage, and they go out and pull something pretty heavy. And this is where the barbell isometric comes in. It's my favorite exercise to give as a primer in this situation, because we can control the environment and give them the work in the position where they feel most vulnerable, where the lift is the most difficult, and not have any movement of the bar. And so for most athletes, that is going to be right when it's coming off the ground. So they're fighting the suit to get down, but they're also trying to pull these extremely heavy loads from the floor. And so typically in the back, during a competition, we would bottom out the J-hooks or the arms and kind of standardize it at the height of where the Olympic plates would rest. And so what the athlete is able to do is get into their conventional or sumo position, get into the bar and then just hold and just maintain some good activation at the rig where they get maximal effort in terms of the extensors, but there's no change in the joints or the muscular position. And so our dosage on competition day is typically going to be something a little bit lower in reps and lower in terms of duration. And so if you've ever watched powerlifting, sometimes those folks are grinding a lift out for anywhere from 5 to 10 seconds. And so I tend to dose the isometric at 3 to 4 reps of around 10 seconds. And so that tends to, again, get some good primers on board during competition day. But you better believe that we've been leveraging these throughout the training leading up to the competition or event. And so the day I like to select for that, for a lot of these power lifting athletes, is on a day when they've done a lot of high volume or heavy benching in that arch position. Their back should be kind of locked up as much as it is. We run through that flexion progression, going from non-weight bearing to across gravity to standing. And then I have them end with some barbell isometrics at the rig. Now we can cook things a little bit longer. And so what we'll typically dose on a training day would be longer holds, anywhere from 10 to 25 seconds for four to five repetitions. And we really, again, want to tax those muscles all the way to work on the endurance and the positional tolerance where they have the most difficulty. And so that's how we really like to leverage the barbell isometric with powerlifting and athletes, both on competition day and in some of the training leading up to the event. It is helpful as this is for both powerlifting athletes. You may be able to transition this to other folks in the clinic. If they have some back spasms or issues at a particular part in the lift, you just match the isometric to where they need it. For a lot of folks, that's in the bottom. But if they were having trouble at mid-range, we would just move the J-hooks up and have them perform the isometric where they're having the most difficulty. And so this has been an incredible way to help these athletes train. Why are these folks having some pain and dysfunction in this area? We guys love the deadlift. The deadlift is king. If there's one exercise below the spine, you know that's what we're going to choose. But what do you do when you get an athlete that rolls into the clinic and they're already deadlifting? Or they're not only already deadlifting, they're doing it multiple times a week, and they're doing it We're going to be answering that question over the next couple of podcasts I'll be throwing down in the coming weeks. And I'm going to give you some seeds of things to kind of marinate on as we get there. But when it comes to loading the spine for folks that are already deadlifting, we need to consider things like planes of motion, as well as speed and fatigue. If we can get our athletes kind of oriented to some of those things, I think we help them create the most robust and resilient spine. So that'll be coming down in the future. SUMMARY Thank you for hanging out with us here on clinical Tuesday. I just want to plug a couple of courses we have coming up next. If you guys are looking to hop to any of our cervical courses, I'll be teaching down in Longmont, Colorado here in just two weeks. There's a couple of seats left, so go ahead and hop on that if you'd like a ticket. For lumbar, We're going to be kind of active April 6th and 7th. I will be out in Carson City, Nevada. Zach Morgan will be on his home turf in Hendersonville, Tennessee. And again, you can grab us on the road for both those surfable and lombar courses. Hope you guys have a great Tuesday. Thanks for hanging out and talking about barbell isometrics with the power lifters. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 11, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses a story of usual patient care when experiencing menopause in the American healthcare system. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION RACHEL MOOREAlright up and running on Instagram and YouTube. What is up guys? My name is Dr. Rachel Moore I am on faculty with the pelvic division here at ice Pollen has been wild in my area of Houston and I have a sinus infection. So I Sorry about the congestion that you're likely going to hear throughout this episode. This morning we are here to talk about menopausal women and how they deserve better and how they have been kind of set aside and really isolated in the type of pelvic care that we are starting to see normalized. I really want to kick this off this morning with a story that inspired me to even pick this topic. So Last weekend I was teaching in California with Alexis for our pelvic live course and on the plane I ended up sitting next to this older couple. It was a husband and a wife and they were having a hard time like connecting to the Wi-Fi. I didn't really know how to get the United app up and running so I leaned over and I helped him kind of figure that out and I had my iPad with all my slides next to it because I was going to prep for my lectures on the plane. So I always like to work on the plane on the way there. And the lady leaned over and she was like, oh, like, thanks so much for your help. And just kind of started making small talk. Asked what I was traveling to California for. And I told her that I was actually going to work. I was going to go teach other physical therapists because I was a physical therapist. And so this kind of kick started a whole conversation where she was telling me she was flying out to California to run a marathon and she had been rehabbing a hamstring injury for like two years and she had gone to in-network PT and then she had gone to out-of-network PT and all along the way like her hamstring would get better and then it would come back and it would get better and it would come back and so we kind of chit-chatted about that a little bit talked about her running volume and things like that and then I kind of alluded or something I said I don't even remember exactly what it was but told her like I'm actually a pelvic floor PT and that's a big part of what I treat And she was like, oh my goodness, I can't believe this. Like I just had a pelvic floor evaluation and her husband leaned over and he was like, oh boy, you have no idea the can of worms you just opened. And we, she really just dove into her story. And so she had had surgery or not surgery. She'd had a bladder pacemaker put in because she was struggling with urgency and frequency of urination. So she had been at this point to a gynecologist, to a urogynecologist, to an orthopedic doctor for her hamstring, and on the MRI that was done for her hamstring, the report also said that she'd had some issues with her bladder, and she asked her ortho doctor about it, and he was like, I don't know, all I know is about the hamstring, I'm not here to treat your bladder. and she was really feeling hopeless about her pelvic floor and about whether or not she could get help for her pelvic floor. She'd gone to a pelvic floor evaluation and she said it was really helpful and she learned a lot but it was an out-of-network provider and she'd already spent a lot of money on out-of-network care for her hamstring and she didn't want to dive into this area at that point. And so in this conversation we really kind of got into the weeds a little bit. So through this conversation, it's like those conversations on the plane, you never know where they're gonna go. We ended up chatting about cycles and menopause, and she was menopausal at this point. And ever since she had been in menopause, that's when her hamstring symptoms started. That's when she started noticing issues with the pain in her hamstring, and we started talking about fueling especially with her running volume and we started talking about how there's estrogen receptors in other parts of your body aside from in your ovaries and all of the ways that being in menopause can potentially set you up for issues with your musculoskeletal system And in this conversation, she was shocked because nobody had ever really talked to her about what menopause consists of, all of the different ways that menopause can cause issues aside from just you don't have a period anymore, you may have hot flashes, and it was really upsetting to her. And we kind of continued talking over the course of the flight, it was a four, three and a half, four hour flight, and it kind of dawned on me in that in this moment in this conversation because she had a son and we were talking about how when she had her son pelvic floor pt was not done nobody talked about it nobody uh it was just normal that you pee on yourself and i know these days we like to feel like that is still a thing but if we think about perspective shifts like 20 30 years ago It was even less common than it is now, right? Like it was not a thing that was really prescribed at all. So many women were getting surgeries right out the gate after having had their kids. And so this group of women that are now going through menopause were really kind of, I don't want to say shafted, but shafted in their prenatal and postpartum pelvic floor care. And I think that that means that we as pelvic floor PTs need to put it out there that we can help them because they have lived their entire lives up until this point, believing that it's normal to pee when they sneeze, believing that it's normal to leak when they exercise, maybe not exercising at all because this has been something that they've dealt with since they delivered their kids 20 or 30 years ago. And now is the time that their symptoms are potentially flaring back up. We see an increase in pelvic symptoms as we transition into this stage of life. And so if we are not addressing these issues and we're not putting it out there that we can address these issues, women aren't getting the care that they deserve. And not only did they not get the care that they deserve initially, when they first got into this pelvic floor space after having had a baby, they're not getting it now. I think as pelvic floor PTs some of us may really lean into the prenatal and postpartum space and it makes sense because a lot of us are maybe in that time stage of life where either we are having kiddos or people that we know are having kiddos or maybe thinking about it in the future. And so it really feels like this easy transition as we're entering into the pelvic space to lean into the prenatal and postpartum space. And it is needed. I'm not saying we shouldn't do that, but I think as pelvic PTs, we really need to get comfortable with explaining menopause and explaining the changes that happen in menopause. And more importantly, talking to women and talking to providers like, gynecologists like urogynecologists getting together with these people and letting them know like we can help mitigate these symptoms. We can help be an adjunct to care on top of things like HRT or hormone replacement therapy which absolutely should be talked about especially now that we're seeing the shift away from like absolutely don't do HRT because it can increase your breast cancer risk We're seeing that language changing. And so it's exciting to see these women start getting the care that they need in the realm of HRT. But as pelvic PTs, we can step up to the plate and help layer on even more in terms of helping them manage their pelvic floor symptoms, the genitourinary syndromes that they're experiencing. We can really talk to them about building up strength and building up muscular support for their bones as everything changes with their bone mineral density. We can maybe teach them how to exercise for the first time if they're people that have been avoiding exercise for the majority of their life because of symptoms that they have been experiencing since they first had their babies. So really, my whole point of this episode this morning is if you are not in this menopausal space, If you're a pelvic PT and you're not comfortable talking to people about menopause, or you really don't feel like you know enough about menopause to really truly serve this population, I truly feel like it's time for us to step up to the plate and get comfortable with it. We have a lot of resources out there. A few resources, I'm just going to list a couple because otherwise it kind of sounds like a rambly list. The North American Menopause Society actually has like a provider list that you can go in and search for menopause-informed urogynecologists and providers. Letstalkmenopause.org is a website that you can take a peek at, you can also direct your patients to, has resources for patients, really kind of breaks things down into patient-friendly language. The Menopause Manifesto by Dr. Jen Gunter. And then in our live course, we actually dive into menopause in week five. And we talk in more depth about how, sorry, our online course, not live course. We talk in depth about how we can help as PTs serve this group of women. I really feel like it is time for us to do this y'all. I think that this group of women and maybe it's my heart going out because I'm thinking about like moms and grandmothers and all of all of these women in our lives that have just been told that this is something they have to deal with. And now they're being told this again. It's time for us to help change this. It's time for us to bring fitness forward PT to this group of women, especially this group of women. They deserve it. I don't want to say more than anybody else because absolutely we all deserve it, but they deserve to get this quality of care. SUMMARY If you're interested in jumping into our online course to learn about menopause in that week five, our next cohort opens up April 29th. We have two live courses coming up, April 6th and 7th in Windsor, Colorado, April 13th and 14th in Spring, Texas. That's where you can catch us on the road in April. We've got some more courses coming up in May as well, so if you're looking into summer, hop on the website, sign up for a live course, and catch us on the road. Thanks for tuning in this morning. If you guys have any questions about menopause, reach out to all of us on the ice pelvic faculty and we'd be happy to answer. Thanks. Have a great Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 8, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses helping patients return to running following ACL reconstruction (ACLR). Jason describes healing & strength benchmarks to use to initiate running, strengthening needed to facilitate return to running, and biomechanical changes that need to be addressed to improve performance. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JASON LUNDENHey, good morning, everyone. Welcome to another edition of PT on ice daily show. My name is Jason London. I am the endurance or the endurance athlete division lead. And I am happy to be chatting with you all today. We'll be talking about return to run following ACL reconstruction. Sorry that I'm on a little late. I just wanted to avoid my dogs going crazy when my daughter was getting picked up. So for those of you who are patiently waiting since seven, thanks for your wait. So we're going to be talking about return to run following ACL reconstruction, covering, you know, why do we care? when that happens and why do we need to be thoughtful about that, what do we look for as our athletes are returning to run, and then how do we address it. So one, why do we care? Well, several different reasons. First and foremost, performance. We want to set our athletes up for success with when they're returning to run and being able to demonstrate good mechanics for performance, but also We do want to be thoughtful of that healing ACL graft and as it is going through the ligamentization phase, we want that to have basically been gone through that full phase before return to run just because of the stresses placed on the ACL with plyometrics, even though running itself in healthy adults should have very low stress on the ACL. And then third, probably the most important piece with really being cognizant of what's going on with their gait mechanics is a high rate of early onset osteoarthritis following ACL reconstruction. And with that, there's been studies looking that have shown that It really comes down to one of the risk factors is patients who under load the operative side seems to be one of the driving factors for early onset arthritis. So it's going to be something that you want to look for. CHANGES IN MECHANICS FOLLOWING ACLR So what do we look for in these patients who are returning to run following ACL reconstruction? Well, the main things that we see in the literature and then I would say I see in the clinic as well is, um, I'm jumping ahead here a little bit. But what we want to look for is those patients that are underloading the knee, so decreased knee flexion on the operative side in the sagittal plane at mid stance compared to the on operative side. So any difference greater than two degrees of knee flexion at mid stance is something that we need to address. That patient is underloading that knee. And then the second thing, particularly for patients following a hamstring autograft, semi-T, semi-membranosis autograft, is increased tibial external rotation during stance, which has been shown to be in the literature. Now, I jumped ahead there a little bit. WHEN CAN WE RETURN TO RUNNING? You know, when are we actually allowing these patients to return to run? Again, we want the graft to have gone through the ligamentization phase. So that is going to be at four months, anywhere between three and four months. But to be on the conservative side, you would want to wait till to the four month mark. And in addition to that, we don't want to just be timeline based because, you know, assuming that the graft has gone through the ligamentization phase is all done on you know, benchtop research. So we do want to have our objective criterion as well for when these patients are ready to return to run. And so we want, first and foremost, you know, full passive range of motion, minimal to no swelling, and normal walking gait. Those three things, in my mind, should almost always have been achieved by the six-week mark, so it gives you plenty of time before you're even thinking about returning to run. In addition to that, objectively we want them to have a certain level of strength. So we want 90% limb symmetry index, so 90% of what they can do on the non-operative side for hip strength, particularly hip abductor, adductor, and extension strength. And we want 80 to 85% LSI of knee strength, so quad and hamstring strength. Ideally testing all of these with, isometrically using a dynamometer. If not, you know, coming up with other ways with one rep maxes, planks, et cetera, to try to get a little bit of a better sense rather than just your hand doing that isometric hold and rating it a, you know, five out of five. In addition to 80-85% LSI with isometric strength testing for the knee, we want there to be some objective testing too. So we want the athletes to be able to perform single leg squat to 60 degrees with really good form without having to put their contralateral leg down and then do a two minute timed single leg squat max reps in two minutes and comparing that to the contralateral side and wanting that to be at 80 to 85% of what they can do on the non-operative limb. So this is, of course, going to take them some time to achieve. And so generally when that is going to happen is between the three and four month mark. So again, 90% hip strength, 80 to 85% knee strength, both isometrically and objectively. INITIATING RETURN TO RUNNING And then when they are returning to run, we're going to start with a walk jog program. where they're going to be jogging for a certain number of minutes and then having a walking interval with that. And gradually ramping up, depending on their experience, to where they are running continuously for 30 minutes. Once they've hit that, then you can have them do a threshold test. And basically, after they've had two successful bouts of running at 30 minutes without pain, having them on that third run of that week going to run as long as they can without pain during the run and for 24 hours after and that would set their threshold in terms of where they're going to be starting out at and then you're going to increase their running volume off of that. LOADING TO FACILITATE RETURN TO RUNNING I got a little bit ahead of myself earlier on but what we do want to look for is decreased knee flexion or underloading in mid stance on that operative side or excessive external rotation on that operative side as well of the tibia. And so how do we address that is mainly making sure that for the loading that one that they do have adequate quad strength to accept the load so really working on a lot of eccentric quad strengthening using the extension machine, leg press or or weighted wall sits, and then also doing focused loading patterns. So I really like having them do crouched carries with the knees flexed to approximately 60 degrees. I'm really teaching them to load through that knee that way, as well as doing some supported hopping with a monster band, a pull-up assist band, to really get them to load through that knee. ADDRESSING GAIT MECHANICSAnd as we know from a lot of the literature is, you know, strengthening alone is not going to carry over to the gait mechanics, unfortunately. And so we need to give them some cues while they're running to increase loading and knee flexion at mid stance. Probably the best cue to give them is to try to hit the ground hard when they're running. It's a nice external cue that seems to work better. Otherwise, other things you could try is telling them to try to sink into their stance more when they're running too. And, you know, having them do that in block training. So, you know, a lot of verbal feedback for them or auditory feedback based on how they're they're striking and titrating that over time. For the increased tibial external rotation that really again goes back to hamstring strength particularly medial hamstring strength since that's where the graft was taken for those hamstring autografts and in the study by absorted kick in 2017, they found that those athletes who had less than 85% hamstring strength compared to the contralateral side were more likely to have that tibial external rotation. So again, focusing back to that strengthening of the hamstring, but having to get that carry over for gait too. And what I found is I don't have really good external cue for them, but just having them thinking about when they're coming into flight phase is having them pick their foot up and internally rotating their foot to overcompensate initially, and then gradually that works itself out. So return to run for ACL reconstruction, you know, we're probably getting in the time right now where this has been happening for a lot of you for those athletes who tore their ACL in fall sports. Winter sports, we're probably not quite there yet unless they tore it in early season, but really be thoughtful about the timing of that. Again, thinking of wanting the graft to have gone through that ligamentization phase, so generally around four months, and generally they're not going to be ready until that point anyways if we look at our objective criteria, particularly of the 85% isometric strength of quadriceps and hamstring and being able to get 85% of what they can do on the control at all time with that two minute timed squat to 60 degrees. Again, this is important for performance. important for good outcomes following that ACL reconstruction and most importantly important for trying to decrease that rate of early onset arthritis at the knee following ACL reconstruction. So hope you gained a few pearls here. Working with ACL reconstruction patients is very rewarding and a lot of fun and don't just fall into the habit of When it's time to return a run, just sending them off with a walk jog program. Make sure you're looking at their gait mechanics and addressing that and thinking also about what is that athlete's history of running and what are their goals for running too. SUMMARY If you're looking to join us for any of the endurance athlete courses, we are just starting up the second cohort of online and unfortunately that is full for any of those that would want to join. So your next option there is May 7th, I believe. The first professional bike fit cert is coming up here in April, April 20th in Asheville. This is a little bit of a special one. as that the other lead faculty, Matt Keister, and myself will both be teaching that, so it should be a lot of fun. And we're really looking forward to hitting the trails around Asheville for some great biking. And then the first rehabilitation of the injured runner live course is going to be in June in Milwaukee. That one is filling fast, so if you're thinking or sitting on the fence on that, Make sure you sign up for that quickly. We do only have two live courses this year for Rehabilitation of the Injured Runner live, but we will be offering more next year as Megan Peach is moving back stateside and we'll be able to teach with that. I hope you all have a wonderful day. Get outside and do something fun with friends and family over the weekend, and we will catch you all later. Bye. Did you see him? I need to go get ready. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 7, 2024

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses the concept of a lateral shift when addressing low back pain, as well as three objective & 1 subjective ways to assess the potential presentation of a shift. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRYAll right, what is up PT on Ice daily show? This is Dr. Jordan Berry coming at you live on a technique Thursday or an assessment Thursday for today. So I'm lead faculty for cervical management, lumbar spine management. And today we're talking about the lateral shift and how in the clinic we can pick up on the lateral shift so that we're not going to miss it. So we're going to talk about just a few ways from an objective and a subjective standpoint that we can pick up on the shift so that we don't miss it. And so one thing that I commonly see in the clinic, whether it's a client who is not getting better, or it's a client who's not progressing like we think they should be, or if I'm doing a case review with another clinician or watching that clinician evaluate the lumbar spine, one thing that we commonly see is the lateral shift is not on that person's radar, or they don't know all of the different ways that a lateral shift can present. We're going to unpack that over the next few minutes here. WHAT IS A LATERAL SHIFT? When we talk about a lateral shift, what we're really talking about is when someone has an acute episode of low back pain, oftentimes it's back and back related leg symptoms as well. they will oftentimes have what we call a lateral shift. And so that is when, quite literally, the body is shifted in a direction where the hips go one way and the shoulders go the other way. And there's a bunch of different theories on why this can happen, but really the person is going to inherently avoid this side of pain. So almost always the shift is going to be in the opposite direction of the side of symptoms. And so when we talk about a lateral shift, we name it based on the shoulder position, not the hip position. So for example, if I had pain on the left side and I was shifted this way, away from the side of symptoms, then we would name the shift based on where the shoulders are heading. So in this case, it would be a right lateral shift if I am going towards the right with my shoulders and towards the opposite side with my hips. And so again, there's a bunch of different theories on why this can happen, but one thing for sure that we see very consistently in the clinic is if someone presents with a lateral shift and it's not corrected or that treatment does not respect the lateral shift, you will typically not make very much progress. But it's not just a visible shift. There are other ways that we can sometimes pick that up. And so we're going to spend just a few minutes unpacking that. So I've got Jenna here to help me with a couple of demos. So if you're listening on the on the podcast right now, jump over to YouTube or Instagram if you want to see an actual visual of what we're talking about. So I've got four ways that you can pick up a lateral shift in the clinic. FINDING A LATERAL SHIFT: USE YOUR EYES So starting with number one, number one is the most obvious. It's actually visible. So when someone has really significant back and or back related leg symptoms, you'll quite often see a visible, a literal shift when you're looking at them square on. And so if I have Jenna stand right here facing the camera. So let's say that Jenna had symptoms in the left part of her low back and then going down the left leg. almost always what you will see is the shift would be towards the opposite side of symptoms. So we would see Jenna's shoulders going towards the right away from the symptoms on the left. And the best spot to look when you're staring square on at the client would be at the forearms. And so we're looking at a difference in space between the forearms. So sometimes you might have to snug up the shirt a little bit or ask the client to relax the arms, but you will see a difference, more space on the side that the person would be shifting towards. It can be very obvious sometimes or it can be really subtle, but I'm always starting just getting a good visual of looking at the person square on. So number one is an actual visible shift. Okay. FINDING A LATERAL SHIFT: LATERAL FLEXION RANGE OF MOTION OR SYMPTOM ASYMMETRIES Number two is an asymmetry in side bend or an asymmetry and lateral flexion. So when we're going through active range of motion, we will typically see that side bending towards the side that they're already shifted towards is gonna be much better than going towards the opposite side. So using this same example here, if Jenna is shifted towards the right, right, her shoulders are going towards the right side, what we will typically see is that she side bends towards that side, right, towards the right side, that it's pretty solid because that's the direction her body's already wanting to go to. And then when you go to the opposite side, it's gonna be, yep, very limited and oftentimes painful. And so anytime I see an asymmetry in lateral flexion or an asymmetry in side bend, I'm for sure gonna test out a lateral shift correction to see if it makes a difference. And when we say asymmetry in side bending, it's not always just an asymmetry in range of motion, can also be an asymmetry in symptoms. So even if the side bending is relatively similar from a range of motion standpoint with how far the person can side bend, if one side is dramatically different from a symptom, from a pain standpoint, that's also sometimes indicative of a lateral shift. Okay, so number two is an asymmetry in side bend. FINDING A LATERAL SHIFT: HIP RANGE OF MOTON ASYMMETRIES Number three, an asymmetry in rotation of the hip. Specifically, internal rotation is usually the one where you're going to pick up on it. So if I have Jenna sit right here on the table and she just does internal rotation while she's sitting right here. So we're just assessing how much internal rotation we have. And then if I had Jenna fake a lateral shift, so let's go in the same direction, right? She's shifted towards that right side because she's off when her shoulders go to the right, she's offloading the left side. And so now it's going to present like she has much better internal rotation on the left versus the right. Now, it might not be true internal rotation that is different. It might just be of the position of the hips that it presents as if it's different. So picking up on internal rotation again, either because of symptoms or because of range of motion, can be a third way to differentiate between someone having a lateral shift. You can test it in sitting like what we're doing here. You could also test it in supine, but Very commonly it is the side opposite of the shift that actually might have a bit more internal rotation. Again, because of the position of the torso or the position of the trunk. FINDING A LATERAL SHIFT: THE SUBJECTIVE HISTORY And then lastly, the fourth way that we can pick up on a lateral shift is in the subjective. So the first three are going to be more in the objective exam, right? The last one, the subjective, is going to be a preference for sleeping or lying on one side versus the other. So that could be, again, sleeping, that could be laying on the couch, it could be any time the person's non-weight bearing, they prefer to go in one side versus the other. And again, because they're offloading the painful side. SUMMARY So if I hear any of those four things, whether it's in the subjective or the objective exam, I'm for sure going to test the lateral shift correction because I can't afford to miss it. So again, as you're going through this week and you're seeing someone that has acute low back pain, back-related leg symptoms, and you're trying to pick up on the lateral shift, what are those four things that might indicate that? Well, number one, the most obvious, it's visible. So you're gonna look at the person square on, and you're gonna look at the forearms to see if there's a difference in space side to side with their arms relaxed. Number two, an asymmetry in side bend. That asymmetry could be range of motion, being asymmetrical or symptoms being asymmetrical side to side. Number three is a difference in hip rotation, more specifically internal rotation. And then lastly, the subjective exam is a preference for sleeping and or lying on one side versus the other. All right, that's all that I got for you today. This is part one of two. So we're going to come back in a few weeks and jump on again and go over different ways that we can actually correct the lateral shift. The one that we know most commonly, right, when you're standing on the side and you're shearing the person or shifting the person in the opposite direction, that is by far the most common. But we've got a lot of other cool variations when the person might not tolerate that position. So as always, if you want to learn more about this, hit us up at one of our live lumbar management courses. And we've got a bunch coming up from the spine division over the next few months. I know we've got two coming up this weekend to next weekend as well. Cervical and lumbar spine management. Have an awesome day in the clinic. Thanks, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 6, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the theory of selective optimization & customization, including how to help patients select goals, optimizing treatment around goals, and being OK with compensation as needed. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MUSGRAVEWelcome to the PT on Ice Daily Show. I'm going to be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday. That means it is all things geriatrics today. So excited to be sharing with you a topic fresh off a really exciting trip, Preparing for Adventure and the SOC Model. Now, don't get sick to your stomach if you're a home health clinician. We're not talking about start of care, okay? We're talking about a theory for successful aging. THE STRONGER LIFE RETREAT So I'm gonna give you a little bit of background on how I got to this topic and why I'm excited to share it with you. just came off a trip out of the country with 20 members that are 55 and older. So we took an adventure retreat. Stronger Life members joined us out of the country to seek adventure and this was a really incredible experience. If I was preparing one of these members from a formal PT standpoint, what would I want to be thinking about? How would I select the goal? How would I optimize? When do we compensate for these patients? So if you're preparing someone for adventure, we need to be thinking about all these things. BALT's successful theory on aging has been a really helpful framework we use very frequently in our division, the older adult division. And what we want to do is, Adventure is relative, right? So we're taking 20 members from Stronger Life to the Dominican Republic where they're going to go snorkeling, where they're going to go horseback riding, where they're going to be walking or running on the beach, they're going to be swimming in the ocean, they're going to be kayaking in the ocean, all these exciting things. But adventure is relative. So maybe the patient in front of you, adventure for them is going to their grandson's baseball game. that may be a big overwhelming task that you need to break down. Or maybe it's just going for a walk outside. Maybe you've got a primarily homebound population and going outside feels like a big adventure. So I am going to use this higher level adventure example because it's fun, interesting, and fresh for me coming off this trip, which was so much fun. But for you, know that all of these things are scalable and this framework is going to be relative regardless. of the functional level of the client in front of you. SELECTIVE OPTIMIZATION AND COMPENSATION So just a little bit more on this SOC model. So Selection Optimization and Compensation. So this has been a tenet of Lifespan Psychology and the process of development that entails Losses and gains of our patients over time. We know that in general, our patients who are not seeking fitness, who are going through this period of time where they're in a decline, if we can't interact with some fitness and get them active, we know it's gonna look like this. But for many of our clients that we're taking this fitness forward approach, there's gonna be gains and losses over time. And what we wanna do is we wanna learn how to partner with them in this aging process, knowing that there are some changes, despite our best efforts, things we can't change. We're really comfortable with things we know we can change, but we have a little more trouble when we bump into barriers and things we can't move forward. So this model, SOC, Selection, Optimization, Compensation, looking at the full lifespan and learning how to use these three tools. SELECTION So the first tool is selection. So when we're talking about selection and we're thinking about older adults and their goals and successful aging for them, we're talking about goals that matter to them, not these BS goals like get better, get out of the hospital, feel better. Those things are things our patients may report to us, but it's our job to dig deeper and figure out why and why they feel that way and what specifically that means to them. So finding that meaningful goal and what they want to accomplish, we've got to break it down and get as specific as possible. The more effort we can put on the front end with selecting a meaningful goal and really understanding what that means, it makes the rest of our job so much easier. When it's time to select exercises, we're trying to figure out what tests and measures we need to be looking at. It becomes so much more clear. So a good start, I'll give you an example. We had lots of members who were planning to go horseback riding for the first time, or first time since they were in their teens. And if I had that client in the clinic, I'm seeing them in the fitness realm currently, but if I was seeing them in the clinic, the questions I would ask based on this framework of selection are, when is this gonna occur? When's our goal need to be accomplished? I would also want to know what's amounting, you know, excuse me. So when's this going to occur? How long are you going to ride? How big is the horse you're getting on? How frequently do you want to ride while you're gone? What gate is this horse going to going to experience? Is this member going to just be doing a slow walk? Are they going to be trotting where they're going to be oscillating up and down which may stimulate the vestibular system? Are they going to be cantering? How much dynamic balance do they need? How much strength do they need to be able to hold their position on the horse? So based on the frequency, the duration, the size of the horse, how often they want to do this, this is really going to help us break down what our patient needs specifically to reach this goal. And reminder, we're going to go through this same process if someone needs to carry their groceries in. We want to select a meaningful goal for them, then we need to break it down. We need to have all the specifics possible at our fingertips. So we want to know the strength, the range of motion requirements, the endurance requirements, the balance requirements, the vestibular requirements, which in this case are very relevant. When you think about the movement of someone on a horse, they're going to be going up and down. That's going to be stimulating the inner ear system, the utricle and the saccule as they accelerate, decelerate. There's going to be head turning. They're on a beautiful beach riding a horse. They're going to be turning their head, looking at stuff or trying to talk to their friends or get some selfies going. during that time. So we want to be as specific as possible to figure out what in the world they are going to need to be able to accomplish this goal. So selection is the first piece. We want to select a meaningful goal to them and we want to get as much information as possible. OPTIMIZATION Once we have all the specifics nailed down, We're going to go on to the next step. And this is where most of us shine is optimization. So the first piece is selection. The second is optimization. Based on where this patient is starting, And the goal, we now have a start and a finish line. We've got to get accurate measurements at the beginning. Our CEO, Jeff Moore, is very famous for saying you can't make good decisions with bad data. We want to be specific of the conditions we're testing. We want to be accurate so we can actually see if we're making change in the future. Otherwise, we might as well not measure, by and large. So we want to be very specific with those measurements. But now we know This person wants to go horseback riding once. It's going to last about 45 minutes. They want to walk. They don't care if they canter or trot. They're going to be on the beach, so they're going to have to walk across the beach to be able to get there. So we now, we're going to say those are the specifics that the patient gave us. So now we're going to be looking at the range of motion of their hips. We're going to say, oh, these are going to be small island horses. There's not as much hip abduction required. We know that we don't have to get them stable in a seated position for a canter or a gallop. We just got to be steady in this seated position for 30, 45 minutes one time. And then we're going to, you know, hopefully the mounting situation we've asked about as well. Are they going to be able to go up steps unsupported to get on this horse? Or are they going to need, in the equestrian world, a leg up? Is someone going to come over and help boost them into position? So once we've got all that information, we've checked the range of motion, strength, balance, vestibular requirements, then we're going to go to work, right? We're going to challenge all of these different systems to reach this big, meaningful goal. range of motion that they need to really make this happen. We want to make sure that we're, you know, not laying on the table, kicking our legs, sitting, or outside of these positions that aren't relative to the goal. We want to make sure that these are big functional movements. We want to make sure that it mimics this movement and this activity as much as possible. Being in a seated position, can they go up and down, accelerate back and forth? There are lots of creative ways to do this on Swiss falls or if you're on, on a rolling chair going back and forth and adding some head turns. There's lots of ways we can replicate this. Even the mounting situation where we can use a high-low table and get really creative and maybe we're getting them onto a bolster or a Bosu ball, something like that. But during this optimization, we've got to make it as much like the actual goal as possible, as quickly as possible. That's going to help us with buy-in, And we know from motor learning, just in general, the more it replicates the actual activity and the conditions. I mean, heck, we can play some seagulls and some ocean music. We could do these things outside with distractions. There's lots of ways to layer in all the specifics that we gained from the first piece of selecting the goal. But once we know the optimization period, we've got to replicate that as much as possible. COMPENSATION Once it's time for the third piece is compensation. This is the part that we get really uncomfortable. Most of us in the rehab world, we want to restore function as much as possible, and that's not a bad thing. We want to do that, but sometimes we don't have enough runway. The patient doesn't come to us in enough time. We can't help them change quickly enough to meet that goal on time. And if we want the goal to be accomplished, we're going to have to compensate. Oftentimes, our OT colleagues are much better at this. They're like, hey, just use the tool. Let's make this thing happen. Most of us that are physical therapists, fitness pros, we want to see people get stronger and we get really uncomfortable when it's time to compensate. but there are simple ways, little on-ramps, like getting a leg up, practicing having someone help them get on the horse, versus saying, you know what, you just can't mount on your own, so I don't think it's a good idea for you to do this, or you don't have quite enough range of motion to be able to throw your leg up behind the horse, for example, so this is really out of the question, versus saying, hey, can we have someone support you? Is someone else going on this trip? Can you bring someone into the office and we can replicate this mounting situation to give them a leg up, swing their leg around the horse, and help them be stable. Heck, even sometimes we can have someone walk alongside them to help keep them steady. If the goal is meaningful enough, we can accomplish it with some compensation. So whether it's an adventure retreat, whether it's a patient that needs to walk outside, get thrown groceries, go to a kid's baseball game for the first time, adventure is relative to the person in front of you. Regardless of that, a great framework, keeping in mind that compensation and changes in capacity happen over time, our BALT's theory of successful aging. So we wanna make sure that we're selecting meaningful goals to the patient, We're optimizing all the systems, getting good baseline data, and then if all else fails, we need to compensate to make those goals happen. SUMMARY Team, I hope this was interesting. I hope this was helpful for you. If you're looking to catch us out on the road, We're gonna be in Newton, Kansas. I'll be there on the 16th and 17th, and then Madison, Wisconsin, we'll be there March 23rd and 24th. If you're trying to hop into one of our online courses, lucky for you, level one course is going to open up on March 13th, and then not long after that, we'll have level two. So I hope you enjoyed this. If you have any questions, comments, please drop them for me. I hope you have a wonderful day, and that's it for now, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 5, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the concept of viewing the human body as a vehicle or mechanical system versus recognizing the underlying physiological systems in place that make the human body adaptable & changeable. Zac encourages listeners to adopt loading a primary intervention as a way to cause physiological change in the body in a manner that could not be done with a vehicle. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ZAC MORGANGood morning, PT on Ice Daily Show. I'm Zac Morgan. I'm a lead faculty here at the Institute with Cervical and Lumbar Spine Management, bringing to you all this morning some concepts on physiology versus physics. And I would say physiology greater than physics is the title of this episode. Before we dive into the actual episode, I kind of wanted to talk through some of the definitions of these two sciences. Do you think it'd be helpful to frame our conversation this morning? And before we even do that, I want to start out by saying that really using physics to describe why someone develops symptoms or why someone gets hurt, I think it could be maybe one of the most unhelpful things we've ever done as a profession. So let's start out with definitions, and then I want to unpack that big statement that I just gave you. So from the physics perspective, let's start there. Physics is a natural science. Its studies matter. It's foundational constituents. and its motion and behavior through space and time. So that's the definition of physics. When you think about physiology, it has a different definition. Physiology's definition, it's a branch of biology. It deals with the normal functions of living organisms and their parts. It's the science of how the body and its parts work and function. Physiology covers a multitude of systems within the living organism, how cells, organs, and tissues work together and interact. The point here isn't that physics are completely irrelevant when it comes to why someone develops symptoms. There is certainly a part of the puzzle. But the unipolar commitment to physics from whether it's us as therapists actually understanding why someone develops symptoms or when we're actually describing to someone why they develop symptoms, that unipolar commitment to physics, it's devastating in the clinic. AN OVERCOMMITMENT TO PHYSICS So let's start with why I think as therapists we tend to overcommit to physics. Physics, while on the particle level, are very challenging to understand, when you think of physics on the big picture level, they're actually not all that challenging to understand. Humans, we tend to believe the things that we can actually lay our eyes on. When we can see something happen, when we can interact with it, we tend to believe those things as humans, and it makes sense because we can actually see them. And when things happen right there in front of us, it's just so much easier to believe them. We can observe the physical universe. We can test these things on ourselves. You think about things like gravity. Gravity is a physics concept. It's really easy to test gravity. You can take basically any object, drop it, and you can observe that object fall towards the center of the earth at a specific time or a specific speed. It doesn't really matter the object. They all move towards the center of the earth at that same speed. we can observe that, we can interact with it. So it's really easy to believe in gravity and it's really rare that you would interact with someone who doesn't believe in gravity. From a physics perspective that's easy to observe. Now let's extrapolate that more towards what we see clinically. I think a lot of times people will use these examples of things like vehicles. That's a very common example for the body. People will compare the body to a vehicle or tires to joints. And you think about like tires, that's a physical object and every mile that you drive on your tires, that tread wears out a little bit more over time. You can watch that happen. You look at the tread on your tires and you can see that it's wearing out with each mile that you drive. Really the only way to avoid your tires wearing out is to not drive as much. So we know that that stuff happens because we can watch it happen, and so we tend to believe in that. So it's so tempting clinically when you look at something like an imaging study that one of our clients comes to us with, and you can look at whether it's an x-ray, CT, MRI, ultrasound, you name it, really any type of imaging, and we can observe those tissue shapes on that image. And when we look at those shapes, we can attribute pathology to the shape of those tissues. It's really easy for us to observe that and say, hey, I bet if that gnarly looking intervertebral frame and that gnarly looking joint were to move through space, it would be painful because it looks really, you know, disrupted. It's not smooth. There's a lot of pressure or a lot of compression in that area. We can observe these things on imaging and then kind of extrapolate that out to the symptom presentation in front of us. And this is what's so devastating in the clinic. While it is a piece of the pie in a lot of our clinical cases, it's certainly not the whole pie. It's only one small slice. PHYSIOLOGY IS THE TICKET When you think about what the rest of that pie is, it's physiology. What environment that those tissues are living in. That's really where the ticket is. I think because it is so easy to wrap our heads around this concept of physics, it's so easy for us to observe it. We have tools that make it easy to observe. It's easy to make a lot of attribution of symptoms to those concepts. And so this is really challenging to our patients. Like you think about what that does to a patient's psychology, like it's devastating. for those people. People don't understand much about their bodies and so when we give them these descriptions they often catastrophize the symptoms or they catastrophize the physics. They worry that it's going to be like what they've seen in their tires where every mile they run their knee ends up with a little bit more osteoarthritis but yet we know that recreational runners have less prevalence of knee osteoarthritis than sedentary folks. So it's clearly not the same as our tires. That's not a physical object, it's a physiological object. It's much, much different. So again, physiology deals more with the ecosystem that these tissues live in and that's where we want to put our attention moving forward as a profession if we really want to have a chance at helping people conceptualize their body and and helping people feel stronger within their body and helping people understand the benefits of exercise. OUR BODY IS AN ECOSYSTEM So let's talk a little bit about that. When you think of those examples like a tire or a vehicle, the big thing that those things lack that our body has are things like a vascular system. Like your vehicle doesn't have a vascular system. It's simply just built by engineers. And like I said, each mile that you drive is one less mile that you can drive in that vehicle. Sure, you can maintain the vehicle. You can rotate your tires, and that will make them last longer. You can change your oil, and that will make your engine last longer. But at the end of the day, shy of not doing anything in that vehicle, it's going to break down over time. Our body is completely different. It has a vascular system. It has intra and extracellular fluid that are full of nutrients that are built to help your body adapt to the stimulus in front of it. It has an immune system that creates specific responses to stimuli that create a more robust underlying system. That can't be said for a vehicle. So when we compare our body to a vehicle, our clients often don't have that understanding that our body is actually full of a lot of adaptations that we've developed over a long period of time that are inherently built within us that help us continue to move forward. They help us build a more robust vehicle. That would be awesome if when you bought a car and you used it and you maintained it well, if it actually It actually lasted longer for every mile that you drove. That would be great. We would all want that car. But over time, cars break down. Over time, if our body has the right ecosystem underlying it, it builds more resilience. You think about like our MMOA crew, so Modern Management of the Older Adult, and you see some of these stories that they share where older adults start to put on so much capacity, so much strength, so much cardiovascular endurance over time. It doesn't make sense. If our vehicle was an actual vehicle made of physical objects that we could interact with, it should break down over time, but we know the physiology drives function. And so when we put it in the right ecosystem, and when we allow it to adapt over time, we get way more out of it. I mean, think about it. Your tire, it doesn't get nutrients from the fenders. The rims don't provide it nutrients. The air within those tires don't allow it to build more tread over time. Again, I would love it if that was the case, because we wouldn't have to replace these things, But our bodies, they do have those things. The vascular system is built for that. The immune system is built for that. Our bodies are so much different than vehicles and when our clients leave our interactions and they have in their head that they're going to break down over time, they end up opting out of activity and that's exactly what we want to avoid. Like you think about if someone feels the that every mile that they run is one less mile that they can run on their knees, or every deadlift that they do is one less time they could pick their grandkid up, think about what that does to them psychologically. It makes them avoid those activities, and so they wind up missing out on all these physiological adaptations that would extend their quality of life and lifespan. That's a huge mistake as a profession, and we need to move dramatically away from that over time. It's easy to observe problems in people's bodies. We can make attributions of the way someone moves with pain. You can look at those imaging studies and say, well, if that nerve root's that compressed, then this person's probably gonna be in a tough spot. But team, it's not like that in the body. The body is so well built to adapt over time. I'll never forget the first time I heard Jeff Moore say, back pain is not a tissue shape issue, it's a tissue health issue. And it just hit so hard in my head when I heard him say that for the first time, because it is that. I mean, you can look at the Brzezinski study, you can look at the Nakashima study, that's lumbar and neck kind of respectively, and you can see that people with no symptoms whatsoever have all sorts of physical deformities in their spines and yet they have no symptoms whatsoever. Over time, we're seeing the same concept throughout the rest of the body. Like I said, the extremity crew does a great job of pointing out the inadequacies often of imaging studies throughout the rest of the body. And team, seeing that over time, it is becoming more and more clear that these physics examples, while they're easy to understand both for us as clinicians, but also for our clients that we're teaching these concepts to, while they're easy to understand, they're such a small piece of the pie, but they have catastrophic responses within people's psychology. People tend to catastrophize those things. So we have to focus on physiology. LOADING CHANGES THE UNDERLYING PHYSIOLOGY And team, I think our treatments, what we choose to do with clients reflect this. When you think about, if you haven't taken the extremity course, you have to because they do such a wonderful job of framing things like tendinopathy. From a physics perspective, sure, you could look at a painful tendon, you could look at a histological study, you could look at an ultrasound sometimes, and you can see that those collagen fibers are disrupted from a physics perspective. But going in and physically stimulating those things isn't what creates adaptation. It's not cross friction massage, it's not those things, it's load. And why does load work? You take a relatively poor vascular supply, but still a vascular supply, and you force angiogenesis to that region, you get that tendon to adapt over time. You change that underlying physics. Vehicles don't do that. So we have to get our heads wrapped around how these things are different so that we can start to push our patients forward and help them work through a little bit of discomfort, which is a big part of tendinopathy management. People need to know that they're going to be okay and that their body is built for these stimuli and it responds in a way that is tremendously different from a lot of the other things that we can observe in the universe. It's so cool that our body is built for that. You think about spine management. We talk a lot about this on the weekend. Often a nerve root is in a really unhelpful environment. There's a lot of concentrated inflammation in the region and the person's reporting a lot of distal symptoms when that's going on. We do things like repeated motions or spinal manipulation or some sort of treatment to intervene on that region and we draw a lot of fluid in there and drop that concentration. Team, that is so amazing that our body can do that and that the person can leave feeling centralized and feeling so much better. But we didn't push the jelly back in the donut. It wasn't a physics issue. It was a chemical soup bathing that region. And when we draw fluid into that region, it feels better. The person feels dramatically better. ENGINEERING VS. BIOLOGY Team, We have to change our perspective. We can't keep comparing our body to a vehicle. Vehicles are built by engineers, and they're really well built, and they're built out of physical materials that we can all observe in the universe put together, and they all have specific wear rates. There are things you can do that might slow that wear rate down, but at the end of the day, they do wear out over time. Our bodies are biological. They're physiological vehicles, and within those, they are well built. They've been built over thousands of years. to heal, to move forward. They've been built for the one specific purpose of survival. It's what makes us so different from everything else in the universe and it's why a huge part of what we do is address this underlying physiology. It's about the ecosystem that the tissues live in. We have to move forward as a profession and this is why things like fitness forward care make so much sense. Because it goes so much far beyond that local tissue, like you think of the environment and you think of when you do address this fitness forward method of care, now you're improving metabolic systems, cardiorespiratory systems, you're improving all systems team. And at the end of the day, that is a huge deal for us. SUMMARY I just want to point you all in the closing moments here towards a couple of upcoming lumbar and cervical spine courses if you are looking for them. A few here in March for cervical, we've got Kuna, Idaho. That one's filling up pretty quick. And then same deal for so that one's March 9th and 10th over and that's close to Boise, Idaho. March 23rd and 24th Longmont Colorado also filling up so if those are on your list make sure you jump in those pretty soon. Casper Wyoming has a few seats left as well. If you're looking for lumbar spine management Brookfield Wisconsin that's right outside of Milwaukee at Onward Milwaukee. to see you on the road. We love having these conversations in a lot more depth on the road, a lot built into those spine courses, but have a good rest of your Tuesday. We'd love to interact with you all here on this thread if you have any questions or thoughts to add to today's podcast. Thanks. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 4, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses female fertility, including what physical therapy interventions are not currently supported by research for use in assisting with conception but also offers some key ideas to come alongside this vulnerable population to assist them within the limits of our scope of practice. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. I'm trying to get YouTube up and running. I don't know why it's telling me that this isn't available, but I am gonna give it another go. If you don't know me, my name is Christina Prevett. I am one of our division leads for our pelvic division as well as our geriatric division. And today I wanted to talk to you all a little bit about our role in fertility. So we are working on our level two, finishing up our level two course content. And one of the areas, our level two course is talking about how to create a fitness forward approach to pelvic health in a variety of different conditions. And so one of those conditions is around fertility, infertility, birth control, that type of space. And I have thought, an astronomical amount about where our role is in fertility, fertility management, and infertility. And so to kind of give context to this, like it really has been in the last five or ten years where we have started to advocate for ourselves as a member of the obstetrical team, right? So we really advocate in pelvic health, especially with rates of pelvic floor dysfunction and pelvic injury that happen around the pregnancy and postpartum period, that we have a role to play from a rehab perspective when it comes to female health and male health in the fertility space potentially. And so we have kind of made this jump where we are now very well known for being in the obstetrical space, helping with birth prep, helping with reducing perennial trauma, rehabbing from perennial or abdominal trauma as a consequence of a C-section or a vaginal delivery. And so we really have etched our role in a wonderful way in the obstetrical space. And so it doesn't really seem like that big of a leap for us to think about coming into the fertility space, right? Because it's all kind of centered around the pelvis. It's an area where there is a lot of misunderstanding. There's a lot of grief. There's a lot of trauma that happens. And so we are seeing more and more of our physical therapists and other allied health providers start advertising services in fertility. FERTILITY GONE WRONG And so Before I go into some of the research in this space and where we at ICE stand in this space, I want to tell you all a story about where this can go terribly wrong. So I owned a physiotherapy clinic and a gym up in Kingston, Ontario for five years. And I had a woman come in to see me and she was looking for a consult for the gym. Her husband was in the military. He had done multiple tours and they were having trouble conceiving. So they had done multiple rounds of IVF, neither of which had been successful. I think they had done two rounds and he was currently deployed and he was struggling with mental health stuff. He was struggling with PTSD. She was, as a consequence of the healing process, was also struggling with a lot of mental health and anxiety, trying to be that person for him. So it was a really complicated situation, their fertility journey. And so they were, she was coming in saying, you know, well, if I can get in better shape, then maybe it's going to help this next round of IVF. And so I was talking about her history with exercise, and then I was talking about her history with rehab, just trying to get to see if, you know, she would want to come into one of our programs and what that program may be. And she told me that she was seeing another provider and was getting adjusted three times a week for fertility. And so I kind of asked her the situations and circumstances around that. And she said that, you know, I am willing to try anything to get pregnant. It's what I want more than anything else. And so she's like, I went to this provider and they did a x-ray of my entire back. And I was starting to have low back pain, which like infertility, trauma, mental health, baby that they want that they cannot have. Like her pain was focusing around her pelvis and her low back. And provider x-rayed the entire spine and said, oh, here it is. Here's your infertility. It is at your neck and you have a issue at C5, C6, and there's an innervation right there, right to the uterus. You're going to get adjusted by me three times a week for six months. And I guarantee you the next time you have IVF, it's going to be successful. And I have never raged internally in a conversation so much in my entire life. It was a really tough spot for me to be because I was a person that she had never met before. Then she was asking about gym-based services, did not even know that I was a physical therapist because that was not the role that I was playing in this interaction. And she was in such a vulnerable space that if I came in super hot and was like, that is not true, then I would have potentially severed a line of hope for her that she had developed, but oh my goodness, how unethical is it for you to make promises that you cannot keep? And so I tell this story to give the frame of reference that I think about when I make statements about where we lie with respect to our role in rehab. FERTILITY: A VULNERABLE POPULATION So the first thing that we always have to think with this, and this is in any space where we are trying to kind of go into new markets, and I am not against being in new markets, but this population in particular is a very vulnerable population. This is a population where individuals are feeling like their body is failing, The emotional and mental load of fertility is high. The shame and guilt and spiraling and social context and people asking you if you're gonna be having babies soon even though it is something you want more than anything else in the world and it is not happening. The feeling of your body failing you at something that you quote unquote should be able to do. These are all things that make us need to think very clearly about the statements and promises that we make as we consider niching into this space. The second filter of this is from a manual therapy perspective. We have no evidence that our manual therapy increases chances of conceiving. So we cannot say that we are changing the orientation of the uterus to make for a more hospitable environment. We cannot say that. It is not ethical for us to say that. One, because we have no evidence that there's going to be any movement of really strong really anchored organs in our body where we are placing hands on people right like our evidence is that we are horrible at landmarking exactly what what muscle we are on we are not doing a hip flexor release and and changing trigger points in our muscles We are not able to really localize our manifs and we're really interacting with the nervous system. So if we can't even do that at the superficial musculoskeletal system, why do we think that our manual therapy is going to impact our organs? So we need to be very mindful about what we are doing. And so the first thing we have to filter is the ethics. THERE IS NO EVIDENCE FOR THE USE OF MANUAL THERAPY TO IMPROVE FERTILITY The second thing we have to recognize is that we are currently going into a space that does not have evidence for our manual therapy techniques to change our fertility. That is number two. That is not to say that this evidence will not develop. It is a new area, but we cannot say, if you come to see me, you're more likely to get pregnant. We cannot say that. We can say that we are exploring different modalities and we can have lots of conversations about fertility. We are educated providers in the fertility space, but we need to be very clear with our communication about what we can promise to individuals because it is unethical for us to say that this is gonna happen. Three, there is a placebo effect of somebody taking care of you when you are in such a vulnerable space, right? There is one of the biggest and best things that we can do as rehab providers is that we are able to have space, have time to listen to our people and cater to and speak toward the emotional side of what they are going through. A lot of the interactions with our medical space when it comes to fertility are very much focused on the physiology of it, right? Because that is what they are trying to remove barriers for from a physiological perspective, whether it's on the male or female side, and allow fertilization to occur in successful implantation. But we need to be very, very mindful. So to finish off this episode, what can we do? Where do we have evidence around a potential role in rehab. Okay, so in order for conception to happen, right, we need to have, on the female side, we have to have an egg that is released on a monthly basis, right, so we have to be ovulating. That egg has to travel into the fallopian tube. Sex needs to occur with ejaculation so that the sperm is meeting the egg in the fallopian tube. And then the fertilized egg needs to travel through the fallopian tube and embed into the uterus and have the hormonal environment, have the enrichment of the uterine walls in order for that implantation to be successful and maintained. Okay. So the first piece in our fertility is the ovulation space. And if you've been following our pelvic crew for a long period of time, you know that one of the areas around ovulation, and we are not medical providers, so we are not looking at their hormone levels. We are not seeing if luteinizing hormone is creating a estrogen surge that allows ovulation to take place. But we are one of those providers that oftentimes can catch relative energy deficiency in sport. So We can have conversations that individuals are amenorrheic to be a resource dealer and a primary care provider to refer on if we think that something is going on with their menstrual cycle that has to do with their nutrition or that they are not ovulating as a consequence of low energy availability. So from that perspective, if they're not getting their period, like we may be that resource dealer to a registered dietitian or nutritionist that has a scope of practice that works with potential disordered eating, potential issues with fertility, and that has a more broad scope of practice to be able to speak to those levels, right? We could be referring to our obstetrician if individuals are thinking of conceiving in the next six months and they don't have their period, let's get them to get their doc to do blood work or let's like get earlier on that process and then send that letter and say, you know, I've been treating this person for musculoskeletal issues. Like I am a little bit worried about relative energy deficiency in sport and we can make that connection. We can also educate on the menstrual cycle and what is required for fertility to take place, right? We can be talking about when our fertility windows are, right? We are not reproductively positive or we're not able to have a fertilized egg at all parts of our cycle, right? Ovulation occurs between day 12 and day 14. So that window, usually between 11 and 15 days of your cycle is like your chance window of getting pregnant. So we can be educating on that. We have evidence for that. Medically, in our scope of practice, we can absolutely be talking about that physiology. We have a role in that space and we have the time to sit down with our people and talk about tracking your menstrual cycle and recognizing some of the signs that you might be ovulating, like changes in cervical mucus and body temperature and those types of things. The second piece where we have a role is that sex needs to be successful in that women are able to have penetrative intercourse and ejaculation needs to occur. And so I'm going to do an entire second episode on male fertility and male fertility factors and our role in male fertility, because fun fact, 30 to 50% of infertility cases are male factors. And yet all of our information is on female related fertility factors. And so in order for sex to be able to happen, individuals have to not have pain. and they need to be able to have penetrative intercourse. So here's another area where our role can be quite massive, right? In really extreme cases of pelvic pain or vaginismus or vulvodynia, there are circumstances where the pain is so severe that individuals do artificial insemination or other assisted reproductive technologies because they are unable, without significant severe pain, to be able to have penetrative intercourse in order for ovulation or fertilization rather to occur. So we have a role in that space as well. And this is where our evidence is, right? So if individuals are having pain with intercourse or on that guarded high nervous system response, right? Parasympathetic tone is a very important part of our arousal response. then we can be interacting with that nervous system and we can be working on pain-centered modalities in order to try and allow individuals to be able to participate in intercourse in order for individuals to be able to successfully, hopefully conceive. Where some individuals, and this is gonna be long, so I'm gonna try not to rant too much, where we're taking a bit too much of a stretch for where we are at in our opinion, is around the hypertonicity and what the hypertonicity of the pelvic floor is doing from a hospitable environment for fertility and saying, well, your body might not be ready. Let's talk about our vagina and our pelvic floor muscles and our cervix. Our pelvic floor muscles are here. Our cervix is here at the top. So once sperm has passed your cervix or has gotten through that, and you, I'm not saying that your penis goes past your cervix, but what I'm saying is when you are having that ejaculation, that the sperm is going to go up towards the cervix. Once you have passed that pelvic floor layer, the pelvic floor has nothing to do with our fertility, right? So that hypertonicity piece, likely has no impact outside of pain responses on successful fertilization of an egg, right? Because that sperm is gonna go up towards the cervix and sneak through to try and be able to ovulate that egg or to be able to fertilize that egg like really quickly and the muscles of the pelvic floor are not impeding sperm from getting there. So again, kind of coming full circle, like our role is in education and pain management from where our evidence stands right now. And if we are going into these areas of gray, we need to be mindful of our language. And then we need to really think critically about what do we truly think is going on? And is some of my manual therapy interacting with that nervous system, bringing that stress response down, getting us into more parasympathetic tone, or am I moving an organ? That's where we need to be critical and we need to be honest with our people. We talk about all the time with diastasis recti rehab that I cannot make any promises about what your belly looks like at rest because all of our interventions are when your belly is contracted. I can get you stronger. I'm going to be able to have more function. I'm going to be able to say this, this, and this, but I cannot promise you that your belly is going to look different or that it is going to look the way it did before pregnancy, nor would I really expect it to. I am very clear with that communication. We need to be mindful and do the same thing when we are thinking about our role in fertility. All right. That was a bit of a rant. I'm so sorry. I went a little bit long, but… This is really important. SUMMARY If you want to talk more about fertility, that is in our level two course, which means that you'll have to take our level one online course. Our next cohort, which sold out a couple of weeks ago, it starts today, which means that our next cohort is starting the week of April 30th. So if you are interested, let us know. Our next cohort of level two that's gonna dive into all this literature is in August. So take that level one, get into that level two, and I am so excited to be able to deep dive into these spaces a little bit more. All right, have a great week, everybody. Talk soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 1, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the strategy behind helping athletes & patients consider adding extra training volume on top of their normal exercise routine. Why should we add it, when should we add it, how should we integrate it into our normal training, and who is appropriate for extra volume? Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALLWelcome in, folks. Good morning. Welcome to the P-Town Ice Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday. It's the best darn day of the week, we would argue here, from the Fitness Athlete Division. Those of you working with crossfitters, Olympic weightlifters, powerlifters, endurance athletes, anybody who is recreationally active, part of that 10% minority of the human race that exercises on a regular basis enough to produce a meaningful health and fitness effect. We're here to help you help those folks. INCREASING TRAINING VOLUME So here on Fitness Athlete Friday, today we're gonna be talking about increasing training volume. A hot topic, especially this time of the year, the CrossFit Open has begun as of yesterday. This is often the time of year as people go through the Open, maybe they did not perform as they thought they would, and they begin to ask questions about how can I make my performance look more like someone else's, right? So 24.1 was released, a couplet of dumbbell snatches and burpees over the dumbbell. I just finished it this morning, just finished judging a few hours as well. First workout, usually very approachable. People maybe have questions of how can I get faster as we get into the later weeks of the Open. Heavy barbell comes out, high skill gymnastics comes out, people begin to have more questions. What else could I be doing besides coming to CrossFit class? This relates to other athletes as well. Endurance athletes who maybe want to get faster in their mile time, faster in their race times, stronger to have less injuries. All of those questions tend to come up of what else could I be doing? So today we want to focus on asking in the concept, in answering the question of increasing our training volume. Why should we do that? When should we do it? Who is the person that's appropriate for it? And then how should we actually begin to introduce increasing training volume? WHY SHOULD WE INCREASE VOLUME? So let's start from the top. Why should we increase training volume? I think this is really important and that's why I have it as the first point today. often folks are maybe disappointed with their performance in the open or a recent road race or competition or something like that and they want to do more training and just adding in more training without understanding why we're doing that training or having a goal for that training can be a very rocky foundation to build upon and can really ultimately maybe set us up for an unsuccessful addition of volume that doesn't meaningfully improve our performance and maybe leads to an increased risk of injury for no reason. because we don't really know why we're training for more volume, right? Just doing more CrossFit metabolic conditioning workouts or just doing more accessory weightlifting or just running or biking more miles without a goal is really just adding meaningless volume to the equation. We need to understand why should we do this. So when folks come to you with that question of What should I be doing extra outside of my running or outside of CrossFit class? We should be asking back, why do you feel the need to add more training volume in? What specific deficit are you understanding or do you feel has been recently exposed that we need to add more training volume in? To just improve general fitness, with those folks we would say, Be patient, right? Continue going to CrossFit class. Continue if you've only been running for a year or two, continue your normal running training, right? Understand that high level performance often comes with most folks. When you look at them, they have a large training age, which means they have been doing whatever they're doing for a long period of time. And so expecting to close that fitness gap in just a couple of years by just adding in more volume is not really an intelligent way to approach that. But if we have identified some specific deficits, then that can be an argument to maybe add in some extra volume. So, folks who are maybe long endurance athletes who are noticing the longer my runs, the slower I become. I perceive that I maybe need to add in some speed work. Folks may be doing CrossFit that say, you know what, I'm great when the weight is body weight or when it's a low to moderate weight, dumbbell, kettlebell, barbell, whatever, I'm okay. But as we get heavier, I perceive that my strength, my upper limits of strength is limiting me from moving the weights around. In CrossFit class, where I'm perceiving that if I added in some more resistance training to whatever I'm doing, Maybe my tissues would be healthier or I don't have some of the skills and I would like to begin to practice them, right? I would like to practice double unders outside of class. I would like to practice pull-ups or muscle-ups or handstand push-ups outside of class or maybe add in an extra day of running if I'm a CrossFit athlete. So understanding why we're adding volume in is very, very, very, very important and it should be to address a specific perceived deficit and all the better if we can actually objectively test that so that we know if we're starting to make up ground on that deficit or not with the extra volume that we're being asked to add into our programming. So starting with why is very important. WHEN SHOULD WE INCREASE VOLUME? The next question is, when should we do this? I would argue that we should really only add in extra training on top of what we're already doing when we feel like our current training has plateaued. Of that person who says, I have been going to CrossFit six days a week for 10 years, and I feel like my ring muscle ups are not getting any better. I feel like I have literally not added a pound to my max, clean and jerk, whatever. When a perceived plateau is there, That can be a good argument to begin to add in some extra volume, especially those folks, uh, endurance athletes as well. Like, Hey man, I have been running for a decade and my marathon pace got faster, faster, faster the first couple of years, but it's been pretty much the same pace for the past two or three years of races. I feel like something needs to change. Or, again, those folks who do not have a skill. So that's when we begin to action that extra volume. For me, over the past year, my extra volume looked like adding in some more running. Doing pretty well, pretty happy with my CrossFit performance, but when runs showed up, especially in workouts where the runs were longer, 800s, miles, workouts like Murph Hero workouts with a lot of running, really, really, really impacted my performance despite doing pretty well on the other stuff that wasn't running. So beginning to add in extra running outside of CrossFit class. HOW DO WE INCREASE TRAINING VOLUME? Now, how do we do this? This is as important as why. How do we add in volume in a very intelligent manner? The key is with anything else, just like when somebody first began an exercise program, we need to start low. We need to go slow. We need to stair step this volume. A lot of folks perceive a deficit or otherwise feel like they want to add in more volume and they just do more of what they're already doing. And sometimes they do it every day, right? The person who leaves CrossFit and goes to Planet Fitness and does an hour on the stair stepper. or does an hour of machine weights, whatever. Adding in a big chunk of volume, again, if we don't have the foundation of why and when we should be doing this, can be a really unintelligent decision. So we should do this carefully. For me, this looked like one extra day of running for a couple of weeks, two extra days of running for a couple of weeks, so on and so forth. Using a running coach to very carefully and controlled add running volume in on top of working with a nutrition coach to make sure that I was fueling appropriately. So making sure that if we do come to the decision that we could benefit from extra training aside from what we're already doing, that we do it very, very, very, very carefully. What we're trying to do adding in extra exercise pieces is we are trying to push ourselves maybe into a short period of what we would call overreaching, functional overreaching. We're pushing the margins just a little bit, but we also need to be mindful of all the other training that we're doing, and we have to be careful that this functional overreach does not become overtraining, right? We need to make sure that if we're adding an extra stuff, we respect this new volume. We do it carefully. This extra volume should come with a progression in a deload. So for example, my running coach always had me on four week cycles. where every fourth week was a deload, added a little bit of miles every week for three weeks, and then a deload, add, deload. That deload week is a chance to give my body a break, go back to essentially my pre-running amount of volume, but it's also a great week to assess how did my body respond to the previous three weeks of training. Should we continue with the next block of extra volume? Or should we stay where I was at? Or should we maybe even regress a little bit because it was a little bit too much of an overtraining feeling rather than that functional overreach? And again, being objective with why are we doing this can really help us know did that little burst of extra volume create a change? Did mile split times go down? Did a race time go down? Did strength go up maybe two pounds or five pounds or whatever? Can I do two muscle-ups now instead of one muscle-up? So on and so forth. Having those objective indicators lets us know, okay, we're making the progress we want to see, and as long as everything is feeling good, we're good to continue going to that next step on the staircase of increasing volume. And when we think about how we add in this training, most importantly, we have to ensure that this extra training does not impact the normal training, right? The worst thing you can do is have your extra volume, make it so that when you show up to your normal training, so in my example, I never wanted to get to a point where my running made it so that I could not come to CrossFit, right? That's a dangerous spiral to get into, where now my normal baseline strength and conditioning program can't be performed, and now I'm adding extra volume even though I can't handle the current level of volume I was already doing before I added in my extra training. So being sure that whatever we're training at baseline, CrossFit, weightlifting, running, whatever, that does not become impacted by whatever extra stuff we're doing. Now that being said, if we're feeling good, we feel like we're making progress, we are objectively making progress, and our normal training is not impacted Okay, continue to either maintain that extra thing, whatever you're doing, or maybe even progress it a little bit. WHO IS APPROPRIATE FOR EXTRA VOLUME? Now the final part of the equation is who should do this? I would argue the answer is very few people should do this. Who is the type of person that is appropriate for extra volume? that person should be incredibly consistent with whatever they're already doing, right? Which by default erases most of the people who want to do extra volume. A lot of people perceive a gap in fitness between maybe themselves and their friends in CrossFit class or themselves and their friends and their run club or whatever. They want to close that gap even though What they don't want to hear is that maybe the gap there is because they're already not consistent with what they're doing, right? They hit the snooze alarm a couple days a week on CrossFit class or going for their run, right? I want that individual who is already incredibly consistent with their normal training. They are training four to six days a week, every week. They understand the importance of active recovery and rest days. They are prioritizing their sleep and their nutrition. The volume means nothing if we can't match that volume with an appropriate dedication to recovery. Again, we're trying to create bouts of small windows of functional overreaching. We're trying not to throw somebody into a downward spiral, a death loop of overtraining where they're going to be at increased risk for injury, where their fatigue, their soreness, whatever is going to impact all of their training, not just the extra volume that they're now doing. Most people are not consistent enough with what they're already doing to consider taking on extra volume. And I think that's tough to hear, but it's the right decision. for you as the coach, the clinician, whatever your role is, to have in a conversation with that athlete. If you are only coming to CrossFit on Monday, Wednesday, Thursday, you sleep in on Tuesday because Monday wrecked you, you sleep in on Friday because you're sore, you don't come to the gym on the weekend, let's see what your fitness looks like when you're consistent with your current fitness routine, and then maybe later on we can revisit talking about extra volume. I have found in my coaching career that the folks who come up to me and tell me, hey coach, I'm ready for butterfly pull-ups, happen to also be, coincidentally, the people who maybe can't even do strict pull-ups, right? The folks who are able to tolerate extra volume, extra skill progression, are the folks who are already very consistent and it's very clear that they, because they are consistent with their normal level of training, recovery, attention to their sleep and diet, They are aware, and I am also aware, that they can probably handle extra stuff, and that the people who want it really, really, really, really bad are almost always likely the people that should probably not do it because they are so inconsistent already. CASE EXAMPLE: RYAN A really good example I have is our friend here at the gym. His name is Ryan Battishill. You may know him. He develops a lot of your websites. He's a website developer by trade. He's a member here at our gym. I love how calculated and intelligent he is with just a little bit of extra training every day after class. So I want to tell you a little bit about him and then tell you the volume that he's added in in the results. So Ryan's been doing CrossFit for five or six years now. He has a history of running as well. He has a good morning fault squat. So a very kind of hingy squat. It tells us there's maybe a deficit in the quads, wants to get better at gymnastics, and wants to train for a half marathon as well. So, a lot of different goals, but it's good. Again, why are you adding extra volume? Are you just doing it meaninglessly, or do you actually have a goal? Okay, we have a couple of goals here. We want to improve our foundational lifts, we want to improve our back squat, our deadlift, We want to improve running. We want to improve our gymnastics. Okay, good. We have concrete objective ways to know that volume is working. What does that extra volume look like? And I think you would be surprised to hear that his extra volume is about 10 to 15 minutes a day after class. It's nothing crazy. One day he does an EMOM, usually a 10 minute EMOM of strict pull-ups and push-ups to help his gymnastics foundations. One day he focuses on front rack barbell step ups to focus on quad strength. Another day he does hip thrusts to work on his posterior chain and low back strength. And a fourth day of the week he adds in a couple extra miles of running. Nothing he does conflicts with his ability to come to CrossFit five days a week. He's a Monday through Friday regular, very consistent with five days a week of CrossFit training, very consistent with his nutrition, very consistent with his recovery, right? Somebody that's getting on most nights, eight plus hours of sleep, getting plenty of fuel as well. What are the results? A lot of people might look at the work he does and say, there's no way that 10 to 15 minutes of extra work could translate into anything meaningful, right? A lot of us look at extra volume, we think, if I want to be better, I need to run five miles extra a day, I need to do an extra hour of CrossFit a day, right? I need to do more and more and more volume instead of really intelligently planned extra accessory work. Over the past year of adding in that extra volume, he has broken through plateaus on his back squat, his deadlift, and his bench press from all of the strict gymnastics, the front rack step ups, and the hip thrusts. He has improved his running, even though he's already a great runner, in accordance with his goals to be able to run and complete a half marathon. and his gymnastics are certainly becoming on another level. His kipping pull-ups, his toes-to-bar, his muscle-ups, his handstand push-ups are all also improving accordingly because of his focus on strict gymnastics work. So I hope from that you glean that when we're talking about adding extra volume, it doesn't need to be this grueling stuff. It doesn't need to be very high-intensity stuff. It just needs to be intelligently designed in a way that does not affect our current training, And that puts us in a short state of functional overreaching, but does not become this long-term overtraining issue. Understanding that as we increase that volume, our nutrition, our calorie intake should increase as well. And we definitely need to make sure that our recovery is on point because we're now taking on extra physical volume that our body will need to recover from. SUMMARY So extra volume, why should we do this? We should do this only to address a specific perceived deficit that we can objectively measure the impact of extra volume on. When should we do this? When we have perceived a plateau, right? If every time we're testing a lift or testing a mile pace or a 5k pace and we are still getting faster, getting stronger, whatever, we have not yet reached that plateau. And so I'd argue it's not yet a time to consider taking on extra volume. If we do decide extra volume, extra work, extra accessory work is appropriate, how should we do that? We should do that very carefully. We should do that as a stair-step approach. We should do that in a manner that we can reassess the impact of our extra training. Is it actually working? And we should do it in a way that our normal training is also not impacted. We should never be skipping our normal run because of our strength training or our speed work. We should never be skipping CrossFit class because of our extra running or our extra accessory work that we maybe do before or after class should not impact our normal training. And then who should do this? Again, I would argue a very small amount of people should actually do this. Folks who are already incredibly consistent with their normal training routine, who are training four to six days per week, understand and are consistent with recovery, right? The stuff that happens outside of training, diet, sleep, nutrition, recovery. and folks who are aware of the nutritional goals are meeting them and are also aware that adding extra volume is going to increase the demand on how much and the dedication we have to our recovery. And then finally understanding it doesn't have to be crazy high volume, crazy high intensity to have an impact. 10 to 15 to 20 to maybe 30 minutes of extra work just a couple of days a week can go a really long way if the extra volume is done in a meaningful manner to address those extra deficits. finishing a metcon and doing another metcon is usually just going to result in that metcon being of even lower intensity that you may have to scale the weights and the ranges of motion more rather than coming over and doing some front rack step-ups or doing some strict pull-ups or doing some sort of skill practice or really judicious strength piece or run piece, cardio piece, something like that, right? Extra metcons, a 60-minute AMRAP, at the end of a 40-minute AMRAP is really not going to push the needle. Again, we're looking for that functional overreach and making sure we don't push that into overtraining. So, extra training, who, when, why, and how, those are our thoughts. So, hope you have a wonderful weekend. If you're going to do 24.1, I hope you have fun. My advice, go fast at the start, go fast in the middle, go fast at the end. It's designed as that kind of workout. Low skill, high work. one of my specialties. So hope you have a great Friday. Have a fantastic weekend. If you're going to be on a live course this weekend, we hope you enjoy yourselves. Have a great Friday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 29, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the mindset behind how we respond to news & change: do we respond positively or negatively? Jeff challenges listeners to consider the many positive benefits to responding to change with a growth mindset, looking for the benefits to change rather than catastrophizing the downsides. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MOOREWhat's up, everybody? Welcome back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursday, which is also a Gut Check Thursday. Remember, this is gonna be the last Gut Check Thursday that we have, because now the Open's gonna fire back up, so the workout for every week, of course, is going to be the Open. But if you wanna get in one more, it's relatively simple, starting from 500, 400 on the row, or it's just gonna be one time through for time. You're looking at 500-400 rower into 30 box jumps and 20 hang power cleans, 135-95. Then you're going to take down those reps across three rounds. So should be a relatively lighter load, pretty approachable. Good one to kind of keep moving as we get into some of the very challenging open workouts. I don't know about you all, I'm going to be doing mine today at 245, kind of right out of the gate. So mountain time, the announcement I think is noon. So I'm going to go right over to the gym at two o'clock. get warmed up and give it a go at 245. So I can't wait to see everybody's open adventures. Hopefully most of you got signed up and are going to see how you kind of stack up. Always important, right, to not run away when the measuring stick comes out. Get out there, do your best, see where you fall, and then look at over time if your consistency can't move you up in those rankings. So let us know, tag us, enjoy the journey. I will be starting mine here in a few short hours. ALTER YOUR REACTION TO NEW I have wanted to chat about this topic for months because of everything you can do in your growth and business interjectory. I think this one might be the most shockingly rapid as far as ensuring that your upward trajectory with whoever you're working for makes the steepest kind of hockey stick sort of climb. So let me explain. The episode is titled change this reflex and change your life. What it revolves around is altering your reaction to new. To new news specifically. altering the way that you compare to everybody else reacts to it. So I am in business, I am obsessed with asymmetry, okay? Where do you have it and where can you demonstrate it? The reason I'm obsessed with it is because it gets attention. And oftentimes, 90% of the battle is who can get somebody's attention. We are wired as creatures, we are wired to look for unexpected differences. That's what stops us in our tracks and makes us pay attention to something, right? I thought this was going to happen, but this happened. That generally speaking, is what gets a consumer's attention, it's what gets your boss's attention, it's what gets anybody's attention, because that's how human beings are wired. I thought this was going to happen, but this happened. Obviously, looking back evolutionarily, it's because that makes you safe, right? Things that aren't expected, things that are unusual, are usually worth paying attention to for survival. But for whatever, However, it came to be that can now be leveraged in the way that you move forward in both your career and your life What we're going to talk about specifically today is your response to change. YOUR RESPONSE TO CHANGE: GROWTH VS. SCARCITY So if you think about the importance of demonstrating asymmetry and you think about where you could demonstrate that that would matter, the number one spot that you could demonstrate asymmetry that would move the meter in the right direction would be your response to change. And the reason for that is because it's the one where it is so unusual to see a difference from a leadership perspective. Most people's response to change, and this is widely and universally known, right? Most, it's why they don't like it. Most people's response to change, the reflexive response is what am I losing? And that is deeply rooted in scarcity mindset, which most people have, which is why most people don't like change. It is relatively universally held that most people don't like change. And the reason for that is because their brains are rooted for scarcity. And so when something is changing, they always fear the worst. If you make an intentional habit to do the exact opposite, you will stand out in a way that I don't think that you could stand out more profoundly by making any other shift in your life or business. If you respond with what's the upside here. it will have massive downstream effects. THREE BENEFITS TO RESPONDING TO CHANGE POSITIVELY Let me just talk about the three biggest ones that will be immediate. If you can get your reflex response to change, to be positive, as opposed to, oh my gosh, what am I losing? Right off the bat, the first one is it will have a profound mental health uptick if you focus first on finding the positives, okay? Because, Wherever you start in anything, one of my favorite sayings in physical therapy is, wherever you start is where you wind up. Meaning, when you look at a lot of the big studies in PT, when people begin with a medical industrialized complex move, i.e. getting an MRI, getting higher level scans done, they tend to kind of stay stuck in the medical industrialized complex. But when they go to a provider that doesn't do those images, that doesn't offer those quote-unquote solutions, they tend to never go in that direction because they get moving and keep moving, things seem to resolve, and they stay in that lane. Because inertia drives so much about life. So wherever you start is where you tend to wind up. So why not start positive? Why not? I assure you, you'll figure out some of the downsides. Those won't escape anybody. We're wired to look for that. But why not start positive? Because now it's life's job to reveal enough to you to pull you away from that position. But it has work to do. So if every time a new thing or a change comes up, your reflex is, ooh, what's the upside here, right? What can I do with this? This could be really good. Now life needs to prove the opposite, to pull you away from that position, which is challenging because you've got momentum in that direction. Most people do the exact opposite, right? They start low, oh my gosh, oh no, what's gonna happen now? And now there has to be a lot of proof to pull them out of that negativity. If you start high, life has to prove to you that you should get pulled down, and oftentimes it can't. So right away, just by having a reflex where you're looking for the positive, the mental health trajectory is very real. Okay, number two, and probably now talking more about business, it will absolutely shock the person who's delivering the news in the best way. If your response, right, because leaders are always dreading sharing any news about change because most people being rooted in a scarcity mindset are going to begin peppering you about what they're losing or why things are going in the wrong before they've even thought it out. They're scared. They're nervous. Their reflex is negative. It's a lot of tough energy that comes at you when you're delivering change news to a group of people. If you're the person in that group that throws their hand up right away and says, Oh sweet. Does that mean that we can blank? If you don't think you've got the attention of that leader, you're crazy. First of all, you're the only person doing that. So already you are the asymmetry. And it's such a positive thing when the leader was expecting a negative response. And now you said, oh cool, does that open up this possibility? Or could we now do this? It will be as shocking as it is positive. So now you've got the attention of that leader and you've got them in an incredibly positive space. There is so much positive work that you can do from that position. And finally, third, and it usually builds off of number two, Looking for the positive reflexively and immediately places you in the best position to find it. With every single change comes new opportunity. Does not matter if it is at first perceived as a calamity, right? You think about big financial crashes. There are massive opportunities in every one of those calamities, right? But you have to be looking for it. If when things are moving and shaking and changing and the ground is shifting, if you're the person who's looking for in this new terrain, how can I now capitalize on variables that weren't present before? You have positioned yourself to find them first. Everyone's going to figure out the downside, but most people see the upside too late because they were consumed by the downside. So if you're the person who, when change is coming, you're looking for the upside, you're going to find it first. And now you've got the attention of leadership on you while you find the early opportunity and you are going to be on a trajectory that is so much quicker and faster than everybody else that when you telescope that out months or years, you obtain that position and thrive in it when other people are still figuring out why some of the change was good. Crew, things happen so fast in business and life. If you're the person who can gain positive attention from decision makers when change is happening, and you're the person that can see the opportunity that arises through change, and you put those two things together, you will move forward relative to your contemporaries at a staggering speed. Because the greatest asymmetry that you could ever demonstrate is being a person who has a reflexively positive response to change. When the entire world is rooted in scarcity mindset and thus has an immediately negative response to change. Enjoy better mental health and enjoy way more business success by making that one simple reflex change. SUMMARY PTOnIce.com, team. It's where all the courses live. Have an amazing Thursday. Enjoy the Open. I will certainly be reporting back on how it goes for me. It never goes overly well, but I will give it my absolute best. Enjoy, team. Have a great Thursday, great Friday, great weekend. Cheers. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 28, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses how to introduce a fitness forward philosophy with your clinic/co-workers. Julie describes four main points to use when trying to change practice philosophy: put fitness forward on display, host in-services, let patients be your voice, and be a mentor to other clinicians. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JULIE BRAUER All right, good morning crew. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Julie and I am a faculty member of the older adult division. This morning, I am going to be answering one of the most commonly asked questions that we get in our online courses and our live courses. That question is, how do I get others on board to a fitness forward philosophy? How do I create consistency when my coworkers don't understand this philosophy or potentially they don't care? The answer to that question is that we are going to pull and not push. We want to pull, not push to attract a fitness forward culture. So let's unpack it and I will give you guys a few actionables that you can start implementing right away. PULLING VS. PUSHING TOWARDS BEHAVIOR CHANGE So what do I mean by pull, don't push? You want to be attractive. You want to be magnetic. You want to pull people towards you and towards a fitness forward culture. You want people to be drawn to you versus pushing your agenda on others aggressively versus sending a message that could potentially be received as my way is better and I am better than you. All right. So I want to relate to so many of you in that I know so many of you are incredibly fired up and passionate about underdosing older adults. You get, I mean, your blood boils when you see that out in the clinic and I understand this. I've been there. And I know that it makes you want to call people out left and right. been there, done that, and I'm telling you that's not the way to get people to change the way that they do things. Now, I do think it's incredibly important to call our profession out as a whole. If you've been to any of our live courses or taken our online courses, you know that we call our profession out. and we ask our students to self-reflect on their clinical practice. However, I do think there's a way where you can be aggressive in that messaging and aggressive towards this mission of ending the professional pandemic of underdosage, but there's a way to do it and be kind about it. APPROACH WITH GRACE What I want to emphasize is that we have to approach this with grace. And believe me, I have made a ton of mistakes in my messaging and been way too aggressive. And that's not going to change culture. That's not the way to do it. But we need to realize that behind a lot of underdosed exercise that we see, there's still humans behind that underdosed exercise. Many of these humans are burnt out clinicians who are just trying to do their very best. And many times in a system that does not set them up for success. I know this to be true. I have hurt feelings of my own friends who are colleagues who are really good clinicians because of my aggressive messaging and because I wasn't realizing that people are out there and they have, they are in different seasons of life. They could be going through a lot of crap. And they're just treading water and they're doing the best that they can. It's not that always someone just doesn't care and wants to phone it in with older adults. We don't know what people are going through. So many people are in tough seasons of life that last a short amount of time or a long time. And we have to have some grace there. So instead, we want to invite people in towards this fitness forward culture. We want to be attractive. We want to be magnetic. So how do we do that? Here are a couple ways. PUT FITNESS FORWARD ON DISPLAY Number one, do your sessions out in the open. Put that fitness forward philosophy on display as much as you possibly can. Why? Because it's the most powerful way to share this message. And instead of, again, pushing a message or telling people what the right way is, you get to show them. So imagine this. You work in inpatient rehab. And instead of kind of flying under the radar, this is what I did a lot for a long time, and you bring your equipment in your own bag and you do that session in the room because you don't want people to ask questions and you just want to do your thing and move on. Instead, go do it out in the open gym. When you know all the people around you, you're going to look around and see we have yellow TheraBands, we're playing balloon toss over there, people are on the new step and chatting it up for 10 or 15 minutes, but you are in the middle of the room. You are loading your patient up with a kettlebell, they're doing a deadlift, you are blasting like really pump up music and drowning out the really like low slow music that doesn't make anyone want to work out so you're pumping the jams your patient is working really hard they're having fun you're having fun everyone around you gets to look over and see like damn i have that patient later in the afternoon and i saw them yesterday i had no idea they could do that Huh? They look like they're having a really good time. That is how you start to get people curious. Like, Whoa, how are they doing that with that patient? That's awesome. I want to learn more. You are pulling people in towards you without saying a word, without telling people, Hey, I want you to do things my way. So that's number one. Do your sessions out in the open as much as you possibly can. Put that fitness forward philosophy on display. Okay. HOST IN-SERVICES Number two, put on an in-service. Be a wave of influence here. This is one of the easiest ways to spread this message to as many people as possible. Okay. Now, a lot of you are like, I don't have time to put together a workshop or an in-service. I don't like to speak in front of a group. I totally get it. That is why the MMOA division has created workshops for you. They are done. They are skeleton slides. You can put your branding on them. You can add to them. You can do whatever you want with them. They're all done for you. They are on topics such as One rep max living, osteoporosis, arthritis, build better balance, learn how to fall. They're done for you. Even better, if you're thinking, okay, I love that the information is there for me, but I'm really nervous presenting in front of a group. We have a solution for you too. The workshops also come along with a recording. of one of our faculty members presenting this information to their communities and to other individuals. So all you have to do is watch the recording and you can say the phrases and do exactly what they do. So it completely mitigates this fear of public speaking because you have a perfect example of how to display this information. I will put the link to all of the workshops. They're on our website on mmoa.online under free resources. I will link it there for you. But that's one of the easiest ways to spread this message to a lot of different people. You get everybody in the same room, hopefully not only clinicians, so your peers, but managers and supervisors. If you were able to get some of the rehab doctors in on that workshop, that would also be amazing. So a wonderful opportunity there to spread this message wide, be a wave of influence. GUIDE YOUR PATIENT'S VOICE All right, number three, guide your patient's voice. Guide your patient's voice. If you want your colleagues to get on board with a fitness-forward culture, empower your patient to help you guys out. Think about what's going to be more effective here? You going to your colleague and saying, hey, I want you to do this with my patient or your patient when they are with one of your colleagues for their session that day or that week saying, hey, I did this thing called a deadlift with a kettlebell last week with Julie, and it was really awesome. I loved it because it really helped me realize how strong I can get so that I'm able to lift my granddaughter up from the ground. If a patient comes to you and says it like that, and they're so excited, you sure as hell bet that therapist is going to be like, okay, this is exactly what my patient wants to do. I'm going to figure out how to replicate what that other therapist did because clearly my patient is all about it. That is really powerful if your patient can also use their voice to help drive this change. So that could be a conversation you have with your patient. Hey, do you think what we're doing during this session has been really helpful? Your patient's going to say, yeah, I mean, it's hard and it's strenuous and I sweat, but I know this is going to help me. Then you guide them, all right, so next week, because I'm not gonna see you for another two weeks, let's figure out a way where you can advocate for yourself and so your next therapist continues to do this work so you continue to get better. So you and your patient come together and figure out what that conversation looks like and then your patient goes to your colleague and has that conversation. it's going to be a lot more powerful than you directly just saying to your colleague, do this, don't do this. Guide your patient's voice. All right. BE A MENTOR And then lastly, be a mentor, be a mentor. So we have a lot of people who at our courses will say, you know, let's say it's a, let's say it's a CODA. Okay. and who's at our course and they're like, well, what's going to happen? I mean, I will be doing this stuff, but my OT isn't going to be doing this stuff. Or it's a, it's a PTA saying like, I love this stuff, but my PT is definitely not going to do this stuff. What do I do? You want to be a mentor. Look at it Not like me versus you, right? Not what I'm doing is right, what you're doing is wrong. Look at it as this is a really great opportunity to teach my colleagues. how to do these things and and think about in a way not just because you know it's going to benefit your patient but because it's going to benefit your colleague. We all want each other to be elevated and we want each other to be inspired to do one percent better the next day with older adults. So why wouldn't we want to invite them in to share how to do this stuff? There could be a lot of reasons why your colleague isn't following your plan of care. They may not understand what an EMOM is or an AMRAP. They're like, what are those letters? I have no idea. Like we're spell check. I don't even understand this. They could never have seen a deadlift before in their life. And they're just very confused about what these movements are. Again, there could be a lot behind it. Don't assume someone is not reading your documentation or likes what you're doing. It could just be that they lack the confidence and they don't have the knowledge. So be a mentor. This is where you can go to your colleague and say, hey, Betty is loving what we've been working on. We're doing some really cool loaded carries and squats and deadlifts. I would love to show you what we're working on so that we can maintain consistency, because I know that Betty's going to get better faster if we do that. You can use your time. Donate your time as a mentor to pull them over, show them some of these movements, show them how you document them, and even better, If they have some time, be like, hey, I've got Betty at this time, right? Maybe you can have some overlap if you're in home health, or you can have some overlap if you're in acute rehab and be like, hey, could you come over and watch a little bit of my session with Betty so you can see what we're doing? and you really make it that individualized mentoring experience. And I guarantee you guys, if you approach this with kindness and try and pull people in and get them to be curious and present yourself as someone that an individual, your colleague can come to you and say, I'm a little nervous, I don't know how to do this. If you're able to do that over and over again, you're gonna start to have a lot of colleagues asking you questions and getting curious because they know that you're an approachable individual that they can seek mentorship from. And I promise that's going to make you feel really, really good about not only the work that you're doing with your patient, but being able to give back to your colleagues. All right. So those are the few ideas of how you can pull people in towards that fitness forward culture versus pushing that agenda on them. SUMMARY So to recap, number one, do those sessions out in the open. Put that fitness forward philosophy on display. Make it as visible as possible. Two, do an in-service. Be a wave of influence. I'm going to link that website for you guys in the comments of this post. Three, guide your patient's voice. Realize it's going to be so much more effective if your patient is advocating to do these fitness forward things versus you just telling your colleague to do them. And then lastly, be a mentor. Donate your time and energy to showing and educating your colleagues how to do this. realize that you're going to be helping them enjoy doing their jobs more, not just benefiting your patients. So it's a win-win. All right, guys. Lastly, I will let you know about what courses the older adult division has coming up. So in March, we're pretty darn busy. Well, first, well, yeah, March is this weekend. It's crazy. So we are in Maryland as well as Georgia this coming weekend. There are spots open for those two courses if you want to snag one. Then we will be in Madison, Wisconsin and Kansas the rest of the month, and we have our next L1 eight week online course starting March 13th. So March is super busy. Go ahead and jump into one of our courses. We would love to see you on the road. We would love to see you online. Have a wonderful rest of your Wednesday. Let me know if some of these techniques worked for you all the rest of this week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 27, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses the safety, efficacy, and utilization of palpation when incorporating dry needling treatment into your practice. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION PAUL KILLORENGood morning, crew. We've got YouTube, we've got Instagram. My name is Paul. I'm representing the dry needling division for ICE. My name is Paul and I would like to talk about palpation this morning. Pretty dry topic you might think, but depending on if you're trained in dry needling and how you're trained in dry needling, palpation may have been one of the key aspects to your course, your training, and then fill in the blank from there. I mean, our accuracy, our safety, and even our effectiveness for dry needling relies at least somewhat, high percentage, low percentage, on palpation. So we're talking palpation this morning, not even actual needles in, but this is heavily a dry needling topic on our clinical Tuesday. IS PALPATION-BASED DRY NEEDLING SAFE? First of all, to get it out of the way, there is actually quite a bit of research saying, is palpation-based dry needling enough? Enough being, is it safe? Is it consistently effective? And the answer is yes, most of the time. Meaning there's solid data that says if we're palpating rotator cuff muscles, so a 2023 publication last year said, if we're palpating infraspinatus, even teres and supraspinatus, compared to ultrasound, we're reliable. Maybe that's because it's accessible, we have a big spine of the scapula to rely on, but unfortunately we have data, a publication from 2021 that says if we're palpating ribs, especially posterior ribs, so deep to rhomboid and trap and all of that, unfortunately we're not very reliable. So first of all, to say, um, not the topic exclusively for this morning is can we rely exclusively on palpation for dry needling safety? The answer is yes. Most of the time. Um, I mean, one stance we do with ice, even on our advanced courses that we do not do rib blocking techniques, uh, meaning we don't palpate and rely on the rib as a bony backdrop for for like thoracic extensors, rhomboid, all of those muscles. So we can rely on it most of the time. There are certain regions where it's less, research says it's less consistent, less safe. And that's pretty obvious stuff. Can we palpate everywhere else in the body? Spinous processes for the spine, trochanter sacrum for the glutes. Can we palpate muscles for quads and all that? The answer is yes. HOW IMPORTANT IS PALPATION FOR DRY NEEDLING? So really the topic of this morning is how important is palpation for dry needling? And I'm gonna break this, the rest of the discussion into two topics. The first one is how important is dry needling as a diagnostic criteria? And the second one is how important is palpation, we have to put it in the palpation bucket, but I'll say how important is tissue control when we're dry needling? So let's tackle topic number one. How important is palpation as a diagnostic criterion for dry needling? And this is where we'll start to see a separation based on when you were trained and how you were trained. Meaning, if you were trained more than five or 10 years ago, or if you took a fairly exclusively trigger point dry needling course, then palpation is key. as a diagnostic aspect, meaning hopefully you're doing other assessment, but when it comes down to firm pressure in tissue, identifying trigger points or top bands or even muscular tissue that reproduces a patient's symptoms or refers into different patterns, very, very high on that diagnostic algorithm, the palpation is. For ice, we are drifting in almost every respect away from the trigger point paradigm. I mean at the highest level we're drifting away from trigger points being necessarily the singular explanation for pain, the direct dry needling target, and even the twitch response as not necessarily being deactivation of shortened sarcomeres, trigger points, all of those things. So the question is immediately asked, so does that mean that we don't palpate? Are we just randomly, generically floating needles into a muscle? The answer is no. We don't palpate trigger points, we palpate motor banding. This follows other philosophies, but motor banding being a slightly larger, slightly more macroscopic tone, I mean it is palpable, but it's not on that microscopic sarcomere level. If you have been needling for any period at all, or if you do any type of any soft tissue work, you know that you can find motor banding in almost everybody's glute medius, vastus lateralis, medial gastroc, tricep, deltoid, infraspinatus. These aren't trigger points, these are motor bands. And there is value to palpating that, and there's value to treating that tautness, that motor banding for dry needling. IS PALPATION DIAGNOSTIC? So back to the question at hand is like, how important is palpation as far as a diagnostic criteria? For ice, for us, it's a little less important than perhaps a purely trigger point based therapist, but it's not completely unimportant. It's just a lower, it's lower importance on our assessment, meaning Hopefully we had a full patient interview, a subjective, a full assessment. There was something that led us to treat vastus medialis for Gladys' knee pain or infraspinatus for Gladys' shoulder pain. So we're already approaching the patient, essentially knowing that we're going to treat these muscles. Then, and the narrative that we use on our courses is that, that very last piece of the puzzle, like if there are any puzzlers out there in the group, you know, depending on how challenging your puzzle is. It just took you a few hours, a few days, a few months. You did the edge first, maybe that's your patient interview. Then you fill in different colors, different objects. Maybe that's the rest of our assessment. But then there's that last puzzle piece. Almost always it's lost under the couch or something, but it's that last piece. And you're like, sweet, found it. I'm gonna put this in. That is our palpation. meaning everything else in our assessment, in our treatment model, interviewing the patient, led us to treat this muscle. That last puzzle piece before we put in a needle, so we've decided we're gonna use dry needling, we've decided we're gonna treat infraspinatus, that last puzzle piece is spending five to 10 seconds finding that motor banding, finding tautness, finding any tenderness, finding anything that reproduces symptoms. But the shift that I'm acknowledging is that that final puzzle piece was not the full puzzle. Depending on how you're trained and when you were trained, palpation was what created the whole puzzle. Meaning if you are a little bit more trigger point centric, we really rely on palpating a trigger point or palpating that banding and having it reproduce the patient's symptoms or at the very least be a familiar sensation. Or to say an extreme opposite of, If you're relying exclusively on trigger point identification and you palpate, you dig your fingers into a muscle and don't find tautness, that almost starts to sound like, okay, we're not gonna treat this muscle. So again, the paradigm shift we're talking about is that palpation is always a part of the equation, even for diagnosis, I'll say, or even when deciding where to place our needle for dry needling. But depending on how you were trained, depending on how much emphasis you put on that pain generating reproduction of palpation based tone, it is like what decides if you're gonna needle at all, or it really just decides where you're gonna put the needle in. So that's number one. If we're just talking palpation this morning, the first topic I wanted to tackle was how important it was diagnostically. and the TLDR there was that we're going to treat that muscle anyways, but there is that final puzzle piece, that final five seconds or so where we look for motor banding. That is where we want to put our needle. GREAT PALPATION IMPROVES PATIENT COMFORT Topic number two, I guess we're still going to call it palpation, but now it is about the technical aspects of controlling tissue while our needle is in. No matter what technique, no matter how you were taught to tap the needle in, set up a bracket window with compressed tensioning of tissue, or squeezing, or setting up the OK sign. Now we're saying, how important are the more nuanced aspects of tissue control? So again, we're not talking diagnostic criterion anymore. Here is where this tissue control, this tissue feel, this firmness of palpation separates novice needlers and more experienced needlers. Here we are saying that this is one of the primary aspects for making dry needling comfortable. You could probably argue this is part of making dry needling safe, but here is where palpation, quote unquote, becomes hugely important. very specifically the technical aspects of needling. Myself, when I'm on courses, every once in a while I get on the table for our faculty or just to get some free needles or just to volunteer my body. And when I'm on the table, this probably applies to all of you out there who have been needling for a while or work with someone who's needled for a while, you can tell pretty quickly, meaning before a needle is even tapped in, you can tell pretty quickly how confident that clinician is, how experienced they are based on how they palpate. And that is key. This tissue control, how we identify those motor bands that we just discussed for diagnostic or deciding where to put our needle, but really making the insertion comfortable, getting through some dense fascial planes or deeper into tissue, or just quickly, confidently, consistently getting into a muscle. There's kind of a clinical proficiency here as well. That is an expert art. Masters who do dry needling do this very well. So again, we've split the road. We're no longer talking about that being important for diagnosis. Now we're saying this is what separates expert clinicians from newer needlers is the tissue control. If you've ever taken a course for me or a course for me recently, when we leave the weekend, the last few slides, I kind of give you a few things to remember. And one of those things I hope was, Dry needling is a skill that you have to use, use it or lose it, unfortunately. That's tough in some states where you just learned, you just took your weekend course, you just learned how to dry needle, and you can't immediately go back and start needling every single patient in the clinic. But what you can do is start palpating your colleagues, your partners, your patients. You can work on that firmness of tissue pressure, you can work on tissue control, and really I'll say that is a primary aspect for dry needling. Again, not diagnosis necessarily, but making dry needling more comfortable, more effective, and clinically more efficient. SUMMARY And that's where I'm gonna drop off today. I mean, the emphasis today, I'm Paul, I'm one of our leads for the dry needling division, so this is kind of a dry needling topic, but really, didn't talk much about needles today. The question I wanted to answer is how important is palpation? And if you're just jumping on, thanks for joining. See a bunch of folks joining on Instagram. First of all, can we be safe with palpation only, meaning compared to ultrasound guided dry needling? The answer is yes, most of the time in most places. If we're palpating ribs posteriorly, maybe not. Number two, How important is palpation for guiding our diagnostic, our diagnosis, as a diagnostic criteria and how important is palpation? And the answer there is a little less if we're not talking trigger points, but it is that final piece of the puzzle. There is that final three to five seconds before we put the needle in that says, aha, motor banding, just palpated it, that's where I'm going. The third aspect of palpation is how important is it for dry needling, comfort, efficiency, all of that. And that's where we say very high. That is really what separates experts from novice or that's what separates a more efficient, proficient, confident clinician when it comes to dry needling. So the challenge this morning is if you have not really been waiting palpation as important for that pre-insertion with your needle. The challenge this morning is to spend two to three extra seconds. Add five more pounds of pressure through your fingertips. See if you can be a little more precise with identifying your motor banding before you put a needle in. And from there, once you've tapped the needle in, maintain that tissue control or that palpation focus for the entire time the needle is in. So this morning we won't talk about are we gonna piston a bunch, are we gonna twist it, are we gonna just leave it, are we gonna do e-stim. For now I'll just say for the entire time you're inserting the needle, you're moving the needle, you're repositioning the needle, focus on the palpation, the tissue control, maybe more than you were before. That is what separates the experts. So with that, I'm going to drop off. I held it to 15 minutes, which is always a victory for me. I apologize for the darkness this morning. I have my ring light on, but otherwise, kiddo is sleeping right next door. So we are dark and quiet here in the Killoran household. It is very early on the Pacific coast. So if you're jumping on, catch the recording, catch the first 10 to 15 minutes. How important do you feel palpation is? Or even to ask it another way, how do you feel your palpation, your tissue control, your confidence in palpating stuff has matured and improved from when you started dry needling to today? I'd love to hear, I'd love to have a poll, maybe I'll throw it up on Instagram, but I'd love to hear some comments on has it gotten better, has it stayed the same, more important, less important, where do you place palpation on your paradigm of importance, your pyramid of significance when it comes to dry needling. Otherwise I'm dropping off, if you're trying to catch a dry needling course with us for ice, The next few months are key, meaning we've had a really busy February. We have a really busy March and April. Then things kind of slow down. May, we take Mother's Day off. We have Memorial Day off. We have a post-sampler rest. So things start to slow as we get into the summer. All of our faculty have kiddos and family, and we know you all do too. So the summer will be a little lighter for courses. So if you're trying to catch us before the summer, Check out March and April courses. Ellie will be in Bozeman, Montana this weekend. I'll be in Baton Rouge. And then we've got a handful of other ones coming up. Otherwise, we're setting up our fall calendar now. So keep your eye on the calendar if you're looking for something post-summer for dry needling. As always, at PTONICE.com or check us out Instagram at Ice Physio or DPT with Needles. Thanks for listening, folks. Catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 26, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the sport-specific nature of gymnastics to the fitness athlete, introduces the strict pull-ups, considerations for when to modify, including the rack pull-up and box-assisted pull-up. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION JESSICA GINGERICH Good morning! Hello, my name is Dr. Jessica Gingrich. I am on faculty with the ice pelvic division here at ice. And today we are going to jump in to treating the pregnant athlete during gymnastics. So gymnastics is a broad term and it encompasses a lot of different movements that are utilized in a lot of different sports. So sports like gymnastics, kind of what we typically think of like with the beams and the floor routines and the uneven bars. That's what we typically think about. We also have cheerleading and we have yoga and trampoline, um, um, stuff, um, and CrossFit. So CrossFit is what we are going to focus on today. There are many movements in CrossFit that are under the term gymnastics. So we have pull-ups, we have handstands, we have toes-to-bar, we have muscle-ups, rope climbs, and even things like pistol squats are considered gymnastics. And of course these movements can be done either strict or kipping. The term gymnastics is defined as physical exercise used to develop and display strength, balance, and agility, especially those performed on or with an apparatus. You will see a lot of things on social media around the dangers of kipping movements within the sports of or in the movements of gymnastics. You may even think that yourself. And so what I want to do, I want to challenge you to reframe how you view kipping. So we're not going to talk about this today, the kipping, uh, any kipping movements. I'm going to talk about that next time I'm on the podcast, but I want you to start thinking about this because this is sports specific, right? So let that sit for a second. GYMNASTICS IS SPORTS-SPECIFIC FOR SOME PATIENTS We talk about sports specific as physical therapists all the time. So if you are talking to an athlete and you're talking about how dangerous and how funky it looks or whatever, it is part of their sport. And you see it in CrossFit and you also see it in gymnastics. We don't tell the baseball player or the baseball pitcher specifically to stop pitching, even though his arm goes through a really gnarly range of motion and kind of looks funky in those pictures once they're slowing down. What we do as physical therapists is we prepare them. We prepare them from a mobility perspective, a strength perspective. We talk about things like programming, sleep, nutrition, stress management, and we try to maximize their recovery so they can maximize their performance. So I wanted to mention this before we dive in to what we're going to talk about today, because I'm going to talk about it later. And then also during pregnancy, we also get that same language, right? We get the language around something being unsafe or dangerous, and it's simply just untrue. It's more about preparedness. So pregnancy does not mean that you have less of an athlete in front of you. So what does it mean for our pregnant athletes that want to come in and they want to continue doing gymnastics movements? THE STRICT PULL-UP So today we're gonna talk about specifically the pull-up, and even more specific, the strict pull-up. So first and foremost, we want to talk about points of performance. Whether your client listens to you or not with the points of performance, because you will run into that, that is something we should be teaching in our space. So the points of performance for a pull-up are your hands are just outside your shoulders, You have a full grip on the bar, so your thumb is wrapped, it's not here. And you start in a full hanging, full elbow extension position. And the movement is complete once you pull and your chin is over the bar. So, is pull-ups during pregnancy dangerous? No. Short answer and long answer, no. When coaching or modifying the pull-up, we want to consider those points of performance that I just talked about. We even want to consider having that athlete get into a hollow position, maintaining a hollow hang throughout the range of a pull-up. If your athlete just simply cannot do it, we modify. But if they can do it, and they are doing a strict pull-up, but they break the points of performance, then we also modify. Now, I know that a lot of you are thinking, what about coning? What about doming? What do we do when we see that? If your athlete is maintaining points of performance at any point or any modification, if you will, in a pull-up, so that is a strict pull-up, that's a band-assisted, that's a box-assisted, we're gonna talk about a couple of modifications. If they're breaking that point of performance in whatever modification they're using, then we further modify. CONSIDERING CONTINUING If they're maintaining their points of performance, but they're still coning, you may consider letting them continue. Now, all of you may be like, oh boy, that's not what we see. Right. However, that's where also when we program, when we talk about sleep and nutrition, all of this stuff comes together. So if you have someone who is, who is maintaining points of performance, but they're also coning, you're not going to necessarily say, Hey, go do a hundred pull-ups. That's where our skills and programming can also benefit these athletes. Remember that some of your athletes may have been able to do, these pregnant athletes may have been able to do a strict pull-up even one week ago during their pregnancy. So that can be incredibly frustrating when they come in and they're like, gosh, I could do this a week ago, what happened? Even five pounds of weight gain, if you've ever done a weighted pull-up, it's significantly harder. Now that weight gain is normal, but it's sometimes really difficult from a mental, physical, emotional perspective. But we want to still be able to give them the appropriate challenge. So their grip strength, their core strength is continued to, is able to continue to grow. So when we modify, we are encouraging movement. We are encouraging strength. we are encouraging that mental load, something where they can go to the gym and just like let the day go and not be even more frustrated by something they can't do. So now, before we go into the modifications, I will say I have had athletes that have maintained points of performance in strict pulling even well into their third trimester. So they keep going. We just let them go. We talk about symptoms to modify for, so if they're doing a pull-up and they're peeing in their pants on that pull, we wanna modify. If they're losing those points of performance, we wanna modify. Those who can't, when we modify, we really just wanna encourage the pull strength. When we talk about the strength, talk about grip and I've talked about core, I am lumping lats into core because I know some of you guys are thinking that. MODIFYING THE PULL-UP: THE RACK PULL-UP & BOX-ASSISTED PULL-UP So, two of my favorite pull modifications are the rack chin pull up in the box assisted pull up. So, where you're uh you got your feet assisted on the box. So, the rack chin pull up is going to be on a low bar or the child's pull-up bar. And so the athlete will stand and you want the bar just under their chin. Then they're going to hang from the bar and they're going to pull from that low bar, both feet on the ground. The box assisted pull-up is going to be the same setup, just with a box. Maybe they have to put a plate on top of the box and they'll stand up and their bar or their chin should be over the bar that they're doing their pull-up on. So the reason we love these is if you have a foot-assisted pull-up, you can use as much or as little assistance as you need in that moment. And if you haven't tried these, I'm gonna encourage you in your clinic or at the gym, try them. I've done these modifications for some shoulder stuff before, and they are hard. I am very sore after using these as a modification. And so this can be awesome. A really awesome, awesome modification. They're on the rig, they're feeling really good. With that box assisted, you can also use one foot instead of two. You can work on negative, so time under tension. They're really, really awesome. This will allow your athlete to continue pulling vertically instead of horizontally with a ring row at really any point in their pregnancy. They can use these as modifications in their workout. They can also use it as accessory work. They can do EMOMs, you can do anything with it. And so, as you go out this week, you've got your pregnant athlete, maybe you even have a postpartum athlete and they're wondering about pull-ups, try these modifications. They're hard, they're challenging. Do it with them so you can see what it feels like. Maintain those points of performance. Get that hollow position. and see how you do. SUMMARY So before I hop off, I'm gonna talk quickly about some of our upcoming courses. So our next online course is already sold out. So if you are wanting to hop on that course, head over to ptonice.com to sign up for our next one. It's gonna be April 29th is that start date. We are on the road this month. We'll be in Newark, California on March 2nd, and then Bismarck, North Dakota on March 9th. So we hope to see you out on the road. And like I said earlier, stay tuned for when I am on the podcast. Next, I'm going to talk about kidney and pull-ups during pregnancy. Have a great week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 22, 2024

Dr. Ellen Csepe // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Older Adult Division faculty member Ellen Csepe demonstrates an example of using motivational interviewing techniques when discussing weight loss with a patient. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ELLEN CSEPE Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a physical therapist. I'm bringing to you live the Technique Thursday and we're going to talk about motivational interviewing today. I'm joined by my co-worker Rachel Jordan. She and I are both physical therapists in Littleton, Colorado. And today what you can expect out of our episode is we're going to talk about what motivational interviewing is, what to look for in our kind of, um, reenacted interview between a patient and a provider and then we're going to kind of sum it up and bring it back home talking about how this case went at the end of the day. So we had an awesome discussion about weight management with one of our patients in the clinic within the last few weeks and I really wanted to share that with you guys. We used motivational interviewing strategies to talk about weight management and truly it was a slam dunk. So today we'll kind of start talking about what motivational interviewing is. So motivational interviewing is basically a counseling technique where we talk about where we invoke out of a patient their own wisdom and their own ideas on how to solve their problems rather than barking at them and telling them what to do. Motivational interviewing is a really powerful technique for providers to really treat patients first like people, then like patients, all while showing them that you genuinely care. This is an excellent strategy to talk about weight, which can be a hugely uncomfortable topic for some providers and patients. So this discussion that we had went super well. Rachel's going to be the patient. I'll be the provider. And what I'd like you to look for in our discussion are four key topics that kind of illustrate the spirit of motivational interviewing. And so those four key topics that really kind of reflect the spirit of motivational interviewing are partnership, acceptance, compassion, and empowerment. So think of it this way, partnership. I want Rachel to leave our session knowing that she has somebody who really, really cares in her corner. Partnership. Acceptance. I'm not gonna look down the end of my nose at Rachel while she's struggling. I'm in her corner and I'm cheering for her. Acceptance. Compassion. I recognize that weight management is really, really hard. From a biomechanical level, from a neuroendocrine level, Weight management is super difficult. So compassion. I see her struggle and I care. And then empowerment. I want Rachel leaving our session like she just won a game of elementary school dodgeball. I want her leaving this session feeling like she has got it made. I want her to leave here feeling like she has a plan, like she's on top. So again, partnership, acceptance, compassion, and empowerment. So we'll go ahead and get into character. So Rachel, I understand that your doctor sent you over to us to kind of check out your ankle. It looks like you had an ankle surgery, but it looks like it's going pretty well. Tell me a little bit more. RACHEL Yeah, I had the ankle surgery not too long ago. I repaired my deltoid ligament. Overall, the ankle's doing pretty well, but ever since, I've had a lot of falls and I'm having a lot of pain and weakness because I keep falling. And, you know, I really think it's a lot to do with my weight, that's why I keep falling. ELLEN It sounds like you're thinking that your weight has been an issue for you in the past. Is this the first time that you've kind of talked about this with a health care provider? RACHEL I've talked a little bit about it with my primary care doctor, but she doesn't really seem to take interest in having a conversation about it. I've asked her about the GLP medications that just came out, because they also have diabetes. She doesn't really seem interested in prescribing them and I just don't feel like I'm really feeling hurt when I go into the doctor. ELLEN That is really frustrating and it sounds to me like you're ready to make some changes. Like you're really eager to change your weight because you know that that's going to be a real stepping stone for you to be healthier in the future. Well, we can definitely talk more about that. So tell me a little bit more about what your history of managing your weight has looked like in the past. How can I help you? RACHEL Yeah, about 17 years ago I had gastric bypass surgery. But ever since, I've pretty much gained all the weight back. And so I'm just really frustrated because nothing has really worked. I've tried all the diets and that's been pretty unsuccessful in losing weight. I'm just feeling really hopeless about how to even go about that or what to do. ELLEN I am so sorry, and I just want you to know you're not the only person. Weight is really hard to manage long-term, and obesity is a chronic disease. Did you know that everything in your biology, after you lose weight, fights to get it back? Your body doesn't know the difference between intentional weight loss and starvation. So I hope you know that you're not the only one. And it can be really hard, but those new medications could be really helpful. It sounds like that's a goal for you, and that's something you've been interested in trying. RACHEL Yeah, I'm definitely interested. I just feel at this point I just need to do something because I'm unable to play with my grandchildren right now because I'm scared of falling and I can't get off the floor because I feel like I'm just really heavy and things. So I'm kind of feeling down about that. ELLEN So it sounds like you're feeling down about that and you're feeling kind of hopeless. Tell me a little bit more about what steps you're taking to manage your mobility. It sounds like It's the weight, but it's also your ability to balance, your strength. All of those things have kind of been keeping you back for the past few years. Tell me more. Are you doing any exercise participation right now? RACHEL No, I don't really like to exercise. I've tried some stuff in the past, but I just don't enjoy it and I feel kind of uncomfortable because I don't know what to do. And I think I just might hurt myself if I try to go. ELLEN That is totally understandable. And I'm sure every exercise attempt that you've had in the past has been to lose weight. Am I right about that? Yeah. And I mean, if you've been unsuccessful in losing weight, I bet exercise could be, feel really like a wasted cause and a lost cause. Yeah. So let's, um, I'd love to challenge how you see exercise because really exercise shouldn't be about punishing your body for what it isn't. It should be helping empower you to do what you want to do. For example, I know that you love playing with your grandkids. Lunges are a really great way to get up and down from the ground. So if you think about it that way, I'm not exercising just arbitrarily to lose weight, but I'm training for grandma duty. RACHEL That's what I really want to look for. ELLEN That's a really great point. It sounds to me like you're ready to make some changes. I have a few ideas that I can offer to you and I want you to tell me what you think. I have a few primary care doctors that I know are really on board with prescribing GLP-1 medications when it's appropriate. If you'd like, I'm happy to send you their names and you can check them out and tell me what you think. Yeah, I think that'd be great. It sounds like your foot is doing great. That's kind of on the back burner of what's important to us. Why don't you and I look at kind of creating an exercise program. to see if we can match what you care about to functional things that you can do in the gym. And if you don't like going to the gym, I can give you a lot of other options, too, to do these exercises at home and still feel like you're really getting a great workout. OK. RACHEL Yeah, I don't say I don't really like going to the gym, but I used to do a swim class, like swim aerobics, and I loved that. That's great. I felt comfortable and, you know, I didn't feel the weight on me. ELLEN Yeah, feeling weightless in the pool, there's nothing like it. And I know, I saw in your intake that you're a scuba diver. I am, I love to scuba dive. That is so cool. I definitely want to get you back into the open water. I bet you love scuba diving for that same reason, just feeling weightless and like you're floating. We've got to get you back into the water. And I know if you felt better about your balance and your mobility, those things would be way more confident. You'd be way more confident in those things. Am I right about that? RACHEL Yeah. Last time I tried to go scuba diving, I actually took a fall before and wasn't able to go because I hit my head. Oh man. And I just ever since haven't really tried again because I've just been a little discouraged about it. ELLEN Oh, I totally get that. That would discourage me too. And it sounds like if you and I have a plan to not just go to the gym mindlessly, but to really say, I'm working for a pragmatic goal to be able to get up and down from the ground, to be able to lift all my equipment, to be able to play with my grandkids. That's far more meaningful than going to the gym to bust out cardio. RACHEL i really feel good about this. I agree. I've never really thought of exercise that way. ELLEN Oh, well I'm so glad that we can kind of reframe how you see exercise because truly exercise isn't punishing you, it's enabling your body to do all the wonderful things that it can do. RACHEL This is awesome. I'm really excited about this. I feel like I have a little bit of hope now that I might be able to play with my grandchildren. ELLEN Well, I hope you know I'm on your team and weight loss and weight management are really tough. And I hope you know that I'm in your corner and I'm here to help you figure this out. RACHEL I really appreciate that. I feel like I finally felt heard today. ELLEN Oh good. So that was almost exactly the conversation that we had in the clinic within the past week. It was a slam dunk. And if I can kind of illustrate how this went further, She came in for an ankle surgery, a deltoid ligament repair, but by the end of the session she left here feeling super positive about the strategies that we discussed. to help manage her weight. And kind of the happy ending to this story is that the patient did get on those medications with her doctor after switching doctors. Her doctor was super old school. She started working with a new doctor and it went super well. It was the perfect medication for her to use. She started exercising regularly at home and she was able to get up and down off of the ground with some skilled training. from our team within a few weeks of this surgery. So I kind of just want to illustrate that this motivational interviewing can be hugely impactful for your patients and in your practice to talk about uncomfortable subjects like weight. The things that we really wanted to look for in our discussion were partnership. Rachel knew that after our session, she and I were on the same team. I was here to help her. Acceptance. I didn't look down the end of my nose and say, well, eat too much and that's why you have obesity or you don't exercise and that's why you're struggling with your weight. She knew that I accepted her for who she is and I saw her journey. So compassion. She knew that I had compassion for this struggle. She knew that I wasn't judging her. I genuinely cared because I genuinely do. empowerment. She left our session having a plan, having a goal, knowing exactly what she was going to do to manage her weight in the future. So thank you guys for joining us on today's Technique Thursday. I'm so glad that you could be here with us and I hope that these motivational interviewing strategies were helpful for you in the clinic. Have a great morning. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 21, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones Dives into why working on kneeling is not a matter of IF we should do it but WHEN. Dustin covers a sequence of kneeling progressions, designed to gradually expose patents to kneeling in a manner where they have control over how much they flex their knee & how much pressure they allow onto the knee cap. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONESWhat's up crew, good morning and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about kneeling after a total knee replacement. kneeling after a total knee replacement. We're gonna dive into this somewhat hot topic if you will or debatable issue that we come across so often with our folks but more importantly give you progressions so you can actually get people's knees to touch the ground again. Alright this is a big issue that in my clinical experience I would often see the detriment of people not working on kneeling you know years decades after they had said surgery and it was really eye-opening for me and I'm sure many of you all as well to see what that does to people when they go for so long thinking that they are not allowed to kneel to let their knee apply pressure to the ground or that they're they're just afraid to right just think of all the functional implications that that has when you are scared to death to let that knee kiss the ground to be able to pick something up off the ground to be able to play with your grandkids to be able to kneel and garden right this is a This has huge implications for our patient's quality of lives and what's unfortunate is that it's often neglected, right? You think about your standard post-op protocol, what are you working on, right? You're trying to get full range of motion, trying to get that full extension, then really working on getting that flexion to be symmetrical with the other side. We're working on our strength deficits, we're working on our balance. and working on getting back to their independence in terms of gait as quickly as possible. But how many of y'all are getting applying pressure to the knee and progressing it to the manner where they're doing half kneeling, full kneeling, floor transfers, burpees, for example. How often is that getting neglected in the rehab setting? And it is far too common, far too common. NO EVIDENCE THAT KNEELING IS HARMFUL AFTER JOINT REPLACEMENT Now the unfortunate reality is we do not have any evidence to state that kneeling is actually harmful for individuals after they've had a knee replacement. There's even a really good article in the Journal of Knee Surgery, all right, so this is an orthopedic surgeon journal, in 2020, that basically said, I'm gonna read this verbatim, which I love this, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. I'm gonna repeat that again for the folks in the back, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. The folks that wrote this article and this quote are orthopedic surgeons from Johns Hopkins University that work in the orthopedic surgery department. These folks are doing lots and lots of total knee replacements, doing lots of follow-up visits. And they're saying there's no reason why we should not be kneeling with these folks. So I think for us as rehab providers and some fitness professionals as well that watch this or listen to this, it's not a question of if we're going to kneel, it's more a question of when. When are we going to kneel in that rehabilitation process? And how do we progress people to the point where they can bear full weight on those knees and trust that they're going to be just fine, right? KNEELING PROGRESSION So let's kind of go through some of these progressions. I'm going to do a reel later on, probably the next couple of days, giving you some tangible video examples. but I'm going to talk through this, especially for the folks that are listening, we'll make sure that you're able to understand kind of this progression that we're talking about here. Alright, so kneeling progressions, this could be in the span of, you know, a few visits for some of your patients, it could be the span of weeks, but there's some important things that we want to have when we're talking about kneeling progressions. is an Airex pad or some type of pillow, right? The home healthers, you got a pillow, probably have an Airex pad as well, right? But you want a soft surface that is mobile, that you can apply to different surfaces, like when you go to the ground, when you go to a box, for example, or some type of elevated surface. You want something that you can take in terms of a soft surface. That's going to be very, very helpful for that individual. And then you want to have good elevated surface options. In the home, it is the couch, right? It is maybe a step. It is a kitchen chair. It's a recliner. It's a bed. In the clinic, it's a therapy table. It may be a plyometric box that you can apply the Airex pad on to give some padding. It may be a lobby chair, for example. Or a bench is another one. You want to have lots of options for these elevated surfaces. So typically when we're thinking about kneeling, where we want to start is with just manual overpressure into extension, maybe their legs just propped up, that person is applying pressure themselves. They are in control, and that first entry into kneeling, we want to do it in a manner where they feel like they're in control. You're probably already doing some manual overpressure, working on getting that full extension back, so we're already covering that, but that is going to translate well when we're applying pressure to kneeling, all right? So doing all that work that you're already doing to get range of motion, that's a good place to start when we're thinking about getting to the point full kneeling. The big thing is that they are applying that pressure. We want them to be in control. because that is going to give them the ability to probably progress a little bit quicker. Alright, so manual overpressure, we're already doing that stuff. Now we're talking about actually getting maybe in a standing position or we're talking about maybe getting to a kneeling position. You want to think about what available flexion do they have, right? And what is the status of the incision? Is the incision healed? Is the scar tissue solid? Are we not worried about any splitting, any tearing, any bleeding, so on and so forth. So if we're kind of well past that healing phase, then all right, we're somewhere, we're in a good spot, but we also wanna be considerate of how much flexion that they have. So if they are really struggling with their flexion, let's say they don't have 90 degrees, or 90 degrees is really tough, we can still apply kneeling in a 45, 60 degree angle, but in a standing position where they're going to apply pressure into a horizontal, or sorry, a vertical surface, all right? So let's say you're standing, your knee is bent to 45, 60 degrees, can have some type of vertical surface. In the home health setting where I would do this, it would be a kitchen cabinet, typically, and I would have some type of padded surface. I would get them to bend as much as they're able to bend, and I would have them shift their weight and basically think about putting their knee into that cabinet or that vertical surface, applying pressure in that manner. They're still in control. They are grading how much pressure they're applying, but they're getting used to applying force through that knee. Alright, now when we get more or closer to full range of motion, 90 degrees is real easy for them to do, then we can think about tall kneeling. When we go tall kneeling, what can be helpful is to have one leg on the ground and one leg on an elevated surface, right, like a bed is a great example, but what's really important here is to have upper extremity support. In the home setting, what I typically do is at a kitchen counter, so I have the hand on the counter and And then I would have a chair on the same side as the surgical side. I would have a cushioned mat, like an Eric's pad, for example. They would put that knee on that chair, and then with their hands, they would shift their weight, shift their weight. They would be grading that pressure, and over time, they would get more and more comfortable, all right? The upper extremity support is really important. Some type of cabinet. If you're in a clinic with parallel bars, that's really great as well. That's going to be very helpful for these individuals. All right, that checks out. Awesome. Let's go on to quadruped. Bed therapy table can be very, very helpful where we're able to really grade that pressure and they're able to rock and shift back and forth. applying more and more pressure to that surgical side. Once they're in quadruped, you are 75% home, right? If they're able to get in that quad position, you're in a really good spot. This is where we're going to start working our way to the ground. Now, when we go to the ground, you want to think about the softness of that surface, right? That's going to be way more tolerable for many of these individuals in a really hard, cold surface. So, if you have maybe a gymnastics pad, if you can maneuver that Arix pad that you've been carrying around under their knee when they're going to the ground, that can be really helpful. You may have a set of knee sleeves. which can be very, very helpful for these individuals. Or you may say, hey, let's get on, you know, two pairs of sweatpants, for example. So just think of some cushion and some padding. When you go down to the ground, that's going to make it a little bit easier for folks. Then we can go all the way to the ground, get in quad, work on getting in prone, working on coming up. In this phase, you do want to have some upper extremity support around. We cover this extensively in our MOA live course where you troubleshoot floor transfers, but there are certain positions where you want a box or a chair at certain phases of a floor transfer that's going to make it conducive for them to be able to use their upper extremities. But have a chair around that you can move around so you can place it appropriately. they can put their upper extremities on it and help grade some of that pressure that they're experiencing through the knee. And as we're working on floor transfers, and they're getting pretty comfortable going to the ground and up from the ground, that's where we may just speed it up, where we may go on to a full-blown burpee, right? So this progression from kind of that manual overpressure early on, still kind of worried about the incision side, we don't have full range of motion, to where they've got partial range we can start to do some standing, not necessarily kneeling, but driving that knee into a vertical surface if they can't get that full 90 degrees and then we're progressing it down to where they're in that quad position doing floor transfers and progressing to a burpee. This is a kneeling progression that almost all of us can do with our folks in some way, shape, or form, right? And I challenge you clinicians watching right now that are listening right now. Zach Kaufman, what's up? I challenge you all to not think of if you want to consider kneeling in your post-op protocol or plan. It's more a matter of when. You need to do it. I've seen the implications of what that means for folks 10, 20 years down the road when they have had the fear of God instilled in them to get down on their knees. dramatically lowers their quality of life and what they are able to do and what they choose to do. It is absolutely sad to watch and you can prevent that by incorporating kneeling and kneeling progression into your plan of care that you're gonna give this person so much freedom to experience so many good things in life when they have the ability to let their knee hit the ground. All right, appreciate y'all. Let me know your take on kneeling after total knee replacement. We could say total hip as well. It's just as applicable for hip replacements too, but let me know your thoughts in the comments of this YouTube video or hit us up on YouTube podcast listeners. We'd love to have you jump on social media. I think this is a really important discussion, something that we often neglect, and I think we need to really change that narrative. All right, appreciate y'all watching. Have a good one. SUMMARY Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 20, 2024

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division faculty member Jordan Berry discusses how slowing down in the clinic both with evaluation & treatment can give clinicians a clearer picture of patient symptoms. Going slower early in the plane of care allows clinicians to better understand if treatment is creating meaningful change or not, thus allowing treatment to accelerate over time. The alternative of attempting to perform multiple treatments to multiple regions each visit can actually complicate clinician understanding of a patient's progress, slowing rehab down significantly. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRY All right, good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management. It is Tuesday, so that means it's Clinical Tuesday. Today we are talking about why in the clinic you have to slow down to speed up. Because if I was reflecting on what is the feedback that I give to most clinicians, either myself that I'm watching clinicians treat, or I'm doing case reviews, working through challenging cases with clinicians, or if we're at our cervical or lumbar live course, we're chatting through some of the more challenging present presentations and patterns. Probably the most common feedback that I found myself giving is telling that person to slow down, right? And you have to slow down in order to speed up the rest of the plan of care. So I want to unpack why if you slow down during the initial eval and during the first few subsequent follow-up sessions, you are going to be able to in turn speed up the rest of the plan of care and maximize your outcomes in the clinic. I think the quote, slow down to speed up, could be somewhat interchangeable with do less, better, right? Which we always talk about in the clinic, doing less, taking your time, but doing a better job. But I want to talk about why specifically slowing down is going to allow you to speed up over the long haul throughout the plan of care. And putting this together and this idea, I have to give a shout out to the book Unreasonable Hospitality by Wilgie Dara. I love that book. If you have chatted with me at all over the last year, year and a half, you know that I love that book so much. I've read it multiple times. And it's something that they talk about in that book as well. The idea of slowing down to speed up. They're talking about it more. So if you're not familiar with that book, you've got to read it. It's about it's about a restaurant and how they grew that restaurant to be the best restaurant in the world So they got ranked number one a few years back and one of the concepts they talk about is slowing down taking your time and making sure that you have everything correct up front as you're servicing that table or waiting on that table to make sure that the rest of the meal goes smoothly. And I love that idea. I think it was because prior to PT school, I was in restaurants. I worked in the restaurant industry pretty much my entire life prior to that. But the idea of slowing down in order to maximize your outcomes applies to the clinic too. And so I want to talk about two case examples. and how we would apply that in the clinic. CASE EXAMPLES: WHEN GOING FAST GOES WRONG Okay. So first case example, we're going to call her Kathy. So Kathy rolls in and she's got a bunch of symptoms. She's got neck pain. She's got shoulder pain, some referral up into the head, maybe some paresthesia down into the forearm and hand. The whole works, right? We know that patient. And during your initial evaluation, day one, right? You're definitely trying to figure out where the symptoms are coming from. In addition to all the other things that we would be trying to do during the initial evaluation. But one of the primary things is you're figuring out what is the primary symptom generator, right? What area am I going to intervene on day one? And let's say that you go through the objective exam and a bunch of things show up. So you're going through cervical active range of motion, you're going through the cervical segmental exam when you're testing the joints and both of those things provocate symptoms. But then also, let's say you're testing the shoulder and in range flexion brings on symptoms and you challenge external rotation manual muscle test, right? And that brings on symptoms. You palpate the posterior rotator cuff and that lights it up. So we've got a bunch of things on board day one. Here's the fork in the road that separates novice from expert on deciding where you're going to go with that initial treatment. What does a novice do with that presentation day one? They try to attack all of it. So in that, let's say eight to 12 minutes of that initial trial treatment, they try to shove all of the cool stuff as many things as they can into that initial treatment. So maybe they do, let's say cervical retraction, let's say some distraction, they're cracking the upper thoracic spine, they're cracking the neck, they sneak in some soft tissue work to the shoulder, they're loading external rotators, the whole thing. And let's hope, number one, that they've done some sort of reassessment throughout. Likely, if they do a reassessment at all, it's at the very end, after they've done all of these interventions, And let's say the patient, Kathy, let's say during the retest, she says, okay, that does feel a bit better, right? I don't have as much pain. Here's the problem. Here's the trap. Regardless of whether or not the patient is feeling better, right? And whether or not they improve over the next session, you have just set yourself up for disaster. because you have no idea what treatments actually helped the patient and they have no idea what treatments actually helped. So over the next few days between this session, the next session, they have absolutely no idea what they should focus on, what area they should be focusing on, what they should be paying attention to. And more importantly, during the next session where they come back, you have no idea of how to press. Because you threw everything at it, well, really your only choice next session is to continue to throw everything at it. So next session, you've got to crack the neck, you've got to crack the upper back, you're doing the soft tissue work, the retraction, you're loading the shoulder, maybe some dry needling now, some soft tissue work, right? You're doing all the things because you did that initially and now we've just got to continue with that. In other words, because you were trying to go fast, You've number one, likely failed to dose anything with enough intensity to actually make a meaningful change. And number two, if you plateau, let's say on visit four, visit five, you literally have no idea what to shift to or where to go because you threw the kitchen sink at it. So you tried to go fast early on and you wound up slowing yourself down over the longterm. Now on the other hand, right, the expert, that initial evaluation after you do the objective exam and all the things show up, what if you stepped back and said, you know, Kathy, we're seeing some different things here. We have some things that showed up in the neck, some things in the shoulder that both brought on your symptoms. However, for today, I'm only going to treat the neck. We will treat the shoulder over the next few sessions, but today I'm only going to treat the neck so that we know over the next week or so what things are actually related to the neck and changing. Now I want to say here, I don't think it matters if you treated the neck or the shoulder day one. I think what matters is that you actually just chose one area and you stuck to that one area. Because let's say she comes back, let's say Kathy comes back next session and she's feeling a bit better. Well, because you only treated the neck, you now know exactly how to progress things. You can say, okay, Kathy, that's great. I'm glad actually everything's actually a bit better than what I was expecting. So now we know the symptoms are primarily coming from the neck, not the shoulder. Now we can focus here. or if Kathy comes back and maybe she's not doing so hot, right? You're not seeing the symptom change that you would expect, right? It's not ideal, but you can still spin it now in a positive way. You can say, okay, Kathy, that's great information. That's not the changes that we were expecting, but what that does is confirm that maybe it is the shoulder that's driving more of the symptoms. So today, if you don't mind, I'd love to change gears and focus now on the shoulder, and we will be able to track this forward and see what kind of symptom change we get from that. But either way, you can now dial in the rest of the plan of care, right? You started out slower. You took your time during those first few sessions to understand the presentation. And now you're going to speed up the progress over the next few visits. And you're going to end up making more change over the longterm than that novice clinician that wanted to throw everything at it from the start. Most complex clinical presentations are just simple presentations, simple patterns stacked on top of each other. I repeat, most complex clinical presentations are just a few simple presentations stacked on top of each other. So all you have to do is take your time and tease them out one by one to figure out what is causing what and what is affecting what. And that will guide how you move forward. Okay, example number two. So it's a little bit shorter, a little bit more simple, right? So let's say Kathy rolls in more simple presentation. She's got some unilateral low back pain referring down into the glute. You go through your objective exam, lumbar active range of motion, pretty limited in all planes and recreate some symptoms. So it's pretty stiff and a bit painful, specifically flexion, super limited. She bends forward, no reversal of the lumbar spine, segmental exam, super stiff, hip totally clear. And you decide, um, for your initial trial treatment that you want to do, you want to mobilize the lumbar spine, right? You want to see if we can improve some of that motion. And let's say you choose that sideline lateral glide, non thrust mobilization. Side note, if you don't know that, that, that lateral glide mobilization, you've got to learn that. We teach that in the live lumbar management course for sure. That is by far my most used non thrust mobilization to the lumbar spine. Anyway, let's say that you choose that and you dose that for two to three minutes. Kathy gets up and let's say you reassess flexion and she's got a nice five degree change in range of motion. So she improves by about five degrees and a little bit less pain. Now, nothing miraculous, but you see a small positive change. Okay, here's that same fork in the road of novice versus expert. So if you were to ask that clinician, the novice clinician, what are you going to do next? Almost always they are going to say, well, I'm now going to do blank, which is some other cool intervention, right? Well, I'm going to do some dry needling. I'm going to do some decompression with cups. I'm going to crack their back. I'm going to do this exercise. It's something different. On the other hand, what does that answer look like from the expert? When you see that small positive change, what are you going to do next? More. You're going to do more of it. So you say, Kathy, get back down there, right? You mobilize your back for another four or five minutes. She gets up. You see another small positive change. What do you do next? You get back down there. You keep working the thing that is working. The expert sees the change and doubles down and does more of it. Maybe you change your angle a bit on the mobilization, maybe you do both sides, maybe you work up and down the lumbar spine again, but you are not leaving that intervention while it's still giving you additional benefit. You ride that horse until it bucks you. If it works, great. Do more of it. Instead of trying to cram everything that you possibly could during that session, right into that one session, focus on the thing that is working and just increase the intensity. And now the patient has one thing to focus on. They know exactly what is actually changing their symptoms and you can sell the next session. Just say, Kathy, when you roll in here next time, we're gonna add a little bit of A, B, and C on top of the thing that we already know is working. And now you can take your time, right, and you can stack interventions on top of each other. So many times in the clinic, when I'm reviewing the quote-unquote challenging cases with clinicians, when they're telling me what they've done, right, throughout those first few sessions, They typically have done at least one intervention that has given some change, some positive change, some improvement. And I always ask, well, why didn't you do more of that? Why did you actually go to this instead of just doing more? And it's crickets. We're so obsessed with doing things, with trying to give the person more interventions, more of our skillset. instead of just doubling down on the thing that's working. So I will take something in the clinic, an intervention is working. Let's take that lumbar spine mobilization. I will just hammer it until it doesn't work anymore. Right? So if you're retesting four times during a session and every time it gets better, just continue to use that same intervention until on your test retest, it fails to give additional benefit. it will simplify your clinical reasoning, slowing down with your intervention, again, allows you to speed up over the long haul. So think about those two examples this week in the clinic, slowing down to speed up. So early on in the plan of care, focus on tackling one area, commit to it, and watch your decision making throughout the rest of the plan of care become so much more clear. And once you do have that treatment that's working, commit to it and ride that horse until it bucks you. Until when you retest, it gives you no additional benefit. But if it does, you stick with it. Those two things together are going to allow you to maximize your outcomes in the clinic. All right, would love to hear thoughts on this. SUMMARY If you want to learn more about this or that technique that we mentioned or any of the clinical reasoning around it, we've got a few live courses coming up. Let's see, for cervical management, we've got one in February in Simi Valley, California. We've got two in March in Kuna, Idaho and Longmont, Colorado. And then for lumbar management, we've got one in March in Cincinnati that is actually sold out already. And then we've got Milwaukee, Wisconsin at the end of March as well. So that is it, team. Have an awesome Tuesday in the clinic. If you're coming to a cervical or a lumbar live course, we will see you soon. Thank you. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 19, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares some insights and a "big win" from a coffee marketing meetup with a physician. She cites 5 clinical pearls for how to approach challenging the status quo of practice patterns with the providers in your community. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Good morning, everyone. This is Dr. April Dominick. I am on faculty with the Ice Pelvic Division. And today I wanted to discuss a recent marketing win that I had with a physician and some insights regarding how to challenge the status quo of practice patterns within providers in your community. One concern that we often get with our ICE courses and especially in the pelvic division is someone will say, hey, I love all of this incredible research that you all are sharing that is completely different from the way that I practice and I'm so stoked and I'm so behind it. But how do I recommend or how do you recommend that I bring this back to a community of providers who are pretty steadfast in their practice patterns? So today I'll share that recent interaction. And again, it was a marketing meetup with a physician and I want to share how it went from an invite for a latte to an invite for a lecture that I could give And all of that happened in just under 35 minutes. So I met with an OB who I have a pretty solid referral relationship with. She refers folks to me, I refer folks to her, and we were just catching up over some mutual patients that we had. And the conversation ended up turning towards how she counsels patients in the pregnant and postpartum space in regards to exercise. And she absolutely encourages people to continue moving, keep exercising, working out. But she says, you know, I caution them against doing planks and I don't really support twisting and turning because I don't want to make that diastasis recti worsen or that thinning of the linea alba. And she also says that she cautions individuals with any sort of impact because she doesn't want to further any sort of urinary incontinence. In my head, I was like, ooh, gosh, there's so much research that has come out, especially in the past six to 10 years, that doesn't support that line of thinking. But how do I share that with her without, you know, stepping on her toes and interrupting this beautiful relationship that I've developed with her? So I asked, I said, would you mind if I shared some updated evidence that we have regarding all of those topics? And she was totally game. She was like, fire away. Yes. So I shared the benefits and the protective mechanisms that we know about as far as core strengthening during pregnancy and early postpartum. I relayed to her the reality of the situation regarding diastasis recti is we don't even really have a consensus in the literature for defining it. And I also quoted some studies that we also talk about in our live courses and our online courses about when it comes to someone who is one year postpartum, they are likely still, some of them still have a diastasis recti and that those with a persistent diastasis recti tend to have a weaker rectus and oblique strength score compared to those without a DRA about a year postpartum. I also anecdotally, I mean, I had to squeeze this in somehow, but I anecdotally shared that since I started loading the core more during pregnancy and early postpartum, that some of our mutual clients, I did some name drops, have actually had relatively quicker recoveries on the back end, on the PT side. And they've returned to their functional activities seemingly with more ease. And that was, of course, all things considered and just an anecdote, but it's something that a trend that I've noticed. And that's all for folks who have prioritize course strength training as opposed to those who have not or those who continued some sort of resistance training of some sort. We also talked about other topics and I threw in that we have a lot of evidence regarding the benefits of resistance training and lifting heavy during pregnancy and some preliminary evidence that says hey, exercise and heavy strength training may support the role of lowering some pregnancy complications, including gestational diabetes, gestational hypertension, and even some perinatal mood disorders. And then of course, I let her know, you know what, I am there to help support someone in their endurance training, their impact training, Um, and I help address that pelvic floor dysfunction. So I actually will come alongside someone, um, with those goals. And if there is any sort of pelvic floor dysfunction or urinary leakage, um, I got them. And, and that's not something that I discourage. Her mind was blown. Like she was glued to me as I was just rattling off all of this new information to her that differed from her current practice patterns and likely what she had been trained under when she went to school or in the last continuing education class that she went to. Or maybe she just hasn't really been to any of this because that's not necessarily her expertise. So she was just mind blown and she was so excited to learn this new information. And I said, you know what, this line of practice that I just shared with you, all of these recent updates and literature, this is more of a recent shift even for me. When I first started practicing in pelvic health, up until three to four years ago, I had many of the same practice patterns that you just shared with me. And in fact, many PTs, many other pelvic PTs are still currently practicing with those similar philosophies because that's how we were trained. And not everyone is caught up in respect to the latest evidence. So we talked about different concerns also that we hear in our clinic rooms. And that was fascinating, a whole nother podcast episode, but it was just really fascinating to hear that some of the concerns that her clients have, that our clients have, what they tell her in the clinic room is very different from what the conversations I have. And of course I shared with her, you know, a lot of the folks who are pregnant and postpartum, They have so much fear on board regarding getting a diastasis recti during pregnancy. By the way, it's 100% normal. And how they often pay for generic programs to get flat abs from Instagram influencers and they don't work and then they're frustrated. Or they share with me how they're just terrified about getting a perineal tear during delivery. or they're just determined not to have their organs fall on the ground after pregnancy. And it was so interesting because she, she was like, April, that is, those are not the main concerns in my sessions. And she was like, this is so informative to hear what's happening over there. She also doesn't have Instagram. So I feel like that may influence what it is that she sees and hears. But again, we were talking about in our clinic spaces. So I also got curious because I had some questions that were more on topics about her expertise, like perimenopause, menopause, and hormone replacement therapy, which all of those topics are being discussed way more in the pelvic PT space now. So at the end of the conversation, she thanked me so much for sharing the recent literature. She said, I am so much more confident now promoting whole body strength, including the core, like I feel comfortable because of what you shared with me, promoting people doing planks and promoting impact exercise throughout pregnancy and postpartum. She wanted those articles emailed to her immediately. And the most surprising and probably the best part of this entire meetup was that she asked if I would like to give a presentation at Grand Rounds of the do's and don'ts of exercise during pregnancy and postpartum. She was like, my colleagues would 100% benefit from hearing what you have to say. It'll be a tough crowd because she said many of her fellow nurses and physicians assistants and doctors practice from what they learned, uh, 20 to 30 years ago and are even way further behind than how she practices. She's like, some of them are still promoting bed rest. Um, even when the client doesn't meet that criteria. And she said that she often will come behind providers as she's rounding up the hospital and say to the clients, no, I want you to get up and move. Moving is good, exercise is good. Because I guess some of her other colleagues have said, no, no, no, just stay in the bed, stay in the bed, that's gonna be better for recovery. So I was of course ecstatic when she asked me to do a Grand Rounds lecture. I told her, you know what, it would even be very helpful from my perspective if clients heard about the benefits of continuing resistance training and core work and impact exercise from the medical community because Clients have so much respect for the medical community. So if they are hearing about it first from them and then they get to see me later, if that's the order that happens, even better that we are reinforcing that strength is queen and that can help knock down a lot of those fear-based messaging that our clients get. So, In a matter of 30 minutes, I went from coffee grounds to grand rounds. I want to identify just five things or themes that I came up with from that interaction that may help you cultivate a relationship with a provider, whether it's an OB, an orthopedic surgeon, or a chiropractor, massage therapist, whatever. Use these when you are going to market. LEVERAGE THE LITERATURE Number one, leverage the literature. and thoughtfully ask if it's okay for you to share that recent literature has overturned some of those old tiny beliefs. So reference some of the amazing evidence-based pearls that you've gotten from your ICE courses or from some of our posts. It's all about being respectful for that delivery in the question. So I'd recommend that you just be honest and say, would it be okay if I shared some of the recent literature with you that I have found incredibly helpful for my practice in bettering client outcomes? VALIDATE THE OTHER PERSON Number two, validate them. Share that it wasn't long ago that you were practicing in a different way that maybe didn't align with some of the recent clinical practice guidelines. Sometimes the oldest techniques don't necessarily stand the test of time and they may not be the most effective. SHARE CLINICAL OUTCOMES Number three, share some stellar clinical outcomes. Use wins from mutual patients if that's an already established referral source. ASK FOR ADVICE Number four, ask them for advice. When it comes to a topic that is in their expertise that you may be curious about, or maybe you have an uptick in this particular diagnosis on your caseload. There is nothing that people love more than talking about themselves. Exhibit A, just kidding. Um, but they love talking about how they treat their philosophy. And when you ask someone for insight that shows, you know what, that shows that you're curious and you're wanting to learn from them. So it becomes more of a two way street. LEAN INTO YOUR PERSONALITY & PASSION And then finally, number five, lean into your unique personality and passion. When people get a sense of how incredibly passionate you are about changing lives and how you practice being about it day in and day out, they listen. Think about the first time you tuned into a PTA on Ice podcast episode with Jeff Moore or Christina Prevett blasting their truths from behind the mic. how you can feel their excitement through your speaker as they rap about getting that PT version 2.0 going, about how we need to remove barriers to exercise in the older adult, the pregnant and postpartum space. So lean into your personality, whether it's loud and proud or quiet confidence, and let that drive your passion behind changing the status quo in your community. I hope you found this marketing one of mine and those insights helpful for your next marketing meeting. Remember, leverage recent literature, validate the provider and how you may have just recently shifted to using these more evidence-based interventions and strategies, share recent client wins and trends, get curious about their expertise, and then lean into your personality and let that elevate your passion for providing Fitness Forward, evidence-informed care in the PT space. SUMMARY If you're feeling like you need to brush up on some of the latest research and treatment strategies in regards to fitness, guidelines, and any sort of pelvic health issue, join us in our Ice Pelvic Courses. We have some live courses coming to you. Alexis and Rachel will be in Newark, California. the first weekend of March, and then Alexis and I will be in Bismarck, North Dakota the second weekend of March. There's still time to sign up for those. And then from an online perspective, our next level one cohort starts March 5th, and we only have a few seats away from being sold out for that cohort. So hop on in. Thank you so much for joining and remember to bring that Be About It attitude not just to your workouts but to your marketing meetings and coffee meetups as well. Cheers y'all! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 16, 2024

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses current recommendations on protein intake, new possible recommendations, and barriers to showing efficacy with different amounts of protein consumption. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning. PT on Ice Daily Show. Happy Friday morning. Hope your morning is off to a great start. My name is Alan. Happy to be here today. Currently have the pleasure of serving as the Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We talk all things related to CrossFit, Olympic weightlifting, powerlifting, endurance athletes, If you are working with a patient or client who is recreationally active, out on the road, on the bike, in the gym, Fitness Athlete Friday is for you. Just a quick announcement before we get into today's topic. If you're going to be at CSM or you're already at CSM, join us tomorrow morning, 5am, CrossFit Southie. We have a free workout going on, led by me. I'm getting on a plane later tonight to fly out there and run the workout tomorrow morning. So whether you have many years of CrossFit experience, whether you have zero minutes of CrossFit experience, we're going to have a fun workout tomorrow morning at five. Please go on our Instagram, go into the pin post and sign up for the sign up form. The link is in that pin post. So today, Fitness Athlete Friday, what are we talking about? We're talking about a paper that just came out at the end of 2023 and was published a few weeks ago, looking specifically at protein digestion. Hang on, buddy. Come here. Sorry about that. We're going to talk about protein digestion and the upper limits of what we think can happen with protein digestion. So we're going to talk about current protein recommendations based on the current body of research. We're going to talk about what this paper found and the conclusions it drew that may change those protein recommendations. And then we're going to talk about barriers to this research. CURRENT PROTEIN CONSUMPTION RECOMMENDATIONS So the paper we're referencing today, the title is the anabolic response to protein ingestion during recovery from exercise has no upper limit in magnitude and duration in humans. was a paper published in December 2023 by Tromelin and colleagues, pardon my sick son coughing, and the journal title is Cell Reports in Medicine. So that's the paper we're referencing. Current protein recommendations quite old and they typically recommend and advocate that humans can't digest or otherwise synthesize protein in amounts above about 20 to 25 grams of protein per hour and If you're like me, you were sitting in a lecture in undergrad maybe 20 years ago and you heard that based on literature from the 90s and the early 2000s and you thought, hmm, that seems really specific and also really impractical given how much protein we're recommending that people eat. How can somebody possibly only synthesize and utilize 20 to 25 grams per hour. That would mean an individual, especially a larger, more muscular individual, would basically need to be always eating protein, right? A lot of these studies look specifically at whey protein, a faster digesting version of protein. Whey protein is essentially the watery portion of milk with all the fat strained out. But even at moderate protein consumptions, think about an individual who's maybe 6'6", 300 pounds. No, no. No, no, okay, we're gonna hold you all the time. Somebody who's 6'6", 300 pounds, that person would need to eat 20 to 25 grams of protein for 12 to 14 hours in a row to get all of their daily protein in, maybe just at a maintenance protein level. That is really impractical and yet, up until this paper was published in 2023, we don't really have any other recommendations that we could give. So cue this paper being published at the end of the year. You see yourself, hi. NEW PROTEIN CONSUMPTION RECOMMENDATIONS This paper, fantastic methodology, amazing study, really good incorporation of inclusion and exclusion criteria of the subjects used, but also did a really good job of being very thorough in measuring and tracking the protein synthesis in the subjects in the study. So let's talk about that study. This study looked at 36 healthy males between 18 and 40. Inclusion criteria, they had to have a BMI between 18 and 30. They had to have already been exercising one to three days per week, so they needed to basically be familiar with exercise, particularly resistance training. And exclusion criteria included anybody who smoked, anybody who was lactose intolerant, and anybody who was taking any sort of prescription medication. So basically we looked at rather young, rather healthy men. What did we do? We had them all perform the same type of resistance exercise. We had them perform the same resistance exercise protocol. They went into the gym, they performed one set of 10 reps at 65% of their max on lat pulldown, leg press, leg extension, and also chest press, so bench press machine. They then did four sets to failure at 80% of their max. So they did all the same resistance training protocol. And then what changed, what varied in this study was how much protein they consumed after the resistance training protocol. So some subjects were given no protein, that was the control group. Some subjects were given 25 grams of protein. And then another group was given 100 grams of protein. So four times current best recommendations. And the hypothesis was, how much protein synthesis might we see compared to the 25 gram group in the 100 gram group. We looked at immediately post-exercise, we looked up to 12 hours post-exercise and we found some really interesting results that essentially the higher protein group saw continually increased levels of protein synthesis out to the end of the study, the end of the 12-hour period. So the 25-gram group had increased protein synthesis obviously compared to the zero-gram group, but the 100-gram group had 20% increased levels of protein synthesis in the zero to four-hour measurement window and 40% higher in the four to 12-hour post-exercise window. So this paper is great because it really opens up the notion that we can front load our protein and that we can potentially catch up on a protein deficit later in the day. For a lot of our folks, especially our active folks who are also maybe working, wrangling kids during the workday, trying to get enough protein in and trying to get it in those 25 gram feedings is probably just not feasible when we're looking at individuals eating 200, 250, maybe even 300 grams of protein a day. Simply not possible to get that. So a lot of those folks have issues with timing of protein intake. and also the belief that any consumption beyond 25 grams might be wasted. This article is really a landmark paper because it shows that that might not be the case, that we can front load large doses of protein or catch up with big doses of protein later in the day and see really long windows of protein synthesis after resistance training. Again, 40% higher at the 12-hour mark compared to 20% higher at the 4-hour mark tells us protein synthesis actually increased the further away we got from both the exercise and the actual consumption of that protein. RESEARCH BARRIERS Now there are some barriers with this research, we need to be mindful of what this paper does not say. This paper did not look at objective measurements of things like strength or hypertrophy, so it would not be fair, hi buddy, you're gonna knock my tripod over, It would not be fair to use this study to say that eating 100 grams of protein at a time makes you stronger, makes your muscles bigger because the study did not look at this and therefore we cannot conclude that 100 gram doses are better. What we can conclude is that this may be an alternative way to consume our protein that results in equal or even higher amounts protein than the traditional recommendations of 25 grams per hour. What we also need to be mindful of is that all of the research on 25 grams per hour looks specifically at subjects fasted eating whey protein. This study literally did the opposite. It looked at individuals who were fed, who had just performed resistance training, and who were essentially eating casein protein, the fatty portion of milk protein. So eating basically the opposite aspect of the protein and doing it under a different mechanism, doing it after exercise as compared to doing it fasted. So it is a little bit of comparing apples to oranges. Nonetheless, what we can take away from this paper is an alternative feeding strategy, especially for those individuals who we see in the clinic, who we see in the gym, who may tell us that they simply don't have time in their day, time in their schedule to eat protein in 25 gram feedings. If those patients, if those athletes, if those clients are already saying, hey, I know I'm not getting enough protein because I don't have time to eat 25 grams every hour for 14 hours, and I'm just simply not eating protein, then this is a very viable alternative solution of, hey, let's try front-loading your protein before you leave the house for the day. Let's try eating, you know, 50, 75, 100 grams of protein, maybe half, maybe 75% of our protein intake for the day before we leave the house. Now again, what we can't promise those people is that they will have equal or better levels of muscular strength or hypertrophy gains, but nonetheless we know how important protein is at least for recovery. so we can make that alternative recommendation to those patients and clients. SUMMARY So, protein, is 25 grams an hour the maximum? It doesn't appear so. It appears that the more we eat, the higher levels of synthesis that we have, at least in the scope of this paper, up to 12 hours after we've consumed that protein. Is it better? We don't know yet. We need more research. We need to now look at a study of folks eating 25 grams versus 100 grams and now measuring them more longitudinally and seeing what does muscular hypertrophy look like, what does muscular strength look like, even what does functional outcomes look like, different functional tests. but that being said this is still a very landmark foundational paper that should change our mind about how we think about eating protein that we can think about front loading if we need to we can think about catching up at the end of the day eating a big dose of protein maybe with dinner. I know Mitch Babcock who teaches here in the fitness athlete division a big fan of a big bowl of cereal with protein powder on it on the end of the day just to get a big lump of protein in before the day's end and that might be a viable successful alternative for a lot of our patients and athletes. So protein get it in get it in where it fits in even if it's a bigger dose than previously you may have been led to believe would be effective. Courses coming your way really quick. If you want to come learn more about protein, recovery, nutrition from the Fitness Athlete Division, our Level 1 online course starts again April 29th. Our Level 2 online course starts September 2nd. And we have a number of live courses coming your way throughout the year. A couple coming your way the next couple months. We have Zach Long down in Charlotte, North Carolina. That'll be February 24th and 25th. Zach will again be out on the road, this time in Boise, Idaho, March 23rd and 24th. And then we have a doubleheader the weekend of April 13th and 14th. Joe Hineska will be out in Renton, Washington, near Seattle. And Mitch Babcock will be down in Oklahoma City, Oklahoma. So I hope you have a wonderful Friday. Please join us at CSM if you're going to be there. 5 a.m. tomorrow morning, CrossFit Southie. Other than that, we hope you have a great Friday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 15, 2024

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the differences in how regret can present from overworking an unrewarding job, but also from underworking in a career with a lot of potential for both personal & professional impact. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MOOREAlright team, what's up? Welcome back to the PT on Ice Daily Show. Thrilled to be here on Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of ICE and always pumped to be here on Leadership Thursday, which always pairs as a Gut Check Thursday. Let's get right into it and talk about the workout. So what we've got is the CSM workout. Both Alan Fredendahl and Paul Kalorin of Ice and iDryNeedle, the combo, are going to be there to lead you all through a workout Saturday morning. Anybody at CSM who wants to get some movement in, please join us. 5 a.m. CrossFit Southie. You've got to sign up on the form. So go to the Ice Students page. The form is on there. It's here on Instagram. It's on the pinned post for the CSM WOD. I think we have like 20 signups and I want to say they're taking in 30 or 40 so as we get very near to Saturday morning make sure you jump on there if you indeed want to work out. It's going to look like this should you choose to attend. It is going to be an AMRAP 25 minutes. Now mind you, anybody not at CSM should still do this. Teams of 2. We've got a 100 calorie row. We've got 80 alternating hang dumbbell snatches at the usual 50-35. You've got 60 box jump overs at 24-20. You've got 40 toes to bar, and then finishing off with 20 burpees over a dumbbell, and then going back up to the top, should you have more time in your 25 minutes. Should be a really nice chipper running through that. Gonna get kind of a one-to-one work-rest ratio. Should be able to keep moving. Should be an awesome workout. If you go to the CSM workout, please make sure to tag us. I won't be there, so I'd love to see photos and videos of all of you getting after it. Let's jump into Leadership Thursday. DEATHBED REGRETS The topic is deathbed regret. Will you have them? I think perhaps not. Let me explain. So the usual story goes something like this, and I think we've got to respectfully counter it. The usual story goes something like this. Your grandfather or your grandparents in their twilight years are regretting spending too much time at the office. right, saying, you know, oh, I wish I would have pursued more of my hobbies, done more things that I really cared about, et cetera, et cetera, et cetera. And the cautionary tale here that we're supposed to pull away from this constantly heard story is that you shouldn't overwork, okay? This is the concern, this is the moral of the story, if you will. REGRET FROM OVERWORKING Okay, I don't know about you all, but my grandfather worked in paint factories in downtown Detroit, Michigan. Tough gig, tough city, right? But he did what he had to do. I have no doubt, given the option, he would look back and say, I never asked him, but I'm sure he would have looked back and said, I wish I could have done a bit more of that. Or I wish I would have chose to, if there were sufficient resources, do a little bit less of that and spend less time there. I have no doubt about that. That's fair. If your job feels like that, like it's tough, it's grindy, it's not necessarily one that you're super passionate about it. You're kind of doing it because you have to, but you can't change that because you're doing what you have to do. That's the job that's available to you and you're getting it done because that's your responsibility. Not only is that noble, but it's totally understandable to do what you need to do, but I would agree, maybe don't do a ton extra. And I can totally appreciate how regret at end of life could come should you choose to do a ton extra of something you don't necessarily love. I will cough that up. I will agree with that. I can appreciate why that's been the narrative for a lot of years. That being said, It is much more likely that you are doing something that you chose and that you are passionate about and that you love. Particularly if you're sitting here on Thursday morning, taking in leadership Thursday, the odds are really good that you chose your career amongst a variety of options and you chose one that you believe in, right? You probably didn't choose the paint factory in downtown Detroit. It's a tough gig, right? That probably isn't one you were drawn to. And again, if you're in this ethos, where you're taking in this kind of content, you're probably in a position where you chose something you loved. Now, if you started a company, or you joined a company that you really believe in, regret is unlikely going to be the byproduct of your hard work in that space. So what I'm saying is that we need to advocate, or I wanna advocate, for a shift from people on their deathbed say to or towards people on their deathbed used to say. Because I don't foresee myself or any of you saying in your twilight years, I really wish I wouldn't have fought so hard for something I believed so much in. I just don't see that coming. I totally see it from the paint factory, right? I don't see it when you chose your passion that you feel most aligned with, where you want to be of some use. I don't see that statement on the horizon. For me, the thing that I believe I'm fighting for is freedom for everybody from dependence on the medical industrialized complex. From the pharmacy, from the surgery, right? Instead, a belief in a utilization of one's own physical resilience, right? The belief that changing the narrative and educating the public that if they train and fuel well, and they don't have a bad accident, that you can maximize and enjoy an incredible health span. And unfortunately, the narrative in this country is solely the opposite. The amount of people who are unbelievably dependent on a ridiculous amount of prescriptions, that are so quick to surgery, that leave anything healthy once they're injured, that we have so much to fight against. But I believe in this fight. And I don't believe that when I'm 80, I'm gonna say I wish I would have fought it less. I don't believe that. The principle runs too deep. REGRET CAN ALSO COME FROM UNDERWORKING Instead, and to close off the episode, a bit of real talk perhaps, I think that our regret risk in this generation, now that that shift where choice is kind of the driver of career has been made, the risk more lies in the following items. I feel like I never made a difference. I feel like I didn't fulfill my potential. I didn't go hard enough. I never found my limits. I don't know what I was capable of doing in the good fight. I never generated sufficient resources to be able to support myself and others. I think this is probably the list of regrets that is more common and they come from underworking, not overworking when you've chosen something that you believe in. And many of us get to make that choice. So my message to you on this Leadership Thursday is first of all, make sure you're doing that if you're able to. I do not mean to put anybody in a bad mental spot if they're like, dude, I'd love to, but my cards don't allow it. My situation, maybe right now and future, totally respect that. Do what you have to do. There's so much honor in that. If you get to choose, if those are your cards, choose something that you believe in and go all in. If you are a part of a team that achieves something that you believe to be deeply meaningful, you are not going to look back and wish you spent more time on yourself on vacation. That isn't how it's gonna shake out. You're gonna look back and say, I'm so glad that I was of some use. I'm so glad that I figured out the maximum that I was able to contribute in an area that I believe needed my efforts. That isn't something you regret. That is something you celebrate. It's time to push back against the narrative. Things have changed. Let's acknowledge it and let's stop scaring people into not working enough to find their potential because of things being different 30, 40, 50, 60 years ago. Give it some thought. Thanks for being here on leadership Thursday. We've got a million courses coming up. It's our busiest time of year. I think this weekend alone, we have 12 to 15 live courses. Make sure you jump on ptonice.com and check out that schedule. Get those skills, get out there and help some people y'all. Cheers. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 14, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he discusses what it looks like to discharge as a fitness-forward clinician. In this episode, we'll cover the do's & don'ts to discharging and even challenge the whole notion of discharge itself. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION DUSTIN JONESWelcome y'all to the PT on Ice daily show. My name is Dustin Jones, one of the lead faculty within the older adult division. And today we are gonna be talking about the fitness forward discharge, the fitness forward discharge, how we can set our patients up for that fitness forward lifestyle once they leave our doors, all right? So before we dive into this conversation, I wanna start by really saying that the whole concept or notion of the discharge as we know it, traditionally, really needs to be challenged, right? The whole concept of, I'm gonna see this person for six to eight weeks, and then I'm gonna have no contact with that person whatsoever, and then cross my fingers and hope that that person will hopefully come back if they do have issues down the road, right? Hopefully, we see some of the issues with that. Hopefully, we can see the problem with bragging about how few visits it takes for you to get particular results, right? It's like we've created this badge of honor for how little that we're seeing people. And if you spend any time around the Institute of Clinical Excellence at any of our courses, you start to see what you have to offer people. Why in the world would someone like you, a fitness-forward trained clinician, want to be around someone less. You have so many valuable skills. You have such an amazing influence. Your be a valid approach, this fitness for lifestyle that you lead and can ultimately give to your patients. Why would you not want to rub shoulders with these folks that you can absolutely change their lives, right? So the whole notion of discharge, I really want to challenge. I think the Onward Physical Therapy crew is doing such a good job with this with their Restore and Perform program where they will have patients and they will transition to more of a maintenance type situation. I know many of you all watching have similar services where they may come off of quote-unquote physical therapy but you're still getting those touch points to change their lives. That is really, really good. What I want to speak to today in terms of the Fitness Forward Challenge is for many folks that are working with individuals and patients that do not partake in fitness, that these folks are not a part of a fitness community and you're going to work with this person and we need to set them up for success after your course of care. How do we handle those situations? I know for The vast majority of you all watching and listening, that is the case. I can say that for myself, definitely in the context of home health where I've spent most of my time. clinically, but now I'm on the other end of the equation where I am mainly in the fitness space at Stronger Life Fitness in Lexington, Kentucky. So I've really enjoyed experiencing what it's like to get people into our fitness community from different clinicians and what clinicians have done really well to set them up for success, but also what they've done really poorly that's made our job really difficult. And I think about all the folks that even come into our doors because of something that happened in that course of care. All right, so the fitness forward discharge for you clinicians that are working with folks that do not partake in fitness right now. We're gonna dive into some practical things. I want you to think of this in three steps. All right, number one is that we start with the end in mind. Number two is we prepare for what's ahead. And number three, we test the plan. All right, I'm gonna dive into some specifics. within those three chunks. START WITH THE END IN MIND So number one, starting with the end in mind. Many of us will hear this saying all the time, especially when you are in a more acute setting like acute care clinicians, right? As soon as they do their eval, they're planning their discharge, right? That is For many of them, the goal is that, all right, what's the discharge disposition so we can get this person to a place where they can receive care? And I think that's a good mindset for us to have across the continuum of healthcare. Discharge planning starts day one. Where is this person headed? where are we taking this individual? Now, for you all, the fitness forward clinician, the question that we often ask ourselves, but ultimately ask the patient or the client, is how fit will you let me get you, right? Betty comes to you for her back, her back pain, and we're gonna take care of that back pain for sure, but ultimately we don't wanna stop there, right? We change lives, not just pain. We're gonna see how fit we can get Betty ultimately in her one rep max living and help her live the fullest life that she can imagine right that goes beyond pain reduction techniques right so how fit will you let me get you now what is really important when we start thinking about the next step after our course of care when we're discharge planning and starting on day one we need to consider what this person is going to be willing to start and but then also sustain in terms of a fitness routine. What they're willing to start and then sustain. And I would say the latter is more important. It's easy to start something, it's tough to sustain it for months, years on end. So this is where we really need to spend a lot of time understanding this person's goals, their desires, their deep desires of what they want to be able to do. What keeps them up the night? What would they want to be doing if they had no pain whatsoever? And then match the fitness regimen that could ultimately make that happen, right? And with that, we have to consider so many factors, like personal preferences. past experiences, their perceptions of certain communities or fitness modalities. What's their financial situation? What do they have available to them to help offset some of the financial barriers? If someone is on Medicare or have a Medicare Advantage plan, there's lots of things available to help reduce the cost of fitness services. Where are they located, right? Location is such a huge variable in the adherence and consistency of an exercise program when someone is leaving their home to partake in fitness. It's a lot easier for someone to go around the corner as opposed to driving across town, right? And what social support, what resources does this person have? We need to take all of these into consideration and that is going to form our recommendation of where we are headed and we can set that out very early on in the process. So for the outpatient clinician, many of you all watching, many of you all are probably a part of some type of CrossFit community or CrossFit box, right? And you may be treating some patients in the outpatient setting where that transition may make a lot of sense. They may be familiar with it. They may not have a lot of baggage associated with that brand or that gym, that CrossFit box. And that transition can be relatively easy for you. And that's a no-brainer for many of you all. But for a lot of folks watching and listening, they have patients that are likely never going to step foot in a CrossFit gym. And I would go as far to say that CrossFit gym is not the best place to serve some folks, right? I know that's blasphemous on this podcast, but the local CrossFit box may not be suitable for every single person that you're working with as a physical therapist. So we need to understand, are there communities out there that can meet this person where they're at and help them make this a sustainable long-term fitness routine? and for the home health clinicians watching. Is there something that could be done for someone that is currently a homebound status? Is there some type of online community? Is there some type of online service or some type of YouTube channel, for example, that someone could partake in and consume that's going to be suitable for their situation? You cannot make these recommendations without truly understanding the person sitting in front of you. So we have to dig in. What are they willing to start and then what are they willing to sustain? Now, this is going to require some work, right? You need to know the communities out in your area, of the differences of them, of how some may be more suitable or welcoming to other groups of people. there's gonna be big differences there. You need to understand what services are available online to folks that may not be able to get out, what services are available that are willing to accept some of these Medicare Advantage plans or Silver Sneakers or Renew Active if they're on United Advantage, for example. So we need to do some work so you can make some of those recommendations. If you're like, what in the hell is he talking about? Hit me up or join the MMoA community where we have a lot of these discussions and we have a really helpful resource of where clinicians threw in some of their favorite YouTube channels, for example, and different resources that they help encourage that fitness-forward lifestyle beyond discharge. But there's options out there. We can do the hard work for you. Hit me up, DM me, and I'd love to share some of those resources. So that's the first one. Start with the end in mind. PREPARE FOR WHAT'S AHEAD Two, we prepare for what's ahead. So we start with the end in mind and then we prepare for what's ahead. When we start with the end in mind, we get a good idea of maybe what type of fitness regimen, what type of fitness community is gonna be good for this person so they can sustain and continue their health journey, right? If we understand what that community and that regimen is about, we can prepare that person for said regimen in our course of care. And I view this kind of like graded exposure. or gradual exposure, where we're gradually exposing people to elements of that fitness community or fitness regimen. Let's take CrossFit, for example. Let's say you have a patient that has never done CrossFit and they have agreed, yeah, I'm going to join that community down the street once we're done. That's really interesting to me. You can do that person a solid by exposing them to some of the CrossFit movements, of some of the movements that you're commonly going to see in the programming. getting a barbell in their hand, teaching them some of the basics of a squat, a deadlift, a press, and then maybe even getting to Olympic lifting. Expose them to those movements to reduce that new member suck, right? We've all experienced it. There are some benefits to the suckiness of being new and not knowing a lot about what's going on in the community. I do want to acknowledge that, but man, it's really nice if you come into a community having a little bit of familiarity with some of these movements and jargon and so on and so forth. So we want to gradually expose them to the movements that are going to be coming down the pike. We also want to expose them to the intensity that they're going to see. This can also be new for a lot of individuals, particularly going into something like a CrossFit gym or some high intensity interval training bootcamps type fitness community, that if these folks have not experienced true intensity, we can do that in the course of our care and expose them to that so they're not blindsided when they join this fitness community. We would also argue within the MOA division that you want to do that regardless to get better outcomes, keep in mind. But when we also think about that fitness forward discharge, this is really, really helpful to do. So gradual exposure to that intensity that they're likely going to experience and then gradual exposure to the movements that they're likely going to see. The beautiful thing about this is it reduces that new member suck when you're partaking of something for the first time. But for a lot of our folks, it often gives them trust in their bodies, that they can trust their body again. Think of what so many of these folks have been through, especially the older adult population that I particularly work with. We're talking decades of different healthcare interactions, maybe a dozen courses of care in the context of physical therapy, who knows how many surgeries, who knows how many diagnoses that were given without context, who knows how many damaging words have been said to this person where they believe that they are weak, fragile, slow, that they are broken pieces. We have the opportunity to show them that is not the case. That is not the case whatsoever. You can trust your body again and you can push your body again and your body can improve and get better and you can do things that you thought were absolutely impossible. You can show people that through this gradual exposure. So that's how we wanna prepare, that gradual exposure to intensity and movements. Number two, we also want to give people a plan to troubleshoot the difficult scenarios that are going to come up, right? Jeff Moore always says this, and I love this, where he will talk about the path to fitness is always gonna run through some musculoskeletal issues, right? And this is where we are such a huge service for individuals, that we, throughout our course of care, can give people a plan to be able to troubleshoot what is ahead, what is common, the question of hurt versus harm. When am I doing damage versus when a little bit of discomfort is okay? Maybe giving them something like the traffic light analogy where, you know, that zero to three out of 10 is kind of that green light. Still send it, you're good. But if that lingers on to, you know, that four, five, six range, that's kind of in the yellow. We need to start thinking about modifying. We're still moving, right? And then, you know, that seven, eight, nine, 10, where we're in kind of that red light, where we're thinking, still need to keep moving but I may need to go come back and see you physical therapist or PTA or whoever you are so that strategy of if this than that so they understand the difference between hurt versus harm and when they need to come back to see you can be very very helpful another one particularly in a population that's not used to exercising is DOMPS. For many of you all you don't even remember what it was like the first time you felt delayed onset muscle soreness if you've been exercising regularly but for someone new it's a very frightening thing when they do something that they perceive is going to be beneficial and helpful for them and then they try to get out of bed the next day or the day after and they're absolutely miserable. a lot of things can go in your head of what may not be helpful or beneficial about what you did that caused so much discomfort and so you can give them context. I've made this mistake way too often where I did not give context to delayed onset muscle soreness and it really comes back to bite you. You can lose that that clip that trust of the patient but ultimately we want to give them the ability to handle kind of the ups and the downs to understand hurt versus harm, to understand DOMS and what to actually do about it, and ultimately, when they really need to come back to you versus continuing on in their fitness regimen or community. Alright? So, number one, start with the end in mind. Number two, prepare for what's ahead. TEST THE PLAN And then last but not least, and where most people really drop the ball, is we test the plan. we test the plan during our course of care. So as the course of care is winding down, we may be kind of reducing some of the focus on pain reduction and thinking more about building physical capacity. We're starting to stress test this person, of how they're handling what we know they're gonna experience down the road, right? This is where Alex Germano, she's watching here, but she has said before that we need to make PT sweaty again. And I absolutely love that phrase, and I feel like that is very, very pertinent throughout the whole course of GARE, but particularly for this phase. That last few weeks where we're stress testing our plan of care, where we're getting people sweaty in PT, seeing how they respond. These folks, we also, during that transition, want some overlap where they're actually partaking in that fitness regimen or a part of that fitness community. When we still have those regular touch points and we're able to handle some of the ups and the downs and what may come and answer some questions and just make sure this person is well prepared while they're under our care, that makes it very, very easy for them to continue and make this a sustainable effort. So we want to test the plan. stress test them in your session. Make PT sweaty again. And there's usually kind of a turning point that you'll see, particularly in Jerry PT, Jerry OT. And sometimes it happens sooner, right? If you really push intensity and your sessions are very challenging and it kind of catches them by surprise. But at the latest, this should happen. during this test the plan phase and what typically happens you got bob that's been coming in bob good old boy wearing his wranglers tucked in button up got a big old leather belt probably has some 30 year old fry cowboy boots rolling in here He's getting after it, just sweating his rear end off during your sessions. Then the next session comes around. What's Bob wearing? Bob's probably still wearing his boots, his fry boots. He's probably still wearing his button up, but he swapped out the Wranglers for some Fruit of the Loom sweatpants. still tucking the shirt in, the hem's probably right around his belly button, you know, that waistline area for them. He has seen, oh my gosh, this is not, quote unquote, physical therapy or occupational therapy. I'm going here to work out. We're getting sweaty, right? We're stress testing Bob, and he changed his outfit as a result. I cannot tell you how many times this has happened in the context of even home health, but then outpatient, and we definitely see this in the context of fitness. as well, but we want to try and see that. We want to stress test for if something bad happens, if they have some type of flare-up, for example, if they have some type of questions, we can handle it within our course of care. And ultimately, you're allowing a little bit of overlap where you're still seeing this person, but they're transitioning to that fitness community. That is what a fitness forward discharge looks like. We start with the end in mind. We're thinking about where this person is going. How fit are you going to let me get you and where are you going to end up? Whether it's a fitness community, whether they're doing something at home, whatever fits their particular needs, we start there. Number two, we prepare them for what is ahead. We make them familiar with the intensity, the movements that they're going to experience and we help them troubleshoot the challenging scenarios that are going to happen. DOMS, hurt versus harm. When should I seek care? when is it okay, when do I need to modify what I'm doing, right? Then number three, we test the plan. We stress test them while we have them in our course of care, while we're regularly seeing them. They may even already be starting that fitness program or fitness regimen. We're able to handle the bumps that come with that and really set them up for success as they continue forward. The fitness forward discharge. I appreciate y'all listening. SUMMARY Before you go, I want to mention MMOA courses. We've got a bunch of stuff lined up for 2024. If you want to see us on the road, I want to highlight a few weekends that are coming up. February 17th, 18th, this upcoming weekend we're in Oklahoma City, so catch that if you're in that area. March 2nd and 3rd, we've got Tripleheader. We're going to be in Rome, Georgia, Halifax, Canada, Glencoe, Maryland. We also have our Level 1 and Level 2 online courses. Our Level 1 course is going to be starting March 13th. We'd love to see you on that. Appreciate y'all. Have a lovely rest of your Wednesday. Go Crutchets! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 13, 2024

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity lead faculty Cody Gingerich discusses the importance of thorough palpation to rule in or out differential diagnosis during an objective exam. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION CODY GINGERICH All right, good morning everybody and welcome to the PT on Ice daily show. My name is Cody Gingrich. I'm one of the lead faculty in the extremity division coming to you on a clinical Tuesday. So getting into it, what I want to talk about today is talking about palpation and using a good palpation exam in your objective exam for doing some differential diagnosis. We're going to talk about the upper extremity and the lower extremity and why doing a really solid palpation job in those areas, specifically when you're dealing with extremity management. is going to be super, super important when you're trying to differentiate, is this something that might be more of an extremity issue or is this potentially something that's coming more from the spine, okay? We're going to talk about different things that you might see from a subjective standpoint that might lead you to figuring out, not having a super clear picture on which of those two things it might be. UPPER EXTREMITY PALPATION So we're going to start in the upper extremity, okay? So things that you might see or hear, I guess, from your patient when you're doing your subjective exam. right? Numbness and tingling that comes down the arm that comes down lower than the, um, than the clavicle elbow, potentially even all the way into the hand. Okay. Anything noticing tingling. A lot of times when we hear numbness, tingling, we're immediately clued into, Oh, that might be a nervous system problem. That can be a cervical radiculopathy, all of those types of things. but then some of their other aggravating factors are going to be, right? Potentially sitting at a desk, if it's a more of a fitness athlete, pressing overhead, all of those type of things might bring out their symptoms. So if they're sitting, if they're driving, where they could be stressing the actual cervical spine, but they could also be very much stressing that posterior shoulder, okay? Another thing that I see all the time is anterior shoulder pain. Okay, anterior shoulder pain with a lot of pressing type of movements and a lot of times if you know someone's sleeping on that shoulder or whatever else, we need to figure out is that coming from that anterior shoulder, but also we get a lot of referral from the posterior shoulder that pings right to that anterior shoulder. Okay, so I want to talk about how then your palpation job is going to be most efficient in bringing out some of those symptoms. The number one thing is you have to have a system. You have to have a system to know when you're going, where you're going to be and how you get back to that spot every time and how you touch each and every muscle area on what you're trying to palpate. In the extremities, specifically posterior shoulder and posterior hip when we get to it, posterior lateral hip, you can actually hit all of those structures and feel good about where you are palpating is touching what you want to touch. In the spine and areas like that, there are so many layers of tissue, you can't really always say, like, I know what I'm on, but specifically in the back of the shoulder, you can say, I'm on infraspinatus, I'm on supraspinatus, I'm touching teres. All of those things can be very confident that you're hitting that. So where do you want to start? Inferior angle of the scapula. Then you work laterally. You know then when you work laterally and you come back to that inferior angle, you go thumb, thumb, and then you start here and then you work away again. Come back, thumb, thumb, thumb. Now you're three thumb widths up. Each time you're touching your thumb, like working and doing your palpation every time. Now the key with this is if you find a spot and your patient says, Ooh yeah, that's tender. You can't just say, oh great, and move on. You need to spend some time in that area and hold and sustain that pressure. If in this objective they said, well it takes sometimes half of the day in order to bring out my symptoms where I start to get that tingling, then four seconds of you palpating that area on the back of their shoulder is not going to be enough to bring out those symptoms. Maybe 30 seconds, maybe 40 seconds of you really sustaining pressure there is going to be necessary before maybe they start saying, Oh, you know what? It's not just tender there anymore. It's actually starting to creep a little bit here. That's when you can say, Oh, well, maybe that extremity management or that extremities focus is going to be where we need to be. And it's not as much in the cervical spine, right? So that's where you want to really pay attention to what you're doing. You don't always have to get symptoms all the way down the arm, because that may take a very long time for them to get those symptoms all the way down. But if it starts to creep, down the arm like this, you can be pretty confident. There's definitely something coming from that shoulder, that posterior shoulder, where it is relevant as opposed to the cervical spine. Same exact conversation. We're talking about anterior shoulder pain. We are really thinking a lot of times when someone says, Hey, yeah, it hurts right here. First clue might be like, Oh, that might be some biceps, uh, tendonitis, tendinopathy, something like that. But If you, and most people are going to be tender when you palpate right on that anterior shoulder. Note that, but also make sure you do that really solid palpation job on the backside of the shoulder and sustain some pressure. If they find some, if you find something that's tender, sustain that pressure very often. They're going to say, Oh, you know what? I actually do feel that in the front of the shoulder. Okay. Now we need to be hitting the back of the shoulder to treat the front of the shoulder. Okay. And that's where our differential diagnosis, that hypothesis list that we generate from the subjective exam pressing, right? You're like, Oh, okay. That's an anterior shoulder. Definitely a lot of heavy work for the anterior shoulder. But if we're pressing, if we're really working our elbows into that front rack or something like that, that post to your shoulder and that rotator cuff in the back is also getting a lot of work to get that hand on top of your elbow. Okay, so both things are relevant there. Those are going to be the two main things in the upper extremity that you're wanting to change that hypothesis list. Cervical spine, we're getting a lot of just numbness, tingling symptoms down the arm. Okay. If the cervical spine is not blipping a bunch of that stuff, check posterior cuff. Same thing with anterior shoulder. If they're saying anterior shoulder, I get that when I'm benching, when I'm pressing, when I'm whatever, palpate the back of the shoulder, make sure you're doing a good job sustaining pressure. This position right here is occluding blood flow to the back of the shoulder where we sit almost all day, just like this. We are now no longer giving the back of our shoulder a really good environment to allow blood flow and healing. Okay? And so if they're just tugging on those structures all day long, now all of a sudden sitting at a desk can bring out some of those symptoms. LOWER EXTREMITY PALPATION Shifting gears to the posterior lateral hip, very similar conversation. In extremity management, palpation can matter. You can be confident in what you are palpating to know that you're on the structures that you are trying to hit. Again, you want to have a system. There are two ways that you can really create your system. If you want to start at the greater trochanter and work your way superiorly, you can do that. And then each time, you know, I went immediately superior from this greater trochanter, we're hitting glute med, and then we are working and fanning away from the iliac crest. and we can work away that way to the posterior hip. So that way we can know we've hit glute med, we've hit glute min, we've hit glute max. You can also start from the PSIS and work your way more anteriorly and then down to the greater trochanter. Very similar in that you will probably need to sustain pressure. There are people that are going to be mostly tender there. If you find tender spots, sustain some pressure. if you have not sustained pressure for upwards of 30 to 45 seconds to at least see if symptoms have changed at all. And the question is, are you still feeling that right under my thumbs or has that started to creep anywhere? you'll get symptoms all the way down the leg. If we're trying to differentiate between lumbar radiculopathy, symptoms down the leg, into the calf, all the way into the foot, can be symptom generators coming from glute med, glute med. They can also be symptom generators of the spine. Okay, you have to get on those structures and see, is there anything creeping? Do you feel changes in your foot in your calf when I'm sustaining pressure on the muscle tissue? If you are on the muscle tissue, you can be pretty confident that that is not a back thing anymore, at least not fully. And you need to then have a good understanding of where am I? Can I then treat that out? We need to pump some blood to it. If we need to do dry needling, if we need to do some soft tissue and then work some strength, some blood perfusion type of exercises there. Okay. Also, hamstring type of things where people are not sure did I tweak a do I have like a high hamstring injury? Do I have more of a low back injury? That's another differential. When you're here and subjectively right sitting prolonged sitting is going to bring on these symptoms. Well, prolonged SIM sitting is stressing the lumbar spine, you are sitting in some lumbar flexion when you're sitting. The other thing that you're doing is you are occluding blood flow to that posterolateral hip at the same time. Okay, so both things can happen and then that can create irritation to the tissue. Very similar to this posture, any prolonged sitting can bring on that posterolateral occluding blood to that aorta and bring on tissue dysfunction. And that can create symptoms down the leg, again, hamstring, calf, foot, ankle, anything like that. COMBINING SUBJECTIVE & OBJECTIVE EXAMS Okay. So the big takeaways here are subjectively, these things are going to feel, you're going to have your hypothesis list, but you may not be like, they might be pretty equal when we're talking about the hypothesis list before you touch the objective exam. Then, same thing, when you're going through your objective exam, if you just do range of motion, if you do lumbar flexion range of motion, and that comes out, potentially you have stress lumbar flexion, yes, you are also tugging on your posterior lateral hip when you bend forward into flexion. Okay, so don't forget to make sure that you are ruling out that palpation and that lat posterior lateral hip in the hip, or that posterior shoulder when you're in the upper extremity, because those things might still be relevant. And you need to do a good job in palpating to make sure that you are clearing those areas and creating a really solid differential. because subjectively your hypothesis list is going to be very equal going into objective exam and not always with functional movements or range of motion. Are you going to really be able to bump one of those things up or down? But if you get into that palpation and say, you know, I've hit these areas and it wasn't maybe it was tender, but I sustained that pressure and I made sure I hit every single section because I was efficient and I was clean with where I was going each time and nothing really came out. then you can be pretty confident. Maybe it's not those tissues in the posterior shoulder or the posterolateral hip. Maybe we are looking more at the spine, okay? So that's really what I wanted to come on here and talk about today. In the extremity management division, we touch on that briefly when we're going through our objective exam, but I wanted to give a little bit more clarity today on what exactly you're looking for subjectively, and then how can you make a really clean objective palpation exam when you're trying to differentially diagnose. So that's what I wanted to come on here and touch on today. If you want to catch Extremity Management on the road here in the next couple weeks, we've got Lindsey on the road out in Carson City this weekend, so if you want to catch Mark or myself, both of us are on the road March 16th and 17th. I will be in Aiken, South Carolina. Mark will be in Spring, Texas. So we pretty much have West Coast to East Coast covered here over the next month or so. So jump into one of those courses. We'd love to see you out. And hopefully we will catch you all tomorrow on the iShow. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 12, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the ins and outs of bracing and how to engage in conversations with fitness professionals to make sure we are all speaking the same language. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL MOORE Good morning, PT on ICE Daily Show. What is up? It is Monday morning. My name is Dr. Rachel Moore. I am here representing our pelvic division, hanging out today to chat with you guys about bracing. So really breaking down the brace, understanding this concept a little bit more, understanding maybe where some pitfalls are in our communication with our fitness professionals that we are working with. So diving into that, let's just get started. IS ALL BRACING INSTRUCTION THE SAME?The brace as a term is kind of like poorly defined. There's really an understanding maybe in the PT world of what the brace is and then maybe in the strength world of what the brace is. And oftentimes what we're seeing or what we're getting feedback from is maybe there's a disconnect between what we're teaching as PTs or being taught as PTs and what the fitness professionals in our communities are being taught. And we wanted to kind of break down where this comes from. So for one, a lot of times fitness professionals aren't necessarily ever truly like taught how to do a brace. The most common cue we hear in like the fitness professional space is brace like somebody is going to punch you in the belly or like somebody is going to hit you in the stomach. And a lot of times that kind of brings about, or people think that this means this push out and this push out. on the PT side of things is actually what we're trying to avoid. And so we get some feedback from students in our courses and that's actually kind of what inspired the topic today is we got an email from one of the students who had taken our courses who said that she was kind of hearing from fitness professionals in her community that the way she was teaching the brace wasn't correct. So what do we do with that conversation? How do we navigate that conversation with those fitness professionals? And how do we kind of get across that we're probably saying the same thing, but it's not coming across the same way. WHAT DOES IT MEAN TO BRACE? So first thing I want to do is really define what the brace is. And in order to define what the brace is, we have to define the component pieces of the core canister, which is what's involved in the brace. So when we're talking about our core canister, we're talking about a 360 degree canister that has a top and a bottom. The top of that is going to be our diaphragm. The bottom of that is going to be our pelvic floor. The front insides are our anterior abdominal wall. A lot of times people just say, oh, that's the transverse abdominal muscles. But in reality, we have to understand that that is more than just the transverse abs. That's actually all of the layers of the abdominal wall. and then the back is the spine and the muscles of the spine. When we talk about this brace, we want the canister to have equal pressure distributed around it and dissipate forces in an equalized manner, rather than maybe one side of the canister getting too much force, which then causes a leakage of pressure into a different direction. So when we're explaining the brace, or we're teaching the brace, We oftentimes teach it as tense your abs, or think about pulling your pelvic bones together. A cue that we use a ton over in the pelvic division with our pregnant athletes is if you have a baby, hug your baby, or if you can remember what it felt like to recently be pregnant, hug baby, that pull together of the abs. We are never queuing a push out because if we think about this canister, a push outwards is going to cause a mismatch of pressure within the inside of that canister. That's then going to come downwards through the pelvic floor. And oftentimes in the pelvic space can elicit pelvic floor symptoms like leakage, heaviness, or farting in the bottom of a squat or when we're lifting. so we expect that the pelvic floor is going to match the degree of abdominal brace we don't necessarily cue an intentional pelvic floor contraction when we're saying brace we might in our populations that are having issues with symptoms cue almost like an over correction because especially if there's somebody that's actually bearing down or pushing when they're bracing and not understanding that they're lengthening their pelvic floor rather than either staying at the same level or allowing their pelvic floor to match the demand of everything that's on top of it. So when we're cuing our brace, it is tense your abs, pelvic floor either stays the same or we slightly lift pelvic floor to match that pressure. That's how we teach that brace. THE CONFUSING NATURE OF THE WEIGHTLIFTING BELT The confusion I think comes in especially when we start talking about layering in a belt. So oftentimes in the strength training world, we see athletes busting out a belt and maybe they're using it all the time for every However, whatever the weight is on the bar, it's not necessarily just that they're heavier lifts or maybe they're reserving it for their heavier lifts. The key thing with the belt is that when we layer in the belt, the brace doesn't change. And that's something that I think we need to make sure our athletes and our coaches are understanding is that the belt is there to give us this extra support and really proprioceptive input to allow that increase in spinal stiffness to happen, but it is not a mechanism to push into. and I have my husband's belt. I left mine at the gym, so this isn't gonna fit me exactly right, but I wanna walk through the fit of the belt and where I think this confusion maybe comes from when we start talking about fitness professionals queuing a push-out. So with the belt, when we're talking about using a weightlifting belt, we want to think about, if you have YouTube or Instagram live up, I've got the belt here, and I'm just gonna kinda walk through the fit of the belt and what we're looking for. So when we are putting a weightlifting belt on, we're looking to fill that space in between our pelvis and our ribcage. If there's a little bit of overlap, that's totally fine, but we're kind of going like the top of the pelvis and that's my marker for where this belt is going to go. When I put my belt on, I'm going to put my belt on and as I tighten it, I want to fully exhale. I'm not like sucking in and shrinking and shriveling up as tiny as I can. I'm just doing a comfortable exhale. And then from there, I'm tightening. And in this tightening, I can breathe. I can talk. I can put a finger in between me and my belt, and I'm not uncomfortable. It's not squeezing me. If we have the fit of the belt correct, then that approximation that comes from inhaling i think is maybe what the confusion is coming from so if i have my belt on right i tightened it on my exhale as i do an inhale and i think about inhaling into my belly and into my spine that good solid 360 breath i feel my tissues push into that belt that is different than me intentionally pushing into the belt, that push your belly out sensation. If you're watching this live or listening to this later, put your hands on your belly and feel what happens when you push your stomach out. What do you feel at your pelvic floor? More than likely, it's a dropdown. If we think about tensing our core, Usually we don't feel much there. Maybe we feel a slight lift. And if we do feel a drop down, then we over correct and think about going up towards the basement to mitigate that. But the key here is the fit of the belt and understanding how to do that brace. So where does the confusion come in? When we're talking about our fitness professionals or maybe people who have never been trained in how to use a belt, the thought is to push out into the belt to create that contact with the belt. But if we have the belt fitting correctly, we don't need to do that push up. That's the biggest thing that I want you guys to understand and take away is it all comes back to the fit and making sure that we're using that belt correctly. Even without the belt, our brace stays the same, right? We're thinking inhale into belly, tense abs. It's never push out as if we're pushing our abdominal wall away. WORKING ALONGSIDE FITNESS PROFESSIONALS So when we're having these conversations with Fitness professionals or other coaches in our community who are maybe pushing back and saying like that's not how we teach our brace Really breaking this down and explaining to them where we're coming from and why. I think a lot of the time like we assume that everybody is just saying the opposite just for the sake of saying the opposite or maybe like they're just digging their heels in and there's no sense in educating them. But in reality like we have a lot of opportunity here to create bridges with these fitness professionals and create positive relationships. And we're not gonna do that by saying, well, you're wrong, or telling the athletes, well, your coach is wrong, just do it how I teach you. So using this as an opportunity to get in front of those coaches and those fitness professionals, and as a way to kind of bridge this relationship of, hey, you guys are coaching, I'm teaching your athletes, I would love to get on the same page, this is how I teach a brace, this is why. The goal here is to create equalized pressure across this core canister, If we push out in one direction or another, we put ourselves at risk of potentially having pressure leakage, quote unquote, out through that wall. It's also just not as strong. And at the end of the day, all of us are here to help people get stronger and move better. So if we think about this and conceptualize all of these walls of this castle being strong rather than one being broken or pushed out, then we can kind of understand that that applies into better, more efficient bracing mechanic, which then leads into better lifting and higher strength with our sets that we're working on, increasing our strength and capacity there. If this is confusing to you, I've got another podcast episode, episode 1577 of PT on Ice Daily Show that's all about the Valsalva, kind of breaks down a little bit more of the specifics of the Valsalva, which is that breath hold with the brace. The Valsalva can also have the belt, so we can have this spectrum of breathing. SUMMARY We really break down the spectrum of breathing in our live courses. Our live course is coming up in March. There are so many opportunities to catch the live course out on the road in March, y'all. March 2nd and 3rd in California, 9th and 10th in North Dakota, 23rd and 24th in South Carolina. So holy cow, so many opportunities to come hang out with us. Be on the lookout. Christina Prevett and I also did a clinical commentary that will be coming out in the spring 2024 edition. of the Journal of Pelvic Obstetric and Gynecologic Physiotherapy, so that should be coming out here pretty soon. We'll be blasting that all over the place when it does come out, but be on the lookout. Sign up for our pelvic newsletter, because that's gonna be one of the first places that drops, as well as on our hump day hustling. Thanks for joining me this morning, guys. I hope that cleared up some confusion. If you have any questions about bracing, or you're not sure how to explain it, or anything along those lines, please reach out, shoot me a message. I'm happy to chat with you more. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 9, 2024

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses how to help your athletes develop a healthy mindset around their longer runs, including progressing them gradually, running them intentionally slow, using them to practice for race day, and how they can translate to the race. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL ELINA All right. Good morning, everyone. And welcome back to the PT on Ice Daily Show. My name is Rachel Salina, and I'm a TA with our Endurance Athlete Division. So I'm happy to be here on a Fitness Athlete Friday. to be able to talk to you about a running topic. So that's where we're going today. We're going to talk about the long run and specifically a couple do's and don'ts about that long run. And the reason I'm bringing this up is that in working with a lot of running groups and with running clients, there seems to be just this like, perception of the long run, right, that like long training run each week as just this like super utmost important, like the only important thing of a training cycle. And so I want to do this topic today to just kind of help us and help us help our patients and clients to kind of reshape their mindset. about the long run to have a healthy mindset of what it actually is and what it's not and how that can be utilized. So I'm going to keep it really simple. We've got two do's and we've got two don'ts. DO: USE LONG RUNS TO TEST YOUR RACE DAY PLANS Our first do is do use the long run to test your race day plan. All right, it gives us an opportunity to test out everything we want to actually use race day, whether that's clothing or food. And this is kind of where that advice, I guess, if you're a runner, you've probably heard this, or you maybe have said it to people, don't try anything new on race day. This is kind of speaking to that. There's value in that advice. So think about if you have your favorite pair of shorts and tank top that feels super comfortable for a one hour run, and you're planning to wear that on race day, but you've never worn it for longer than whatever, an hour and a half. Right? Maybe that same combination does not feel comfortable once it's like two hours saturated in sweat. And maybe it starts to chafe, but you wouldn't have known that if you didn't test it. Right? So you use the long run to test your clothing. That way, you know, either you need to change your clothing to something different or know how to like use body glide or something like that to prevent chafing. But it also gives your runners a chance to test their hydration and their nutrition strategy. So using that long run when the body's going to be working longer to see how do they feel with taking goos and chews and gels, like that kind of thing, like kind of fake food. Does their stomach and their gut tolerate that? If you haven't tested that before going into race day, like you can set yourself up for a not great situation with just not knowing how your body will respond. So can you, you know, have Can you test the fuel that you plan to use on race day? Can you test the clothing that you plan to use on race day? Are you comfortable carrying your water? Do you know what the aid stations at this race will have so that you can start to practice with what those products are? So do use the long run as a test for race day. DO: GRADUALLY PROGRESS LONG RUNS Our second do is do progress that long run gradually over a training cycle. So just like we have the 10% rule for kind of our overall progression of running volume, we can kind of think of the long run itself, like that one longer distance run in the week, following a similar pattern. And it doesn't necessarily have to be like stick to only 10% or always 10%, but just the idea that it should, as overall running volume is progressing, that's when that long run volume should also progress. So it wouldn't make sense if someone maybe starts out and one of the weeks they're doing a 10 mile long run because that's what they have time for. But the next week, like maybe they have vacation from work or they're on vacation, something like that. They have more time and they decide they're gonna go do 16 that week just because they can fit it in. We're not setting the body up in a great way to tolerate that longer stimulus if we haven't gradually built up to it. So what the actual number for the long run is will obviously depend on what distance of a race you're doing and what the experience of that runner is. But just using that concept of progressing it gradually as the training cycle is also progressing. DON'T: COUNT ON THE LONG RUN TO BE MAGIC For our first don't, don't count on the long run to be magic. And I think this is where a lot of the mind like kind of the unhealthy mindset is. We get it in our mind that like that's the only important run of a cycle of that week. Right. If nothing else, I need to get that long run in because that's what's going to make me more fit and better prepared for my race. But really the mileage there is the same importance as our mileage through the rest of the week. There's nothing different about it. Like it's still just mileage and time on the feet and giving the body time to make those adaptations to become a better runner. So we can get in a really sticky spot if, again, this is a situation like I know I've been in, I've heard from other people that when they're struggling with this, like think of the person that gets really busy during the week, okay? They're supposed to maybe have three or four like shorter or middle distance runs during the week. The week gets really busy, maybe kids were sick, there was an issue at work, like whatever combination of things that build up a lot, like, and make that person decide to not hit those kind of less important, um, weekday runs. And then, but the thought is they're like, Oh, well, it's okay. Like that stuff doesn't matter as much. I just have to hit this long run on the weekend and I'll be good. Like that's, what's going to get me prepared. But then we have this big gap rate of, well, even if you hit 15 miles over the weekend, but we missed. 10 miles during the week, like we're still not building and progressing in a way that's going to best prepare our bodies for that, that event. Um, just because we hit the long run mileage and we actually can set up for just a not great situation if all of our mileage is happening on like one specific day. So don't count on that long run to be magic, right? Or other runs or other volume are just as important. DON'T: RUN YOUR LONG RUNS TOO FAST And then our second, don't, right? Don't run the long run too fast. It's supposed to be longer, slower training, building those physiological adaptations, right? Our long run is not our race. If we race pace every single long run during training, right? We're not training, we're just racing those days. So keep long run, cases, moderate, conservative, right? You can work in some shorter intervals into a long run or maybe do some pickups as a strategy to test that pace when you are fatigued or encouraging your runners to do that. But in general, we wanna keep our faster running, our fast paces, interval work, tempo work on days separate from that long run stimulus, right? Keep each day distinct. Know what the intention is for that day. Explain to your patients what you want from that run, right? And leave the speed work, the fast work to a day when you can fully capitalize on that intention and on that work. Kind of a, maybe like a quick way to think of, is my long run too intense? Would be if you can get back to running again in within two days. If you do such a long distance run or it's so intense that you are just trash, like I cannot run again, I'm so sore, I'm so tired, I can't run for three days, right? Again, we're setting either ourselves up or our patients are setting themselves up to not hit the rest of their weekly volume because they're needing those extra recovery days because they push the long run too much. So keep it conservative. It should be something you can recover from and be back to running again within one to two days. So that's it. Super simple, right? Two do's. Do use the long run to test your race day plan. Do progress that run, that long run volume gradually over the training cycle. Don't count on the long run to be magic. Know what it can do and what it can't do. and then don't run that long run too fast. So that's it. Like I said, I hope you can use this personally or to help your clients kind of develop a better mindset about the long run and kind of how they view their whole training. SUMMARY If you are interested in working with runners or you already do and you wanna expand your knowledge, we have our next cohort of Rehabilitation of the Injured Runner Online is coming up March 5th. So registration is open for that on PTUNICE.com. You can jump in. And then our first live course will not be until June. It's June 1st and 2nd, just outside of Milwaukee. So we'd love to have you either online, live, both, either one. Feel free to jump into one of those. Otherwise, take advantage of the super warm weather we're having. It's odd, it's 60 degrees in Michigan right now. So go outside, get a run in, and have a great weekend. Thanks. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 8, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the current state of the insurance-based healthcare systems, alternative practice styles, and the "magic" behind building a sustainable practice. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL All right, good morning, PT On ICE Daily Show. Happy Thursday morning, I hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the Division Leader in our Fitness Athlete Division. It is Thursday, it is Leadership Thursday, that means it is also Gut Check Thursday. This week's Gut Check Thursday is another qualifier workout, so it's on the more aggressive end. So we have every four minutes for four sets. You're basically going to go through one workout of the Hero Workout DT. You're going to do 12 deadlifts. You're going to go 9 hang cleans. The caveat this week is that they're hang squat cleans. So they're going to take longer to cycle and they're definitely going to take more out of your legs than the traditional power clean we find in DT. Then you're going to finish with six shoulder to overhead. So for most folks, that's going to be a push jerk. The weight there is 155-105 on the barbell. Ideally, we're finishing one round of that complex in about two minutes. And then in any remaining time in that four-minute window, we're doing as many wall balls as we can. Guys are going to throw a 20-pound ball to a 10-foot target. Ladies, a 14-pound ball to a 9-foot target. The goal of that workout is to get through the barbell and get to the wall balls and accrue some wall balls. Great scores are going to be really anything above 50 reps. Exceeding 100, making your way towards 150 is definitely going to be an exceptional score. Modify the weight on that barbell, modify the reps if you need to make sure that you get off the barbell in about two minutes and that you have time for wall balls. There is no rest between sets, so keep that in mind as well. You probably don't want to be doing wall balls right until the whistle and need to turn and pick up that barbell without a break. You're probably going to want to allow yourself maybe 15 to 20 seconds of rest on the last set of wall balls and then go and pick up that barbell when the clock beeps. So have fun with that one. That's from a qualifier workout for a really awesome competition we have here in Michigan out on the west coast of Michigan out near Grand Rapids called Fresh Coast Fit Fest. Really fun CrossFit workout two day event on the beach. So some of our teams here from our gym at CrossFit and Fenton are going to be doing that. So have fun with that qualifier workout. THE CURRENT STATE OF THE PT INDUSTRY Today what are we talking about? We are talking about cash-based practice, insurance-based practice, or maybe in between what we call a hybrid-based practice, where is the magic? So today I want to make a couple points. I want to really have a candid discussion on insurance and really the physical therapy profession in general. I want to talk about what it means to open a sustainable and ethical practice. I want to talk about the down-low with payment methods and payment amounts as far as how much we get paid. and I want to talk about the concept that I call the golden rule of private practice. So let's start with that discussion on insurance. So Kaiser Foundation back in 2022 published that about 95% of Americans have health insurance. Why do I bring that up? I bring that up because if you only get information from social media, which unfortunately many folks now do, you might have this perception that cash-based therapy, cash-based medicine in general, concierge medicine, has taken off and that if you still accept insurance, you are somehow maybe 100 years behind what's currently happening. and it could not be further from the truth. Most Americans, most consumers have insurance. Again, 95% of people. So certainly while folks are getting more used to maybe their high deductible plan and that they do probably need to pay out of pocket for some or maybe all of their health care, Certainly that's not the case for everybody. In this idea, this mantra on social media that Americans have just rebelled against health insurance and none of them have it anymore and everybody is totally willing to pay cash for everything and you can charge whatever you want is the name of the game could not be further from the truth. In fact, 33% of Americans have Blue Cross Blue Shield PPO insurance which means they carry pretty nice insurance that they probably pay a lot of money for. So I say all that to say this, we need to be realistic that most of us will probably come and go from this profession before we really see a significant shift in how patients interact with the healthcare system, most notably from how they pay for their healthcare. Why does that matter? And why is that unlikely to change? I think looking at the state of the economy in general, again, if you get a lot of your news from social media, you may believe that the economy is on the edge of being destroyed at any minute. But again, that could not be further from the truth. We dodged the depression that was forecasted. The economy is at an all-time high. And that is shown if we look at insurance company profits. So let's go down this list. I love to look at data like this. Blue Cross Blue Shield last year, $457 billion. Almost half a trillion dollars. UnitedHealthcare right behind them, $414 billion. Anthem Blue Cross Blue Shield, so kind of a conglomerate of a bunch of different state Blue Cross Blue Shield associations, $109 billion. Cigna, that's a private commercial insurance, $76 billion. Humana is another private insurer, $55 billion. If we look at just the five largest health insurance providers in the country, they comprise 5% of the country's total GDP. All of the money that we essentially generate and spend across the span of a year. We also need to recognize as we've talked on here before that by 2030, 70% of Americans will be Medicare eligible. So if anything, what we see over time is that more people are carrying insurance, more people have nicer insurance, whether they're paying for that themselves or whether they're just being provided nicer insurance through their employer and that more and more Americans are also going to be carrying Medicare insurance as they turn 65 or whatever that age becomes over the next couple years. So why are we unlikely to see a significant shift in payment methodology in physical therapy or in health care in general? Look at all of that money, right? If we include all the other health insurers, we're looking about one-tenth of all of our money coming and being generated by health insurance providers. If we include what's being spent on health care, both through insurance and through private pay, that is beginning to comprise almost a quarter of our economy. What does that translate to practically? What can we glean from that? It really says that the chief product that the United States produces is sick, injured people in pain, and that our primary export is dealing with the subsequent secondary issues that come with a sedentary lifestyle that produces really sick people. So I think we're really unlikely to see things shift because a lot of people are making a lot of money either being on the health insurance side of the equation or being on the health care system side of the equation. And I think we are living in denial if we don't think that those giant companies that are making half a trillion dollars a year aren't making sure that some of that money goes to lobbying members of Congress to make sure that there are laws that require health insurance to make sure that we build brand new headquarters buildings that employ a lot of people where case adjusters and claims adjusters and all these folks that run a health insurance company can work and that that company can say to the government, look how many jobs we're creating. And when you really see that these companies are starting to take in nearing a trillion dollars, you recognize how much money is truly in this system. INSURANCE IS WEIRD & NEEDS TO CHANGE That being said, we need to be honest that insurance is totally weird. Health insurance is so weird. It is the most inefficient, weird thing that we probably do, right? We're used to having auto insurance. If you've ever had to make an auto insurance claim, you would probably say that by comparison to health insurance, it was a pretty easy process, right? If you've ever wrecked your car, somebody came out and probably said, Oh dude, that car is wrecked. Yeah, we're going to get you a new car. So we'll do some paperwork. And then you'll get a check and you can go get a new car, right? I just had a windshield crack. It was really cold here in Michigan. It was negative 20 degrees. Made a call. Somebody came out and said, yep, dude, your windshield is indeed cracked to the point where it's probably dangerous for you to be driving. Drop your car off here and in an hour somebody will fix your windshield. We don't see that smooth process with healthcare. We see a really weird process filled with a lot of paperwork, a lot of limitations on access to service, and otherwise, the health insurance company trying to hold on to the money that they're getting from patients. It would be totally weird to have insurance in a lot of the other things we do, right? Imagine you need to get your hair cut. I need to get my hair cut really bad. Imagine I go to get a haircut and they tell me, hey, your haircut insurance will only pay to cut half of your head today. You'll have to wait six months, and they'll cut the other half of your head. How impractical would that be? Yet, that's how healthcare insurance functions. So we need to acknowledge the dichotomy here. There's a lot of money in this system. It's probably not changing anytime soon. That being said, it's very weird and inefficient, and it's not working for a lot of people. So that being said, if this is the current state of our healthcare system, and our industry is physical therapists, how do we navigate this? NAME THE ENEMY We navigate this by naming the enemy, right? Corporate physical therapy with hundreds or thousands of locations, employing thousands or tens of thousands of therapists, overbilling patients, seeing multiple patients an hour, driving up that revenue for both their businesses and the health insurance companies, and really delivering low-quality care. We will never win against those folks one-on-one. We'll never be able to go toe-to-toe with them. If you missed Virtual Ice on Tuesday with Jeff Moore, our CEO, you missed a really good discussion on effortless clinical practice. And he really touched on the idea of the solution to high volume, low quality is not to try even more volume with even less quality. That is a losing game. We can certainly try the same strategy to win. What's probably going to happen is that It's not going to last very long, you're probably going to burn yourself out, and you're just going to become another clinic that gets bought up by one of those big chains. So we need to name that enemy, we need to recognize what's being provided, and we need to begin to chip away at them. We need to hit them where it counts, which is to take their patients away from them. How do we do that? We need to fundamentally understand and recognize and be comfortable with what an hour of our time is worth. WHAT IS AN HOUR OF YOUR TIME WORTH? This is something I heard many, many years now, almost a decade ago now from Zach Long, of no matter what you're doing, you should know what an hour of your time is worth and you should be trying to get that. It doesn't matter if you're treating a patient, it doesn't matter if you're doing back-end work, It doesn't matter if you're doing marketing for your clinic, you should be getting relatively the same amount per hour, and you should have a really good understanding of what an hour of your time is worth. Building upon that is how we build a successful, sustainable practice. We just crossed the halfway point in our most recent cohort of Brick by Brick, our practice management course, and this is something I really hammer on people with how to establish your practice, that before you launch, before you start seeing patients, Now is the time to make sure that you set your practice up so that you have a successful, sustainable practice because that is the only way that we're going to chip away at all of these high volume, low quality establishments in a way that we might actually turn this ship around. What's not going to work is doing the same thing of seeing and taking insurance that does not pay well, seeing two, three, four people an hour and getting stuck in the same volume trap that all of these clinics are already stuck in. $40 a visit is profitable if you see four of those visits per hour, right? We can't get caught up trying to fight fire with fire here. We need to go a different route. We need five high-quality, independent, private practices around every chain clinic to provide really quality service to take those patients away over time from the chain clinic and drive them out. And we need to replicate that across the country. The worst possible outcome of fighting fire with fire is that after a couple years, you decide that you're done and you sell your practice to one of those corporate chains, right? You become the enemy. you turn your practice into another version of something that already exists, the volume goes up, the quality goes down, you just become another cog in the machine. That is the worst possible outcome if you do not think about starting your practice sustainably. How do we do that? PAYMENT METHOD: THE PATIENT'S PROBLEM My third point is that it comes down to payment method. We need to understand and recognize that Some people want to use our insurance, but that some insurance simply doesn't pay us a living wage such that we can pay ourselves what we think we're worth. We can pay the people who may work with us what they're worth, cover our expenses and still turn a profit. We need to really think about sustainability. That means that you probably should not accept every insurance possible and that depending on where you live and depending on what an hour of your time is worth, maybe no insurance is good enough for you. And that's also okay, right? Hence, cash-based physical therapy. And that for the majority of folks, the magic is going to probably lie somewhere in the middle. Taking a handful of insurances that let you reach a moderate amount of patients, and everybody else is going to have to pay cash. With that comes the hard truth that not every patient is going to be able to see us. And that at the end of the day, how a patient pays for their service, their physical therapy, is really their responsibility. There are certainly ways we can help. We can offer cheaper rates. We can offer pro bono. And that's a topic for a different day. But at the end of the day, how they pay needs to be in a form that is sustainable for us to take. And I don't think we consider that enough when we're about to launch a practice. I think we go full spectrum. How many people can we reach? Let's take every insurance. Doesn't matter how terrible it pays. Doesn't matter how much paperwork is involved with seeing those patients. Let's take it all and then we'll deal with it later. And then later becomes, I'm tired of doing this and I'm going to sell my clinic to one of the big chains. Again, the worst possible outcome. We need to recognize that if we accept more insurance and we provide lower quality, higher volume care, that we're going to have a minimal impact overall, not only on our patients' lives, but on the profession in general. PAYMENT AMOUNT: THE OWNER'S PROBLEM Looking at payment amount, we need to recognize that there's a natural give and take between employer and employed. And at the end of the day, for those folks in management positions or leadership positions, We need to recognize and truly embrace the idea that the staff physical therapist, the person who comes to work every day and treats patients, is our frontline worker, and that they need to be supported more so than anybody else. Far and away in our industry, far and away across healthcare, the people who see patients are often treated the worst. They are the people who have been told, guess what? There's no money for a raise this year. Guess what? We're taking away your Con Ed money. Guess what? We were going to give you an extra week of vacation. We can't afford that now, right? We continually strip money and benefits and autonomy away from our frontline workers and then we're totally shocked that they leave and open up their own practice, right? Attrition is one of the worst things that can happen to your clinic and we need to understand that while payment method is the patient's responsibility, Payment amount is the owner, the leader's responsibility of controlling what we get paid is ultimately, for me here at our clinic, my responsibility. I need to make sure that we take in enough money, that the frontline workers are supported, and whatever's left is for the ownership. And far too often in clinics, it is the other way around. If the insurances you take aren't paying you enough to take care of your people, you should probably stop taking that insurance. If the insurances you take require you to hire another staff member to do all of their authorizations and certifications, you should probably stop taking that insurance. And if working with an insurance company requires you to reduce your quality or increase your volume and become a detriment to the healthcare system instead of a positive influence, you should probably stop taking that insurance. THE GOLDEN RULE TO SUSTAINABLE PRACTICE The golden rule, my last point here, what do I think the golden rule is? Is that you should only work with organizations that value and reward high quality physical therapy that pay you at or above what your desired rate per hour is. Folks often ask us, hey Alan, hey Mitch, why do you guys take insurance? Well, we only take three of them. We take our Blue Cross Blue Shield state PPO. we take Medicare and TRICARE. Why? Because they don't have any documentation authorization requirements, they pay at or above our desired rate, and they have a really quick turnaround on payment, usually 48 hours for Medicare TRICARE and about 10 days total for Blue Cross, about five to seven business days. So we have relatively no turnaround on payment and it pays at or above what we want to get paid. And I don't think enough clinics appreciate how important that simple rule is. SUMMARY So I think, will things be fixed? Probably not anytime soon. We need to recognize that most Americans have insurance. They want to use insurance. Cash-based therapy is getting more popular, but is widely dependent on geographic area and local socioeconomics. We cannot fall into the traps on social media where we see all of these paid ads maybe from cash-based physical therapy owners that tell you you need to be 100% cash-based or you're behind the times. We need to have some sort of compromise as long as that compromise doesn't require us to sacrifice quality in order to obtain really good outcomes at a volume of patient care that is sustainable for our therapists and ourselves in a manner that rewards them for the work that we put in. We need to recognize how much money is in the health insurance and the healthcare industry, and how little of it those of us going to work every day and treating patients are actually seeing. I laugh every time somebody lets me know they just scored a sick $500 quarterly bonus for treating 80 patients a week. Because I know that clinic probably made hundreds of thousands of dollars off those patients that quarter, and the staff physical therapist got $500. Whoopee, that means nothing, right? We need to acknowledge that amount of money, excuse me, and we need to know that that is part of the reason why things may not be changing as quickly as we want them to change. If we're thinking about opening our own practice, we need to make sure we do the things necessary to make it sustainable. We need to take a really long, hard look at our local socioeconomics, our population, In Brick by Brick, we have people do a SWOT analysis, strengths, weaknesses, opportunities, and threats. And one of the things we encourage students to do is who are the biggest employers in your area and what insurance do they carry. If you work in a town where 80% of the people are employed by the same employer and they have Blue Cross Blue Shield PPO or it's a military base and they have TRICARE, it's probably in your best interest to take those insurances provided it pays you what you want and the documentation requirements are acceptable to you. If not, we need to also recognize it's okay to not take every insurance and that hybrid practice is probably long term the best solution moving forward until we can make significant changes in the insurance market or until we can shift enough folks over to the cash based side of healthcare practice. So cash-based, insurance-based, hybrid-based, where's the magic? Probably somewhere in the middle as with most things, right? And not or, but also recognizing that we're on the same team, right? If you are operating a cash-based practice, if you are operating insurance practice or hybrid practice, and you are providing really high quality care, you are doing your part to chip away at the problem. And if you're working for a company that is not doing that, or you are part of the management leadership team at a company that is not, you do need to acknowledge that you are providing a negative impact on the healthcare system. and you need to be understanding and recognizing of that fact. So, I love this topic. I think about this topic literally a thousand times a day. So I'd love to hear your discussion, your comments on this. Have fun with Gut Check Thursday. I hope you all have a fantastic weekend. If you're gonna be at Fitness Athlete Live this weekend with Mitch, Don, and Raleigh, have a great time. Have a fun Super Bowl. Go Chiefs. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 7, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how it can feel very overwhelming when your practice looks very different then what you are exposed to in a course like Modern Management of the Older Adult. You don't need to change drastically overnight (though you can!) but we encourage you to take the first step. In today's episode, Christina takes you through 4 steps you can take TODAY, to level up Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE daily show. My name is Christina Prevett. I am one of the lead faculty within our geriatric division. And today I wanted to talk to you about something that we see a lot as we talk to clinicians across the country, across North America, sometimes internationally, about some of the barriers to implementing some of these exercise interventions that we know are so, so relevant and helpful to get our older adults as strong as possible, to give them as much reserve as possible. So when we go into different live courses, we have our two-day online, or we have our eight-week online course, we have our two-day live course. We talk to clinicians in the geriatric space who are in a lot of different practice settings, right? It's really great and really unique that one, we oftentimes have a multidisciplinary group. So we're seeing OTs, PTs, CODAs, PTAs. But then we also have a lot of people in the room who are in different practice settings. So in any course, we can have some people who are in acute care, in home health, in skilled nursing facilities, long-term care facilities, outpatient clinics, fitness. We kind of see this spectrum, right? And we know that with our older adults, that there is a spectrum. And in our courses, we try to speak to that spectrum. So we try to speak to the clinician who is working with really sick folks in the hospital, to the, person who's in fitness and is keeping older adults who are doing fairly well as active as they can into hopefully their 90s and 100s. But sometimes there can be these barriers that are maybe not to do with the client that you're seeing, but the clinician and the space at which the clinician is at in order for it to feel like an overwhelming barrier to get individuals to or to see some of the changes we know are going to lead to better outcomes. And this is not to cast any blame on the clinician, but to acknowledge that it is not just you working with the client, it's you working with the client within the system that is medicine and the system that is your employer. And it's something that we want to acknowledge. So I was at a course recently and I had a person come up to me and I just, I loved the vulnerability, but she said to me, you know, I am a worse clinician than I was five years ago. And she was, she's about five, six years out. And you know, I'm going to talk about what you can do today, but I want to acknowledge this first. And she said, I'm just so tired. And she wasn't saying it for, you know, sympathy. She was just wanting an acknowledgement that she knew that all of the things that we were talking about in this course were exactly what she needed to be doing. And yet all of the other stuff around the system that she was experiencing was making it so that she was exhausted and it made it hard to do the better thing, right? Because Seated Therax is not as cognitively demanding on us as clinicians. The safety profile is oftentimes a lot lower, is a lot lower, even if the returns are not as good. And I first, before we start talking about ways that we can start leveling up our therapy practice, like what is the next step that we can take? If this story is resonating with you, what I want you to do is know that we see you. We see how hard clinicians are working. We see how hard it can be to push back against a narrative that has been, you know, kind of placed into our system that makes it so that there are barriers that are systems and administrative barriers that make, you know, leveling up in geriatrics be difficult to do. It is especially difficult if you are the one trying to push against this and everybody else in your practice is not. And so I first want to just acknowledge you and say, you know, I'm going to start trying to give some practical tips around ways that you can take that next step. But if your biggest barrier is where you are at from a headspace perspective or where you are at from a cultural perspective, just know that I acknowledge that where you are. and maybe some of that reflection will help work towards, you know, I don't know what that next step is for you to try and help get you out of that burnout or out of that exhaustion state, but it may be your biggest hurdle when it comes to leveling up in the geriatric space. So I wanted to acknowledge that first. "WHERE DO I START?" Okay, so the next step is I have no idea where to start. and I have no idea what to do. And so where I want all of you to start, and this is gonna be my challenge for you for the rest of the week, is do one thing different. level up in one thing. So when people come and take our course, they think, okay, now everything that I do has to be different. And that would be like taking you and you eat fast food six times a day or six times a week and you don't exercise at all and you're not sleeping and you're over caffeinated and you don't know what water is. And then you say, okay, I'm going to go and I'm going to eat super clean. I'm never going to have any fast food ever again. I'm just going to drink water. I'm going to kick out caffeine and I'm going to exercise 150 minutes. of aerobic and two times a week of strength training. I love that goal for you, but we wanna make it so that it makes what seems impossible possible. And we're gonna start taking these little steps, right? So we talk a lot in MMA about graded exposure and acknowledging that process when it comes to our patients, but we acknowledge that that practice change also takes time. And if this is not an area where you are focusing with respect to intensity, and this is particularly true in the resistance training space, just know that we don't need to drastically change. LAYER IN STANDING EXERCISES We need to take the next step. And so what can that be? Let's go through three examples of what that can look like. So you have a patient who is coming in and you have been doing predominantly seated exercise. and this is no shame at all. This is where you are at with this person. They are tired, their joints are irritable, and you know that you're gonna have to do a lot of pressing to get that session to be mostly in standing. Great. I want you to get them standing for one. If that's one exercise, that's one set. If you are doing long arc quad, change that to a standing terminal knee extension with a band around the rig or around a doorknob or around the high-low table that allows them to do that exercise in standing. So the one next step can be is to choose one person on your caseload where the easier choice was to do the seated option, but you're going to get them to do the standing option. So that's taking the step Here, that was number one. START USING AMRAP SETS Number two, if you are a person who has had trouble finding a quantifiable baseline assessment of strength. And this is so many people in our profession, like we ask all the time, like how many people take a kind of estimated strength measurement before they prescribe strength exercise? And most people are saying, well, shoot, I don't really do that. And it was a big growth area for me too. So the first opportunity for leveling up, today in your geriatric practice is to get a person who you would have chose a seated option, but you're going to try and get them into standing for at least one set. The second one is going to be to pick one exercise for one person and do an AMRAP set. So we talk about using estimated 100 maxes. So an AMRAP set is as many repetitions as possible. We can use it for a quantifiable baseline amount of strength, You're going to choose a weight that you think individuals can do for 10 repetitions or less because there's a cardiovascular component if we're over 10, if you've ever lifted heavy weights for more than 10 reps, you know what I'm talking about. And I want you to put an AMRAP set in today. So that's number two. Number three is you take one person's session and you get an objective measure for every set. So this is my number three. So one is get a person in standing if we want to have them sitting even though we know they can stand. Number two is getting an AMRAP set to try and find a quantifiable baseline amount of strength. BEGIN TO OBJECTIVELY QUANTITY EFFORT WITH RPE And three is to find a rate using a rating of perceived exertion, an RPE, for each exercise. and try and get individuals in that moderate sweet spot between five and seven. Hey, if you want to push them up to 10, I'm here for it. But if we are trying to take the first step to level up, what we want to make sure is that we are asking our patients, how hard do you think this is? And some people are going to say it's hard because they're tired. Some people are going to say it's hard because of pain. or some people are going to say it's hard because it's effortful, and effort is the name of the game, right? Effort when we're bumping up against pain can be that we're kind of toggling in this wiggle room between this increase in pain and how long it takes for their pain to come down to baseline. It can be exertional effort, but effort is the currency that we are looking at when it comes to all of our rehab interventions. And so the step that I want you all to take is to take a rate of perceived exertion for every exercise. So if they are doing clams, if they are doing bed mobility, I wanna say how hard do you think that was on a scale of one to 10? Or was it easy, medium, or hard? And you want them at least in the medium. There are so many times where I think that I am hitting the right mark when it comes to intensity for my older adults, and then I ask them, and they're like, oh, it's like a three. And I was like, well, dang. Linda, I'm going to switch this weight for you." And we end up taking the weight and putting it higher. Of course, your clients learn that and they'll look at you and you'll ask and they'll say, eight. And I was like, I don't believe you. That's not an eight. And you switch that exercise out. But giving you a rating of perceived exertion, one, that's something that you can document to make sure that you're getting that intensity, is a great way for you to be able to level up your Jerry game today. Okay, I know I said three, but I'm gonna give you four. BEGIN TO MEASURE REST INTERVALS The fourth one that you can do, and then I'll kind of go through all of them again, is to record your rest. Oftentimes we do our sets and then we kind of wait and we wave a little bit and we think, oh, well, I'm getting bored or they're getting bored or they're finished with the story. Okay, we'll start the next set. And we have no idea what that intensity looks like if they are resting for 30 seconds versus 90. If you are working with an individual with a high enough amount of load, they should need that full minute to recover. And so if we don't Check how much rest they're getting it can be really difficult for us to know if we're hitting the mark again with intensity So I gave you a bonus one So I'll do three plus bonus that I didn't lie to you at the beginning of this session About or this podcast about what our ways for us to level up our Jerry game So let's bring this around full circle the first thing is I want to acknowledge you if the hardest part about leveling up your Jerry game is because of the mental state that you are in right now if that is because of your job if that is because of family stress if that has become because of work culture expectations that make it difficult. I want to first acknowledge that and where you are. And know that sometimes if you are sitting at a 40% baseline, your cognitive reserve, and you're giving 40%, then you're giving 100% of the effort that you have available right now. And I want that acknowledged. And I know that it's not just simple as like, let's just change these one things for individuals who are kind of in the throes of some of those difficulties. If you are able to get through and try one thing different today, I gave four options, right? So doing that AMRAP set, getting a person doing an exercise in standing that we probably would have biased towards sitting, taking a rating of perceived exertion for every exercise in a session, or measuring rest, putting a clock on in the background and having it roll up and just kind of getting an idea of how much rest individuals are taking. You'd be surprised how much of our exercises, our interventions are gone because of us taking longer rest intervals than are probably necessary. SUMMARY All right, if you want to learn more of these level up steps, you can hit us up at MMOA Live. In two weeks on the 17th, 18th, I'm in Oklahoma City, Oklahoma with Sam. It's going to be such a fun course. On the 23rd, 24th, We are in Gales Ferry, Connecticut. We actually also have a sold out course right now in Rochester on that same weekend, which is super exciting. I love when we see these big crowds. But Alex is going to be in Gales Ferry. And then March 2nd and 3rd, we are in Rome, Georgia and Sparks Glencoe, Maryland. So if you are looking to find us on the road, if you want to figure out all these level up techniques, That is the place to do it. It is two days. It is so fun. You get to hang out with us and our crew. Maybe we can give you that little boost of motivation that you need to take that first step forward. And we would love to be that little bit of a motivation boost and a culture for you if you are struggling right now with different aspects that are outside of your control and your patient's control. within our healthcare system. So I encourage you to see us on the road if you haven't yet. Have a wonderful rest of your week, everybody, and hopefully I will see you all eyeball to eyeball at a course soon. Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 6, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren takes a deep dive into how dry needling has been traditionally marketed and offers some tips to improve your marketing via your website & social media to demystify dry needling in a manner that results in more patients choosing your clinic for treatment. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. PAUL KILLOREN Good morning team. This is the PT on Ice daily show and I am broadcasting worldwide from my hometown of Appleton, Wisconsin. My name is Paul Killoren. I'm the current division lead for dry needling for ice. We just wrapped up a banger, an awesome group in Milwaukee last weekend. I am from Wisconsin, so wife, kiddo came with me and we drove up to Appleton, which is my hometown. So I am broadcasting from Appleton from my father's office. The childhood nostalgic vibes are strong. I've been in Wisconsin for a week, so you might hear some accent come out of me like, oh, you know, here we are in Wisconsin but wanted to grab this PT on ICE slot to jump on today and discuss how to market dry needling and even kind of how to market dry needling 2.0 maybe even differently than the other dry needling out there. DRY NEEDLING MARKETING 1.0 So I'm gonna be quick this morning, but picture with me, and this shouldn't be hard to picture because almost any website, almost any social media post, if it's a clinic, state to state across the country, here's our list of services, manual therapy, BFR, dry needling, when you click on that dry needling tab, it jumps you to a page, what is dry needling? And that's the page I wanna discuss this morning. Because here is what 90% of those pages start with and look like. Dry needling is a technique that uses a monofilament needle. And from there, I mean, first of all, from there, most narratives, most websites, most explanations of dry needling still kind of go into trigger point-ish theories. So I'm going to give a few tips today. One of them is, is not to go down there, but, and if you've taken a course from us, you get that, that influence that we have better explanations, better narratives to how we do the technique, but what the benefits of dry needling are. But first I want you to picture that snapshot of you've jumped over that dry dealing page on a website. Before I get into the actual explanation, the content of the page, let's just talk how that page should be designed. Because we are in the social media, the Google web page realm where we're trying to get a three second impression to that patient. Everything we know now is that that patient is not necessarily going to spend two to five minutes reading one, two, three paragraphs about dry needling. So really we have above that scroll line, above that page to capture their attention, I mean make it visually appealing, but also give them enough info that either we answered their general question or intrigued them enough to keep scrolling down. MAKE DRY NEEDLING MORE VISUALLY APPEALING So what is dry needling? Before I get into the content, this page. should be visually appealing. I mean, it should fit your website for sure. But here, when I say visually appealing, we have that main homepage. I think a good half or third of it, so large enough to be visible, central, and appealing, should be a video or a picture of dry needling. And here's where I'll say 90% of the webpages out there have a pretty generic stock photo of, you know, maybe a hand, maybe a hand without a glove, gently placing a needle. And I get it, we're using Canva, we're pulling from Shutterstock, we're using generic stock photo libraries for this. First, I think we could admit the stock photo libraries are getting better. So if you created your webpage years ago, there are more dry needling specific images out there to use for this webpage. So if you're not going to have photography of yourself, which first of all I think is a nice touch to have you with a patient doing the technique, but if we're gonna use a substantial portion of this above the scroll line presence on the what is dry needling page, make it a nice looking photo and make it dry needling looking versus acupuncture looking. I know from a still photo there's arguments that you can't tell, but find an image of a clinician using a glove. Find an image of, you know, a more assertive tissue grasp where it looks like the dry needling technique that we're going to do in the clinic. If you use electrical stimulation, find a nice image of a needle with the clip attached, or you the clinician or a clinician using e-stim with dry needling. So make it visually appealing and make that image or video informative. Again, if we only have this small footprint on a webpage or three seconds to grab someone's attention, or really answer their questions. Like, oh yeah, I've kind of heard about dry needling. They click over to your what is dry needling page. That image, that video should immediately answer lots of questions. SIMPLIFY YOUR DRY NEEDLING EXPLANATION Part of why I think that visual is so important is now let's go to the text block. Now let's go to the content, the written information. I would say you have two good sentences that a patient is actually gonna read. Or to be even more extreme, I'll say, if your definition of dry needling says, dry needling is a technique done by physical therapists using a monofilament needle, I think you've already lost your audience. I mean, at this point, I think as soon as we say filiform needle, monofilament needle, they're like, I have no idea what a monofilament needle is, I'm out. We're not talking to colleagues here, we're talking to patients. So again, back to I think that image, that video or that image on the page is intentional. It shows a monofilament needle. They get it. They can see it's not a hypodermic syringe. It's not a blood draw or injection. we immediately answered one of their questions, which is, man, what does this needle look like? What does it feel like is what they're asking, but really they're saying, what does this needle look like? That's what the image is for. Don't waste half or a full sentence in your initial description of what is dry needling to say monofilament needle, which no one in the public has any idea what a monofilament or filiform needle is. So let's not start with that. Again, what we see a lot of over here is dry needling is a technique performed by PTs with a monofilament needle. From there it typically goes into to deactivate trigger points, improve tissue health, all of these things. I think we can refine this first sentence a little bit. And whether I'm saying that this is now how all of us as rehab professionals should market dry needling, or if I'm really just talking to this, to our ICE dry needling 2.0 crowd, I would say dry needling is an intramuscular technique with electrical stimulation. And from there we can say two, improve tissue health, decrease pain, improve muscle responsiveness, improve performance, evacuate fluid. So that would be my first sentence. From that first sentence, I removed that monofilament, filiform, that distracting word that patients don't know anyways. I did that with my picture. And I explained intramuscular. I mean, maybe that might lose some patience, but what we're trying to say in a word or two is this needle's going into a muscle, deeper into a muscle. Again, I think a video or an image showing that should be helpful. Use of electrical stimulation, that is key. And I'll take that point a step further in a moment. But we have an intramuscular with electrical stimulation and then why? And I think that why is just the generic. Patients are saying, why would I consider this? And if they're considering it to decrease pain, improve muscle function, maybe rehab a specific injury, improve muscle responsiveness, tissue health, all those things. That would be my first sentence. I'm not saying from that first sentence we've answered all of the patient questions, but we're starting to frame dry needling in a context that either they're going to form more questions, and I guess if I haven't said it already, the intent of this first paragraph, this first what is dry needling above the scroll line block is not to answer all of their questions. If you think we can answer all of their questions about what does it feel like? Is it acupuncture? Does it hurt? Is this the same as a blood draw or injection? If we think we can answer all those questions in one paragraph, I think that's going to be unsuccessful and to some degree is going to be a little scattered and chaotic. We have our webpage, we have an appealing picture that fits how we treat with dry needling. We started it with an explanation, ideally explaining that it is inside of a muscle using E-Stim and what the goals are. And we removed the words monofilament or filiform needle and removed the narrative and the explanation of trigger points. DRY NEEDLING MARKETING 2.0 So big picture, let's say you were just trained or let's say you were trained years ago I'd love you to go back to your webpage, go back to maybe your most recent patient-specific or informative social media post for patients and look it over. And I mean, be that naive patient and say, take a look at that page for three seconds and say, man, how was that interaction? Could I update this picture? Could I invest in taking my own photos or maybe making a 15 to 20 second video post? If you do that, it should be you, your voice explaining the procedure, but also have the procedure there. Again, the visual of dry needling answers many questions. Everything from the size of the needle, what does it look like? to your specific application of, are we just placing needles like acupuncture? Are we pistoning a little bit? Are we using e-stim? Is it one needle? Is it 20 needles? That little snapshot, actual snapshot of an image or 15 to 20 second video is very helpful for patients. So from there, I think that might be a slightly updated version of preparing for this podcast. I really just went typed in dry needling and a few specific cities. So that the main hits weren't like Wikipedia and all that. It was actually like physical therapy clinics. There are some good looking websites out there. So I love that. But the what is dry needling page, I think needs to be better across the board. I think we need to be more succinct in our explanation and narrative of what dry needling is a little more contemporary, which again, is not just that sterile definition of a monofilament needle. One more thing I'll add is that we are now living in a world, depending on which state you're in, but really if dry needling has been more and more mainstream, really starting in the 90s, early 2000s, a decade, a decade. So let's say we're at least 20 to 30 years removed to where Dry needling has been a part of physical therapy practice in the public sector for a while now. What that brings is either confusion or patients with previous needling experience. More and more patients are saying, I've had dry needling. And whether they loved it or whether they did not love it, we now have to explain how we specifically, you specifically, are going to use dry needling. So if you are ice trained, I'm speaking to you all to say, how do you market dry needling 2.0, the training you all have had, how do you market that as slightly different than just other forms of dry needling out there? First of all, you all know, you should know, and you should be marketing pretty strongly, the use of e-stim. And really, if that patient comes in and says, You're talking about dry needling, I saw your poster, I saw it on your website, like, I really don't wanna do dry needling. Patient's always in charge for sure, but I have more questions first. I'm like, okay, respect that. Where did you have dry needling before? Was it a PT? Was it a chiropractor? Was it an acupuncturist that is just going to call it dry needling? What was it like? Did they piston? Did they just place needles fairly superficially, not very deep? Did they use e-stim? How many needles did they do? These are all questions that we kind of need answers to. If the patient is saying, I had dry needling and I hated it. I was sore for two days. I'm not sure if it helped. Okay. Was the needle dose, the mechanical pistoning, a little too aggressive? Did they not use e-stim? Did they not reinforce it well after the treatment? Or, I had dry needling, you know, I don't care about the needle, but I just, I didn't feel like it did much. That patient is like, well, okay, how did they use the needle? Did they displace it? All the same questions. So we kind of have to frame the patient's previous experience. And that's easy with a patient in front of us where we can do a quick Q and A. But let's say it is just general patients coming. Maybe you have a pretty good grasp of your competition, I guess I'll say, or people in your community who are marketing dry needling, maybe you already have a pretty good awareness of how they're doing it versus how we do it differently. we need to have that on our webpage as well. We need to market that actively as well. And at this point, it's my own sample size. It's previously not using as much e-stim to now I use e-stim almost exclusively. It is worth marketing that our e-stim or our needling, sorry, our needling with e-stim is a little different than maybe the dry needling that our patient has had at this other clinic or other types of dry needling. So I'd put that on the page, and I'd put that high on the page of, at DPT with Needles Physical Therapy, we do dry needling a little differently. We really believe on a little less tissue trauma, that's less pistoning, and using E-Stim. E-Stim allows us to be a little more deliberate, a little more tactical for pain relief, neuromuscular changes, moving fluid. However you need to market that, but I would market that. The E-Stim, The e-stim across the board might be novel and unique to your patient, but having the ability to decrease that post-treatment soreness and be more effective or be more intentional and tactical is worth marketing for the patient. And again, I think that has to be a pretty succinct written webpage, text block explanation, but there's value in having a really nice looking image or a 15 to 20 second video. So I think that's where I'm going to drop off today. And really what inspired this, I think it was a month or so ago. Mitch Babcock jumped on and he's like, how do we perform the art of that 15 minute exposure? He wasn't talking needling directly, but he was saying, you're at that CrossFit gym, that competition, you have your booth set up, your table set up. How do we master that 15 minute exposure? I think we can run something similar to that for dry needling in the future. But even before I got there, I thought it was worth kind of having this discussion of, we need to kind of update, we need to modify some of our social media and webpage appearances. I was gonna say explanations and that's part of it, but it's not just the words, it's not just the text block. We really have to update how it looks and feels on that first, what is dry needling webpage on your website or on social media. So, Go take a look at your own website or make a post today or in the next week and give it that fresh look. Give it the fresh look using Canva, do all your stuff or with an image, but give it a fresher explanation. I'm going to drop off there. If you've got questions, this will be, uh, I guess live is wrapping up now, not seeing any immediate comments. Thanks for joining those. See lots of folks jumping on. Um, but drop some comments, questions on Instagram or YouTube. Uh, I am at DPT with needles, otherwise at ice physio on Instagram. How does your dry needling marketing look if you have three to five seconds or if you have that above the scroll line page? That's the challenge today. Let's see how it looks, folks. Thanks for joining. We'll catch you next time on the Institute of Clinical Excellence, PTN Ice Daily Show. Out. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 5, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the essential, yet often overlooked as aspect of early postoperative care. Alexis explores the wide range of concerns and adjustments individuals face postoperatively beyond the usual need for return to exercise. From emotional and mental health needs to navigating the logistics of daily life, we share valuable insights on how to care for individuals early postoperatively. Save this podcast and share it with your communities to educate them, and let them know what an early postop visit with you might would look like too! Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALEXIS MORGAN Good morning, YouTube. Get Instagram going here. Good morning. Welcome to the PT on Ice Daily Show. Happy Monday. My name is Dr. Alexis Morgan, and I am one of the faculty with Ice Pelvic. In our pelvic division, we enjoy talking about all things around exercise. And, you know, if you are part of ICE, you know that and understand that. But sometimes our reputation scares people. It might scare our community like, oh, that's the exercise person. They're definitely going to make me exercise immediately. Today's topic is surrounding non-exercise topics for that early post-op care. non-exercise topics for the early post-op care. This is incredibly important, maybe because of the reputation that you have in your community, which if you have that, great, so do I. Awesome reputation to have. However, we need our potential patients, we need our clients, we need them to understand a lot of the things that we can do early post-operatively that don't necessarily involve exercise. And that's not just to get them in the door, but that's also because there's a huge role that we play in early post-op management. Now I'm discussing this with the lens of early post-op post C-section or post-op post hysterectomy or any of these post hernia surgery, any kind of core and or pelvic floor, pelvis type of surgery. That's the lens that I'm going to be discussing this in. However, I will say this is going to be in many of these cases pertaining to really post-op, any surgeries. And we've had a couple of great podcasts on this topic. And Lindsey Hughey has one that comes right to mind on things that we can do to educate to reduce inflammation postoperatively. But I'm going to add a couple other things to that list. So let's go ahead and jump right into those. ASSESSING VITAL SIGNS So number one, we need to be assessing vital signs. This is incredibly important in the postpartum period as maternal death rates are actually increasing in America. And for black women, maternal death rates are three times the rate as white women. Many of these are because of some type of cardiovascular event. We have got to check blood pressures. And in many cases, we as the conservative care providers, those physical therapists or rehab providers, we're some of the only ones that are checking postpartum. Or we might be able to catch something very soon before they might have a six or eight or 12 week follow-up postpartum. we've got to be checking their vital signs and assessing and making certain calls when necessary. That is absolutely important and definitely not exercise related at all. We can get them in and get their blood pressures checked. OWNING SCAR MANAGEMENT Additionally, we, we assess sutures or incision sites or whatever whether that was an abdominoplasty where they have an incision from ASIS to ASIS, whether that is a C-section incision, a little bit smaller, more midline, or that might be smaller little incisions all throughout the belly from some type of laparoscopic surgery. Whatever the case, We, as their rehab providers, assess that incision. We're gonna look for signs of infection and we're also educating about those signs of infection. We're assessing to see how the patient feels about it. Maybe we need to set some expectations surrounding what the C-section scar or what any of these scars are going to look like in a month and in six months. And with that, we can go ahead and begin some scar mobilizations. Now, very early postpartum, we're still in the proliferation phase, inflammation, then proliferation, and then maturation. We're still in that proliferation phase, so we're not gonna be doing scar mobilization on the actual scar, but we can come inches above and below and surrounding. We can teach them how to pull on their skin and press on their skin well away from the scar to go ahead and begin that desensitization. That is incredibly valuable. And just going ahead and painting the picture of what that scar rehab is going to look like over the next three to four months. Many individuals have a lot of fear and concerns surrounding the scar. And we are the best people to be giving them home exercise program, these interventions and helping them understand what it's going to look like. We know we're the rehab providers that have seen this all along the way in several other of our patients. So we can help them understand what to expect and If there's concerns where we need to refer to a mental health provider, then we're absolutely going to do that. That is completely within our realm to assess that and to refer out. And what a great opportunity to help someone. Body image is rather difficult. It always has been, but with social media and the way the world that we live in right now, It is incredibly difficult. And so we need a lot of times mental health providers to help us navigate that. So first we talked about vital signs. Now talking about sutures, we can absolutely discuss fueling. That's the podcast I mentioned with Lindsay Huey, so I won't jump into that necessarily. ASSESSING DAILY FUNCTION But next is ADLs. I was just looking through my messages, some screenshots that I've saved from various, um, various people who have messaged me about, um, pelvic floor related topics. And what I saw was this message from someone who said, I just went to my, uh, follow-up and they told me not to lift any weight. And the person asked, can I lift my baby? And they said, no. Now, obviously this is hopefully a one-off. Hopefully that word is not being said. And who actually, I don't know if the doctor actually said that, but the point is, is that this individual did think that that's what the doctor said. We are here to help them understand how can they be safe? How can they hold their baby? How can they get out of bed? How can they bend over and get the clothes out of the dryer, out of the washer? We can help them navigate these things. This is a great opportunity for occupational therapists as well. We can lean into their expertise here. Helping individuals with these ADLs can be really valuable for these individuals and can help them feel more confident in their body in that early postpartum period. Sometimes they just need to share their story. I think a lot of times we as rehab providers really feel this urge to do, do, do, put hands on, give home exercise program. I need you to do all three of these. We feel like so rushed in order to provide and sometimes The best thing that we can provide is a listening ear, is someone to be someone who can just ask questions about their surgery, about how they felt, about how they felt going into that and how they felt coming out of it. That can be incredibly helpful. ASSESSING READINESS TO EXERCISE While we're talking about non-exercise plans, I said that we wouldn't be doing exercise, but I didn't say that we wouldn't be talking about it. So when we have someone early postpartum, they might be an exerciser and they might be saying, oh, I'm not ready for exercise just yet. Well, that's okay. Let's talk about what does exercise mean to you? What does readiness look like to you? What do you want and what are your timeline expectations? And do they match up with what we have seen or what we expect? Having a conversation about an exercise plan and exercise expectations can be incredibly helpful. Some people may not understand that they can go ahead and start to move now. and they think exercise is any type of movement, and we can kind of break that down. We can discuss different exercises that individuals can do or that this person in front of us can do in this early time, like walking or some basic hip exercises or arm exercises. A lot of times there's several restrictions surrounding surgeries. But just because there's restrictions doesn't mean that there has to be zero exercise. So we can discuss that plan and kind of help them understand what that overarching picture of exercise and health looks like. I already mentioned one referral, but there are several other referrals that we can also make. So in the postpartum realm, referring back to their provider, their OB or their midwife. We can refer to a lactation consultant, to mental health providers. Postpartum doulas are another great referral source, particularly for people who are postpartum and maybe don't have a lot of family nearby. There are so many ways in which we can help people and We don't hold the keys to everything. I can't help with mental health. I can listen, but I don't have all of the tools, but I can absolutely refer to somebody who does. And together we can work to get this person in front of us feeling really good. SUMMARY So vital signs, checking the sutures or those incision sites, discussing fueling, helping them with their activities of daily living, their ADLs, listening to them, listening to their story, figuring out an exercise plan and referring out. The last thing I'll just mention here with pelvic floor and particularly with postpartum, we're gonna discuss with them expectations surrounding those. That's a whole nother podcast for another day, but discussing the expectations surrounding bleeding postpartum, leaking heaviness and pain and giving them what to listen to when we say, listen to your body, giving them a key to understanding what that exactly means. That way, once again, they can be successful. So that's just a little sneak peek into a whole lot of what you're going to learn if you take our online level one course. Our next cohort for our online level one starts March 5 so upcoming in one month at the beginning of March. It is going to sell out, just like this current cohort did so if you're on the fence about it, I recommend going ahead and purchasing that ticket because. If you wait too long, you're not going to get a seat. And we are very strict on keeping our student to faculty ratio at an appropriate level. That way you get your questions answered and you get the care that you need as you're learning from us in the course. So sign up for that. And we also have our first online level two course coming up at the very end of April. And so you're not going to miss that. Once again, that is definitely going to sell out. We are still months away from that, but only a few few seats remain for that. We're going to shut that one down pretty soon. So if you're on the fence about the online level to go ahead and sign up for that one. We are all over the place in twenty twenty four. Our next upcoming cohorts. for our live course. We're going to be in California, North Dakota, South Carolina, and Colorado. Those are our upcoming next courses, all in March and April. So be sure to check us out on the road. And remember, when you do all three of these courses, you are eligible for the ICE certification certified in pelvic. We are here to change the game when it comes to pelvic floor health and pelvic floor rehab. And we need more of you. So please consider hopping on the train, coming to our courses. We know you're going to have a great time. Thanks for being here this morning and listening with me. Have a great rest of your day and we'll catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 2, 2024

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty member Mitch Babcock discusses developing youth strength & conditioning programs, including optimal timing & frequency, age groups, and training progressions. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MITCH BABCOCK And good morning. Welcome to the PT on ICE Daily Show. It is Friday, that means it is Fitness Athlete Friday. We are excited you are here. If you're on YouTube, thanks for watching when you're catching this recording back. And if you're on Instagram, thank you so much for being here as well. Thank you to our listeners who are loyal and downloading this podcast on Spotify and Apple Podcasts and anywhere else that you get your podcasts from. If I am talking to you on your morning commute, I wish you a great day in the clinic. And if you're on your way home or anywhere else, I wish you a great day as well. So I am Mitch. I am your host of this Fitness Athlete Friday. I'm a lead faculty in the fitness athlete division. And I want to talk today about youth sport, youth fitness athlete programs and what you can be doing as a fitness forward clinic to really be reducing those injury risks that we all talk so much about in the youth athletes. Before we jump into that, I just want to draw your attention to two main fitness athlete courses that we have coming up for the month of February that we're in now. On Super Bowl Sunday weekend, I will be in Richmond, Virginia. I was getting a little worried. My Detroit Lions making a once-in-a-lifetime run at the Super Bowl. I was getting a little nervous that maybe I did some scheduling error there. fortunate or unfortunate as it may be, they won't be in the Super Bowl. So Super Bowl weekend, I will be in Richmond, Virginia. And I know what you're thinking, I don't want to take a course on Super Bowl Sunday. We're going to get out in plenty of time early enough for you to go make it to your Super Bowl party and enjoy the rest of the weekend with your friends and watch the game. So if you're in the Richmond area, join me there on February 10th and 11th. And then at the end of the month, February 24th and 25th, you can catch Zach, the Barbell Physio. He's going to be at his home gym in Charlotte, North Carolina. for a fitness athlete course as well. And we just kicked off our next cohort of our Level 1 Essential Foundations course online, and so I wanna make a special hello to all of you that are starting the process of the CMFA certification online with us. We're excited to do the next eight weeks together. We've got a lot of learning that we're gonna engage in, so I'm stoked for that. YOUTH INJURY REDUCTION STRENGTH TRAINING & CONDITIONING PROGRAMS So without further ado, let's get into our podcast today. Youth Injury Reduction Strength Training Conditioning Programs. Here's what we know about injury risk reduction. The screening tools that we have been given, the systems that were promised to help identify and reduce risk of injuries, they're no good. They don't mesh out in the data. We have enough long-term studies now to be very conclusive that these movement screen systems that we think that we're putting kids through to help reduce their risk of injury are in fact doing nothing to help actually reduce their risk of injury, and they're no better than a coin toss oftentimes of being able to identify kids that are at risk. What we know conclusively in the evidence, and then we're looking at now in adolescent athletes and also collegiate level athletes, is that the more that they're engaged in a strength and conditioning program, that the stronger their legs are, the stronger their core is, many of these programs focusing on those two elements primarily, that the better they do at reducing actual risk of injury and the more prepared these athletes are for the demands of their sport, whatever that sport may be. And so when you think about the constraints that the youth athlete is under, oftentimes, and we know this problem exists, where these kids are involved in a one singular sport for 9, 10, or even 12 months out of the year, they're hyper specialized into that one athletic arena. They're going from practice to speed and agility camps to to sport positional specific camps. They're constantly engaged in the demands and the domains of their sport and they're doing way too much in that arena and they're not doing enough either other sports or general physical preparedness. The GPP work that we know is the foundation for all athletic endeavors to be built upon. DEVELOP GENERAL PHYSICAL PREPAREDNESS So our pitch, our recommendation for our fitness forward clinics out there, and there are so many now that are branding themselves as being fitness forward, when you're going out and you want to reach this next population, you want to get ahead of these injuries. You want to do something for that youth athlete. You treat their parents already in the clinic. You know that their son or daughter is engaged in travel volleyball, travel baseball, their competitive wrestler, football, whatever that may be. You know their kids, you know their families, and you want to put a program together that gets as many of those kids as possible in your clinic, in your gym, and really helps to teach the fundamentals of strength training. Right? Because if we can get these kids in and start to help educate their motor control patterns, help to instruct them on strength training, under the supervision of a doctor of PT who's trained in the barbell, who's trained in the dumbbell, in the strength and conditioning community like many of you are, and taking our courses now, there is no better instructor to take these kids under your wing and really lead them to where they need to go, which is learning the fundamentals of how to move their body in space, how to get stronger, and therefore how to be more protective against injury. Stronger athletes get hurt less on the field. And if we can start teaching these movement patterns at a younger age, that gives us such a better upslide for being able to instruct and progressively overload these movements over time. So what we need to be doing as Fitness Forward clinicians is setting up some sort of camp, setting up some sort of program. Maybe you have the resources to do it year long, that's great. Maybe you don't. Maybe you can just divide six or eight weeks of your schedule out to fitting in these youth sport performance camps. And you can do them at various times throughout the year. What we have found to be successful is doing a camp in the summer because they're about to lead into whatever their fall sport is. That could be volleyball, that could be Football, I'm not even sure what sports going at that time if I'm being honest, but but getting them into that late summer Is a great time to run some sort of eight-week camp where you teach the fundamentals of strength and conditioning Keep it very simple. OPTIMAL CLASS LENGTH My first point here is to keep it brief 30 to 60 minute classes are gonna be perfect 30 minute class if you're just looking to instruct the strength component closer to a 60 minute class if you're looking to do strength and conditioning together and Okay, so your choice 30-minute class is about what you're gonna need if you're wanting to instruct at least a strength movement Maybe a 60-minute window if you're looking to add some conditioning in there, okay? Keep these programs at two to three days per week Keep in mind how much these kids are already training right how many times they're already doing their sport specific work their speed and agility work there and They're engaged in a lot of things already. If you can keep your program very precise during days of the week, maybe a Tuesday, Thursday, or we have tried like a Monday, Wednesday, Friday, whatever works for you and your schedule, two to three days per week, 30 to 60 minutes is gonna be ideal for these kids, okay? GROUPING BY AGE Now, what age groups? You can't just, we have had not great success by throwing kids anywhere from six to 14 in the same room together, right? The development of those athletes at various milestones throughout their development is so wide and so different that you're not gonna have a successful class with that many different types of athletes. What I would recommend doing is grabbing kids from the nine to 12 group When they hit about eight, nine years old, they're really development enough, they're cognizant enough, they're engaged in the sport, they like what's going on. So if you can grab a group of nine to 12 year olds, and then maybe have another segment of like 13 to 16 year olds. I think those are two really good spaces where you're getting kids at various ends of development, and you're teaching them very different things. At the nine to 12, our strength work for them is really motor control. The stronger they get is really just more repetitions they've had doing that movement. And so we don't really need progressive overload for that group, we don't need barbell training precisely, but really bodyweight and dumbbell or kettlebell loads are going to be perfect for them. and use the load as the reward. So the key here is that, good job, Timmy. Your air squat is looking really good. Because it's looking really good, I want to give you this dumbbell. Hold this at your chest. You're one of the leaders in the class right now. Hold this dumbbell. Keep your squats looking good. So you're rewarding good movement mechanics with load. In that 9-12 year old range, using dumbbells, using kettlebells to instruct your major fundamental movements, your hinge like a deadlift, your squat like a goblet squat, and a press, a dumbbell push press, overhead press, PVC pipe if they need a lighter load. You're instructing that overhead full lockout position, you're instructing a squat pattern, you're instructing a hinge pattern. And for your older kids, your 13 to 16, if they have been with you and they've shown you some good movement patterns now, now we can start to add the barbell in here. Now we can say, good job on your air squat. Let's go barbell front squat. Let's go barbell back squat. Let's go barbell deadlift. Let's go barbell overhead press, strict, or push press. Team, if you don't feel confident teaching those movements, please take a class with us this year. In two days, Saturday, Sunday, eight to five on Saturday, eight to five on Sunday, you're gonna walk away being very confident in your ability to walk right back into the clinic, whether that's with one person or 10 people, and instruct these movements that need coaching. Okay, so if you feel like that's a gap in your game, it is so easy to sure it up. Just join me in a class, join Zach, join Joe, find one of the fitness athlete courses that's in your area, and we'll help you close that gap very quickly, okay? So that's kind of your range of strength movements that you want to focus your energy on. If you've only got a class that's two days a week, do one day squatting, one day hinging, or one day squatting, one day pressing, and just kind of flip-flop your order that you're programming those in. For the younger kids, using load as the reward. And the last thing that I would, well, excuse me, I got two more things. TEACH THE FUNDAMENTALS OF BODY WEIGHT MOVEMENT Teach the fundamentals of body weight movement. You've got to have these kids doing more push-ups. You've got to have these kids doing bodyweight lunging. You've got to have these kids doing some form of a pull-up. And that can be in the form of a ring roll if they're not strong enough, or an assisted vertical pull. But these kids need to develop upper body strength and core strength, do more planks, do more lunging, do more push-ups, do more pull-ups. do a lot of them. It is so easy to teach them really well and give them to them for homework. Like not enough kids are doing that. And I run into this problem year after year with my teens program is that their ability to do a really sound pushup is lacking. And we can have the debate on generation after generation of how bad that's gotten year after year. Ultimately, I don't care. I don't care to engage in that debate. What I care to engage is that what are we going to do with it now? And right now I'm seeing kids that can't do a pushup. So add the push-up, add the pull-up, add a bodyweight lunge, a bodyweight plank. We need to develop some core strength and some solid bodyweight resisted movements. So keep them as a really good accessory movement to the foundational movement that you're teaching that day. ADD CARDIOVASCULAR FATIGUE TO MAKE LIGHT LOADS CHALLENGING And then the last thing, here we go, is adding your conditioning to make the lighter loads you're using more challenging. If all you're giving little Timmy is a light dumbbell or a PVC pipe, by the time I get them done with a 100 meter sprint and then they go back and do this movement, you're going to see some more variability in their movement. By adding that little bit of conditioning, that little bit of metabolic or heart rate duress to the system, you're going to start to see some changes in movement pattern that allows you to coach and improve. Which, guess what team, you can argue this all you want, but that's exactly what they're doing in their sport too. They're getting their heart rate up, they're running around, they're crashing into their friends on the field or on the sport. Their heart rate is going to be elevated and we still need them to move well. So that's what we're doing in the gym as well. Get them on the rower, have them bang out a 30 second sprint on the rower and then get off and do their squats. Send them on a 100 meter sprint, come back in, let's do some deadlifting now. right? Utilize that assault bike. Hammer out 10 calories as fast as you can. Get off. Let me see your vertical overhead press now. Utilizing the conditioning component first to make the load and the weight training that's coming second even more Exposed even bring to light some of the deficits that they have in their movement And that's really where they start to learn how to move soundly under the duress of the environmental constraints and in sport, right? SUMMARY So teaching the foundational movements the squat the hinge the press and using them with lighter loads, dumbbells, kettlebells, with your younger group for motor control, repetition, and with your older group, emphasizing and adding in the barbell. Utilizing a 30-minute session of all you're doing is strength work, stretching it out to a 60-minute session if you're going to add some conditioning work in there, which I recommend you do. And then recognizing that, hey, when I add the conditioning component into the strength component, that's going to really expose a lot of areas that I can coach and develop these athletes in. And through that process, whether you're doing a couple eight week camps throughout the year, you're getting them in maybe right after school, you've blocked off an hour for this at an after school hour or in the evening at the end of your clinical day, you've got this little camp. that you can run this. You're gonna make a couple hundred bucks per kid, and you're gonna get a room full of 20 or 30 kids in there. It's gonna be lucrative for your business and for your staff that you're getting in there to run that. So I really would highly encourage that these PT clinics that have the means, that you have the equipment, that you have the shared gym space, that you're partnered up with a CrossFit gym right next to you, that you can talk to them about utilizing and running this camp through. I highly recommend that you start getting out there in the community. and helping these youth athletes prevent injuries, getting them stronger, and then getting them excited about working out. I mean, these kids are so stoked. The kids that we have in our youth programs, they can't wait to come back to CrossFit. Their parents tell me all the time about how much fun they're having. So, getting them excited about working out might be the biggest win overall. Yeah, if we can prevent a few ACL injuries, that's great. But if we can get these kids excited at a young age about exercise and working out and not seeing it as punishment or something that they have to do, I think we're starting to build a generation of kids that really look at exercise a much different way than maybe our generation has. So that's the key points that I have for you today, guys. Thank you so much for joining. If you're on the Instagram Live, I saw a few comments. I'm gonna circle back and read through those later. Thank you so much. But think about how you can implement that in the clinic. And again, if you have some weaknesses, if you have some gaps that you need shared up, jump into a Fitness Athlete Live course, and let's teach those fundamentals that we need, and then get you right back out there to make a change in the community. Have a great Friday, have a great weekend, and go kick some ass in the clinic. See you guys. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Feb 1, 2024

Dr. Zac Morgan // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses how to subjectively & objectively identify patients presenting with acute back spasms, how to treat spasm, and how to follow-up treatment with appropriate homework. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZAC MORGAN Alright, good morning PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the cervical and lumbar division, here to bring you a Technique Thursday talking about myofascial decompression or cupping for an acute back spasm. For those of you all who work with acute back pain, so this is something that early in my career I did not see an awful lot of, but as I have kind of entered the market of seeing more and more acute low back pain, you will see these people walk through the door that are clearly in a spasm. And I want to talk today about why cupping has kind of become the treatment of choice here for that exact presentation. ACUTE BACK SPASM PRESENTATION And let's just kind of narrow in on why we're focusing on back spasms to start. And the real thing is, this is one of those diagnoses you don't read a ton about in the literature, but it's one of those things that you know it when you see it. So it's fairly empirical. So every so often, people kind of walk through the door, and they're kind of in that shape of a question mark. They're really off to the side, and you can tell as they walk through the door that the severity of their situation is really, really high. Even just watching them move about the world, their activities of daily living are extremely challenging when they're experiencing a back spasm. They're not able to freely move through space and move that spine around because their erector or QL or some of that posterior musculature is in a full spasm. So this is something you will see if you're seeing people day of within a couple of days of a back pain episode. So it's certainly one of those acute low back pain scenarios. Now the issue is, you'll see a lot within our profession of people sort of argue about, well this is just going to regress to the mean. And I don't disagree. A back spasm is going to go away on its own, for the most part. So generally speaking, untreated, in my experience watching these things happen around the gym, having some of them myself, a lot of times people have some movement limitations for ten days or so, seven to ten days, maybe a week, maybe a little bit longer, but then they're usually back to normal life after that point. So it's not one of those conditions that sticks around for months the way like a radiculopathy would. It's just something that's acute, but while it's present, it's very severe. I think it's important for us to say We know it regresses to the mean. It will get better on its own. WHAT IF REHAB CAN BEAT REGRESSION TO THE MEAN? Here's the thing. With early treatment, what I'm about to show you all, I think we can take several days off of the episode. And I think that because of empirical data here in the clinic. So I'll watch people walk in in that situation that we just described. Very put off to the side, huge spasm in that erector. You can almost see it through their shirt. and they're unable to do much, and we treat them with some cupping, we treat them with some relaxation techniques that we're going to unpack here in a moment, and often that person feels tremendously better, tremendously quickly, so within a couple of days, maybe three max, versus that seven to ten. Now that's a difference, right? That's almost a week of time different that that person is going to end up walking around with pain or not walking around with pain. Why does that matter? When you think about how influential this spasm is to their activities of daily living, they can't do much. Now deconditioning is going to set in, even on healthy people. If healthy people move around the world for a full week without really flexing their back, without allowing it to move, they're going to have some deconditioning on board. And if we could have gotten rid of that a week earlier, we've given them more of an opportunity to maintain or even gain fitness during this period of time that they have some acute pain. So I think it's really important that we focus in on this because while it's not a usually a long-term disabling diagnosis, it is a short-term disabling diagnosis. And when people are in that disabled period, they're looking for short-term help. And I think we can be helpful with that. IDENTIFYING CANDIDATES FOR CUPPING So let's talk a little bit about identifying these before we actually get into the treatment. And from an identifying standpoint, you want to start with that body chart. So if you've been to cervical and lumbar management, you know we always start out with quantifying where are the symptoms on this person's body. When someone's in an acute back spasm, it'll be a little complicated to find the exact spot of symptoms. They don't usually point to one thing. They often kind of talk about that whole erector side. They might even point to that whole area of their low back and say it just feels locked up. I've certainly had plenty of clients who reported just like local pain sort of at the waistline, like right where the waist of your pants are. I've had unilateral, bilateral, it bounces around a little bit on the body chart, but typically whatever muscle is in spasm is where the pain is. And often the person has a hard time describing it because of the severity. They just say my whole back is out, my whole back's out of whack. So it's not one of those focal diagnoses on the body chart. Subjectively, you're going to see some common aggravating factors. The biggest one's flexion. The person probably won't even allow their back to flex. And when you look at that from the active range of motion standpoint, you see it's just hip flexion. The lumbar spine is not actually actively flexing. The person's just kind of absorbing into hip flexion. Any quick movements are often painful subjectively. So they talk about transfers, they talk about when they've been lying down to get up. Really anything where they have to move quickly will often be an aggravating factor. And then things like bending, sneezing can also be pretty painful for these folks. In their history, they'll usually tell you about some sort of fatigue-based activity that onset this. So this won't usually be like a one rep max deadlift. That makes me more think of a strain. Where this presents itself is in a workout with a bunch of deadlifts. So when somebody's, you know, several sets in and their back is already tired and then it just fully locks up and kind of worsens throughout the evening or worsens throughout the day, that's more of the spasm presentation. It's not just in weightlifters or competitive athletes. You'll see this really with any human who has exceeded their capacity. So I've definitely had plenty of folks that were gardening all day or mulching all day and just using their back a bunch and then it wound up in spasm. So it's really whatever over challenges that musculature tends to create the spasm. So subjectively, you'll see those common ags and then you'll also see that history where the person was either fatigued entering an activity or did an activity so much that it created enough fatigue that eventually created a spasm. Objectively, again, their lumbar spine, it's not going to reverse. When they flex, it's going to stay very flat. You're going to see a lot of guarded movement. The person's probably going to be very hesitant to move, and you'll notice that quite a bit through this active range of motion exam. You will even often see cervical flexion. bother that person's symptoms because the erectors, they attach all the way up in the neck, in the suboccipital spine. So you will see cervical flexion be bothersome, but then it's not like a sensitization thing from a neurodynamics exam because the ankle won't make any difference. So, when you see that cervical component create a lot of discomfort in that acute pain scenario, and then you dorsiflex and plantarflex the person's ankle, and it doesn't make any difference, that's ruling spasm higher on my list. So, objectively, that'll often be how it presents, and then a lot of it's just observation. You'll just look at this person's back, and like I said in the beginning, they'll be twisted off to one side. They may even be kind of in the shape of a question mark. Like you can see that that erector on that side has just shortened in the area of the lumbar spine. And so the person is fairly obviously uncomfortable. A lot of times the erector itself is swollen or hypertonic or larger, whatever you want to call that. And it'll be tender to the touch. So just palpating that region, a person is going to report most of their symptoms. So like I said, a fairly obvious diagnosis. And again, it's one that I didn't see a lot of until I got that really acute back pain person in the clinic. So that's sort of how they present. TREATING BACK SPASMS Let's talk about treatment. There are a lot of things that jump into my head that I would like to do. Like if you have acute non-radicular low back pain, the first thing that jumps into my mind is spinal manipulation. But often moving these people's backs through space is just not a realistic possibility for you on day one. Team, over the last couple of years I've spent a lot more time learning about cupping and doing a lot of cupping with clients and this is the one thing that whenever you see this presentation show up, whenever we drop the cups on that region, get it nice and relaxed and it doesn't even have to be all that vigorous. The person often gets off the table stunned at how much better they feel. So cupping has definitely become the treatment of choice and I like to just keep it really really simple. Now the biggest issue from a treatment standpoint when someone's in spasm is it's really challenging for you to get that person comfortable most of the time. They don't like laying in supine, they often don't like laying in prone, and then on one side or the other they're often really uncomfortable. If you can get them in side-lying, which is typically the most successful for me, you want the erector that is in spasm up. So I have Caitlin here behind me, and you can imagine in this situation, her left erector would be the one that would be in spasm. So that's the one that I'm going to target with treatment, and that side's up. You also want to prop a pillow between the person's knees just so that hip doesn't adduct and create even more tension on that lower back region. Instead, let's keep those hips nice and neutral and get this person in a relatively comfortable position. This will often be the position they've told you in the subjective exam that they like the most. So we're going to go right to that position and then treat in that position. So I'm going to move to the other side of the table, show you sort of where I put the cups, some of the verbal cueing alongside of that, and then we'll wrap this thing up. and summarize at the end. So anytime you're doing cupping you always want to use a little bit of cream. It's just a lot easier to glide the cup around and it's a lot more comfortable for your client. So make sure you add a little bit of cream to that region that you intend to cup just so that that way it's more comfortable for your client. You're then going to grab your first cup and localize it to the region that you think is in spasm. It doesn't have to be directly over it. Reminder, these muscles are literally all the way across the spine. So if the person's too pressure sensitive, you could certainly move away from it. But you want to be in that basic region. And then you're just going to get these things on. with a little bit of tension. So a couple of pumps to start is plenty. So I don't have this thing cinched all the way down where she's in a ton of a stretch feel. Instead, I just have a little bit of air out of the cup and a little bit of domed tissue within that cup. this gives you that nice decompressive feel if you're the client a lot of times they'll be a bit uncomfortable when you first do this but they're uncomfortable anyway they've been in spasm for a few days and so it's no major deal to them these cups are probably only like 30 to 40% pulled out. So typically if I'm being more aggressive with cups, I get it a little closer to that full capacity of vacuum. But for this, I've got a very severe patient in front of me, they're very fear avoidant, they're not moving all that much, and I've just got a little bit of tension in those cups. I start out just like this, like you all are seeing. So the person just kind of gets comfortable, relaxes, feels that pull. But after they've sat here for a couple of minutes, I'm going to start to try to cue that person to do a bit of a posterior pelvic tilt. The point of that posterior pelvic tilt is just to access a little bit of their lumbar flexion while they're in this nice, friendly, non-weight-bearing position. Anytime they're in weight-bearing, that erector tends to want to be in spasm. So I'm going to get them to just relax things a little bit here in sideline in a nice comfortable position. So I might have them move through 10-20 reps here, maybe even cueing some deep breathing in between if they're very severe. So 4-7-8 breathing pattern is often a helpful one, that physiological sigh. Either one of those are typical go-to's while we're in this position and the person's nice and relaxed. Now, for those of you all who treat human beings, you know a lot of times our female clientele is a little tougher than our male clientele. Sometimes the men are already sweating in this position and they're already having a lot of challenge. If that's the case, I'm going to stay right here and just have them work those pelvic tilts. If I do perceive that the person, if they're telling me, hey, this feels quite a bit better, you know, it seems like they would like a little bit more treatment, the next move I'm going to have them carefully make is getting into the position of quadruped. So they don't like prone and supine, so I'm going to leave the cups on and the person is going to ease their way to quadruped. And then from this position, they're just going to do some gentle angry cats. So I'm going to cue them up into some spinal flexion, telling them to separate the cups. They do have a tendency to pop off, so you want to keep that gun handy. But I'm essentially just going to cue her through 10, 15 reps here of angry cats, thinking about really elongating this whole erector. If you want to make it a little bit more vigorous, you can have them gently flex their cervical spine as they go into the cat position. That's going to give you even more stretch across the erectors and often feel pretty tight for the person, but quite good. Once we're done with that, I'm going to have them just lay back down in sideline in the original position. And this is where I think a nice little bit of massage can be helpful. So just popping the cups off, you may have some light bruising, but then getting in here and just showing that area some love and getting a little bit of massage going to that region. Team, I realize what I just showed you is quite simple. and I'm not trying to be overdramatic, but simplicity often makes this person pop off the table and feel dramatically better. FOLLOW-UP TO CUPPING I think what we follow it up with is very important as well. Earlier in my career, it was always, hey, let's load, load, load. Let's make sure we're getting this person moving. This person is overloaded. That's why they ended up in spasm. So what I'm actually going to target these days is a lot more relaxation techniques. So maybe that breathwork pattern we did with the cups on, I assigned for homework. I need five minutes of this a day minimum. Convince that person to give you some breath work. Convince that person to up their hydration by a bottle or two of water over the next few days. Hey, I really think this is going to help. If you're in a little bit more hydrated state, I think that muscle can relax more. Convince them maybe to add some electrolytes. Heck, I'm fine with a warm bath at night with some Epsom salts. It doesn't matter to me. I'm going to get this person to relax. I'm not going to go have them do more deadlifts. Their problem isn't necessarily that they're weak with deadlifts. It's that they got fatigued. Do we need to build the endurance of that region? Possibly. Maybe that's why it contributed to a spasm. But for right now, my main goal is relaxation. And team, I'm always going to argue for more treatment in this scenario. Earlier and more treatment. The reason being is imagine Kaitlyn is that person who has the back spasm. And she then loses 7 days of not just training, but also moving around like a normal human being. We only have 52 weeks in a year. I don't want to sacrifice an entire week of that person's life to fear avoidance, to lack of ability to move like a normal human being just because it's going to regress to the mean. Not when I could simply get in, assess it, help that person feel like, you know what, I think I'm going to be better in the long term. get them gently moving, teach them some relaxation techniques, and get rid of this thing seven days faster. It's gonna be hard to convince me that that is a harmful approach, even though we are utilizing passive tools to help that person relax. I think this is exactly why we need those tools, is to help put that fire out, and then in that process, convince this person to start addressing some of their lifestyle factors, to start addressing that ramped up nervous system, getting them to calm it down, to start addressing hydration. Some of the basics, right? Just the basics of what it means to be a human, people mess up quite a bit. So, we want to make sure that we check those basic boxes, and often you're going to follow up with this person in 48 hours, and they're going to say, Zach, feels tremendously better. Can't believe how much relief we have. and now we can perhaps get after some of that loading or regional interdependence or anything that you think might have contributed. But team, I think it's a simple approach and I don't think you should feel bad about treating people with acute back pain even though you know that they're going to regress to the mean. It's worth it to save them that week in my mind. I'm always going to opt towards more treatment. SUMMARY So team, that's all I've got for you this morning. Last couple things I want to leave you with is just the upcoming spine courses. So if you're looking for cervical spine this weekend in the DFW area, make sure you jump over to Hazlet, Texas. That course will be right there near Dallas-Fort Worth Airport, kind of north of Fort Worth. If you're looking a little bit later in the month, Simi Valley, California, that one's getting closer to a sellout, so don't wait if you're in that region, you want to take that course. There's not too many seats left. And then March 9th and 10th, will be in Kuna, Idaho. If you're looking for Lumbar, March 23rd and 24th, Brookfield, Wisconsin, that's right outside of Milwaukee, that'll be at Onward Milwaukee. And then April 6th and 7th, we have two courses going on, one on the west side of the country over in Carson City, Nevada, and then one right here in Hendersonville, Tennessee. And again, that's April 6th and 7th. So we hope to catch you at some of those on the road. We'd love to catch up with you, talk more shop like this, talk about the main patterns that show up in the back of the neck and how to best utilize them. Team, I hope you have a great rest of your Thursday. Crush it in clinic today and I will see you soon here on the podcast. SPEAKER_00: Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 31, 2024

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave to discuss recent research evaluating the efficacy of high-volume vs. low-volume resistance training for older adults as it relates to facilitating muscular hypertrophy. Jeff breaks down the research but also offers practical implications for the clinic. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MUSGRAVE Welcome to the PT on ICE Daily Show. I'm gonna be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy, currently serving in the Older Adult Division, trying to demolish things like underdosing, ending frailty, and I am super excited to bring to you a very interesting research study that just dropped January 4th of this year. So the title of this article we're gonna be digging into today is Higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So, trying to dig in to figure out if someone is not responding to resistance training, what can we do about it? So, obviously if you're listening today, if you're following in the world of ICE, you know that resistance training is paramount. Getting people strong is how we're going to break the cycle for people that are coming in with pain and dysfunction, musculoskeletal disorders. There aren't any conditions where we can get people too strong. And we know specifically through the lens of working with older adults, when we've got things like frailty, adults who are pre-frail, who are very vulnerable to external stressors, or maybe one rep max living, we've got to bring them quality resistance training. We need everyone to have a path back to load. As quoted by Lindsey Huey in the extremity division, we love to say that load is our love language and all paths lead to load. HIGH VS. LOW VOLUME RESISTANCE TRAINING So let's dig into this a bit more. So higher resistance training volume offsets muscle hypertrophy, non-responsiveness in older adults. So what we've got, we've got 85 subjects. over 60 years old male and female that had 14 dropouts and everyone was required inclusion criteria included they could not be doing any formal aerobic training or resistance training prior to being included in the study. Their nutrition was actually analyzed by a dietician, which I thought was really cool for this study that they were looking at that. They also acknowledged that variations in sleep patterns are going to impact people's ability to recover. They weren't able to control for sleep, but they did figure out that by and large, there weren't any huge variants in nutrition, but they did have everyone supplement protein So they did a 20 gram protein supplement in the morning and in the evenings in between meals. The purpose of this study was they were trying to figure out, can we identify strategies like what's gonna happen when we adjust volume at a set intensity for older adults? and then figuring out like what do we do with non-responders so we do have people that are going to respond to resistance training but maybe we may have some people in our caseload and you've probably seen this clinically that don't respond as quickly to resistance training and they were just isolating out the variable of volume, not intensity. So what they did is they had each participant was a study in themselves where one leg was identified for lower volume and one leg was identified for higher volume. What they did is they were looking at the quadriceps muscle They got a baseline cross-sectional area from an MRI, and then they did one rep max testing on a single limb knee extension machine. So single limb knee extension machine to get a baseline one rep max, and then they did an MRI to look at the cross-sectional area of the quad muscle. And then the right or the left leg was assigned randomly to a higher volume program and a lower volume program. METHODOLOGY: WHAT IS LOW VOLUME AND WHAT IS HIGH VOLUME? So when we dive into the methods here a little bit, what we find is for the first couple weeks of the program, they were, the low volume group was doing one set. Okay, one set, trying to hit an eight to 15 rep max. And then the higher volume set did four sets at that eight to 15 rep max. So we got one set versus four sets. So that's what they're calling low volume, and that's what they're calling high volume. And that was for each person. So they were able to like kind of control for a lot of factors by testing the low and high volume on the same person, which I thought was really cool, a really cool way to test this. So after the first two weeks, they amped up the intensity a little bit and they were asking them to hit a eight to 12 rep max, still one set on the limb that was identified for low volume, and then four sets on the side that was for higher volume. So they continue that from weeks three to 10. So 10 week duration of intervention, we've got a low volume side and a high volume side. So what they did is they analyzed the results and they were looking to figure out who are our non-responders and who are our responders. So they're looking at cross-sectional area of the quad and changes in one rep max on knee extension. So what they found between all the subjects between the right and the left limb, they found that 60% went into their non-responsive category where they did not make statistically significant changes in their one rep max and or their quad volume. So those were 60% were deemed as non-responders. And then the responders, about 40%, it didn't matter, the low and the high volume side, both improved in their quad size based on the MRI and their one rep max. So really interesting here that they found that the responders, it didn't really matter the volume as long as the dosage was there and that maximal effort. And when you look at the literature for older adults, it is all over the map. And in general, this is a wide brush stroke here, okay? So not for every study, but a lot of the studies will say the more deconditioned someone is, the less, Intense a dosage needs to be to make change. So if you've been doing absolutely nothing Something is going to be beneficial But then the dosage for true strength training, you know, there are lots of studies Landmark studies for older adults like the lift more trial that's looking at you know hitting percentages of 80% for a five by five five sets of five repetitions, but when we you know dig a little deeper into this dosage and you know, based on the rep ranges for their intervention there, because they were doing eight to 15 rep maxes, sets of that. So we're looking at a 60 to 80% rep range, not rep range, percentage of a one rep max. So, pretty decent on dosage, but typically we're going to start people at a minimum of a 60% and then we're going to amp that up to 80%, maybe 80 plus, and then be adjusting the rep scheme. But this is just looking at maximal volitional output to muscular failure in that eight to 10 rep range. And what they did is if they hit more than that number of reps, then they would add a little bit of weight in increments of one kilogram. some weight away if they were doing multiple sets like on the high volume side. CLINICAL IMPLICAITONS So really interesting to really think about the impact of volume but this isn't typically what we're going to do clinically right so if we're going to add a higher percentage of one rep max we're going to drop those sets and reps and not be doing these AMRAP sets for each set. Not a great experience, causes lots of soreness, can produce symptoms. And these were all non-symptomatic patients. These weren't people having pain like what you're going to see in the clinic. So there's one caveat there, but just keeping in mind like rep ranges and kind of these basic rules that we try to use for programming strength training. When you look at something like Perlepin's chart, for example, that's been used in the strength and conditioning and Olympic lifting world for years, you're going to see that Rep ranges are going to vary, but you know, if we're in that 70 to 80 rep range, we're going to be doing sets and reps of three to six. So add a total volume of about 18 reps total. And same thing for our 55 to 65% of a one rep max, we're gonna be doing sets of three to six, not these eight to 15 rep maxes, which I understand for the study design and to try to equalize this, that was necessary to be able to compare apples to apples. But clinically, we're gonna be doing smaller sets and reps, and we're gonna be, as we increase a one rep max, not this 8 to 15 maximal effort. So when we're looking at this through the lens of Prolepin's chart for the low volume to be doing one set of an 8 to 15 rep max, you're maybe not going to hit the minimum threshold on volume to make strength adaptations. IS LOW VOLUME TOO LOW FOR SOME PATIENTS? And I know there's some studies that say, that are leaning into one maximal effort being enough for strength gains, but I would say clinically, that's not typically what we do. If we're gonna be using that 60 to 80% rep range, we're gonna be breaking that up into smaller sets and reps, and we're gonna be adding more volume than that. So I would question that the low volume group because we did not adjust the intensity up, it's not apples to apples here. Because if we're going to increase that percentage, we're typically going to be doing smaller sets and reps, but also going to be hitting more volume. So I feel like the low volume group probably didn't really hit threshold. And I think that probably impacted, this is all opinion of course, but I think that impacted the low volume group's ability to make changes. And I think that's why we're seeing 60% non-responders. But if we were going to dose this out at that volume, we would have been doing much higher percentages. And the high volume group is probably more a normal rep range and percentage that we would use if we were just going to create a program for someone. So I think that's a weakness in this study, but I still think there's some things we can take away from this. USING RESISTANCE TRAINING DOSAGE TO OVERCOME BARRIERS So if we're thinking about training with older adults, we know that there are often lots of barriers. So our older adults come in typically with lots of fear. They may have beliefs on board that are going to limit our ability to be able to really push that intensity or push the weight because of fear, bad experience, or maybe just lack of experience with weight training, that they're scared, there could be histological barriers where maybe someone's coming in and their primary concern is they've had a fragility fracture or they've got low bone mineral density. And knowing the timeframes for healing on bone, we're gonna make muscular adaptations much faster than we're gonna make changes in the bone. So we may actually hit what's appropriate at that point we're going to be adding volume which goes in line with what this study is telling us is if someone's not responding to lower volume up the volume and we're not looking at high intensity and the other thing this study is not testing is it is not comparing low and intensity to high intensity resistance training it's moderate intensity and high volume or low volume which is not typically what we do but it was just looking at the impact of volume is all it's doing at a set intensity so for those people that we hit barriers where we can't go heavier then we're gonna have to add more volume. But keeping in mind that there are specific benefits to higher volume or higher intensity, higher load training that we will not get with moderate or low load training. But we will, if we want the strength adaptation, we are gonna have to adjust that total volume up. So our people that aren't responding or we've got barriers, then we need to up the volume. So I know all this digging in to say, If we hit barriers in hitting that higher load, then we're going to have to add more volume. But that's a reality of what we see in clinical practice, especially with older adults. And I think that's something that's valuable to keep in mind if we're working around injuries or belief systems or fear or time frames for healing. of tissue, especially like bone or cartilage that may have a longer duration of time, that we're going to have to supplement with more volume. So really from a clinical standpoint, I think that's helpful to keep in mind. But still keeping in mind that if we can hit high load, we want it because we're going to get strength adaptations, adaptations to the bone and other tissues faster and create more margin. Because with older adults, it's all about building as much strength and as much margin in the tissues, whether we're talking about strength or fitness or bone density, we want as much margin as possible. And the only way you're gonna get that is with high load. But if we can't, the next best option is to add volume. SUMMARY Team, I hope this was helpful. I found this article really interesting. I'd never seen a study put together quite like this. If you have maybe taken our online courses and you want to get into live, where we do lots of practical labs, you've got some great opportunities coming up. So we've got MMOA Live in Kearney, Missouri, January 27th and 28th. We've got Oklahoma City, Oklahoma, February 17th and 18th, that same. And then the weekend after in February, we've got course in Connecticut and Minnesota on February 24th and 25th. Team, I hope you enjoyed this talk. I would love to hear your thoughts on this article or your experience with older adults with adjusting volume and maybe what you've seen. Other than that, team, have a wonderful rest of your Wednesday and we will catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 30, 2024

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the current literature around best practices for degenerative meniscal issues, including graded manual therapy, self-relief at home, and loading. Mark also discusses how to begin with the highly irritable patient & progress through the full plan of care as symptoms reduce & tolerance to load increases. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT All right, what is up PT on ICE Daily Crew? Dr. Mark Gallant here, lead faculty of the Extremity Management Division alongside Lindsey Huey. Happy to be here today, coming at you on Clinical Tuesday. What I'd like to talk about today is degenerative meniscus tears and what is the best path going forward to treat them. So what we'll get into today is a few things of overall arching research and philosophy about degenerative meniscus tears. So those are those tears that person's around the age of 40. There's usually no relevant recent trauma. So we'll get into again, general research philosophy. And then what we're going to talk about is what do you do when that tissue is really irritated? How do you move them forward clinically? And then what do you do when it's, when it's less irritable and we're really trying to get them back to all the things that they love the most. GENERAL RESEARCH PHILOSOPHY So what we see with these degenerative meniscus tears in the research, a few interesting points. So first is, that when Horga et al in 2020 took 230 asymptomatic knees, ran them all through the MRI tube, what they found in their research is about 30% of those folks had a meniscus tear or some sort of meniscus degeneration. So even in asymptomatic folks, having some tissue changes to the meniscus tissue is quite normal. Then Thorland et al in 2018, they had a surgeon who went in and did a scope of arthroscopic surgery to over 600 knees and while the surgeon went in there determined is there damage to the meniscus or is there no damage to the meniscus. What they found was an equal number of folks with no damage to the meniscus reported signs of mechanical knee pain that we typically associate with meniscus injury. So things like catching, locking, and lack of extension of the knee, we have historically associated those with a damaged or torn meniscus. And what Thorland et al found is, no, this really is more of a sign of that the knee is not doing well, that the health of the knee is not at its max capacity. and that's likely why they're getting those catching, locking, lack of extension, not that one specific tissue or a couple of specific tissues are to blame. And then finally, over the last decade, we have study after study, systematic reviews, randomized control trials showing that if you compare someone who had conservative care like physical therapy versus having surgery to their meniscus, that after a year, the outcomes are the same, if not better, favoring the physical therapy side with far less medical cost. Last year, what came out is we now have Cochrane-level review evidence, a Cochrane study showing that scoping these meniscus knees, or knees that supposedly have meniscus damage, is no better than placebo. So again, many asymptomatic knees are gonna have changes to the meniscus, whether that's degeneration or tears, Most knees, whether they have a meniscus tear or not, if they are unhealthy and not doing well, they're going to show signs of mechanical knee pain such as catching, locking, and lack of knee extension. And when we take it even further and we look at who gets better if we treat them out for a year, again, Cochran level review evidence saying that we should not be scoping those knees, which has led my partner, Lindsey Huey, to often using the phrase, stop the scope. There's a couple podcasts here a ways back if you want to check them out where Lindsey went into more depth of the all the research showing why we should not be scoping degenerative meniscus tears or at least not scoping them as a first line of treatment. She also has a episode on our virtual ice where she goes in depth to the scoping the knees. STOP THE SCOPE: THEN WHAT? So what I want to talk about today is stop the scope, then what? Then what do we do after that? So how are we going to effectively treat these people to get them back doing the things they love? So Let's start with the highly irritable patients, someone who comes in, their symptoms are at that 7, 8, 9 out of 10 symptoms. How are we going to treat them? Well, modulating their pain is always a good place to start. So can you use your manual therapy, your joint mobilizations, your dry needling, your myofascial decompression, or your soft tissue techniques to take their symptoms from that 8 and get their symptoms down to a four, a three, a two, something that's a little more manageable. When we're doing our joint mobilizations for these folks early on, what we're going to do is we want to do them in more of a open pact or positions that are not challenging the end range as much. So both flexion mobilizations or knee extension mobilizations. Again, at this point, we are not trying to get after knee stiffness or range of motion limitations. We're trying to create fluid exchange. We're also trying to pump any chemical irritants out of the area. And really the biggest thing is we are trying to get a positive stimulus into those tissues so that the central nervous system will calm down a bit and allow us to load the knee, which will effectively improve its long-term health. So again, very mid-range, open-pack joint mobilizations. With your dry needling, what we typically see is it works well to go distal from the knee. So putting your needles in hamstrings, quads, glutes, tissues that relate to the knee, but are not going to create fear for that patient by putting the needle directly into the area or tissue that is sensitized. Same with your soft tissue mobilization or your cupping. When you, after you do your joint mobs, your dry needling, they're feeling a little better. Then we're going to give them a self-mobilization to follow it up when that person is more irritated. Again, we want that to be more of that open packed, less challenging end range. If they have a flexion deficit, we like to go on the floor doing a heel slide, but having a thick band provide an anterior tibial glide, which will further modulate their symptoms and allow them to get through a nice comfortable range of flexion. If their deficit is more knee extension and the pain and symptoms are high, we're going to have them do a quad set but put a towel behind their knee so that they know there's an end range and they're not going to bottom all the way out into their symptoms. You can also add a band to distract the tibia and that sometimes can be an added benefit for those folks. So you're going to do your pain modulation technique in the clinic You're going to give them some sort of self-mobilizLation to help further modulate pain at a fairly high volume, 15 to 20 reps to really pump that tissue. LOAD AROUND THE KNEE And then as early as we can, we want to load the tissues surrounding the knee. So the quads, the hamstrings, the gastroc soleus complex early on when things are irritated, it's going to be challenging to get a lot of tensile load through these, through these tissues. It's also going to be challenging to get them at an end range. So, we're going to do mid-range knee extensions and we're going to do Knee flexion, so either banded, monkey feet, whatever you can do to challenge those hamstrings with a light load and a mid-range at a high volume. And then whatever way you want to load the gastrocs and soleus, but again, going low tensile load, high volume. And then what sort of functional thing can you get that person into? A lot of times those folks have challenge with loaded knee movements. We want to get them back to that as early as possible. without stirring up their symptoms. Early on, what we find best is to go double leg activities that don't have a lot of shear involved with them. So not a lot of twisting and rotation. So we love a body weight squat and even a body weight squat to limited depth to keep that person comfortable early on. So again, symptoms are high. You're gonna go manual therapy, more for challenging symptoms, not challenging their end range. You're going to go self-mobes that have the same type of style where they're more mid-range, really creating a pump to that tissue, giving some positive input. You're going to start to challenge the knee extensors, the knee flexors, and the gastroc soleus complex with lighter tensile load. higher volume again thinking pump and getting positive positive stimulus in the system and we want to get them used to doing their functional activities double leg body weight squat with a depth that they feel comfortable with is a really nice way to do this now then that person is going to come back and their symptoms are going to be lower so they're going to tell you know what i was at an 8 out of 10 but over the last couple weeks, I've been hitting all the stuff we talked about. The manual therapy felt good. Now my symptoms are more in that two out of 10 range. I feel like I can get after it a little bit more. So now when we're doing our joint mobilizations, we are gonna go straight down to the end range and really challenge the end ranges of these tissues and make sure we facilitate that they can restore full flexion, full knee extension. For our dry needling, now we are gonna get much more direct at the tissues of the knee. So we really like to needle the popliteus, the hamstrings, the gastroc soleus, tissues that are right there interacting with the intra-articular knee tissues. For your follow-ups, now again, we want to get them right into those end ranges of tissues and really start to challenge them. CHALLENGE END-RANGE We love the classic terminal knee extension with a really thick band. Spanish squats can be another way to get after this. We also, for the knee flexion after the mobilization, we're gonna get into a child's pose position with a towel behind the knee. I'll come on tomorrow on our Instagram feed and demonstrate what this looks like. So they're gonna have a towel behind the knee with a band keeping it placed, and they're gonna rock all the way back into deep end range knee flexion to really challenge the end range of that motion. Now, loading up the local quad, loading up the local hamstrings and gastroc soleus at that point where they can tolerate more tensile load, we're going to go long arc quads, really loading that up, whether that's a classic knee extension machine, your monkey feet, banded long arc quads. you can hit spanish squats in this position to really load the quads up for our hamstrings we're really going to start to challenge the length tension relationship of those by doing things like nordic curls You can also do Nordic curls or bridge walkouts to really challenge those hamstrings can be another nice one. And then in this phase, we are really getting into the concentric eccentric in functional activities. We really like transitioning to single leg activities in this phase. your split squats, your kickstand RDLs, your single leg RDLs are very nice for this phase, really challenging that knee overall from both a proprioceptive balance and load perspective. When you're doing your squats and your deadlifts in this phase, really starting to load them up, how heavy and how much stress can that tissue take during this phase. Step ups are another really nice one to add in. So again, during that low irritability phase, now we are challenging end ranges of tissue. We're really trying to put positive stress into the quads, hamstrings, calves, Our functional activities, doing single leg, whether that's split squats, RDLs, heavier on the double leg squats, deadlifts, step ups, all work really well. Once they can tolerate that phase, with 2 or 3 out of 10 or less symptoms, then we've got to really get them back to their more dynamic activities if that's what they choose to do. Here's where we're going to do things like box jumps, rebounding jumps where they jump from one box height to the floor up to another box height. We're going to hit things like jumping ropes so they get their plyometric endurance up. single leg hops for distance, running for distance, cutting. This phase we really want to focus them on getting back to the activities that are challenging them and some pivot rotation movements that are going to challenge that sheer force to the knee. SUMMARY So overarching themes. For these degenerative meniscus tears or degenerative meniscus damage, surgery is never the first line of defense for these folks. When they're more irritable, our manual therapy is gonna be much more mid-range, calming things down, giving a positive stimulus to the nervous system. Our follow-ups are also gonna challenge more in this mid-range, again giving positive stimulus, mid-range knee extension, banded or monkey feet hamstring curls, low to the gastroc soleus, and typically double leg functional activities. Once they can handle those things where symptoms drop below that five, now our manual therapy gets much more into the end range of those tissues. Our follow-up MOBS are also gonna get into the end range of those tissues. I'll show that, Child's Pose Rock Back tomorrow on our Instagram feed. Our knee extension, our hamstring activities are gonna be much more higher tensile load. Our functional activities will switch into single leg or much heavier and stressful double leg activities. Once they can tolerate that at a two or three out of 10, then we're really gonna start getting into their running, jumping, cutting, dynamic motions overall. Hope this helps as far as treating out those alleged meniscus tears and avoiding them from going into an unnecessary surgery. If you'd like to catch us on the road, I'm gonna be in Highland, Michigan, just outside of Detroit this weekend. Lindsey will be in Scottsdale, Arizona this weekend. And then the next opportunity to catch us will be Lindsey will be in Carson City, Nevada, February 17th and 18th. Hope to see you all soon. Hit us up in the comments if you have any questions or things to add to this conversation. Have a great rest of your Tuesday. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 29, 2024

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to get patients performing more fitness in their plan of care, as well as suggestions on how to help patients transition to becoming "everyday athletes" with a wide variety of home & community fitness programs. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL MOORE Good morning, PT on Ice Daily Show. It is 8 a.m. on a Monday morning, which means we are here tuning in for our ice pelvic. We are hanging out here today. We are gonna be talking about building the bridge to fitness in the pelvic floor PT space. So we talk a lot at Ice about being fitness forward. We've had Jeff Moore on the podcast a few weeks ago talking about what fitness forward means. and we really pride ourselves on being fitness forward right sometimes that can create this like mindset of if i'm not seeing athletes quote unquote how can i bring this fitness forward um style of therapy into pelvic floor pt WHAT DOES BEING AN ATHLETE MEAN? And first I want to talk about what athlete means, like define what that means in this space and kind of dive in from there. So when we talk about like athletes, quote unquote, in our space, that's anybody that's like intentionally moving their body for exercise. That doesn't mean that they're CrossFit Games athletes. That doesn't mean that they're super competitive. It just means that they are moving their body intentionally to get some effect. I would argue that every parent that is chasing after kiddos is an athlete in that case. And so if we take this term of athlete and broaden it out, we can apply that concept to everybody that walks into our clinic. This is a really huge key point in the pelvic space because there are so many people that are coming into pelvic floor PT that maybe have not ever exercised before or maybe exercise like back in high school played sports and since they graduated high school haven't done anything in the gym intentionally or haven't done any sport. So this season of life of pregnancy and even postpartum is a fabulous reintroduction into potentially the world of exercise. And that's where we come in. So when we have people coming in that are pregnant that want to get out of pain, maybe their goal isn't even anything to do with staying in the gym or getting back into the gym and their entire goal is to get rid of their back pain in pregnancy or get rid of their pelvic girdle pain in pregnancy. We can help not only accomplish that, like we know that. We talk about it in all of our courses, in our live course and in our online course, how we can use resistance training to mitigate pain and get rid of pain in these populations. But we have a fabulous opportunity here to literally change somebody's life. We can help them fall in love with fitness and fall in love with that feeling of being strong. a lot of times people are coming in and again maybe they haven't resistance trained ever and we put a barbell or a dumbbell in their hands and they kind of look at you like I'm not really sure who you think I am but there's no chance I can do this and so having conversations with them about like look this is a 20 pound dumbbell and your toddler weighs 30 so yeah you can and I know this looks scary because it is this little metal handle with two big old heads on the side But in reality, you're already lifting more than this. Let's just build your capacity by doing it intentionally at a higher volume. And then they start feeling those effects of that. We can have so many downstream effects from resistance training, not just getting them out of pain, not just giving them a new hobby. We can shift the trajectory of their life and impact things like metabolic diseases in their future. So this really is a powerful thing that we can do. And we have to recognize that every time somebody comes into our clinic, whether or not they've exercised before, we have a lot of opportunity to help build this capacity for them, not only physically, but also emotionally and mentally. In our PT sessions, we do a lot to help build confidence and rapport, right? Like we're in there with them. We're going over form. We're talking to them about like, okay, this is how you do a deadlift. This is how I want you to brace. This is what a brace means. Now we're going to practice it. Let's go apply it. Like let's actually lift heavy things while bracing. And when they're in the clinic with us, that can be incredibly empowering and amazing. And we love that, but sometimes that doesn't translate over into the next step. So great. WHAT TO DO AFTER FORMAL PT HAS ENDED? When I'm in the clinic and you're watching me do the things, I feel awesome and I feel like I can knock that out of the park, but I'm just not really sure what to do when I leave here. A lot of the times the way that I'll program HEPs is I'll do like our rehab EMOM style and I'll give them two or three workouts, if you will, and they cycle through them. But I think we all can agree that if you're just doing the same thing like three times in a week, so like A day, B day, C day, and do that for a few weeks, it can kind of start getting stale. And we kind of like crave that variety, right? Especially as people are starting to get a little bit more confident. So there's kind of this like gap between I'm done with PT, informal PT sessions. A lot of clinics are now coming out with like once a month or like once every other month kind of like check-in style appointments where you come in, you get a progression of your exercises, you get maybe some updated programming, and then you go off for another month or so on your own again. And those are really the two big things that we see. And then the third option is like, okay, you discharge and you're done. I'm here to talk today about another option, right? So when we have our person who's coming in and they've been coming to us for several weeks, they're feeling really great or maybe a couple months and they want to continue working out, but they want something a little bit more than once a month. and they don't really want to do like a full blown PT session. Like they just want to come in and work hard. We've got two options. We can create a program within ourselves and within our clinics, or we can get really, really good at helping find a home gym or a home space for them. If we're talking about the creating a program route, this is something we're about to roll out in my clinic. We're calling it like the bridge. Feel free to take that same concept. But the whole idea is when you're done with PT, quote unquote, like you're not in pain anymore, all your symptoms are gone. You're feeling really solid. You want to work out, but you're just not sure where to go and you're not sure if you feel like you can confidently take the things that we've done in our sessions. and apply them across the board, this is the spot for you. So we're doing it as a couple times a week and obviously this depends on what the capacity is within your clinics. We're rolling it out starting out two times a week and these are group HIIT style classes, where we're going to have a cardio component, we're going to have a strength component, we're going to take them through different movements, and so there will be a variety of movements that they can increase their comfort and their confidence in while they're in our classes. They're also building community here. They're meeting other people that are in a similar stage of life as they are. Not only are they maybe pregnant or postpartum just like they are, but they're people that are wanting to get into exercise and wanting a little bit more, but maybe haven't really known how to do that up until this point. So we're taking these people and we're bringing them together and then we're lifting heavy things together. So powerful. If you've ever set foot in a CrossFit gym or any type of like group fitness setting, you know how powerful these connections are that get built in under like shared suffering, if you will. This class, though, isn't meant to be forever. Like, its whole goal or the whole purpose is to build capacity, increase confidence, so that these people can go from working out a couple times a week, doing their PT exercises, and then coming to these bridge classes. But I want you getting to the point where you're like, let's send it five days a week, or whatever that looks like in your schedule. And truthfully, I want you to have more variety. Like I want you to get out and do different things and try new sports. BUILDING A NETWORK OF FITNESS PROFESSIONALS And so that's where option two comes in, where we as professionals need to have a really reliable, strong network of fitness providers. So we need to know not only the CrossFit gyms in our area, Because truthfully, not everybody vibes with CrossFit. That's OK. There's the whole phrase, like, CrossFit is for everybody, but it's not for everybody. So CrossFit gyms in your area, knowing those coaches, being comfortable with, like, if I send you there as a newbie, I know that you're going to be in really solid hands and be taken care of. But also the other types of workout spaces, too. So we're thinking things like F45 or burn boot camp, maybe having some options for, like, Pilates studios, where you've taken some classes there you understand how they teach the bracing piece of it and if it isn't maybe what the way that you've taught them you kind of have that conversation beforehand or you have an opportunity to educate those Pilates instructors on like hey this is how we do things from a pelvic floor PT side you've got somebody coming in that's postpartum or pregnant So this is kind of the messaging that we have. We also really love things like PureBar. We've got actually evidence for PureBar helping reduce stress urinary incontinence, not even full-blown pelvic floor PT, but just going to PureBar classes. So having a variety, knowing who these people are, knowing what these spaces are like, and knowing what the environment is like. It is powerful to be able to have your hands directly on give the people the thing that they need as far as improving their fitness and improving their form. But it's also powerful to then watch them take that and go off into the world and utilize it. And then you're seeing them maybe on Instagram months later, or you run into them at a workshop, and they've been going to these gym classes for like a year. And now maybe they're competing at different things that they're in CrossFit. And you can see this like spark ignite. And we have the opportunity to start that spark at our very first visit, our very first appointment when somebody comes waddling into our office because they're in so much pain, they can't even take a full length step because their pubic bone pain is so bad. We can be the ones that not only knock that pain out, because I know we can, but also create this bridge into a completely different life for this person. Increasing their capacity, increasing their confidence, helping them find community and support, and having that far reach outside of the realm of what our typical plan of care is. This is huge. This is a massive piece of the puzzle in the pelvic floor PT space. So if you are not somebody who has the ability or desire, totally understand, to create a group class within your own setting, whether it's in your clinic or your gym or whatever, start reaching out and start making those connections with providers, fitness providers in your area. Meet those gyms, take those classes, get out there and build that network. Have some cards on hand when your patients are talking about, hey, I just really think I'm ready to get out there and do more. Lay them all out. Here's everything we know about all the gyms in the area. Let's talk about all your options and help you find the perfect home for you. I hope that kind of lights a fire under you guys if you have an eval coming in this afternoon on the ways that you can really implement all of these strength training principles to change their lives and also to get out there and make some connections in your community. SUMMARY If you are looking to join any of our pelvic classes, we've got our live courses. We actually have a ton coming up in the next couple months. We've got one in February, February 3rd and 4th in Bellingham, Washington. And then we've got three rolling out in March. Our first two are gonna be March 2nd and 3rd in Newark, California, and March 9th and 10th in Bismarck, North Dakota. Our next online cohort comes on March 5th. If you're interested in that L1 online cohort, hop into it, because we are, man, we're getting full. So grab your spot before there's not one, because if so, you've gotta wait another nine weeks after that March 5th cohort to hop into the next one. I hope you guys have a great Monday morning. Absolutely crush it. Thanks for joining. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 26, 2024

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Jason Lunden discusses the prevalence of runners returning after joint replacement, risks of returning to running, and how providers can set these athletes up for success on their return. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JASON LUNDENHey, good morning, everyone. Welcome to another edition of the PT on ICE Daily Show. Happy Friday. My name is Jason Lunden. Uh, I am the lead for our endurance athlete division, and I am very excited today to talk to you about return to run following total joint replacement. So this is a topic that has held great interest to me for a number of years. Um, and really hasn't been a lot out there. Until more recently, there's still not a lot out there, but there have been some really neat studies that have come out in the past year that can help guide us with that. So today we're going to cover, one, do runners return to running following total joint replacement? Two, what are the risks that we and they need to be aware of? And then three, How can we set them up for success if they do indeed want to return to running? DO RUNNERS RETURN TO RUNNING AFTER JOINT REPLACEMENT? So first, answering the question, do runners return to running following total joint replacement? The short answer is yes. I think we've all probably heard anecdotal stories of runners who've had a total joint replacement and returned to running despite being told that they should never return to running from their surgeon. Furthermore, a study from 2018 just looking at the prevalence of osteoarthritis in marathon runners made the observation that out of their cohort that they were studying, there were seven marathoners who were running with total joint replacement. So, you know, are these unicorns, you know, people who are going against the advice of their physicians and maybe their PTs and you know finding some success? Is it that they're finding very short-term success and then having to go on to you know early revision of their total joint? You know really didn't have any of that data until until recently. So a really cool study in 2023 came out by Antonelli et al looking at the return to run rate for runners following total joint replacement, namely total hip, unilateral knee, and total knee arthroplasty. And what they found is that yes, runners do indeed return to running following total joint replacement. And depending on the type of joint replacement they had, some of them return at a very high rate, while others return at a pretty modest rate. But overall, one of the interesting things out of that study is the number of people going into total joint replacement that classified themselves as a runner is actually really small when you're looking at the whole population out of the study. And that really, you know, reinforces our knowledge that we've been gaining recently that, you know, running is not a precursor to osteoarthritis and perhaps it may be chondroprotective. So that's one kind of neat takeaway from that study. The other really cool thing is that for patients following a total hip arthroplasty, if they're a runner prior to total hip, 75% of them returned to running after getting a total hip arthroplasty. With knee replacements, the percentage is much lower at around 10 to 15%. of those runners who were running, runners, and then going on to get a knee replacement, only 10 to 15% of them returned to running. And then even more surprising is a certain number of patients who did not run prior to joint replacement actually picked up running following joint replacement. About 1% of patients studied in the study. So yes, patients, can and do return to running following total joint replacement. RISKS OF RETURNING TO RUNNING AFTER JOINT REPLACEMENT But what are the risks? I think we all have heard the narrative that you definitely should not avoid impact and avoid running following total joint replacement. And there are concerns for periprosthetic fracture, so fracture around where the orthodesis is or where the implant is. you know, concern for dislocation for total hip replacements, as well as polyethylene wear and loosening of the implant. Those are the kind of the four main concerns that surgeons have. And I think there, you know, is probably some validity to those concerns. And we do want to be thoughtful in having those discussions with patients if they are looking to return to run following total joint replacement. But another really neat finding out of the Antonelli study is that there was no difference in revision rates between those patients that went on to return to run following total joint arthroplasty and those that did not run at all. So the revision rate is around 5%, which depending on how you look at it, is either pretty small or still a pretty large number if we're thinking of 5% of people are having to go on to get a revision following the first total joint. And unfortunately, as with most surgeries, the second time around, the outcomes just aren't as good. So we definitely do want to avoid revision of a total joint if we can. And one way we can think about doing this is being really smart and methodical in how we're helping these patients return to running. Keep in mind that You know, following most lower extremity surgeries, patients actually see a decrease in bone mineral density, typically for the first year or maybe even up to two years following surgery. And that seems to peak in total joint patients at around three months, and then not actually improve, but the amount of loss peaks at about three months. So right around when we would be thinking about implementing a return to run program with a total joint patient, realize that their bone mineral density is probably at the lowest that it's been recently. And particularly if they are osteopenic patient or osteoporotic. You really want to go slow with them with implementing impact just to avoid periprosthetic fracture. So that also is making sure that you as a practitioner have knowledge of what's going on with the human in front of you, not just that they've had a total joint, but what's the bigger picture? Do they have a history of osteopenia or osteoporosis? And is there anything that they can do to help combat that? SETTING PATIENTS UP FOR SUCCESS TO RETURN TO RUNNING So setting up our patients for success that do want to return to run following total joint replacement. One, we want to have a good idea of what's going on with them as a human and on a global scale and making sure that we're being specific to that. Two, regardless of that, we do want to have a slow progression with return to running and return to running volume. So this is a patient population where we definitely want to start with more of our walk, jog intervals than just going into straight jogging or running, making sure that they are able to tolerate a good walking program first. So being able to walk, you know, certainly 45 minutes or an hour without any issue, implementing impact in a controlled setting. So having them do stomping, um, you know, jump rope, uh, and, and things of that nature and making sure that they are tolerating some impact before we really get, uh, have them get to a lot of repetition, which running is a lot of repetition, um, for that. And part of doing that is really making sure that they are regaining and probably even gaining more strength than they had going into surgery, particularly with, if we're talking about the knee and the hip, quad strength, hamstring strength, and then global hip strength. So really making sure that they are, have had a good program with that and that they are at you know, 80 to 90% of what their contralateral leg is before even thinking about implementing a return to run program. And also making sure that what we're comparing their operative leg to with the contralateral leg isn't just comparing to, you know, crap numbers. So making sure that they do have a certain level of strength and fitness going into a return to run program. A couple things that we like to use as quick screening tools in the endurance athlete division are the ability to do single leg squats and the ability to be able to do at least 20 single leg squats with good form and with maintaining balance, as well as being able to do single leg heel raises and the ability to do at least, in this older population, 10 to 15 single leg heel raises to full height if possible. So we're really being methodical about how we're implementing that return to run program and progression of volume. We're making sure that prior to doing that, we have maximized their strength gains around the hip and the knee. And then we also want to make sure that they have the mobility to have, you know, the best gait mechanics that they can. So really making sure that they are getting, particularly with total hip patients, that they are getting hip extension, that they have good mobility of the rockers of the foot and ankle. So good ankle dorsiflexion, good, great toe extension, et cetera. And if they don't, working on that, either using your manual techniques or giving them some mobility drills to work on with that, And then bringing it all together with when we are implementing that return to run program, really trying to set them up for success by looking at their gait mechanics and then implementing some drills to help decrease impact at the hip and knee. Namely, if they do have decreased rockers, you know, and even with working on it manually and with some mobility drills, they're just not getting that back. getting them in a shoe with a rocker bottom to help with that can be extremely helpful in our older adult population. So something like, you know, Hoka has several shoes with a rocker bottom, as do other brands. And then if they're really limited in their, they're not able to get that hip extension or you're not observing hip extension at toe off, getting them to have a little bit of a forward lean, a forward lean not a forward bend so that they're basically just leaning their center of mass further forward to prevent over striding which over striding really increases impact at the hip and the knee and probably even more importantly it increases the the loading rate at the hip and the knee so those would be kind of two things to to really look for in your total joint patients that are returning to run. So in summary, you know, return to run for total joint replacements, yes, patients do and can, can and do return to run following total joint replacement. Much higher rate with, if they've had a total hip replacement compared to a total knee, but overall, those patients that we're working with that have had a total joint are likely to not be a runner to begin with. Two, we do want to be aware of what the risks are. There is no difference, at least in Tonelli's study, in revision rates between those patients that went on to return to run and those patients that did not return to run following total joint replacement, but those risks still are you know, I think valid with paraprosthetic fracture, risk of… hip dislocation, particularly if they were to fall, polyethylene wear, and implant loosening. So just really having a good understanding, particularly the bone health of the patient in front of you. And then lastly, set your patients up for success. Get them strong, work on their mobility, have all that tie into good gait mechanics, and slowly progress their volume. That's all I got for you today. Uh, thank you for listening. SUMMARY If you are interested in treating endurance athletes, um, or you do treat endurance athletes and are looking for some CEUs, uh, we do have a variety of offer offerings within endurance athlete division. Uh, for coming up first is our second cohort of rehabilitation of the injured runner online, um, starting in early March. Also in March, we have our first offering. of the year of professional bike fit in Texas. And then we have a bike fitting offer, the professional bike fitting course offered also in April in North Carolina, and then in May in Minneapolis. And then our first rehabilitation of the injured runner live is going to be early June in Milwaukee. Come join us for those courses. We have a lot of fun and I think you pick up some really good skills and clinical pearls with treating endurance athletes. Have a great weekend, everyone. Get outside, do something fun with friends and family, and we will catch you later. Bye. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 25, 2024

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses how friction opposes the momentum of starting a business but offers different solutions on how to overcome the initial friction encountered when starting. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MOORE All right, team, what is up? Welcome back to the PT on ICE Daily Show. My name is Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be on the Daily Show, Mike, and always happy to be here on a Leadership Thursday that is a Gut Check Thursday. As always, let's start with the workout. It's gonna be a little bit rough. We got five rounds for time. It's just a simple couplet, but there's no rest to be found. The workout is five rounds for time, you are gonna do 30 calories for the gents, 25 calories for the gals on the rower, and then you're gonna do 15 burpees over that same rower. and you're simply going to, I say simply, but ouch, going to repeat that for five rounds, okay? So thinking a little bit about time domain as always, you got to think about maybe that row is going to take you what? Maybe up on two minutes and then a little bit over a minute for those burpees. So a great target would be 15 minutes. Try to keep it inside of 20. I think that would be a reasonable goal for the workout. It was a qualifier workout. It's gonna hurt. The heart rate's gonna be peaked. There's just nowhere to hide during those five rounds. So enjoy that. Make sure you're tagging Ice Physio. Make sure you hit Gut Check Thursday with that hashtag. It's so fun for us to be able to follow along with you. So enjoy that workout today. "IS IT WORTH IT?"Let's talk about friction in your business. Specifically, Let's talk about friction coefficients and how it relates to your business. So I get to talk to a lot of people who are in the process of starting up their companies, kind of in that early phase, okay? And many of them engage with me when they're in the harder part of that phase, right? Where they're starting to wonder, is this worth it? Like maybe the excitement of starting something new and all the fervor that comes along with that has legitimately turned into the daily grind and some real questions about, is this going to turn over? Is this going to catch some momentum? Is this gonna work? Are really starting to come to the forefront? Is the ROI there? The first thing I want to say is don't shame yourself. If you're in these shoes, don't shame yourself for asking that question. I think that this latest generation of business gurus, this mantra of everything is going to work as long as you keep going is the most ridiculous mantra of all time. That makes absolutely no sense. I can list off an innumerable people who have hit dead ends and pivoted and had drastic levels of success because they were willing to say, this route, the way I went about it, this approach, this area doesn't make as much sense. Now that I've seen around the corner a bit, that does not make sense. I'm going to pivot. I'm going to pull back. I'm going to redirect. And those people have a huge amount of success. So don't feel like It's not logical or you're less than because you're asking the question, is it gonna be worth it? It isn't always. That being said, if you've hit that spot and you've thought, is it worth it? Do I really wanna be in this space? And the answer is a hell yes. You say, I love serving these people. I know it's what I'm called to do. I know I bring some unique value to this area. I know that I've got something to share in this space. I wanna keep going. I want this to work. If that's you, then I want to share with you what I think is both an accurate and helpful analogy from physics that correlates beautifully with the business journey. OVERCOMING FRICTION So, in physics, If we can get you to think way back, right? When an object is stationary and you want to move it, to do so, you have to overcome static friction, right? And this is really hard. You know this because you've encountered it in plenty of places on a daily basis, maybe even in your workout. So if you're in the gym and you're trying to push a box, right, you're trying to do box pushes across the floor. You can all picture how agonizing that is. You know the worst part is getting the box started, right? It's that initial setting into motion. Once the box is sliding across the ground, I'm not saying it's easier, but it's certainly better, right? The same is true for plate pushes. Like when the 45 pound plate is on the ground and you're trying to push it across the floor, it's getting it started that's the absolute worst. Keeping it moving isn't nearly as hard. Mathematically, The reason for that is that the coefficient of static friction is larger than the coefficient of kinetic friction, right? When you're doing equations, the thing you multiply the forces against is larger when you're talking about static friction, things that are not yet in motion. Now, you don't have to, if you're not a math person, you don't need to gravitate towards that part of the conversation. It's best illustrated visually probably that, let's imagine that you had two hand saws, okay? We're talking about like the saw that you would cut a Christmas tree down with, right? Let's say this is one hand saw. These are all the teeth of the hand saw. This is the other hand saw, okay? So you're putting teeth to teeth on these two hand saws, yeah? Like this, okay. If they're sitting stationary, the one on the top, settles into the one at the bottom, right? And they've been sitting there for a while. And now you wanna move the top saw relative to the bottom saw. This is gonna be tough, right? Because you've gotta break all of that and get things moving. However, once the top saw is moving across the bottom saw, as long as there's decent speed here, there's not enough time for the top saw to sink and settle into the bottom saw. Thus, you kind of click across the top significantly easier than it was to break that original static bond. Once something is in motion, it's not settled into the other object. Keeping it in motion is not nearly as hard. Team getting a company going and keeping a company going is the exact same scenario. BUSINESS IS PHYSICSThe business rules follow the physical world. It's why we use all the same terminology all the time, right? How often do we say, oh, it's an uphill battle, right? I've got the wind at my back. We've got momentum, right? Momentum. We're talking physics all the time because the same mechanics happen. They're in different environments, but the same terminology, the same laws apply. Okay, so if what we're saying is, you gotta get some speed going, because that is significantly easier once built up to keep it going, well, what do we mean by the speed of our business? We gotta break that down, because that's where the action item lives for today. So, the speed of your business, getting the saw moving over the other saw, is best looked at as a compilation or an aggregate or a sum of the speed of all the different parts of your business. And this is where it can get actionable. First of all, appreciate that at the beginning, they all start at zero. They are settled into one another. Each part of your business has to break the static friction to get things into motion. For example, idea or concept generation, right? The hardest thing is thinking of that first original concept that's paradigm shifting. It's got static friction. It's hard to create that first great idea. But once you do it, once a unique and valuable concept has been created, building off of it seems effortless, right? Then it's like, once you've done that, you're like, oh, now we should do this, and now this opportunity becomes available. Once you get that first great original idea, Building off of it seems effortless. Team building has significant static friction. Think about it. People want to join a great culture. Well, you need a team to have a culture. So in the beginning, there is no culture, which is why there's so much static friction to team building. But once you get a couple great people on board, they naturally attract a bunch of other great people. Once the saw is moving, it's really easy to keep it moving. You just got to get it moving. It's all about finding those first couple people that will then attract other great people almost effortlessly. ATTRACTING BUSINESS IS OVERCOMING STATIC FRICTION Attracting consumers or customers has significant static friction. Think about when you walk by a restaurant and there's nobody in there. Do you want to be the first people to go in, especially if you're not familiar with the area? Absolutely not. But once there's a few people in there and they seem to be having a good time, other people just naturally come in. Why do you think happy hour is always so discounted, right? People want their restaurants to look full and bustling, so people will come in and actually have dinner. That's what draws them in. Consumers attracting them has significant static friction. When there's none, it's hard to get one. But once you have a few, it's easy to keep the saw blades moving. This is how I want you to think about your business. And your action item is to realize that you can get each of these going, or any of these going, and the beauty of getting them going is you can use them to nudge the other one. This is where you got to get clinical with it, right? So when you've got that box for that box push that you know is going to be tough to get moving, right? The best, the hack would be, could there be another moving box that you could slam into this one just to break that static friction? So then you could then push it from there once it's already in motion. The answer in business is yes. You could choose any of those boxes if you will. Idea generation, team building, attracting consumers. Those are all individual physics scenarios that you could focus on and get one of those in motion and I promise you it'll ram into the next one. If you break the static friction of team building and you get a couple of great people, I promise you, you'll get more great ideas, right? So that one box that's now moving will slam into the other box and you won't have to do quite so much work to break the static friction of the other one. So you can use success or momentum in any of these individual areas to nudge into the other one and make it easier to get it into motion. FINDING THE LOWEST BARRIER TO ENTRY IN BUSINESS TO BUILD MOMENTUM The key then is to figure out which one for your business has the lowest barrier of entry. Which box, if you will, can you get moving the easiest? Is it team building? Is it attracting consumers and getting social proof? What area in your business can you get moving so it can slam into the other boxes and get them moving for you without quite as heavy of a lift? That's what I want you to really think on today. Before I let you go though, there's a couple other thoughts that go along with this topic that I've got to share, especially because I think they give you a lot of hope. And the first one is, you only do this once, in most cases. There's exceptions, things happen. But in most cases, you only get it going, if you will. You only get the box moving or the saw blades rubbing. You only do it once. Once you've got momentum, once you've got speed, once you're only dealing with kinetic friction, you just keep it moving, right? You don't have to start and stop again. So realize that if you're feeling like, my gosh, this is a heavy lift, it gets lighter, because the boxes, once moving, are easier, but they also slam into each other, and overall, the momentum builds and it does get easier. You don't have to keep facing that your entire career. So if that's you and you're in that spot, hold onto that. And number two, to get even more exciting, to think a little bit bigger this morning, soon, it's not that one component of your business bumps into the next one. A couple of years down the road, what begins to happen is your businesses begin to bump into each other, right? If you're playing this game right, if you've got one business that's really humming, Oftentimes, that can help to create an offshoot business that doesn't have nearly as much labor required to break the bonds of static friction because you have so many resources from the first one. So pretty soon, what you realize in the game of business is that every time you create, it's a little bit less effort and a little bit more impact. If you're watching this and resonating, you're probably at the hardest part right now. But if you can think about how to use one box to bang into the other, you can get this thing moving. If you can realize that you only have to do it once, hopefully that can help you have the effort you need to build the speed. If you can really dream and realize that soon one of these lifts can make all the other ones happen almost for free, you can realize this game becomes, you never want to say effortless, but you do want to say a return on investment that you probably never imagined. when you were first starting off and maybe sitting right now in a bit of a tough trough looking at a big mountain, right? The top is brighter than you could ever imagine. So think a little bit about how the physics of friction in your business work together and think about the upside of that, not just how hard it is to get that damn box started to begin with. I hope that gives you a little bit of hope this morning on Leadership Thursday. Team, There are so many courses going on. I'm in Reno, Nevada right now. I'm doing all the logistics for Ice Sampler. Ice Sampler is sold out for this year. It's been sold out for a long time. Those of you coming to the event, this is going to be an absolute banger. Carson City is so beautiful. The gym is so beautiful. Carson City CrossFit. So if you're coming to Sampler, get excited for that. Other than that, we have some online courses that are almost sold out. Essential Foundations Level 1 only has a handful of seats left. We are more than half sold out for Pelvic Level 1, which starts in March. Point is, a lot of these online courses, especially, are selling out like crazy. So get on ptinex.com, jump in, grab what you need, get it done, break that static friction. Cheers, team. Have an awesome day. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 24, 2024

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses workout ideas for acute care patients, including those who are confined to bed, able to move at the edge-of-bed, and those who can transfer & ambulate with assistance. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JULIE BRAUER Good morning crew. Welcome to the PT on ICE daily show. My name is Julie. I am a member of the older adult division. Excited to be talking to you all this morning about a few workout ideas for your hospitalized patients. All right. So what we're going to dive into this morning is first, we're going to talk about why it is so incredibly important to bring a fitness forward approach to our medically complex sick older adults in the hospital. and then we're gonna dive right into how to do it. So I am going to give you three different workouts. They're simple. They only consist of three exercises and they're going to be for three different individuals. FITNESS FORWARD ACUTE CARESo the individual who is the bed level patient, so they are not ambulating, they are not transferring. Then I'm going to give you a workout for the individual who can sit edge of bed, so who can tolerate those positional changes, but again it's not someone who is transferring or ambulating. And then lastly for the individual who is able to transfer out of bed. Okay, Let's dive in. First and foremost, team, what I think we can all agree on is that patients are being sent home sicker and sicker and sicker. Insurance is denying acute rehab left and right. And once patients do make it to acute rehab, if they're lucky enough to get there, they're only getting enough days to just barely make them functional. We have to agree that these patients need to get as strong as possible and they need to do it as quickly as possible. If we can agree on that, then we have to realize the massive opportunity we have in the acute care setting to bring a fitness-forward approach. Now, I know what a lot of you are thinking. Fitness in the hospital What the heck? No way. It doesn't belong there. I don't have the equipment. They're too sick. That's for down the road. I want you to come along with me and get a little curious. I want you to be open minded and perhaps shift that perspective. Think about it this way. You are a fitness forward clinician. You are working in the hospital setting. You have hundreds and hundreds of patients handed to you on a silver platter. All these patients are in one place, door after door after door, literally right in front of your eyes. And they are just waiting for you to walk in, inspire the hell out of them, and guide them to the land of wellness and fitness. You do not have to hope that these patients who need you walk into your clinic doors. You do not have to hope that your Facebook marketing or your Instagram post is seen by your target avatar. They're all there waiting for you. You literally have a captive audience. Literally, these patients are in their hospital rooms. They are in their hospital beds. They have alarms on. They are tied to lines and tubes, et cetera. They're all there at your disposal. Team, the patients who need you the most, the ones who are medically complex and sick, They are waiting for you. They are handed to you on a silver platter in the hospital. Do not waste this opportunity. We have to realize that ankle pumps and glute sets, walking to the door and back, doing 10,000 tenettis a day, are not going to get the job done. Those are not going to increase our patient's reserve and resiliency, so they don't end up back on your caseload in a week. Fitness forward therapy is absolutely critical for these sick folks. Okay, so we've gotten curious. We're starting to shift our perspective. The most important thing that comes next is, well, how the heck do we do it? So let's dive into three different types of workouts we could do. WORKOUTS FOR BED-LEVEL PATIENTS Workout number one, this is going to be for your bed-level patient. So this is an individual who is in the ICU, perhaps, or they are in inpatient rehab. They cannot tolerate positional changes. Maybe their vitals go totally wild when they try to sit up. The alarms are going off, the nurses are running in. Vitals go wild, you gotta lay them back down. Perhaps they're incredibly orthostatic when they do sit up. Their blood pressure absolutely tanks, and you have to lay them back down. or they may have significant fear or pain. They just refuse to get out of bed. Hell, this could be the patient who, you know, your last session should hits the fan. You went way over time and now you have barely any time with this human. You do not have the time that it's going to take to get this person up and out of bed. Okay, so think about a couple of those scenarios that you may walk in to your patient today and this perfectly fits that description. This workout is for them. Okay, so what are we going to do? This individual supine is pretty much all they got. The bed is all they got. What we're gonna do is turn that bed into a workout machine. The hospital bed turns into a home gym. What do you need? You need a Sally tube slide. So what is that? You've seen them if you've been in the hospital. They're yellow, they're plastic. Individuals and the staff will use them to transfer patients because it decreases friction. You need that and you're gonna need a wedge or a slide board. and a gait belt. So three pieces of equipment, sally tube slide, a wedge or a slide board, or and a slide board, and a gait belt. Okay, so what are the three movements that we're going to do? We are going to do a modified pull-up, we are going to do a modified leg press, and we are going to do a modified rope climb using the gatebell. Okay, so how do we set this up? You get that sally tube slide underneath them. For our modified pull-up, you're going to tilt the bed. They are going to reach to the bed rail that's above their head and they are going to pull themselves up. That sally tube slide is going to allow them to slide and we're going to add some gravity onto them so we get them to a degree of a vertical pull. For our leg press, you're going to set that on the slide board, sometimes the wedge on top of the slide board at the bottom of the bed. We're going to tilt that bed again. They are going to kick and press to do a leg press, and then they'll slide back down, and then they push again, slide back down, etc. For our rope climb, you're gonna use that gait belt. You're gonna tie it to the foot bed rail. You're gonna tie that gait belt on there, and then they are going to grab onto it. They are going to pull themselves as much as they can to get to an upright, long sitting position, and then slowly let themselves down. Okay, so that's how those three exercises with the equipment are gonna be set up. Now, how do we dose this? Remember, this is an individual who has very low tolerance. We are just trying to get that blood flowing. We are trying to do very short bouts of activity and they're going to need a lot of rest. So how I would set this up is an EMOM, maybe an EMOM for six or nine minutes. Minute one, we're going to do that pull-up. I'm going to have them work for 20 seconds, and then I'm going to give them a full 40 seconds of rest. What am I doing during that time? Taking their vitals, right? Watching to see that they are responding okay to the exercise. I'm going to want to know what their blood pressure is, their heart rate, their oxygen saturation. Minute two, they're going to do that leg press, 20 seconds, and then they get 40 seconds of rest. And then lastly, they're going to do that rope climb for 20 seconds, 40 seconds of rest. What is beautiful about a workout like this is that many times what you will find after you're able to increase the intensity with them in the bed where their vitals are staying at a reasonable level, they're not going wild, then you sit this individual up and you will find all of a sudden their blood pressure actually stabilizes here. And now they're someone that you can safely get out of bed. Okay, there's your bed level workout for that individual. WORKOUTS FOR EDGE-OF-BED Next, now you have someone who can tolerate a little bit more. We're going to do a combination of a bed level exercise and sitting edge of bed. So they can tolerate positional changes. This is for that patient who can transfer out of bed, but it totally exhausts them. One rep and they're absolutely toast. This is for the patient who you know would thrive at acute rehab, but you really need to build their tolerance. You need to be able to say to those acute rehab liaisons, hey, this patient can tolerate multiple sessions of therapy per day. So we're going after endurance here. All right, so what do we need for this one? We need a heavy TheraBand or a resistance band. And that's it. One piece of equipment. So what we're going to do is we are going to do a AMRAP here. A 15-minute AMRAP. As many rounds as possible. Three exercises. Why are we doing that? Because we want to show, hey this individual tolerated 15 minutes of non-stop work. What are our three exercises? First, we are going to do a resisted bridge. How do you set up a resisted bridge in a hospital bed? You take your TheraBand and you anchor it one side of the bed rail to the other side of the bed rail. Now, when they go to bridge up, they have some resistance there. You can do it double leg, you can do it single leg. Exercise number two, we are going to do repeated supine to sideline to sit transitions, all right? And then exercise number three, while they're sitting on the edge of the bed, they're gonna scoot laterally to the foot of the bed and then to the head of the bed, okay? So those are your three exercises. How are we gonna dose this? Again, the goal is endurance. So we want them to be doing only enough repetitions to where that RPE at the end is only like a four to five. We don't want them to be seven, eight, nine. Remember this is endurance we want them to be able to sustain for 15 minutes total because that is going to be the buzzword that helps get them to acute rehab. So for that entire 15 minutes you're going to do as many rounds of those three exercises and you're going to try and keep the rep scheme to as many that keeps that RPE about four to five. That you're going to go ahead and document about why this person is perfect for acute rehab because they can tolerate 15 minutes and then you are going to progress them from there, try and get to 18 minutes the next time you see them and then get to 22, etc. Okay, that's your second patient. WORKOUTS FOR AMBULATORY PATIENTS The third patient, this is an individual who can transfer out of bed all right so they only need a little bit of help they can transfer out of bed but when they get really fatigued their can their performance is really inconsistent so this may be where the physicians or the case managers are like hey they can transfer out of bed like they're high level, they can go home. But you know that when they get fatigued, their knee buckles, or they really lose that eccentric control, their balance starts to go out the window. You know they need acute rehab in order to improve their tolerance so that they are able to do safe transfers throughout the day. Mimicking when someone throughout their day is going to have high and low levels of fatigue, you want to know that that consistent performance is safe. So, what are we gonna do here? In this workout, what we're gonna do, three exercises, we're gonna do an overhead press, a standing march, and then a stand-step transfer, okay? So that overhead press, what do we need? You are gonna get that toiletry bucket that every patient is given, you're gonna dump all the crap out of it, you're gonna take a towel, you're gonna roll it up, you're gonna soak it in water. That makes that toiletry bucket now have some load. This is what we're going to use for the overhead press. It's going to be done sitting on the edge of the bed. Next is going to be the standing march. This can be a standing march that doesn't have any load to it. You can have your arms on the walker for upper extremity support or you can use something like a bedside commode bucket. clean that you put a bunch of weights in like ankle weights load it up and they can do a one-handed uh carry or a hold while they march okay and then with the stand step transfer you just need their assistive device and a chair set up next to the bed all right so in This type of workout, what we are wanting to do is we are wanting to really increase the intensity of those first two exercises, the overhead press and the standing march, and then have them do the transfer because we want to show Hey, this is what it looks like when this person is under fatigue and then tries to do a transfer. You want to prove to those acute rehab liaisons, balance gets really poor. I have to jump in and I have to give them some support in order for them to not lose their balance when they do that transfer. So you're showing the deficit here. So in those first two exercises, you want intensity to be really high. So comparatively to our first imam, it's going to be the same exact thing, but work and rest is going to be reversed. So you are going to have them work for 40 seconds, and then you can give them only 20 seconds of rest. and that 40 seconds, you want it to be sprint effort, okay? You want them to be working at RPE 789. You want them to really, really push it. So similarly, you can do this for 6, 9 minutes, 12 minutes, 15 minutes, and the goal here is that when they get to that stand-step transfer, they're under fatigue, you are going to see what happens. Then you can document and show acute rehab, hey, This is all the assist that they need. This is how their technique breaks down when they are under fatigue. That is going to be the buzzword that you're going to be able to use to advocate for them to get to acute rehab. You're going to also use that and progress them to just try and build that endurance. So let's say acute rehab is still like, screw you, we're not letting you in. Now you have a baseline workout. You continue to hammer in on improving their endurance so that when they get to that transfer, they have stability. SUMMARY All right, three workouts for you. That bed-level patient who cannot get out of bed, supine's all you got. You turn the bed into a workout machine. You got your second workout for that individual who can tolerate transfers, transitionals, and can get to that edge of bed. And then the third, you got a workout for someone who is able to get up and transfer out of bed. I have multiple reels that I've made about each of these individually. I'm going to put them together and post it. You will have that soon so you can get a visual of what all this looks like with my actual patients. And I cannot wait to hear how you guys use some of this stuff out there in the clinic this week. All right, to finish this off, we've got courses coming up. We want to see you guys out on the road. We would absolutely love to see you. We got tons of spots left in Missouri. That is this weekend. Alex will be out there. That course is going to be absolutely amazing. We got multiple courses coming up in February. I will be in Minnesota. It's going to be a freaking blizzard. I cannot wait. And then our online courses are going to be starting up in March. So we'd love to see you online or on the road. All right, y'all, that's all I got for you. Get out there, bring that fitness forward approach to your hospitalized patients. I cannot wait to hear about it. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 24, 2024

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses a modern approach to carpal tunnel syndrome (CTS), including when central findings are present. Lindsey discusses examination and treatment, including the use of the rehabilitation every-minute-on-the-minute style (rEMOM) exercise dose. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. LINDSEY HUGHEYGood morning, PT on ICE Daily Show. How are you? Welcome to Clinical Tuesday, my favorite day of the week. I am Dr. Lindsay Hughey from our extremity management team, and I am here to chat with you today about an ortho-cert approach to carpal tunnel syndrome. And what do we do when it's not just the carpal tunnel, when we also see some central symptoms? So I am going to unpack what a fitness-forward approach looks like, how we will use our manual therapy to modulate symptoms, and then what psychologically informed looks like for this condition when we think about combining all the courses from our OrthoCert and putting that all together in an integrative way, how we can approach this condition. and then I'll leave you with a couple rehab e-moms at the end, so stay for that. CARPAL TUNNEL SYNDROME OVERVIEW So first off, let's briefly review what the subjective and objective presentation with someone with carpal tunnel syndrome and then possible central considerations that are present as well. Think double crush is kind of a common medical term present. So for that CTS, that carpal tunnel syndrome, we'll see classic sensory anesthesias or paresthesias in those first three fingers and then possibly that radial half of the ring finger. There may be motor deficits in our first and second lumbricals, opponent's pollicis, abductor pollicis brevis. So think about in your objective exam, thub abduction and thumb flexion may be weak. We'll also see, from an objective perspective, locally we'll see a positive phalanx and tonels, and then our carpal compression test. Patients will complain of interruption in gripping and daily tasks. They may even drop objects or have to shake out their hand to ameliorate symptoms. Often symptoms are worse at night, and then when they first wake up in the morning, and then tend to improve as the day goes on. When we also consider there might be some central things going on, it's that person that not only complains of what I just told you and had objective exam findings, but they also say they have some numbness tingling along that C5, C6 dermatome. They may complain of some local neck tightness or achiness in that mid to lower cervical spine area. on exam, you will find a UPA or central PA will elicit those familiar symptoms when you're around C5, C6. In addition, that dermatome distribution will be impaired and then reflex changes in that biceps reflex might be abnormal compared to that uninvolved side and we really understand the whole clinical picture when we use a body chart right and we really listen to that subjective and dial in their ags and eases so you find out when all of that's on board that there's two things going on at the same time and here's where we'll need our ortho hats where we need to put into practice what we know in our cervical class and what we know from our extremity class. APPLYING FITNESS FORWARD So first off what is fitness forward? when that's one of our primary pillars. So what does that mean for this condition and in general? Well, we are going to approach the whole human in front of us. We know that this typically affects females later in that fourth and fifth decade. they are two times females are two times more likely than males to have this condition and so appreciate that in that decade that's either you know a career focused time or family focused or a mix of the two so consider the stressors for that human that may or may not be involved in that decade. And then we see some links to obesity as well. So thinking about the whole human holistically, we see worsening symptoms for those that have higher BMIs. So not only will we consider the whole human from a fitness forward perspective, but we're going to think about how can we attack local tissue getting irritability down. So think about local tissue in the hand and even in that C5, C6 area of cervical spine. And then we'll start with local treatment but then eventually we're already thinking about how globally will we make this human more resilient and robust in their grip strength and their overall upper quarter strength. So even day one when we're trying to just calm symptoms we're thinking fitness forward. How fit will you let me get you? We're gonna consider those system influence that I already mentioned, sex and possible stressors in life. We're gonna consider mindset, the physical activity levels of that human, because again, I said there's links to increased BMI and obesity. So we're dealing with an underlying systemic inflammation probably on board as well. We'll think about what's that sleep hygiene like? Are they getting the eight to nine hours of sleep? How's their diet and hydration? Are they getting half their body weight in ounces? Are they eating colorfully? That is all a part of fitness for it. So it's not just loading them up locally, globally, making tissues robust, but really we want a whole system-wide robustness. MANUAL THERAPY FOR CARPAL TUNNEL SYNDROME And the way we'll first approach these humans is through symptom modulation, through our manual therapy techniques. This is how we'll really get trust and buy-in when we're dealing with carpal tunnel syndrome, or CTS, and then there's central possible involvement as well. double crush, whatever kind of terminology makes you comfortable. I tend to think labels limit. And if you've been to our extremity course, you know that. So symptom modulation locally first looks like bracing, actually. So an over-the-counter splint at night is first-line defense because that's when symptomatology is worse because we're sleeping in that phalanx position. And if there's worsening symptoms in the day, we'll even recommend a wearing schedule during the day. But we first start with night. We'll educate on any ags and easing postures, right? If moving in and out of postures is really important. We don't want someone hunched over like this all the time, and we also don't want someone being perfectly erect. So depending on their job and life and family functions, we'll give some advice there as well, as our education starts to dampen irritability and symptomatology. Our manual therapy perspective though, so here's our second pillar coming to play. is that we are going to target the CT junction and then an upper T spine. And we're going to use manipulation. You'll hear at our course that if you have any upper quarter symptoms and you have a pulse, you are going to get some kind of thoracic manipulation. for that neurophysiologic effect. So what you learn in your cervical and total spine thrust courses, you're going to bring forward here. And this is going to help dampen pain, not only centrally right in the cervical spine, but also we see pain dampening and increase motor output in our upper quarter when we use those techniques. So those will be our go-to techniques, prone CT junction, and then our upper T-spine manip. In addition, doing some lateral gliding for a pumping action in those higher irritability stages targeted at that C5, C6 area. Follow up for that will be some cervical retractions to get a pumping action centrally. And we may or may not combine that with some traction. a manual therapy perspective from extremity management local to those carpal bones and that wrist, we'll actually start doing some wrist mobilization. Extension's often a common impairment here, so we'll work into progressive extension, mobilizing those carpals, and we'll even do this nice soft tissue splay technique. If you've been to the course, you know, and if you're on the fence, you'll join us to learn this, but a splay technique to just open up right where that median nerve travels through where all of our flexor retinaculum is, it gets tight in there when there's inflammation on board. So just doing some soft tissue mobilization and splay. And it's interesting is this is a tech, the technique we teach is one that was actually used in that PTJ study in 2020 from De La Penas and crew, where they looked at four-year follow-up of those with carpal tunnel syndrome that did conservative care, which was only three bouts of PT, and this splay stretch was included in the 30 minutes of manual therapy that these folks got, and they compared this group to those that went on to get surgery, and they followed them over four years. What was similar about both groups is both groups got education and they got tendon and nerve glides. And what we saw is similar similarities. So meaning pain and function was the same whether you got surgery or conservative care, which lets us know that our conservative care, our manual therapy techniques like this splay technique can be a really powerful resource for our patients to modulate symptoms and to lower that irritability in their tissues. In addition, not only will we do some wrist extension mobs, do that splay stretch, but we'll also work locally at that thenar eminence. And we will target our wrist flexors with myofascial decompression, soft tissue massage, and or dry needling. So targeting wrist flexors, forearm pronators, and the thenar eminence anywhere where that median nerve could be compressed. So those are our manual therapy targets. PSYCHOLOGICAL CONSIDERATIONS FOR CARPAL TUNNEL SYNDROME Moving on to our next pillar, psychologically informed, how do we address psychological considerations for this human that has CTS and then symptoms along that C5, C6 dermatome with reflex changes as well? Well, we're going to have a conversation about lifestyle, about what we call meds health. Simply that is M is mindfulness, E is exercise, D is diet, and sleep. And this is a nice framework to address lifestyle behaviors. Now we might not address them all at once and we'll choose our education and dose it wisely, right? We don't want to fire hydrant lifestyle behavior modification to patients, but we do want to make sure all the pillars and how they're functioning are in the background of our mind. So consider M mindset. or mindfulness what we're thinking here is what can we give this human that's kind of stressed and in pain to just calm their system and one really great way to bring them into a more parasympathetic state is doing breathing so breathing in just five minutes a day physiologic sighing right, where you do that two inhalations through your nose and exhale has been found to be beneficial in reducing physiologic factors like heart rate and just calming our system. So consider that can be an easy thing to integrate into a patient's life that is stressed or maybe suggesting some green space, go out for a walk and or journaling if that is their thing. from an e-perspective, exercise, what I want you thinking about is just what's their physical activity like? Are they getting their 10,000 steps daily? Are they meeting the daily requirements of physical activity, which is 30 to 60 minutes every day, right? We want a total of 150 to 300 minutes a week. Is this human getting that activity? And if we consider some of the common profiles, which is obesity and being female in that later decades of life, we need to consider what is that like and how can we influence them to move more to help with this inflammatory state that's going throughout their body. D is diet, so education on what is your diet like? Are you eating enough protein to support healing and function? Can you reduce that sugar intake to calm inflammation? Can you eat colorfully, eating more plants, again, to help control inflammation? How's your hydration? Are you getting half your body weight in ounces? These are additive behaviors that we can help, always trying to add first and then take away if necessary. And then finally that final pillar, sleep. How is sleep hygiene? Talk to this human about maybe very dark in the room an hour before bed, no heavy big meals or your phone or TV. This can help just with quality of sleep. So consider that psychologically informed piece is so important. And you'll kind of notice that there's always a synergy between our pillars, right? You can't be fitness forward, right? And build up local tissue and global tissue robustness if you don't first symptom modulate through manual therapy, right? And our manual therapy needs to be excellent and executed well with the right dosage so that we can be effective in symptom modulation, which gives us this modulating window of opportunity to then load them better locally and then globally when we think about the upper quarter. And then the psychologically informed piece, we need solid education and lifestyle counsel to help this whole human, this whole system be more robust in their world. And that's why the trifecta and the synergy of the pillars is so important. USING THE rEMOM FOR CARPAL TUNNEL SYNDROME I want to leave you with two rehab EMOMs inspired by exercises that we learn in our cervical course and then exercise that we prescribe in our extremity course. So, and if you want to write it down, feel free, but early in our care with high irritability, I would suggest a 12 minute rehab EMOM that looks like this. We're thinking about someone that has lots of numbness, tingling, lots of inflammation on board. All ADLs and IADLs are limited. their sleep sucks, right? They need a massive blood pump. Minute one, we're going to do a UBE, a salt bike, or echo, or rower, whatever the patient loves. Minute two, we're going to do tending glides because we see tending glides in some of our RCTs being superior than our nerve glides and helping create a local pump to our flexor tissues. Number three, minute three, is nerve glides, right? We're going to do a slider glider for that median nerve and even try to get that cervical spine involved. And then number four, we're going to do cervical retraction with or without traction. So we put that band on a secure surface and there's this traction environment where we're offloading the lower to mid cervical and then doing some pumping action cervical retraction. We'll do that three rounds and that's why it's a 12 minute rehab EMOM, early in care, high inflammation on board. I'm going to leave you one more EMOM, and then we'll call it a day for PTL Nice. But later in care, when irritability is dampened, right, and we more are at that lower irritability stage, there's no longer numbness and tingling symptoms. We're thinking about robustness of local and global tissue, and we're working on resilience, we want to layer in more volume and intensity. So we'll use that same structure, 12 minutes. Minute one, we're going to do grip training. So we are going to specifically target doing a spherical grip. So you would turn that kettlebell upside down and work on carries, which works on the whole upper quarter, arm at side or arm here. So we get that cuff firing up as well. And we'll work on that. You can even work on your tip grip or palmar grip as well to really target median nerve and the muscles that feeds. That's minute one. Minute two, we're going to do some wrist flexion and wrist extension exercise. Recommend rehab dose if you've been to one of our courses, you know, that's 8 to 20 reps 3 to 4 sets Anywhere from 30 to 80 percent intensity, right? You'll meet the patient where they're at minute two again just a repeat wrist flexion extension exercise and then minute three will be pronation supination and then finally minute four we'll actually do prone cervical retraction off the table to start building up robustness of the cervical extensors. These are just two examples of how when you take our ortho cert courses specifically our spine courses and then our extremity courses it's helpful to prepare you for management for something like cts when there's also that double crush right there's involvement um centrally and distally. SUMMARY Our author's cert, we would love you to be a part of it and learn more about it. If you're interested or the first time you're hearing this, check us out on ptlonice.com and it'll tell you all the courses required, total spine thrust, cervical, lumbar, extremity management, and testing for this is free. You just take those courses and you test out at the end. It's been a blast kind of talking to you about how we integrate our classes. From an extremity management perspective, class is coming up. Mark and I are both on the road this weekend, and there's still, there's one spot left in Mark's course in Fayetteville, North Carolina. There's lots of spots left in Burlington, New Jersey, if you want to join us. And then the following weekend, we're at it again. We will be in Highland, Michigan, and then Scottsdale, Arizona, and we have spots. So again, ptonice.com to check out OrthoCert, and then check out extremity management courses. Thank you for your time this morning and in listening to that OrthoCert approach to CTS. Happy Tuesday, everyone. And if you think about it, wish our CEO a happy, happy birthday. He'll love that. See y'all later. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 22, 2024

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses a case study where external pelvic floor treatment was beneficial for a patient presenting with complaints of low back pain. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JESSICA GINGERICH Good morning. Welcome back to the PT on Ice daily show. My name is Dr. Jessica Gingerich and I'm on faculty here in the pelvic division here at ICE. So I'm going to talk to you today about when back pain isn't coming from the back. So what I mean by that is that we have done our lumbar screen. The active range of motion, combined motions, overpressures, segmental exam, neural exam, and the neuro exam, if symptoms are passing the gluteal fold, are negative. I'm talking about when the hip screen, passive range of motions with overpressures, combined motions, palpation, and strength testing is also negative. So nothing is revealing the symptoms consistent with a subjective exam. In the pelvic space, it may be common for the general population to not correlate symptoms of pelvic floor dysfunction with pelvic pain or back pain or hip pain. Therefore, they may not disclose one of the symptoms, likely whichever is not bother or is least bothering, right? So if they have back pain, but they also have pelvic floor dysfunction, they may not disclose the pelvic floor dysfunction because the back pain is more important to them and they're not connecting the two. So for the internally trained PT, we're gonna assess the pelvic floor as well. We do this by looking at different tasks that the pelvic floor is doing. So we tell them to contract, we tell them to relax, we ask them to bear down. We do this with an external visual assessment. So there we're looking at their total range of motion. And we also palpate internally to see if we can Provoke any pain per the patient's consent. Screens for the non-internal pelvic floor PT will include subjective asterisk signs. So toileting behaviors. Are they bearing down when they have a bowel movement? Are they bearing down when they're voiding? Are they peeing just in case? Do they feel like they pee all the time or is the urge really sudden? Do they have pain with insertion, whether that is a penis, a tampon, bedroom toys, a speculum, all of these are important. What are their stress levels like at home, at work? Heaviness in the vagina, leakage, and also pelvic pain. So pelvic pain being pubic symphysis pain, tailbone pain, SI joint pain. Of course, we are gonna be grabbing ags and eases around back pain. But now you may be adding pelvic floor agonizes. So everything we just talked about above. And remember that the general population may not correlate their pain with pelvic floor symptoms, unless their pelvic floor symptoms may be pain, then they may connect them. But it's our job to connect the two. So from here, we need to dial in our hypothesis. Is it weakness of the pelvic floor? Is it a proprioception awareness? Where are they in space? Is it a behavioral issue like toileting? Can we change how they're going to the bathroom to make this something that is normal? We need to potentially teach them about the squatty potty, the NAC, general strength training, and even nutritional guidance around pelvic floor dysfunction. So I have a patient right now that I wanna talk about. And so she's this wonderful human. She stands all day for work and she came in with complaints of painful intercourse. From here, I asked her about if she had any pain and she disclosed that she also has back pain. And so she came in wanting pelvic floor PT. That was her main complaint. She did not correlate necessarily that her back pain and her pelvic pain or dyspareunia was the same or was correlated. So when I was asking her about her symptoms, it turns out that her back pain and then the time she noticed that intercourse was painful, it came on around the same time. So we decided between the two of us that we were going to stick with an external exam. We weren't going to do an internal exam for comfort reasons. So when we dialed that in we found that the octorator internus was painful upon external palpation. She denied any bearing down with bowel movements or urinating, which I will encourage you guys to, if you ask someone if they're bearing down with toileting behaviors, go back and ask them on their follow-up visit if they do that. Because chances are, they've been going to the bathroom the same way their whole life, that they're not necessarily paying attention to it. And you may notice that they actually do bear down, even though they thought they didn't. So for her, what we did was we started with the pelvic floor. We treated the pelvic floor first. For her, we started with the squatty potty, teaching her how to have a bowel movement where she can sit down and relax. We started by giving her exercises where she was actually thinking about where her pelvic floor was in space. Was she lifted really tight or was she able to relax? And it turns out that she was not able to. She did not know where her pelvic floor was in space. So that was her homework. She came back two weeks later and told me she knew where she was in space, that she actually felt her pelvic floor drop the more she practiced it. Now, before that two-week follow-up, she had emailed me 24 hours later and said that her following day at work, she had zero back pain. no back pain. This was something where she was carrying around a stool so she could sit down when she needed to. So from place to place she was dragging a stool around and she didn't have to do that. That's pretty powerful. So in my exam I didn't provoke her back pain. I didn't know that her back pain was potentially coming from her pelvic floor. I had my suspicions. So I treated what was important to her in that moment, thinking that maybe her back pain would respond, and it did. So from here on out, we are still treating the dyspareumia. However, we are also now loading the spine. And that has been really powerful. So we're about a month in, and she has had pain-free intercourse. and she's having pain-free days at work when she is standing. So, I'm gonna encourage you guys to go out there, try to correlate the two, whether you're an internal pelvic floor PT or a non-internal pelvic floor PT, or you don't consider yourself a pelvic floor PT at all, you are. So start asking the questions about leakage, pressure, heaviness in the vagina, any pain with insertion, and just following that up with the, hey, this may be related to your back, and I just wanna make sure I don't miss anything. If you are uncomfortable, speaking of this, please, please let me know. SUMMARY So I'm gonna end today with where we will be, the pelvic division. We will be live in Hendersonville, January 22nd, or excuse me, 27th, and our level two course will kick off April 30th. Here you will learn about advanced pelvic floor dysfunction, pelvic floor syndromes, managing pelvic issues post-op, sexual health, birth control and fertility, and birth prep for the athletic population. So we look forward to seeing you. Hopefully you guys sign up and we'll see you around. Have a great Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 19, 2024

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the role of the lat and its importance in functional fitness as well as his top three exercises to strengthen the lats. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. GUILLERMO CONTRERAS Good morning, PT on Ice, Daily Show. Welcome to the Best Day of the Week Fitness Athlete Friday. I am Guillermo Contreras on the teaching team within the fitness athlete division of the Institute of Clinical Excellence. My basement gym here. Today's topic at hand is lighting up the lats. One topic that we see most often discussed or looked at within the fitness athlete division, whether it be in the live course or the online course, is the idea of lat weakness. And also, right, we talk about very heavily how to cue engagement of the lats, right? We never wanna say engage the lats, but squeeze oranges between your armpits, pretend I'm not gonna tickle you, don't let me tickle you. And in essence, we want to be able to teach individuals how to better utilize, use, and strengthen their latissimus muscles. The best way we can do that is not only using the pull-up, which we teach in the live and online courses, but also giving some accessory movements. And the accessory movements are where most people tend to have the greatest amount of questions. What movements do we do? What can we actually use to strengthen it besides a standard lat pull-down machine or a seated row machine? Especially when in the fitness athlete realm, we don't have those pulley systems. We don't have a giant cable pulley machine. We don't have a big lat pulldown, seated lat pulldown, or a seated row machine. So being able to give really good accessory movements that individuals can utilize in the gym to improve that lat strength, that awareness of what their lats are doing, is really pivotal. in helping improve the quality of movement, the strength of movement, and the ability for our fitness athletes to complete what they want to be doing in and out of the CrossFit box. STRAIGHT ARM LAT PULLDOWNS So, quick anatomy review for you all, right? We know the lat originates right here on the front side of the shoulder, wraps down around into the low back, and then attaches itself through to the lumbar spine via the thoracolumbar fascia, which is why the pelvis can play a part in the position of the length of the latissimus as well. So with that, I'm gonna give three of my favorite or three of the best movements or exercises that I give, that I prescribe out for a home exercise program or within the clinic to help improve individual's lat strength and lat activation. Number one is a direct strengthener of the lat. It's just gonna target it, it's gonna help people feel it really, really well, and that is right here. It's a straight arm lat pulldown. And I'm gonna show two variations that this one can be performed, depending on, I would say like the level or the strength of the individual you're working with. We start simply by anchoring that band onto a pull-up bar or anything just above head height. We then take that band, we can hold it in both hands here, back away there so there's some tension. We get a nice forward lean, keeping that nice neutral spine. And then I simply keep my elbow straight and pull that band down to my hips. By keeping the arms straight, we ensure we are hitting that lat muscle by performing that shoulder flexion all the way to end range. And in this upward position, we are hitting that end range position of the lat overhead when it's fully lengthened like we would see at the bottom of a pull-up. A way that I progress this for individuals is by adding hip movement or combining that shoulder flexion with hip extension. Because as we extend the hips, we change the length of latissimus by letting the thoracolumbar fascia can relax a little bit more, contract a little bit more, and we get up to the top. This movement is called a lat prayer. Again, I don't know who named it, who comes up with the names of it. It's simply what I know it as, a lat prayer. And what that looks like is a very similar setup. I am here in this forward flexed position, hips back, arms at that end range. As I pull down on that band, I am bringing my hips up towards that band and come into a full contracted position of the lats. as I descend back down, I'm going to that fully lengthened position once again. So it's just a combination of movements. We can do this both as a smooth kind of movement, all occurring at once, or we can segment it as a pull to the hips with that straight arm pull down, and then a stand, return to the hinge, and then come back up. So that is your straight arm lat pull down. dosing that with some good amount of volume right this is just a a rogue blue band i think it's like a half inch or a quarter inch band, but it's got a nice amount of tension on it. I can do anywhere between like 15 to 20 reps, really feel that nice active muscular pump as I'm doing it, and it creates a lot of awareness in that shoulder. The lat is huge when we think of pull-ups. When we're doing kipping pull-ups, chest-to-bar pull-ups, butterfly pull-ups, whatever it is, we wanna have proficient strength in the lats to be able to maintain a stable shoulder and protect us from injury when we're dropping down to the bottom. So number one, again, straight arm pull down or lat prayer. However you want to do that, you can dose it out in different ways. BANDED KETTLEBELL ROW Number two is a unique one in which we use a kettlebell and then a band anchored to the rack or a rig. Here, we take that band and we put it around the handle of the kettlebell. It can also be around our wrist or something like that, or you can actually like attach it onto the kettlebell itself. Easiest way for me to set this up for my athletes is just to have it right around the handle there. And then we set up in the same way we would do a bent over row or a single arm row. So it can either be supported on a bench or a box. It can be in this kind of double leg hinge position here, or we can be in just our standard staggered stance position here. From here, forearm goes on the knee, take a hold of that kettlebell, pick it up. We then row back towards our hip. So I'm here and I'm pulling back to my hip and then letting it pull me forward. So the motion is more of a J. So I like to think of it that way. It's a J back up to the hip and then bringing it back down. So more of a curved motion of that row versus the standard kind of straight vertical row. or I guess you could say horizontal row. What this does is because it is now anchored, as I do that row, it's not a simple horizontal row where I'm just doing a little bit of an upright motion there. I am now getting a bit of a vertical pull force as well, where I have to actually pull against that band, up to my hip, and then back down. Up to my hip, and then back down. This is a really nice one because you can load it different ways. You can load it with a heavier kettlebell going 35, 45, 53, whatever weight you want to use for that weight. Or you can make it much tougher by going with a much heavier band. This is like the Rogue quarter inch band. This is I think like 15 pounds, 20 pounds of force, stress. But you can go much heavier attention on that band, make it much tougher. There, maybe you probably are bracing on something so you don't get pulled over. But this one, if you've never done it before, if you've never prescribed this for your athletes before, this works wonders. It hits that so much better than anything else you've seen. And it feels great. I think it feels really good. It's a very strong movement there. So that is a banded kettlebell row. Again, think of a curved pull towards the hip rather than a straight vertical row. And you're going to get much more of that lat activation as you come back. BANDED LAT SWEEPS The final movement, because we know that the lat is responsible for much more than just doing vertical pulling, It's also responsible for maintaining tension on the bar when we're doing deadlifts, Olympic lifts like the snatch and the clean. We want to make sure we're also training it to do those things. So this here is my favorite exercise for those athletes who struggle to find their lats, to find that armpit squeeze, that pinch, and we can cue it with something called a sweeping deadlift. This here is just a five pound kids bar, it's my daughter's, but we can also use a PVC pipe or a dowel, anything works fine. we take that bar or that PVC pipe, it goes in the band as well. So again, once again, it's anchored on a rack or a rig, something that's not gonna fall over on top of you. We move back away from that anchor point, so now we have some tension on that band. We then pull that bar towards our hips, and then we begin our movement. So here I'm going to bring my hips back, maintaining tension the whole time, bend at the knees, down to the bottom, And then as I come back up, I am maintaining tension, so I'm scraping my shins to my thighs, pulling through, and maintaining that tension there. And back up. We can obviously do this with different grips, right? So this would be more of like my deadlift or clean grip. I can go much wider, as wide as this bar lets me go, and go with more of a snatch grip, and then really focus on more of a snatch setup, or more upright torso, and really think, of going through that first and second pull as I come there, as I come here, getting tall with it, and continuing to use that tension to train how that should feel when I'm pulling that bar towards my body. So there it is, right? A nice recap. Three movements that I love to give my athletes who are struggling either with getting pull-ups or with shoulder pain because the lats might be weak and they're kind of dropping and crashing down in their kipping pull-ups or their butterfly pull-ups. One here, that straight arm pull-down, pulling down to the hips, keeping the elbow straight. Can I add in some hip motion to just really increase that tension and that full range of motion for it? that banded kettlebell row with a vertical and horizontal pull that's working together at the same time to really hit that lat musculature there. And then that sweeping deadlift for maybe my athlete that just really struggles to understand what it means to use their lat to be able to hold that bar close to their body to create more tension through their spine, through the thoracolumbar fascia to maintain a neutral spine when deadlifting, Olympic lifting with the clean, the snatch, et cetera. So there again, three movements that I love to prescribe out to my athletes for that there. SUMMARY If that was good, if you enjoyed learning those, or you're like, oh my gosh, I've never seen those before, never heard of those before, and you want to learn more, please join us on the road, please join us online. We have a number of courses coming up. We have our next course of Clinical Management with a Fitness Athlete, Level 1 course, or what used to be known as the Ascendant Foundations. That kicks off on January 29th. We would love to have you join us there. We do all things squat, front squat, back squat, deadlift, press, pull-ups. We learn how to program for CrossFit. We understand what it looks like to do a Metcon. It's a great experience, great course, especially if you're new to this area and you want to get more involved in the fitness athlete realm. And then our live courses, we have a handful coming up. Next week, we're going to be in Portland, Oregon, January 10th and 11th. We're going to be in Richmond, Virginia, February, I said February 10th and 11th, February 24th and 25th down in Charlotte, North Carolina, so hitting that East Coast. And then in March 23rd and 24th, we're going to be out West in Meridian, Idaho. So if any of those are near you, if you've been looking to take a live course, please head to PTOnIce.com, go to our live courses, check that out. And if you have taken these courses, and you're interested more in kind of just the exercise prescription realm, what do movements look like, these ones right here, there's a resource we have in our self-study courses section of the PT Honors website called the Clinical Management of the Fitness Athlete Exercise Library, over 150 exercises all different realms for deadlift, for squat, for pressing, for pull-ups, for gymnastics. Myself and Kelly Benfinger, the TA, worked really hard to send that out. We just came up with a new version 5.0, fully updated, that we'd love for you to use to help your athletes and have a really great resource for you. So gang, thank you so much for joining this Friday morning. Hope you have a wonderful weekend. And again, thank you for tuning in. We will catch you next week on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 19, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the various types of taxes encountered in personal & business finance, how tax liability is calculated, and how to use tax deductions/tax credits to reduce how much tax you pay. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Hope your Thursday is off to a great start. My name is Al. I'm happy to be your host today. Currently have the pleasure of serving as our chief operating officer here at ICE and a faculty member in our fitness athlete and practice management divisions. It is Thursday. It is Leadership Thursday. That also means it is Gut Check Thursday. So today is Gut Check Thursday. A little bit kind of heavier and slower. We have a workout. 15 hang power cleans, 9 wall walks, 12 hang power cleans, 7 wall walks, 9 hang power cleans, 5 wall walks. The barbell weight for this week, 135 for gents, 95 for ladies. That should be a moderate weight barbell that maybe you even have to break up. Maybe you deadlift it up to the hip. Maybe you break those cleans into maybe 2 or 3 sets. and then you're really just kind of grinding through wall walks. It's going to be a very shoulder, upper body heavy workout designed for maybe the 10 to 15 minute time domain. Any modifications you need, suggestions on how to approach the workout, you can check out the post from last night on our Instagram page and see a bunch of different scaling and modification options. So that's Gut Check Thursday. TAXES Today it is the middle of January, which means it is tax time. Hopefully you have already started to wrap up 2023 finances, personal and maybe also business if you happen to be a clinic owner. So I want to take some time and talk about different types of taxes, especially for those of you who are maybe dipping your toe in the water and thinking about What I might do if I were to open my own clinic, maybe you're somebody who is in the process of opening your own clinic Maybe you have a side hustle Treating folks from your CrossFit gym or your run club or whatever and a lot of this stuff is all brand new to you so we're going to break down the different types of taxes that you'll encounter and We'll talk about how tax actually works as far as how does the government decide what you owe them. And then most importantly to all of you, we're going to talk about different types of tax deductions and credits, the difference between a deduction and a credit, and a bunch of different things that you're probably not doing to reduce how much tax you owe the government, whether through your personal finances or through your business finances. DIFFERENT TAXATION TYPES So let's start at the top and let's talk about all the different ways that we can be taxed in the United States of America. So very common that we all pay federal income tax. That's something you can't get away with unless you happen to make very little or no money. We also have payroll taxes. Inside of payroll taxes are two different taxes. That's our Medicare tax and our Social Security retirement tax. We talked about those two weeks ago when we talked about changes in Medicare for 2024. We talked about how we pay into the Medicare and Social Security system from our paycheck, and that is the payroll tax. If you're a W-2 employee, you pay half of those taxes. Your employer pays the other half. If you are self-employed or otherwise you work as a contractor, you the individual taxpayer, you pay all of those payroll taxes. Now some of these that I'm going to talk about may change based on where you live. So depending on the state that you live in, you may or may not pay state income tax. Depending on the state you live in, you may or may not pay state property tax if you happen to own a home. depending on the state you live in. You may or may not encounter sales tax. We're very familiar with sales tax. Anytime we buy something, we typically pay a tax. And then getting into kind of some more advanced taxes. If you do happen to own a company, you may or may not be paying corporate income tax. And hopefully if you're a larger company, you're not doing that. And if you have questions about how to avoid that, we have a whole course for you that I'll tell you about at the end of this episode. And then finally, if you do have any sort of investments in the stock market or retirement or whatever, if you receive any sort of money back from those investments, dividends or whatever, you will pay capital gains tax. So just about 15 different types of taxes that we encounter in our life that results in our paycheck being smaller than maybe we would like it to be. So that is types of taxes. HOW ARE TAXES CALCULATED? Now, how does the tax burden that we owe get calculated? In the United States of America, specifically with federal income tax, we have a bracket system. A range of income, zero to $10,000. $10,001 to $19,999 and so on and so forth. You get the picture. As you move up those brackets, you can kind of think of it like ascending a staircase. As you move up that staircase, as you move into different income brackets, your amount of income that you are taxed on changes. So the percent of tax that you owe changes. Now that is essentially the name of the game when we're talking about how to pay less taxes over time both again for our personal finances but also for our business. Our goal as individuals and as business owners is to push ourselves back down those brackets reduce the percentage of tax that we pay, reduce the amount of what is called taxable income that's going to be calculated to determine how much tax we owe. How do we do that? We do that through a series of deductions and credits. Now, these are not the same thing. TAX DEDUCTIONS VS. TAX CREDITS What is a tax deduction? A tax deduction may be commonly called a write-off or an expense. It is something that reduces your taxable income, which may potentially push you far enough down in that bracket system that you now enter a lower bracket for your taxable income and pay less of a percent of your income as tax. That is very different from a tax credit, which at the end of the day when you finish your taxes and you get told you owe X amount of dollars, A tax credit will reduce that amount owed one to one. So the key difference is tax deductions do not reduce your tax bill at the end of the day in a one to one fashion. They cumulatively push you back down those tax brackets. which hopefully results in you potentially paying less taxes. But that's not guaranteed. You can certainly have a lot of deductions, a lot of expenses, but maybe not enough to push you down a bracket, which means your tax bracket does not change, which means there's really a minimal impact on the tax you owe. Very different from a tax credit where you have a tax bill, you know how much you are owed, and the tax credit is going to reduce how much you owe in a one-to-one fashion. So now let's talk about what you probably all care about are what are all the different ways? What are all the different deductions and credits available? There are for most of us around 15 ish different deductions and credits. Some of them depend on if you have children or student loans or if you own a business. But let's rip through all of those and talk about them and see which ones may apply to you that maybe prior to this podcast, you didn't even know were a thing, which can maybe hopefully result in you paying some less taxes this year. So the first one is called the Child Tax Care Credit. Again, tax credit reduces your tax bill in a one-to-one fashion. This is about $2,000 per kid for the 2023 tax year. So if you don't have kids, you can't get this. The more kids, the more tax credit you get. There's also a Child Care Tax Credit, which is not as well known. This will allow you to get a credit for 35% of $3,000 of childcare cost incurred for one kid or 35% of $6,000 for two or more kids. So if you are sending your kids to daycare or you're otherwise paying out of pocket for childcare, you can reduce your tax bill by a little bit, 35% of whatever you spent up to three or $6,000 depending on how many kids you've had. If you are still in school or maybe you have college age kids, there are a couple different tax credits that are mainly going to apply to the person in school. So we have the American Opportunity and the Lifetime Learning Credit. Those are geared towards college students. If you're listening to this and you're not currently a college student, I would not recommend going back to college just to get these tax credits. That's definitely not going to work out. But if you are listening to this and you're a student or you know a student or you have a student in your family, then these may apply to them. This next one applies to almost all of us. You may not know that you can deduct, so again, not a tax credit, but you can deduct up to $2,500 a year of your student loan interest. So some of us may not have paid interest the past couple of years with the COVID forbearances for our student loans, but if you have been paying on your loans through the past couple of years, you have accrued interest and definitely at least this year going forward, with everybody's payments resuming, you will have interest and you can deduct up to $2,500 of that interest. So that is information available from whoever services your loans. They should send you an email or something in the mail telling you how much you paid in interest and you can deduct up to $2,500 of that. Adoption credit is another tax credit available. Again, probably not for most of us, but if you do happen to adopt a child, you should know there's a tax credit for that. You can get up to 60% of your gross income in deductions for donating to charity. So whenever you are donating to charity, you should keep those receipts. You should keep a record of that because that can be a very significant deduction for you on your taxes. Medical expenses saw a big change over the past couple years. You can only deduct medical expenses if that expense happens to be 7.5% or more of your gross income. So a medical expense that's probably going to be in the thousands or maybe tens of thousands of dollars. Again, probably not applicable to all of you, but possibly someone out there, this is relevant to you. You should know that you can deduct your property tax and any state sales tax that you may have paid. This obviously is going to require that you've kept a lot of receipts. And for many of you, this is going to be an automatic deduction that you take in lieu of needing to provide a receipt for literally everything you may have purchased in the past year. If you own a home or you're currently in the process of buying a home, you can deduct your mortgage interest. You can deduct any sort of contribution to a retirement account, IRA, 401k, HSA, whatever. And then these last two deductions and credits, I think are widely underutilized in general, but especially in the field of physical therapy. You should know that you can take a home office deduction if you do any portion of your work from home. This is very relevant to us. A lot of you are doing notes at home outside of clinic hours. Maybe you're not given time in the clinic. Maybe you choose to have a flexible schedule and instead of doing notes at the clinic, you peace out and go home and change into your PJs and you do your notes at home. Whatever you're rocking, if you're at home and you're doing work, you should not feel bad about taking that home office deduction, right? Especially in the era of so many people across the country working from home, you should not feel bad one bit about taking that home office deduction. And then the final tax credit I want to talk about is called Form 8826. We've talked about this specifically on the podcast. We've had some posts on our social media about this. This is a tax credit designed to improve access. through the Americans with Disabilities Act, the ADA Act, designing with the intent of improving access, essentially, to rehab and there is a limit on this credit every year and that limit is a $5,000 tax credit, which means if you have spent up to $10,000, half of $10,000 is $5,000, you can have a $5,000 tax credit. this year if you have justified spending that much money. So what qualifies? The tax credit is very vague. We love vague laws here at ICE. What does that mean? Things like high-low tables that I'm standing at right now. Maybe things for adaptive fitness. A wide base ski machine for wheelchair users. Maybe lap mats so that seated patients can perform dumbbell, kettlebell, barbell work in the clinic. Anything that you can justify as improving access. Maybe you got the push button door to your facility. Whatever. If you widen the door frame, you've made a bathroom ADA accessible. If you can reasonably justify that you have made your facility more accessible, you can grab that credit and that's a credit that you can use every year, year over year. So if you're out there, you're a clinic manager, you're a clinic owner, maybe you're thinking about becoming a clinic owner, start to think strategically about equipment purchases such that you can maximize that tax credit every year. So I'll leave you with this. We've talked about different types of taxes, how taxes are calculated, common tax deductions and credits. WHEN IN DOUBT, HIRE IT OUT I'll leave you with this. If this stuff drives you crazy, if it makes you nervous, if you truly know in your heart of hearts that you're bad at it, when in doubt, hire it out, right? You can very easily get access to a high quality accountant who would love for sure to do your bookkeeping, but would love to help you with tax prep as well. I think often of accountants and lawyers is they are doing this stuff every day. To them, you coming in with whatever you have going on with your personal or business finances is as easy for them as when somebody comes in and they have low back pain, right? You will know what to do just like they know what to do. with your taxes or the law. So when in doubt, hire it out. Let the experts handle it. You can certainly do your own bookkeeping throughout the year. Keep track of your credit card statements or whatever and just hand it over for tax prep. There are also a lot of accounting firms that will do all of your bookkeeping for you. They'll go into your bank account or your credit card account every month, every quarter, once a year, whatever. pull out all of your expenses itemized for you and help you prep for taxes. I recommend, again, if you're not strong at this, if you don't want to become strong at this, if it makes you nervous, if you get worried about getting in trouble with the government, it's in your best interest to shed a couple hundred bucks and pay an expert to do it for you. So when in doubt, hire it out. SUMMARY So if you'd like to learn more about opening your own practice, we'd love to have you in our Brick by Brick course. Our next cohort starts April 2nd. We talk all things incorporation, taxes, getting a tax ID, a type 2 NPI number. We talk about the differences between insurance and cash and hybrid. We talk about working with Medicare. We talk about budgeting. We talk about different types of EMRs, everything you need to go from maybe a pipe dream of opening your practice all the way to potentially launching your practice by the end of that eight week course. So the next cohort starts April 2nd. We'd love to have you. So taxes, complicated, but a lot of good information hopefully that maybe you didn't know about to save you some more money this upcoming tax season. So have fun with Gut Check Thursday. Have a fantastic Thursday. Have a wonderful weekend. We'll see you next week. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 18, 2024

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to navigate a pelvic PT eval when a "hands-on approach" for assessment & treatment may be off the table due to an individual comfort level with pelvic examinations or when trauma is on board. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. APRIL DOMINICK Good morning, everyone. Welcome to the PT on Ice Daily Show. This is Dr. April Dominick here from the Ice Pelvic Faculty Division. And today we're discussing how to navigate a PT eval when hands-on treatment and assessment isn't an option. Psychiatrist Jacob Marino once said, the body remembers what the mind forgets. Why should we consider a hands-off approach during an eval for someone with pelvic floor symptoms? Maybe the client has some trauma, maybe they experienced nervousness about what a pelvic floor assessment is, or maybe they've had previous discomfort during other pelvic examinations with other medical providers or in a different setting. So for some of these folks, that hands-on assessment and manual treatment just is not going to be the best go-to during the evaluation and maybe even for some subsequent, if not all, follow-up visits. The idea that an internal or external exam is a requirement to make pelvic PT a success is just not true. Is it helpful? 100%. But we are the detectives of the musculoskeletal system. And we take into account the cognitive and emotional state into consideration of the human in front of us. just like all great sleuths like Nancy Drew, she's not making her next move based off of palpating the person in front of her, but she's taking cues from the person in front of her. So I'll give you some tips today for how to go about a hands-off assessment for an eval specifically, from the subjective to the objective, through the treatment, and then post-session. Pre-session, We want to make sure that your intake form has an area for a client to share some trauma or abuse that may have happened to them, whether that's current or they have a history of it, whether it's physical, emotional, whatever the case is. Whether they mark something on that intake form or not, as pelvic PTs, we are dealing with an extremely intimate part of the body. And that means that someone may not even realize that they're holding on to some trauma until maybe in session. They have some sort of trauma response because you palpated their low back, right? Or because you brought up during discussion or during subjective, um, a certain word and that was triggering to them like, um, anus. And knowing that their executive functioning is probably not working optimally in that moment is very helpful for us to make that session for them the best experience possible. If someone has a trauma response, just thinking before we even dive into the subjective, just having that in our head is important. We want to be non-judgmental. We want to be compassionate. in our responses, we should be patient and supportive of a pause that that person may need to take. They may need to take a breath or ground themselves or stretch. I have these little small animals like a llama, this one doesn't have any legs, just for them to hold on to and little fidgets as well. So know that that may happen in session and later on, You could ask them when they're not in that traumatic response or in the next session. You could ask them, hey, what would be appropriate for me to do to help you through that? Do you know? They may not have any thoughts on what to do if that does happen again. During the subjective, let's talk about that. With these clients, I tend to rely heavily on the subjective. We want to be looking at the verbal and nonverbal communication from our clients. These can cue us for the need for a hands-off objective and treatment session, even if the trauma was not shared on the intake. From a nonverbal perspective, when you're looking at your client, do they have knees to chest? Are they folded in super flexed? Do they have minimal eye contact? Are they wringing their hands and fingers throughout the entire session? From a verbal perspective, type of words for pain. So in the pelvic setting, we hear a lot of really scary sounding words and words that sound harmful. Things like, it feels like there's a chainsaw in my vagina or every time I sit, it's like a hot poker is going up my butthole. So listening for those intense words when they're describing their pain, as well as a tremor in their voice, are they shaking? And then any sort of non-specific description of their pain. Oftentimes I'll be like, yeah, tell me, can you show me, or can you tell me more about where your pain is? And if they show me, they kind of like, point in this giant circle of like from sternum to mid-thigh is where their pain is, and for some that is where their pain is. But for others, their pain is at the tip of the penis, but they just aren't comfortable or maybe again, that is triggering to them to say the actual anatomical word. And then verbal communication from you as a provider is important. So we're thinking active listening, we're going to ask them about prior health visits, and then you're going to dial in some of your questioning. So from an active listening standpoint, they've probably been dismissed or maybe not heard in previous medical provider settings. So we want to be the ears for them. and asking them specifically about previous physical pelvic assessments, if they've had any, how did it go at the gynecologist or the urologist, or even if they worked with a prior pelvic PT, that can give you an idea for what worked and what didn't or doesn't work for them. And then get curious about some of their personal life events and their symptoms. So, If they've shared any sort of major surgeries or shifts in their personal life, ask with some compassionate curiosity, do you think that your jaw surgery is related to the urinary leakage that you're now having? And then they think back and they're like, oh my gosh, the urinary leakage started happening basically when I had my jaw surgery. So they have sometimes like an aha moment or if a family member died or if they shifted jobs or got fired from their job, that's when they started having intense pelvic pain. So you can, again, be a detective and kind of connect some events together and that can help them feel very heard for sure. And then I went during my actual, if I am going to do a hands-on assessment, before I even palpate someone, I always ask them, hey, is there anywhere that's off limits or that I cannot touch or assess? And I'm going to do the same thing with the person in front of me. If I feel like this is going to be a hands-off assessment, I'm going to ask them, are there any topics or body regions to avoid during our discussion or assessment? And then finally, for the subjective side of things, preconceived notions about the pelvic PT visit. Do they have any? What have they heard? Be sure that you are explaining the pelvic floor assessment thoroughly and that you ask them for their preferred learning type. So if they are a visual learner, is it okay that I show you this pelvic model? Even that, just the visual look of seeing the perineum could be triggering for someone. I had someone who I was showing them the muscles on the pelvic model and they had a visceral, nauseous, triggering response that we worked through. And they kind of actually had a flashback of when they had some childhood molestation. And then moving towards the objective, we want to reframe this appointment like it's a virtual visit. which virtual visits are hands-off. Same, same, but different. Lean heavily on your visual range of motion. Again, if that's okay with them. In terms of asking them to do standing or seated spinal range of motion, hip mobility, we can learn a lot from a seated 90-90 for their hips in general. Abdominal movement with breath. Offer hands-off assessment options that they can select. So is self-palpation of their own pelvic floor okay for them? Or can we do a visual assessment, no hands, but a visual assessment of their pelvic anatomy? And like I said earlier, an external exam, but especially an internal pelvic exam, whether it's vaginal or rectal, is not required to make a pelvic PT session a success. It can though be something that the client and provider work towards if that's something that the client is interested in. A previous client once told me, they said, thank you so much for saying that an internal exam was not a requirement because they had apparently gone to two previous PTs who were basically saying like, hey, if we are gonna figure this out, we're going to have to do an internal exam, which can be very triggering for them. Then in that objective, looking at functional movements like squats, lunges, you get a good idea of range of motion, strength, growth strength, and then the quality. Is it smooth? Is it rigid? Don't forget to collect some pelvic specific outcome measures or even at the very least, a patient-specific functional scale. And then moving on to the treatment section, tuck your manual skills away and focus on the exercise, the education, the ecosystem. Do they have mental health providers or resources on board? From a exercise standpoint, we wanna be thinking movement snacks for these humans, just to keep it short and simple, or rehab EMOMs that focus on mobility, strength, aerobic activity, maybe some self-mobilization or desensitization on a post-op or a C-section or a perineal area. Any sort of scarring, can they do some work themselves? Are they okay with that? Example of a remom for someone, it's got four exercise in it and I gave it to a client who had that traumatic response when I was showing the pelvic model. And they weren't very motivated to exercise. They hadn't been for six months, but they love to exercise. But because they had some onset of urinary symptoms and a recent jaw surgery, I made sure to ask her, what are your favorite exercises? and they said planks and bridges. So I made a EMOM that consisted of a bird dog with a row. So we've got some sneaky strength and motor control of midline, tapping into the pelvic floor based off of the urinary, the, sorry, upper extremity and lower extremity connections. And this is helpful, especially if they are just so disassociated from their pelvic floor. And then I had kettlebell swings. That's gonna tap into our aerobic piece. A deep supported wall squat with diaphragmatic breathing is going to help us kind of calm the sympathetic nervous system and maybe even help them start to connect with their pelvic floor. And then self-mobilization externally of the jaw. One thing to make sure is that these people are comfortable in the positions, the exercises that you suggest. Some of them may be a little triggering, so just make sure like, hey, is prone okay for you? And then for the objective session or treatment session, education is queen here. Okay, so keep it simple and short. A lot of times these folks don't have a lot of room for processing lots of detail. Use their learning style to connect with them. If they're visual learners, send them home with the animated video explaining the anatomy and physiology of the pelvic floor or your whiteboard drawing. And then, definitely tap into their ecosystem, ask them about what's their sleep like, are they getting adequate fuel and hydration, how do they manage their stress, and do they have any mental health providers on board. And then for the after session of this hands-off eval, make sure you follow up with an email or a phone call, check in with them, make sure that they know that you So appreciate them sharing these things with them. SUMMARY So when it comes to someone who is apprehensive about a pelvic floor evaluation or who has experienced some trauma, a hands-on assessment may not be in the cards. So be sure that in your pre-session, you've got something in your intake forms that they can check off for trauma or any sort of abuse or things like that. From a subjective standpoint, we want to be emphasizing active listening, looking at their nonverbal and verbal communications, and then dialing in our specific line of questioning. From an objective standpoint, remember that you can remind them they are in charge of the session and there are plenty of hands-off objective measurements that can be taken. From a treatment side of things, make sure that you give them movements that align with their preferences and that you're giving them a ton of education about the pelvic floor and checking in with their ecosystem and mental health providers. And then after the session, give them a roadmap of how the session went. So as a pelvic PT, know that it's okay. In fact, it may be better not to palpate during the first visit in order to establish trust and rapport. We know a lot of outcomes and symptoms can improve purely based on education alone. In our ice pelvic division, we have two live courses that I'll chat about in Hendersonville, Tennessee, January 26th and 27th. Alexis and I will be there. Teaching All Things Pelvic Health. And then the following weekend, Christina, Heather, and I will be in Bellingham, Washington, February 3rd and 4th. And there is still time to sign up for those. Thank you all so much for tuning in and until next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 18, 2024

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses this new class of medicines and how they impact your patients and their overall journeys to maximize their fitness and manage their weight. Take a listen or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLEN CSEPEHey, good morning everybody. And welcome to the PT on ICE daily show brought to you by the coolest continuing education company in all of healthcare. My name is Ellen Csepe. I'm coming to you live from Littleton, Colorado. I normally teach with the older adult division, but today we're going to be talking about GLP one agonist medications and their impact on your patients. Um, You guys have probably heard about GLP-1 medications. They're all over social media right now. They're used to manage obesity and weight issues um and diabetes, so These medications are the medicines like ozempic that you've heard all about or the medication brand of that same Ozempic, but used for obesity, which is called Wegovy. So you've probably heard a lot about these medicines already. And if you didn't see them on your board questions, you might be feeling a little bit out of the loop as to how they could impact your patients. If you're like me, these medications have come out after I've already gotten my licensure as a PT, and these medicines are impacting our patients in ways that I'm not really familiar with. So, this podcast episode today is for you to know a little bit more about how these medicines could be impacting your patients as a rehab professional. This podcast is going to be a lot about introductory level information to talk about these medicines in context of our Patients with obesity this podcast is not going to be a conversation to talk about How these medicines are used by celebrities they're not going to be we're not going to talk about how these compound medications or Illegal versions of these medicines are flooding our healthcare scene and causing a lot of illnesses today, we're gonna be really talking about what they are and how they work, who they're for, what they do other than help people lose weight, and some considerations and practical tips for your patients. GLP-1 MEDICATION So let's talk a little bit more about how these medicines work. So in context of treating obesity, these GLP-1 medications are super helpful to kind of overcome the biology behind our body's resistance to losing weight. Let me break that down a little bit. I know it's really easy to look at somebody with weight issues and think, gosh, wouldn't they just feel better if they lost weight? And it's an interesting paradox because our bodies actually fight to regain lost weight. Our bodies might feel better. We might have less pain, less inflammation, less joint problems, but Unfortunately, when we lose a substantial amount of weight, our body's biology fights to regain that. Why? Because usually in the context of our human existence, losing weight has always been a bad thing and it usually means being in starvation. Unfortunately, our biology doesn't know that obesity can be just as much of a threat to our health as starvation. So, when our weight changes, unfortunately our ghrelin or the hormone circulating in our blood blood that's Tells us we're hungry unfortunately that increases when we've lost weight and unfortunately leptin or that satiety hormone is decreases when we lose weight. What does that mean for our patients? It means that losing weight is very difficult to maintain because our body is constantly fighting to get that weight back. So let's talk about these GLP-1 medications. I'd like to first start out by saying GLP-1 medications are the newest medications that are used to treat obesity, but they're not the only ones. They just have a lot fewer side effects than some of the other medications that we've used in the past. For example, oralistat is a medication that works at our gut to decrease the absorption of fat. It comes with a ton of really gnarly side effects. Google what steatorrhea is, and you'll see what I mean. Unfortunately, there are tons of GI side effects for people that use this medication that cause significant fat in their stools and a lot of loose stools with it. Another medication is fentramine or topiramate. Those medications used in combination Basically act as a sympathomimetic to increase our metabolism But those medications are really only effective for a short period of time and they can have a lot of cardiac side effects There are some medications that are used in combination to treat obesity specifically naltrexone was a medication to use to treat opioid addiction and bupropion is which is another antidepressant, in combination that kind of changes our satisfaction behind eating. Those are medications used to treat obesity too. And usually what we can guess is that those medications aren't going to be quite as effective as GLP-1 medicines. Just to kind of review if you're tuning in now, those GLP-1 medications are medications like Wegovy, Sexenda, Ozempic, although of note, Ozempic is only used to treat obesity as an off-label benefit. Ozempic is actually only, excuse me, only approved to treat diabetes by the FDA right now. MECHANISMS OF GLP-1 MEDICATION So let's talk a little bit more about what this GLP medication is. GLP-1 is a hormone that we naturally secrete in our bodies. and the GLP-1 medicines are receptor agonists that look pretty similar to that hormone in our bodies and that when used mimic that hormones actions throughout our tissues. For example at the pancreas that GLP-1 receptor increases our body's secretion of insulin and helps to make that insulin last better. So that's why it's also used for people with diabetes. Interestingly enough, we also have GLP-1 receptors in our stomach. So another way this medicine works is to slow gastric emptying and basically make our food last longer throughout our stomachs so that we feel fuller for longer. What I think is the most interesting is that we have these GLP-1 receptors in our brain, in our hypothalamus, and the way these GLP-1 medicines work is to suppress both hunger and cravings. A lot of people with obesity experience something called food noise. And basically because of the obesity, they have these constant and intrusive thoughts about food. They could be eating something and have no hunger, but already be thinking about their next meal. So this GLP-1 agonists, Turn down that food noise to make it less likely for them to experience these constant intrusive thoughts about hunger So we talked a little bit about how they work. Let's talk a little bit more about who they're for so GLP-1 agonists are used for people with obesity. So that means generally their BMI is 30 or more or they could have overweight and a BMI of 27 with comorbidities. Comorbidities specific to their weight significantly causing risks to their health. So these medications aren't just for people who are looking to shed a few pounds. Obesity is a disease and these medicines really help us treat that disease process, which is a long-term, lifelong problem that relapses and recurs, unfortunately, in a lot of patients. It's contraindicated in a few patients. Good news, patients' physicians have to figure that out, not us. But just for context, people that are pregnant, people that have gastroparesis, irritable bowel disease, those patients might not be appropriate for these medicines, as well as those with certain thyroid cancers or familial risks of those cancers. So these medicines are also used to treat diabetes and in patients with obesity and diabetes, this is a great new medication to manage both conditions at once. Interestingly, or Wigovy, which is the ozempic for obesity, is also used to treat those who are 12 and older. So it's not just adults that are using these medicines, it's also those with obesity who are children who are 12 or older and weigh 132 pounds or more and have obesity. So let's talk a little bit about what they do. So pragmatically, they really reduce cravings. We talked about that. They can result in about an 8 to 15 percent weight loss in the first year of use. That's a lot compared to some of the older classes of medication. Liraglutide decreases the risk of diabetes compared to a placebo. So in those with obesity, liraglutide decreases the risk of obesity development and that rate of onset much sooner. So these aren't just to lose a few pounds before summer and celebrities. This medication can be very helpful for people who are struggling with their weight long term. Notably, Long term is how long these medications have to be used. So unfortunately, in most users, if they discontinue this medication, weight is almost always regained, and about 66% of the weight that they've lost over the past year is regained when people stop using this medication. but again, this isn't just a cosmetic thing to lose weight and a lot of us as Providers think about weight in the context of how we look societally and how we feel but this medication in those with obesity and diabetes Decreases the risk of cardiovascular events decreases the risk of stroke atherosclerosis Heart attack. So these medications aren't just here to help you get shed a few pounds These can be really life-saving medications for those with obesity CLINICAL CONSIDERATIONS Let's kind of talk through some of the considerations for you as a clinician. So keep in mind these medications are injected by the patient at home one time a week. And the dose is gradually increased to a therapeutic dose over several months. Here's why that matters. Because there are quite a few side effects with these medications. It's not a medicine that comes without side effects. This is not the easy way out to lose medicine. It does not feel good to be on these medicines. And a lot of the most common side effects are going to be nausea, vomiting, GI issues, cramping, bloating, dizziness, headaches and fatigue, hypoglycemia, which is important for us to consider for our patients if we're going to be having them exercising, acute pancreatitis, and gallbladder disease. So how does that impact our patients? Friends, team, we are in the business of helping our patients maintain their muscle mass. That's our job. Our job is to be fitness forward, to advocate for our patients, and to be here for them through every season of life. And on the days that they're taking these medicines and throughout the week, there's a lot of stigma attached to these medicines that we have to be aware of as providers. Where I'm going with that is that they need a hype squad. Patients need somebody to cheer them on and say hey, I know you feel like crap. I know that this medication is hard What I want you to know is that I'm here in your corner You are making a big decision for your health and even if you only lose five to ten percent of your weight Overall, that is a huge huge way to reduce your risk of overall cardiovascular disease. HYPE UP YOUR PATIENTS So friends We need to hype up our patients who are on these medicines when it's appropriate and it usually is if it's prescribed by a doctor. This needs to be our goal to hype up our patients and encourage them to maintain their consistency with this medicine. A lot of patients stop because they plateau losing weight after about a year. And they still have the side effects. So they feel like crap. They don't want to take this medicine. They're not seeing the pounds shed off anymore. And they need a health care provider to say, hey, this isn't just a quick fix to lose a few pounds. This is a lifelong endeavor to manage obesity, which has serious risks to your health. So another consideration, our business is to make sure that our patients are sticking through these medicines and Also maintaining their exercise participation and their muscle mass So patients who are taking these medicines feel like crap. They need somebody to still say hey I know you don't feel great. We still need to have a plan to have you doing strength training. We still need to have a plan for you to get enough protein in your, in your, in your mouth throughout the day, because unfortunately these medicines work by saying, Hey, you're not so hungry anymore, which is how those medicines are effective. But unfortunately, if you're not intentional, you will lose not only fat mass, but muscle mass with this endeavor with using these medicines. So, Encouraging your patient. Hey, I know you're losing weight. This is awesome Let's really keep this ball rolling and be super Intentional to make sure that you're still able to get to the gym that you're still able to get enough protein in your diet I'm on your team. I am in your corner to help you and These patients are prime time for behavioral change to say i'm making a change on myself already with this medicine. How can I really? Maximize this and get as much as I can and we are on their team team I recommend patients to talk with their doctor about these medicines. I talk with my patients about their weight all the time in a way that's constructive and empathetic. I listen to my patients and recognize that losing weight is a struggle. These medicines can be super helpful for our patients who have struggled for a long time to manage their weight. And that's not because they're unmotivated or lazy, it's because their biology is fighting to get that weight back. This is not cheating and these medications can be super helpful. I often talk with patients and recommend them to go back to their doctors and ask if it could be helpful in their journey to manage their weight. A quick caveat on that, not all insurances in all states cover these medicines the same, which is very unfair. These medications can be really life-saving for our patients with obesity, and unfortunately, insurance is making it hard for people that need it most to get access to it, specifically those in poverty. Obesity disproportionately affects those from a lower socioeconomic status, and it's really important to recognize that in the treatment of obesity, those people are unfortunately going to be the last to get access to this stuff, and that stinks. So knowing that as a provider is another important thing that I've learned. You can't just shoot from the hip and say, oh, you've got to go talk to your doctor about this. It might not be covered by their insurance, and that's super demoralizing. So make sure that you kind of know that before you make this recommendation that, oh, you can be on this new drug, it'll be super helpful for you, and it's not covered. So friends, to wrap up this summary, so these GLP-1 medications are new but not the only way that obesity can be treated medically. They're very helpful and effective in helping those individuals lose weight but they often come with side effects. Our job as providers is to know what those side effects look like and feel like and how to still emphasize exercise participation to our patients no matter how they feel and come up with a plan to say, hey, we still need to do strength training. We still have protein goals to make sure that you maintain your muscle mass. Thank you guys so much for taking time out of your morning to join me to talk about these medicines. And I hope that it was helpful in the long run for you to know how they can be helpful for your patients. Have a great day. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 12, 2024

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko discusses a recent encounter with low back pain in the gym, offering lessons learned on empathy, the benefits of early intervention, and finishing the drill by returning to regular fitness activities. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JOE HANISKO Awesome. Good morning team. This is your PT on Ice daily show podcast. It is Friday, January 12th. So it is a fitness athlete Friday. My name is Joe Hanisko. I am one of the lead faculty of the clinical management and fitness athlete division here at Ice. Uh, today's topic we're going to get right into it is the benefits of being injured as a physical therapist. And I know upfront saying that a little strange, By no way, shape, or form do I mean that having an injury is a positive experience. We know that injuries can be quite mentally and physically disturbing, but I've recently had an injury and it brought so much back in terms of the value of the experience for me and how I can better shape my practice and reinforce some of my own beliefs about what we do as physical therapists and how we can really bring a good one-two punch to kind of help people who are dealing with injuries as well. So I want to get into the story quickly just to lay the ground. This is like a month ago now, five, six weeks ago. Doing a workout, it was progressively heavy power cleans and intermittently decreasing rep schemes of wall walks. So as you had high volume cleans with a lighter weight, you had high volume Wall walks and you progress down and reps up and weight and down in the wall walks So a lot of just back and forth and I got lazy somewhere in the middle decently heavy bar about 225 Not my max range but an upper level range and I was just trying to get through these reps and I caught it Essentially almost like in a muscle clean position where I didn't do a good job Redipping under the bar and absorbing load and I sort of just got jammed up like it felt like I kind of like Compressed my spine and in the moment as it happened. I was more or less like that didn't feel so hot I dropped the bar. I was doing singles. Anyways picked it up felt. Okay, I Third rep into that, felt a little tight. Only had to do four, I think. On that fourth rep, I was like, oh, something's happening here. My gamer in me, I just kept going, hit the wall walks, but by the time I got back to the barbell, now at 245, man, I was pretty seized up. So, this is sort of like live and learn. I had an opportunity there to maybe back down, but it was just me and my buddy Dakota sending this workout. Couldn't leave him hanging. I continued to go through, and we'll fast forward to the end of the workout, in which I felt like I had a steel rod in my back. Preface this with, I've never experienced a back injury personally myself. Somehow I've been lucky enough to train for 15 years and not have any major back injuries to really talk about. But this was rough. Bending over, taking the plates off. It was one of those within a matter of a minute or two I was in a pretty rough spot and I was like, where is this going? Wasn't too confident about it. So that night though I went home and started working on it myself, doing what we should. pick that the move it or use it option here and we went after moving it i was doing some bat banded cat cows some cat camels but the real story starts with what I feel like came in the next day or two afterwards. MAKING DECISIONS EARLY IN REHAB And this is where I feel like us as physical therapists, what we know from our injury rehab experience, and when it happens to us, we're able to make great decisions early on. This is what really started to highlight to me the benefit of having this injury and reminded me all the things that I need to do when I have athletes and clients who come to me with these acute injuries or injuries of any kind. So what I wanted to do basically is lay out the top three we'll call them experiences or lessons learned from this. LESSON #1 - EMPATHY The first one being empathy. Had I not known what I know about the human body, about physical therapy, about rehab, about movement and how it is truly medicine, had I not known that this injury would have been debilitating. Not only physically, I was, you know, having a hard time getting around, doing basic things, putting the shoes on, getting dressed. Not only physically was it debilitating, but mentally I would have felt wrecked. I love fitness. Every day I get to show up in the gym and spend time there just like a lot of our clients and members at the gym. and clients here in the clinic, I love it. And I did not feel like I was anywhere close to getting back into the gym. I was wrecked. And having that empathy as a physical therapist now for what clients feel like, especially when they don't necessarily know that there's light at the end of the tunnel, and hopefully sooner than later, that was a terrible experience. Again, my ability to change my psyche on that was helpful, knowing that I wasn't doomed, I was gonna get this taken care of. I wasn't dealing with, neurologic symptoms or things that were overly concerning. No red flags in my history. But again, taking this from the perspective of people who don't have that, the ability of the therapist to empathize with people and say, hey, I understand where you're coming from, man. That back tweak is no joke. It really makes you feel like you're doomed and that you got no bright future ahead of you. But let me tell you that you do. I've had this, I've experienced it, I've walked it on, right side next to you, knowing what this feels like, and we are gonna get this better, and you're in the right spot. That empathy and ability to kind of connect on that emotional level with them after experiencing something like this, I think is super powerful. It puts you right in their shoes, and you've lived it, you've learned it, and you know that it takes a little bit of strategy on our part to kind of convince and educate people that they're gonna be okay when they're feeling like they're hitting the frickin' rock bottom after an injury like that. So empathy or relatability, you can combine those two. But I felt like that was probably one of the most beneficial lessons learned from this whole process is being able to connect with the patient on that level. So it's scary, it sucks, but. we have the ability to control some of that with our education and our ability to empathize and to relate with our patients. So lesson number one, empathy. LESSON #2 - POSITIVE BENEFITS OF EARLY INTERVENTION Lesson number two, the positive benefits of early intervention. You cannot sell this enough. Uh, my experience was great. I have a team, uh, onward Grand Rapids. My employees were fantastic. I was able to get in 36 hours after my injury because it was on a weekend. Get in, I got some needles, some cupping, a little bit of manipulation. And man, I was within 36 hours. When I walked in the door, I was in rough shape 36 hours after this injury. When I got off that table, I was 75% better in the moment. 75% better. Early intervention for me was nice because physically I was feeling better and your patients will feel better as well, but this is where it starts to go back to a little bit of empathy and the psychological component of it. The fact that I could bend over, touch my toes with minimal discomfort, 25% of what I was dealing with before, was so, so rewarding to me and reminded me that there is no greater tool than early intervention, especially with these acute injuries. So the early intervention process and It kind of rolls back into patient education, especially if you're incorporating yourself into gyms and fitness. If you get an opportunity, workshops, if you get an opportunity to talk to somebody after an injury, you gotta double down on that because we know that it's so much easier to rehab an injury early on in the process rather than waiting three weeks, six weeks, whatever it might be. But also, psychologically and physiologically, the changes that you can make with these early intervention tactics can be so powerful. It certainly does take a good chunk of education on our part to let people know that, but I think we sometimes struggle as a profession to commit to what we know works because it seems like an inconvenience or it costs money or whatever it might be, but it's our jobs as professionals to relay what we do know and to be confident and to trust our own processes. And in my personal experience, that 36 hour intervention, it was more than worth it. I would have paid whatever it took to feel as good as I felt afterwards. Luckily, I got the free 99 coupon, which is nice, but I'm serious. That was huge So I had intervention at 36 hours and then roughly around 72 hours later and by 72 hours I was probably a 90% to 95% meaning that I could feel some stiffness with flexion. I wouldn't even consider it pain I felt like I could go back and do everything that I wanted to do. LESSON #3 - FINISH THE DRILL And I did I got back in the gym and that was really my third lesson then of this after empathy early intervention is make sure we do a good job completing the drill. You know, this is me lacking my ability to walk my own walk and talk my own talk here. I, you know, three days essentially after this back injury was back to training and I chose to avoid intelligently and modify certain things. I wasn't going to go load up my max PR deadlift and just start cranking away. I think the first real workout that I got back to doing was a combination of dumbbell box step-ups, handstand walking, and goblet squats, like a dumbbell goblet squat. So a lot of legs, movement. I was like, man, and going upside down, a challenging position there where it sometimes can cause back pain with that overextension. I was doing really good. So I went from that to a ski erg and did some ski erg intervals, which is a lot of flexion, and I was doing really good. And I swear to God, 40, 50 minutes into my workout when I went to kind of do a little cool down recovery row, some zone two style stuff, it was within the third pull on that rower that everything literally seized up. I'm going to say at like 75% of the worst that it had been, but I just done all that stuff. Uh, I had been doing some rehab stuff for three to five days before that feeling good and I lacked the ability to commit to completing the drill. as a patient and as a therapist. Like I wasn't honest with myself and pushing myself to continue to do the stuff that we know works and building out a plan to really bulletproof and rehab something. I kind of took it as a grain of salt, like, oh, I'm doing so good so quickly. I can probably just go back to doing whatever I want to do. But I learned my lesson. I went right back to essentially square one, had to go back, see Hondo, one of our dogs here, the day after. Luckily, again, early intervention, second time around here. and got back on track. But now I'm four weeks after this process, five weeks after this process, I'm committed to really taking a stand on building some back strength back up. And even if it meant that I wasn't really essentially weak going into it or whatever, I know that I came out weaker from that injury and need to rebuild my foundation. And there's no point in just sweeping this under the rug. I really need to attack it. And so our jobs here as physical therapists with our clients is to reiterate a either empathetic or relatable experience in which we maybe didn't do a great job following through like I did and educate again on the importance of, Hey, even when you're feeling good, especially early on in your recovery process, this is the time to double down. This is when we go after the gas pedal, we floor it and we say, Hey, this window of opportunity that I have right now where I was doing terrible, the window is open, I'm feeling pretty dang good right now, that's the window that we need to double down, get after this, and really start to build back our capacity into whatever injury, region, interlocation that we're talking about there. So, a super, super valuable experience in my opinion. I don't want to understate the fact that obviously injuries are never truly a positive thing, but I tried to spin this as best I could and going after this process and learning about empathy, learning about early intervention and reminding myself about how important it is to complete the drill was so valued to me as a physical therapist because I can now take all these experiences and apply them back into my clinical experience here. Also, the bigger picture here at the end of the day is that it reminded me of why I'm doing what I'm doing from a fitness perspective. Yeah, I like to be competitive. Yeah, I like to throw heavier weights around, but really what we're looking for here is the long journey, the end goal, the healthy longevity lifespan approach. And I will take that back injury 1000 times. over all the other things that could come with not being willing to put your body on the line a little bit, build some resilience and strength and capacity, and suffer from chronic disease or other debilitating comorbidities that are out there just grabbing people left and right right now across the country. So I'm by no means deterred by this. SUMMARY We need to remind our patients they should not be deterred by this. We are gonna get them better. You're going to relate with them. You're gonna provide intervention early, and you are going to complete the drill, and they're gonna be in a really good spot there. Hopefully that was helpful. Don't go get injured, but if you do, spin it, be positive, learn from it and help your clients. Or at least take my experience and help your clients and really do a good job selling our profession and what we are capable of because people deserve to feel good and to get back to their sport. Last little sign off here from the CMFA team. We got a couple of courses coming up. It's the New Year's 2024, so live courses are kicking off. Our first couple live courses In order are in January. We got one out in Portland and then we're gonna follow that up with Richmond, Virginia Charlotte, North Carolina, and then I'll be out in April in the Seattle area. I think Renton Washington so look at the PT on ice.com website to look for signups for those and And also early February, first week of February, the CMFA online level two is kicking off with Zach and Mitch and myself as well. That's February 7th, I believe, but definitely that first week of February. So hop on, let's get those Con Ed credits built up. We're looking forward to seeing you guys. Have a great start of your year and have a happy Friday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 11, 2024

Dr. Ellison Melrose // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses key set-up, anatomy, and technique to target the subscapularis muscle. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLISON MELROSE All right, U2 is up. Good morning, PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I am here to piggyback off of the Fitness Athlete Fridays for the past two weekend, or two weeks. Two weeks ago, we had Alan going over the evaluation process for determining if the gene is subscapularis muscle. And then last week, Zach Wong went over some treatment techniques, and he hinted at one of the most efficient ways to treat the subscapularis muscle, which is dry needling. So what I wanted to do today was to go over a demonstration of how to needle the subscap muscle safely and efficiently. NEEDLING THE SUBSCAP So in order to be able to do this muscle, our patient needs to be able to get 90 degrees of shoulder abduction with some moderate external rotation as well. So patient positioning, they're going to be laying with their arm up in this abducted and externally rotated position. My patient here has some decent mobility, so she doesn't have any issues getting into that position. But for someone that maybe struggled with maintaining that position for the duration of treatment, we can bring their shoulder down slightly. And you can also prop their wrist up so they're not in so much external rotation as well. But again, this patient doesn't have issues getting into that range of motion. The reason we need to have this position is because we need this scapula to be protracted out from underneath the thorax for this to be a safe and effective drain forming technique. So we need to be able to palpate the lateral border of the scapula and appreciate the difference between the lateral border of the scapula and where the lateral border of the thorax is. In this position as well, we can think about the rib cage. It's not parallel, or excuse me, perpendicular with the table in this position. It's kind of diving around. It's oval shaped, right? So it's diving around and posterior and a little bit medial there. So if we get that scapula out from underneath that rib cage, we have some good real estate to needle this muscle. This is a direct technique. So we go for different types of techniques. We have a threading technique and a direct technique. Typically, when we talk about direct techniques, they are direct to a bony contact. So in order to ensure that we're at the depth of the subscapularis muscle, we need to have a bony contact with our needle in that subscap fossa there. IMPORTANT ANATOMY So again, patient positioning here. Some other considerations in this area. A, we have the lung field. Appreciating where that rib cage is and how it's diving away and where our scapula is in relationship to that. But we also have some other sensitive structures in the axilla. So we have our brachial plexus that actually runs just anterior to the subscap muscle and exits down the medial humerus here. So we want to orient ourself to where the brachial pulse is as to avoid needling in that region, right? So the best window for subscapularis is going to be just distal in the axilla. If we go too distal, we're likely going to miss that bony contact that we need for ensuring that we're in the subscapularis muscle. Some other considerations here is we have a really strong and powerful motor branch or motor nerve, the thoracodorsal nerve, that runs along that lateral border of the ribcage, which innervates the lats. So if we were to interact with that, we would likely get some fairly strong um, lat muscle activation. So typically it kind of looks like that sprinkler, um, dance move that we all know too well from middle school dance. Um, but so those are our main considerations. So one field and some other sensitive structures, uh, the brachial plexus and brachial artery and vein in that axilla. So again, first we want to bring our patient into this abducted externally rotated position. If you feel like you can't appreciate the, or you don't have a good real estate of that scapula, you can assist by protracting, like grabbing the medial border of the scapula and pulling it laterally. So again, you should be able to appreciate lateral border of the thorax is there, lateral border of there. So we have a good two inches of room to play with. A lot of these athletes that have So we're thinking the athletic population would be one where we want to treat this. Crossfitters, for example, they also have fairly hypertrophy flats. So that's another thing that we have to appreciate is we're going to have to be sinking in to get, again, that bony contact on the scapula. Another common patient population that you may be needling this muscle in is going to be the thawing stages of frozen shoulder, right? So this person was able to They're now in that pain-free, able to access at least 90 degrees of shoulder abduction, or post-op rotator cuff, where they're really struggling with some of that end range shoulder abduction, external rotation, and shoulder flexion even. Sub-scalp is going to be a good muscle target for those patients as well. So before we do anything, we want to prep the tissues. So we're going to clean the skin. SUBSCAPULARIS TECHNIQUE I prefer to do most of my needling techniques in standing, especially for this muscle, as sometimes our fingers are not going to, like just our finger pressure is not going to be enough pressure to sink in to approximate that subscap fossa that we want to. We're going to be needing a longer needle than we think. So for Sam, I have a 75 millimeter needle. Some folks may even need longer and that's just based on excess muscular tissue, the lat, the pec muscle that we're kind of orienting ourself around, the skin recoil. So as we compress that tissue, once you release, that skin recoil is going to potentially move that needle. If we don't have a long enough needle and it will choke up on the handle there and it'll pull it off of that bony contact that we've Spent so much time finding. So we want to make sure that we have a long enough needle to maintain that bone depth. ADDING E-STIM Another thing to consider is when we're with ice, we are dry needling with e-stim, right? So we're not doing a ton of heavy pistoning. Again, there's a lot of sensitive structures in this area, so it's usually not very comfortable to piston a lot. So we're going to be wanting to layer in the strategy with Easton. When thinking about ECM, you always want to be thinking in pairs. So how can we pair this muscle with another muscle that may be doing something, a similar movement pattern that may be also restricted, or something that's going to reach that motor threshold at the same time? So we want to be thinking about muscle spindle density in our muscle tissue of what's going to reach that motor response around the same time. Typically, I like to pair subscapularis with the clavicular fibers of pec major. So we have another technique for pec major clavicular fibers. Of course. Of course. Why was I logged out? OK, well, I was logged out on Instagram, so we're just going to continue on YouTube here. So we want to maintain the or we want to be able to pair this muscle with another similar muscle that has a similar muscle density. And it's also going to be limiting some of that external rotation in this position as well. So I like to pair those muscles. For today, we're just going to go with the dry needling demonstration of subscapularis. SUMMARY So again, we want to orient our patient into abduction external rotation. We want to maintain an appreciation of that lateral border of the thorax. And then we're going to compress the tissue down, down towards the subscap fossa. Usually your palpation here is going to be the most assertive part of the technique. And you might get what we call the Grunner sign, where some people don't tolerate that very well. So orient yourself to that brachial artery. We can find the pulse. So typically I would come around to the other side, palpate the pulse here. Pulse is under my index finger, so I've oriented myself to where that neuromuscular bundle is, and I'm going to be treating just distal to that. So, right in here. All right, so we have an appreciation of that anterior surface of the scapula. Again, using a 75 millimeter needle. So I'm doing a firm palpation, my medial aspect of my hand, so my pinky, ring finger are appreciating that lateral border of the thorax. My needle angle is going to be perpendicular to the scapula here. So really, it's fairly directly anterior to posterior, almost paralleling, or excuse me, yeah, paralleling the ribcage, anterior to posterior. So we're almost, we're very close to that ribcage, but we're going, we're paralleling it, so we're not going to be interacting with in a postural space or lung field here. So again, appreciating lateral border, knowing where that neurovascular structure is, that means safety, lateral border of our scapula, firm compression down. I feel that muscle. You can always do a little internal rotation, good and relaxed, to feel that muscle activation under your fingertips, compressing, giving yourself a little treatment window directly anterior-posterior. and you're on bone right there. So if you look at this, you're like, dang, she's got a lot of needle left over, but let's allow for that tissue recoil. So as we let for that tissue recoil, we have about a centimeter left. So a 60 millimeter needle would not have been long enough to appreciate that depth of the sunscan. As we allow for that tissue recoil, you may start to see like the needle directions a little bit and it may look a little bit suspect, but knowing that we're on that bony contact, that needle tip is not going to be going anywhere once we've reached that depth of the scapula. So we can allow for that tissue recoil and set up our next needle and then set up the stem and feel fairly confident that that needle is not going to go anywhere. Main concern with safety here is if this person were to move their arm, right? That would be something to be concerned. or if we're interacting with that thoracodorsal nerve and we get a very big motor response into that sprinkler dance move. So when we are bringing the stim up and looking for that motor response, typically I would suggest maintaining that appreciation of where that lateral order is and kind of bringing that needle back into its original orientation. Once you feel confident that we're not getting any sort of interaction a less of a motor response than what we want or more of a motor response than what we want, we feel fairly confident that leaving that needle at that bony contact is a safe needling technique. We are rarely or really ever, we shouldn't be leaving our patients stimming with needles in them by themselves. I feel like that is a best practice to be in the area with our patients. And so if this needle were to move slightly or anything like that, you can always maintain contact or redirect as needed. So there we have the dry needling demonstration for subscapularis muscle. Again, my name is Dr. Allison Melrose. I am the faculty with the dry needling division. Some of our upcoming upper quarter courses where you can catch this technique and a bunch of other techniques. We have a three-day course in Longmont, January 26th through 28th. Paul will be out in Wisconsin, February 3rd through the 4th. I will be down in Greenville, South Carolina, February 17th, 18th. Paul will be out in Bozeman, March 2nd through the 3rd. And then I'll be out in Maryland. It's Sparks, Maryland, 22nd through the 24th. So there we have our upcoming courses. And this, hopefully, was a good review or a new driving learning technique that you guys can use in the clinic. Awesome. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 10, 2024

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones covers some good accessories to have on hand (ha) when working with older adults. Links to these accessories and TONS of other equipment ideas are in our NEW Ultimate #Geri Equipment eBook. Download now by clicking HERE . Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. DUSTIN JONES What's up crew? This is Dustin Jones. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'm one of the lead faculty within the older adult division. Today we are going to be talking about accessories for grip in hand issues. We do not want a sore hand, sore grip, sore wrist be the limitation of us being able to achieve higher intensities, right? This is a very common thing that we run into, right? When you are working in that old not weak mindset and philosophy that you are trying to put higher intensity loads on individuals, right? You're gonna run into bears, and we're gonna talk about how we can overcome these with different accessories and different strategies, all right? The first one I wanna speak to is a very important intervention that we will do very often in the realm of geriatrics, and that is weight bearing, floor transfers, think ground mobility, right? The ability to have confidence and independence in a floor transfer just has huge implications for folks in so many areas of life that it really reduces their fear, their fear of falling, and ultimately improves their confidence in what they can do. The walk across the room, if they fall, becomes a little bit less scary. And just think of the implications of that, right? But when we often go to do those transfers, when we go to bear weight on the ground, that can be kind of troublesome for the wrist in particular. but we don't want that to be the reason we don't do this type of intervention or transfer. WEIGHT BEARING: THE SURFACE So if we're bearing weight, one thing I want you to think about is the surface. If we're going to and from the ground or maybe a higher level like a bed or a therapy table, think about the The surface in the sense of, you know, you probably want a little bit of cushion, a little bit of softness is great, but if you have too much, that can actually be troublesome for folks. It may feel great on their knees, but it's not gonna feel great on their wrists for most individuals. If it's too soft, what ends up happening is when we go to bare weight, our palms really press down, we end up going into wrist hyperextension, which for a lot of folks is not a comfortable situation. So when we think about surface, when we're going to do floor-based activities, ground mobility, Soft, but firm. Soft, but firm. You don't want a super soft, cushy surface. Soft, but firm is going to be better, provide a little bit of cushion for the knees and a little bit better for the upper extremities and the wrists, for example. WEIGHT BEARING: CHANGE TE HAND Next thing you want to think about is maybe if we don't go open hands, maybe we go fists. That'll be a little bit easier. We could also think about using the forearms as well. And so that's the first trouble area, very common trouble area for a lot of folks. We can work around that. We could also use an accessory as well. This is the first one I want to bring out. This is basically going to be show and tell, all right? So for those that are listening, for those that are watching, I'm gonna share where you can get links to all of these things at the end of the episode, but if you're listening, I'll be sure to kind of describe these as well, so you'll get just as much out of it as the folks that are watching. So weight-bearing, floor-based activities, think about the strategies, think about the surface. WEIGHT BEARING: THE WRIST WRAP Also think about compression using something like this, a wrist wrap, a wrist wrap. Basically, a little elastic loop that you put your thumb through and then a lovely you know kind of elastic strap that you wrap around your wrist and applies compression and that can often allow people to bear a little bit more weight through their hands also typically allows them to to hold a little bit more weight particularly with something like a overhead press for example makes it a little bit easier on folks so wrist wraps our wrist wraps can be helpful in in the situation of a floor-based transfer all right so that's The first thing I wanted to mention out the bat, now I'm going to be talking about some different accessories that are focused more on working around hand grip issues, alright? WORKOUT GLOVES So, the first one, and I cannot believe I'm going to say this, because this is an accessory that I often have maybe made fun of, never thought I would ever recommend, or even wear at some point, and that is workout gloves. I said, I never thought I would say this, but workout gloves, yes. The ones with the fingers cut out and the padding, you know, you see them, right? You see them all over the place. A lot of our folks here at Stronger Life will wear them, and I was very critical of this initially, and then once I checked my bias and just dug in a little bit of why people actually like these, particularly for folks that may have arthritis, that may have a painful grip, With that workout glove, it obviously reduces friction so you don't get blisters and all that stuff. Whatever, right? I don't care about that. But what's really cool about these workout gloves is when you wrap that hand around that barbell, that dumbbell, that kettlebell, that padding basically increases the circumference of the grip and if you've ever worked with anyone that has you know that kind of arthritic pain just grip issues that the wider the circumference of the grip up to a certain point the more comfortable they're going to be. It can be very painful to kind of lock down on a barbell or a dumbbell or a kettlebell, but when you increase that circumference of the grip, even by a little bit with that padding, it makes it a lot more tolerable. And so we found a lot of folks really respond well to using workout gloves for that manner. Never thought I would say that, but I'm going to go ahead and recommend them now. So workout gloves is going to be the first one that can be helpful if we do see a grip kind of limitation or pain. WEIGHTLIFTING STRAPS Next one, weight lifting straps. All right, lifting straps. So this is basically a glorified piece of nylon that's stitched so it has a loop and you basically wrap that strap around your wrist and then you wrap it around either the barbell, dumbbell, or kettlebell. Traditionally you see it with the barbell, but I've used it with dumbbells and kettlebells with a lot of folks and they've responded really well. And it basically That strap helps support your grip strength so you can lift a lot more weight and it distributes that load more across the wrist and so you're able to hold more weight and it's usually a little more tolerable if folks do have painful, you know, painful grips while they're loading heavily. The only drawback with this one, particularly with the folks that I work with, we're talking geriatrics, I typically have to assist them in setting this up. It can be kind of clumsy to get a really good grip, a good purchase with that loop on the weight, and so I'm usually helping them out. If you're in home health or you don't have a weightlifting strap, you can kind of rig this up with something like a gait belt. Wrap that gait belt around the wrist, loop it around the weight and hold on on top of that and you've functionally created a lifting strap. So gait belts work. The only downside to that one is the thickness or the width of the gait belt is pretty big which can cut into the wrist a little bit and you're going to have a ton of extra slack or extra gait belt to manage, but it gets the job done. If you're having to help that person in any way, it's not too big of a deal. All right, so we mentioned workout gloves. Can't believe I said that. We mentioned workout or lifting straps. LIFTING HOOKS The next thing is going to be a lifting hook, a lifting hook. So what this is, is basically a Velcro strap around your wrist, and that has sewn into it a metal hook. So this is really helpful, particularly for folks that have painful grips, but also very weak grips that you can still load them up in a heavy manner, do a heavy deadlift with someone, even if they can't hold on to the bar. It is convenient for barbells, dumbbells, kettlebells. Also helpful if someone's had a stroke, for example, where they have one side of weakness and their grip is not up to par, but they can still handle some weight using kind of the rest of their body. So a lifting hook. This is really convenient. And all of these things are very affordable as well. Like we're talking, you know, south of $20 that you'll be able to find. And I'll show those links at the end. So lifting hooks. All right. WRIST WRAPS REVISITED And I also want to mention here, the wrist wraps again, because I find them helpful with weight bearing activities, but then also with anything where you're holding the weight particularly in like a front rack position or overhead where you're going to press particularly for folks when they are new to handling heavier loads and they're really pushing those higher intensities there's that adaptation period and all y'all probably felt this too right when you started to press heavy overhead or work on that clean or a lot of folks will feel when they start to work on handstand or inverted gymnastic movements, the compression can help. We don't want to use it as a crutch, we want to build tolerance in that joint, but it can help early on. All right, so those are some accessories that I've found very, very helpful in working with older adults. Now let's talk about what we can think about if we just need to take the whole upper extremity off the table in the sense of we don't even want to load the upper extremity at all, right? Because let's say I have someone with a right-sided stroke and they have a weak grip and so I'm going to use this lifting hook. Well, what if they don't have great right shoulder stability, right? That's not going to be great if I'm going to do something like a loaded carry for example, and they're not able to maintain that shoulder stability and could potentially, you know, sublux for example. So how can we distribute the weight just taking the upper extremity off the table? THE ALDRIDGE ARM So the first one I want to mention, it's a really cool piece of equipment, is the Adaptive Single Arm Lifting Attachment. And so what this is, it is a popularizer created by Logan Aldridge who is He has upper extremity amputation. He's now a Peloton coach, but he's really well known in the CrossFit space, definitely in the adaptive athlete space. And he's thrown around some super heavy weight, particularly barbell deadlift with the single arm lifting attachment. It basically hooks on one side of the barbell, goes up over your shoulder, and then hooks up on the other side of the barbell. And so the upper extremity is taken out of the equation. You're still able to load very, very heavy. Next up, kind of a similar philosophy, and that is a purse carry. So this is something that I learned from Alex Germano, faculty within the Older Adult Division, and that's basically taking, kettlebells are great for this, where you basically take that kettlebell, gait belts are useful, you loop that gait belt through the kettlebell handle, and then you just put that weight on like a purse, one side or cross body, and you're basically getting load through the trunk and you can do lots of movements, carries are great for this, but you're not asking hardly anything of the upper extremity. Gate belt, I typically use gate belts for this one. So that's the purse carry. We talked about the adaptive single arm lifting attachment, the purse carry. WEIGHTED VESTS Next, think weighted vest. How can we wear the weight not using the upper extremity? Weighted vests are a great option. Backpacks, loading them up with cans of beans if you're in home health, great option to wear the weight to remove the upper extremity. Belt squats is another great example where we have a belt Around our waist and that is that belt is attached to some form of resistance You can get some real fancy pieces of equipment You could use the gait belt again wrap the gait belt around the waist and then loop That the gait belt through the handle of like a kettlebell for example and get a similar stimulus but you're basically loading up the pelvis and the legs and and able to achieve a higher intensity, particularly for the lower extremities, without bothering the upper extremity at all. And then think about some different pieces of equipment outside the barbell, dumbbell, kettlebell, but think about like the rower, for example. Cardio piece of equipment that we still want to maintain that cardio fitness, you can get a single arm rowing attachment. So you are not having to use that upper extremity that's limited and you can use the other one. So there's lots of options. I think the big thing from this is that we don't want to let that sore grip, hand, wrist be the limiting factor in being able to apply heavy loads to folks. We can work around these issues so folks can achieve those higher intensities and get the results that we know they deserve. THE ULTIMATE GERI EQUIPMENT E-BOOK All right, so I've mentioned a bunch of stuff. I showed a bunch of stuff. You can get links to all of these things in one place. Last week, the MMOA division, we released our new e-book, the Ultimate Geri Equipment e-book. In that e-book, you will see links for all of these accessories, but also all kinds of ideas for other pieces of equipment that you would want in your clinic or gym if you're going to be working with older adults. This is basically, if we had a blank slate, what would we want in our spot? And the whole team contributed. We organized that list by what's fundamental and what's optional, but then also by benefit, strength, endurance, balance, and mobility. All right, so you can get that ebook for free. It's a free download. It's in the Humpday Hustle email that just went out. So it's the first link on there or you can go to ptonice.com and then click on free resources And you will find that at the bottom of that page Tons of good stuff on there. So check out that resource lots of good stuff Just to mention those links are not affiliate links or anything. We don't get any kickbacks for any of that stuff We just want to share helpful information and basically our wish list right of what we think is cool And hopefully you'll find some good ideas in there as well. All right, so check out that ebook. Don't let those grip or hand issues be a limiting factor in the progress of your patients. SUMMARY And before we go, just real quick, want to mention our CERT MMOA courses, our level one online, level two, and then our live courses. All three of those culminate into the CERT. Level one just sold out. Our next cohort is going to be March 13th. Level two starts tomorrow. There's some seats left there. Our next cohort will be around May or June. and then three live courses I wanna bring your attention to. We're gonna be across the country all year, so we're gonna be close to you at some point, but three in particular that are coming up pretty quick. January 20th and 21st will be in Greenville, South Carolina, and then Clearwater, Florida, and then on January 27th and 28th, we will be in Kearney, Missouri. We'd love to see y'all in the row. We'd love to see y'all in the online cohorts and pursue that CERT-MMOA. All right, appreciate y'all. Have a lovely Wednesday. Grab that e-book. I'll see y'all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 9, 2024

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses key research supporting using dry needling with electrical stimulation to target peripheral nerves to reduce pain and improve muscular function. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. PAUL KILLOREN Good morning team. We've got YouTube up. We've got Instagram live. Happy to kick off the PT on ICEDaily Show this morning. If we've never met, my name is Paul Killoren. I'm the current division lead for the dry needling division with ice. And this week you actually have a dry needling double header coming at you. On Thursday, our lead faculty, Ellie Melrose, is going to dive into technique Thursday. with some subscap tips. Zach Long, barbell physio, hit subscap pretty hard last week. So we want to bring you the dry needling tips for subscap on Thursday. That's with Ellie. Catch it live in the morning or catch the recording. Today is clinical Tuesday, and we're actually going to kick off a topic that really celebrates our advanced dry needling course. As a division, we have two courses going down this weekend. One of them is myself hitting the advanced dry needling course in Bellingham, which is really cool for all of the reasons. It's an advanced course, it's kind of the last part of our dry needling trilogy, our three course series, which will build out our dry needling cert with ice. It's really cool in Washington that that third course is what gives our kind of our inaugural group the 75 hours, which as of last week, the word is that in Washington, PTs will be able to dry needle patients as early as July. So really cool stuff happening this weekend. And the advanced course is really my direct segue into the topic this morning. PERIPHERAL NERVE STIMULATION If you saw the teaser yesterday, we're going to talk peripheral nerve stim. And I guess first to qualify our advanced course, the first half of the course is treating more technical or slightly higher risk targets. Muscles around the scapula, around the thorax, we treat the suboccipitals, we treat some more technical muscular targets. That's the first half of the advanced course. But the second half of the advanced course, we stop having intramuscular interactions with our needles and e-stim. And what I mean by that is we do tendon needling, we do scar needling, but we do peripheral nerve stim techniques. So I figured it'd be worth at least having a little teaser topic on the podcast to discuss What are we doing with all that? And really, this is a short format this morning. So what I'm not going to do is dive deep into all of the things and all of the reasons and all of the research as to why we might intentionally, directly interact with a peripheral nerve with our needling and e-stem. But I wanted to give you some research teasers, kind of a little sampler platter, a little charcuterie board of research when it comes to peripheral nerve stem. And again, without getting into all of the reasons we might do it, it might be obvious for me to say that there's actually some pretty sound research that says if we have a true nerve injury, it was injured in surgery or there's a degeneration or a palsy or a tractioning, but if there's a direct trauma to a nerve and we're trying to regenerate or we're trying to improve the nerve health, It might sound kind of obvious that there's quite a bit of research that says if we can directly stimulate that nerve with our needle and e-stim, that there's great benefit there. I mean, that's obvious, that's a home run. Treat the tissue that was injured, all of that stuff. What you might not necessarily immediately assume is that there's actually pretty solid research when it comes to direct nerve stim being the sciatic nerve for low back pain or for improving muscular performance. even some neuropopulation stuff. That might not be the immediate thought when we talk about influencing a nerve with e-stim. And again, what I'm not going to get into today is all of the stratifying, the decision-making process of when we might stim a nerve versus when we do our intramuscular stuff. I really just want to tease you with some research because these techniques are out there. These percutaneous neuromodulation therapies are actually becoming much more popular. whether it's for pain relief as an alternative to pharmaceuticals, whether it's post-surgical pain modulation or improving muscular performance. These techniques are growing in the rehab realm, in the sports medicine realm. So I want to tease you with some research. THE RESEARCH BEHIND PERIPHERAL NERVE STIMULATION The first one, it's kind of a pilot research study from 2019. The author is Alvarez-Pretz. That's a hyphenated last name. And what they did was basically did one bout, it was 10 trains of 10 hertz frequency, but one session of femoral nerve stim. And what they looked at, these are patients with unilateral knee pain, they looked at immediately before and immediately after strength output. So max isometric strength for the quads before and after femoral nerve stim. And it improved. Not only did it improve statistically significantly from pre to post, but it outperformed a healthy control. So pretty cool stuff. Again, I'm just giving you these little nuggets today. But here's the first citation that says femoral nerve stem improved quad performance. And these are knee pain patients. So again, you can get deeper into the inhibition mechanisms and why that might be, but immediate change in max strength output of the quads with femoral nerve stem. Since I brought up the femoral nerve stem, let me tease you with one more. It's a 2020 publication by Paola Garcia Barmejo. Again, she's looking at anterior knee pain. One bout of ultrasound guided femoral nerve stem improved knee pain, but also range of motion, functionality, and there was a crossover. So they did it on one side, and they saw changes on both. So again, femoral nerve stim, we have changes in not just quad strength, but knee pain, functionality, range of motion, all the things. But let's talk back pain. Or let's frame it this way. Let's talk sciatic nerve stim for a moment. Because the first research publication, 2008, it's by an O, Fascinating stuff. Because again, it might be kind of obvious for me to say if we wanted to improve blood flow to the sciatic nerve, if we wanted to send blood into the vasonevorum, like engorge the vessels to the nerve, improve blood flow to that nerve tissue, it might be pretty obvious for me to say that doing direct sciatic stim does that. And it does. But here's a research article that's fascinating and gives context as to other interactions. Because for this research, they're looking at blood flow to the sciatic nerve, and they had three groups. Group one, they actually did lumbar muscle pumping e-stim. So they didn't necessarily say multifidus, but they did that muscular motor response e-stim to the lumbar paraspinals, and then they looked at blood flow to the sciatic nerve. Group two, they did the sciatic nerve stim. They put a peripheral nerve stem directly on the sciatic nerve and they looked at blood flow. Group three, they actually did e-stem to the pudendal nerve. So a separate nerve, but again, they're looking at blood flow to the sciatic nerve. Here are the fascinating findings. 57% of the folks in that lumbar paraspinal group saw improved blood flow to the nerve. So whether you want to say that that pushes us kind of towards the the changan, the radiculopathic influence, or like the segmental influence of nerves, the myotomal influence you could say, 57% of the folks that got lumbar paraspinal e-stim saw improved blood flow to the sciatic nerve. But here's the rest of the fascinating findings. 100% of the folks that received sciatic nerve stim saw improved blood flow to the sciatic nerve. That was almost their control and it worked. But the last piece here is that 100% of the folks that received e-stim to the pudendal nerve, also 100% of them saw increased blood flow to the sciatic nerve. Fascinating. So we do have an influence approximately from that muscle pump of the lumbar paraspinals, but it's almost like we don't have to be nerve specific because we can put some e-stim on the pudendal nerve and we saw improved blood flow in the sciatic nerve. Again, I'm just going to tease you with more research. The next publication by San Mitro Iglesia in 2021. Love these names. I mean, I will say most of the research being done right now is overseas, international. For this research, they had folks with low back pain and they had three groups. Those three groups all received sciatic nerve e-stem. but they were in three separate anatomical locations. So group A, they put e-stim on the sciatic nerve proximally, so near the issue of tuberosity. Group B, they put e-stim mid-hamstring, so mid-thigh, just a different anatomical location for a sciatic nerve. And then the last one was actually the popliteal fossa, so you wanna call that tibial nerve, whatever. But they're stimming the sciatic nerve or sciatic components in three separate anatomical locations. Fascinating outcomes, these are folks with low back pain. Every single group that received eSTIM to a nerve improved in low back pain, in range of motion, actually in their balance tests, and in their functional scales. And there was no difference between these three groups. So with those last two kind of research nuggets, I'm calling them, it almost seems like we can have a profound impact with nerve stem, peripheral nerve stem, and maybe we don't need to be nerve specific and we certainly don't need to be location specific, meaning we're having a global impact here. And if you've, and if you're out there and you've taken one of our upper or lower courses already, hopefully you gathered that the nervous system influence is really the driver of our contemporary understanding for the therapeutic benefit, the therapeutic mechanisms of dry needling. Now that we're interacting with a nerve, a peripheral nerve, early indications are that we're having a very similar, but maybe a more profound, more substantial nervous system interaction. Maybe it's everything we talk about, muscle spindle and motor unit loop interactions up to the dorsal horn and then, you know, supraspinal centers going to the cortex and somatosensory, all of that stuff. We're now interacting with a much more sensitive much more nervous peripheral nerve structure, and that nervous system influence has to be times 10. So again, today I really just wanted to tease you with that. We do cover peripheral nerve stim techniques on our advanced course. Again, the first half of the course, we keep doing muscular interactions. We do the rest of the muscles that you didn't get in upper and lower, the more advanced, the higher technical muscles. But then the second half of our advanced course, we do peripheral nerve stem, tendon needling, and scar needling. And maybe we can grab a few more of these podcast spots throughout the rest of this year to say, why would we interact with a peripheral nerve? Today, I just set for you a little charcuterie board of research that says we can change, not just nerve health, not just nerve blood flow or neuro regeneration, but we can improve muscle function. We can change strength. We can change pain. And maybe there are patients like low back pain where the initial strategies of conservative therapy, maybe even our, our typical paraspinal or multifidus estim isn't working. We now have one more strategy, one more tissue interaction to consider. But again, that's all I wanted to jump on today was to give you a quick snapshot of nerve stim research. Not gonna give away all of our secrets on how we stim nerves. It's probably fair to say or fair to acknowledge that all of the research I just went through, almost all of the percutaneous neuromodulation, so peripheral nerve stim with needles, fair to say that almost all of that research is done under ultrasound. And that's to ensure safety kind of, but also ensure that it is a direct peripheral nerve interaction. We're not going to use ultrasound on the course. So really the beauty of the technique is how do we interact with it safely again, for sure, but consistently and effectively. So peripheral nerve stim is a big topic on our advanced course. We have a couple that will be popping up. Again, the first one is this weekend in Bellingham. If we're not sold out, we're nearly sold out. We have one in December in Colorado, and there'll probably be one or two more that pop up Q2 and Q3. Hopefully we're targeting the Midwest. We are probably going to be back here in Washington, because again, we need that for our 75 hours to treat patients. But peripheral nerve stim, if anything, I wanted to put that in your mind today. And I mean, big picture before we continue this podcast series about why and how and when for peripheral nerve stim. At the very least, I want to keep throwing out this topic because on the ground floor, if nothing else changes in your mind, I'd like to kind of decrease the paranoia or the concern of needling near a peripheral nerve. Or if you use eSTIM, I'm sure you've had that interaction where the needle goes in, all of the words from the patient are normal, achy, crampy, sore, no nerve words. But then you add yeast into the equation and clearly you're near a peripheral nerve and you generate a different response. At the very least, I'd like to turn off some of the alarm bells that we're so paranoid of interacting with a peripheral nerve that we don't acknowledge there's benefit there. Again, upper and lower, our goal is just to treat muscular targets. We're not intentionally trying to interact with a nerve, but advanced we will. So on the ground floor, I'd love for just The, we always respect nerves for sure, but we don't want to respect them so much that we don't see that there's benefit there. Again, you should be trained in a technique. We're not trying to intentionally or accidentally interact with the nerve. We need to know where they live. If you took a level one or a level two course from somewhere else, I'm sure they mapped the large vessels, the large nerves, and we want to avoid them at all costs. And you should do that to start with. I mean, there's, There's something very precise and very safe about knowing how to not interact with it directly with the needle. But then there is another layer on top of that, that eventually, especially when we use e-stim, so we're going to piston much less, we're going to use e-stim, there's value to knowing where these tissues live and interacting with them directly. So for now, I just want to put that thought in your mind. I want to decrease some of the paranoia, some of the nervousness of being around a nerve, and hopefully I can keep teasing you with certain research. We'll throw some stuff up on Instagram. If you've taken upper or lower through us, you can look for the advanced courses popping up. To complete the CERT for ice, it is upper, lower, and advanced, but you only need to take one of them to show up on the advanced course. So let me know what you think. I mean, do you have questions on peripheral nerve stem? Throw them on Instagram. Hit me up directly on Instagram if you'd like, at dptwithneedles. Otherwise, stay tuned for Thursday. Ellie is going to jump on and show you some subscap tips. Such a key muscle for your shoulder, folks. Again, go back and listen to Zach Long's episode from last week. and how he assesses it and how important it is to treat and how he loads it because Thursday Ellie's just going to bring the dry needling smoke. She's going to teach you how to get in there safely, consistently and effectively. It's a key target. So that's what we got coming at you. Thanks for joining. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 8, 2024

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses her journey to becoming a pelvic floor PT. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETT Everyone and welcome to the PT on ICE daily show My name is Christina Prevett and I am one of the lead faculty within our pelvic health division Today I want to talk a little bit about kind of my journey in to pelvic PT and the reason why I want to do that is because when I first started in pelvic I was actually really adamant that I was never going to be a pelvic PT. It was not something that I wanted. It was not something that I wanted to do. And I want to talk to you a little bit about why I think that's important and where we have seen a shift in pelvic PT that I think is super beneficial. So you all haven't seen me on the podcast now for a while. You know that my start and my love is working in geriatrics, right? My PhD was in geriatrics. My business model was very focused on, with Stavoff, on healthy aging. I did a lot of bridge programming between one-on-one rehab and group fitness wellness for individuals with complexities with the idea of removing barriers to exercise, and optimizing as many facilitators as possible in kind of a medically supervised but not medically necessary type of way. And part of my PhD was really trying to get into this health and wellness space. And you know that fits the bias at ICE really beautifully because we truly believe in preventative healthcare versus our sick care system that we currently have. And part of that was to do a scoping review around where physical therapists could be involved in health and wellness. And I meant that as a primary and secondary prevention aim. So not once disease has already been established, but what to think about this bridge, identifying risk factors to potential issues, or to really think about population level health. And of course, there was a lot of things in the literature that lit up around, you know, chronic Z self-management and working and isolating at risk factors like blood pressure. But one of the other things that came up and came up really strongly in the evidence base was around perinatal care. And so a lot of people go into pelvic PT around their own experiences, and that was actually not the case for me. And so I had applied for a city grant. I was like, well, if this is where we are going and we want to take a lifespan approach, then let's try and get involved in exercise in the perinatal space. And so we applied for a grant, we were able to get grant funding, and we started a program called Strong Like Mom. it was a new area for me you know i did my research on like exercise this is a lot of postpartum exercise in canada we have a year of maternity leave so a lot of moms in the first year would bring their babies in it was really great i was kind of in a period of my life where my husband and i were talking about having kids so i got exposure to other moms and their experiences i got to talk through different pelvic health complaints. And from an external perspective, I was able to help manage a lot of those conditions. But I was not internally trained. And this was back 2018, 2019. And I was still adamant that I was not going to be internally trained. And here's why. I had this belief that I had to be a Volvo Cupcake type of person. And this is absolutely no, no negativity at those who go into pelvic and love it so much that they buy a costume where their head is the clitoris. Like we need those people because they reach individuals in such a unique way. But that was the way that I had interpreted going into pelvic. So I had my exercise class. I was talking about pelvic health issues. But I really truly thought that as soon as I became a pelvic PT, all I did was internal assessments. I stayed in the room with people in supine and I stopped getting an orthopedic caseload because everybody that I talked to, their entire caseload turned into pelvic. And I loved working with older adults. I loved working orthopedically. I saw a lot of people with complexities and multimorbidity. I loved that part of my job. And I did not want that to go away from me. And so in 2018, so I must've started this program in 2017. So we're talking some years now. In 2018, I was a national level weightlifter and I got pregnant with my daughter. And we got pregnant faster than we thought we were going to, which is such a blessing. But I was prepping for a weightlifting meet, trying to qualify for nationals again for 2019. And I already had the meat. I was like well into my prep. And so I was like, you know, I'm not worried about weight. I'm well off my weight category. I'm still gonna compete. And I remember the first time I went to snatch heavy and I made contact at my hip, I started to cry. And I knew that exercise was not bad. I had well gone into the literature with me being a PhD student around exercise and pregnancy, but the visceral, fear response and the thought that everything in my brain had said, I need to protect was real. And I was lucky. We had a referral network with individuals. We were working in a research program with a high-risk fetal medicine physician and obstetrician. And we were doing referrals back and forth for individuals with cardiovascular risk. That's a whole other conversation for another day. But in that moment, I reached out to him and I said, Hey, like I'm a weightlifter. And I sent him a video of a snatch. I was like, I'm prepping for a meet. What are your thoughts?" And his messaging was so clear. He said, that baby's so small, it is back in your pelvis, and your body is used to this. It's okay, you are going to be fine. And my fear melted. It melted. And I will never, never not be grateful for that interaction. And in that moment, I recognized one, how much fear we can have around pregnancy because it's so protected. But number two, how much that fear can be melted away by somebody in the obstetrical space that you trust, that allows that fear to extinguish. And so, This was all kind of happening. Again, I wasn't doing internal PT, but I started to feel this like gut pull to this space. But I still had this like interaction where I just did not want to do only internal assessments. This is kind of the origin story of pelvic. And so I was still not coming to terms with this, but I really wanted to start bridging towards this fitness. I had been doing Strong Like Mom for a couple of years. I was a national-level weightlifter on Instagram and social media. I was getting comments about my body prolapsing and all these things that were so fear-focused, and it started to just gut me that it was so fear-invoking. and I was going and I was interacting with other pelvic BTs, they were the ones who were making me afraid because they were the ones telling me that I was going to prolapse. They were the ones who were saying, and this is not against them because that is truly what we believed and what we were taught in our training. We have come so far to move away from that narrative, but that was where the narrative was in 2018. My staff member who was an internal trained PT and I went to fitness athlete and being in this space, we kind of took over a little bit, sorry guys. In this live course, talking about things like diastasis recti and talking about how to load the core and it very naturally for me became this teaching moment. And this was in 2018, 2019. And in that moment, because Alan was there, he was like, this needs to happen. This needs to happen. And even then. When I started teaching, I was like, I do so much externally. I've seen such great results. I know there's a referral network if I need it for looking at these interactions, but I'm not, I'm still resisting against it. So I was there and we have so much evidence around telemedicine. And it was just, it was still, I was still doing everything externally. And I was like, I'm not going to bridge that gap. And so you're probably wondering where it switched. It switched when I realized that I could do pelvic PT my way. I did not have to be a person who loved looking at vulvas on cupcakes in order to be unbelievably passionate about removing barriers to exercise. You have heard me say that very quickly, when people start interacting with the healthcare system, they start to be afraid. in females or peoples with uteruses where their fear often can start is in pregnancy because they want to protect and our medical system is designed to look for what is wrong and try and mitigate those risks. And I recognize that in order to be a frontline person, to be able to mitigate that messaging, the internal PT part was necessary. And so in 2019, I went back and started doing some internal training and the training was fantastic. I loved it, but it taught me the assessment. I spent a lot of time on the assessment and I was so thankful that my external training and just figuring out my own caseload over several years had allowed me to know the intervention side of things. And they had to marry. And so our online course is very focused on external techniques. That was where my expertise was. I started blending that with my internal techniques. And I realized that the internal assessment is a tool in our toolbox. It is not our profession. It is not our profession. And as I have started to interact and build more experience and all these types of things in this space, in tandem with some of the research side of things, I so sparingly use the internal assessment outside of often times if we're working with individuals with pain. But it is not who pelvic PT is. And when I removed that expectation, yeah, 100% this, when I removed that expectation that that is what my job was, that is what defined me as a pelvic PT, I became very free to explore this beautiful area of our profession. And I blend my orthopedic knowledge all the time. I use the information from the internal assessment to provide education. And as we were doing this, and as Alexis was coming into our division and all these things were happening, I realized that our online course would not be enough. It would not be enough because we had to be able to bridge from lying in supine to fitness. We were having this disconnect where we had exercise professionals who felt very good about being able to have all of these movements and interact with these different conditions. And then we have these pelvic PTs who are very good at the assessment aspect. But going from that assessment and early foundational graded exposure to getting individuals running and playing and expressing joy with different planes of movement and different unexpected changes in their body's positions, we had a disconnect there. And so our life course started to really take form in 2020. And I know that people may think that while we do it really differently in our pelvic course, than others and the reason why it's so different is that yes we teach the foundations of the internal but we teach it in the morning of the first day because it is a tool in our toolbox. It is not an entire entry-level course in our perspective. And so we teach it in Supine, and then we bridge that to standing because how are we going to figure out where people are leaking? Yes, Supine gives us tons of information, It allows us to get some orientation, and then we go into the standing assessment, and from there we bridge. And we spend the rest of the weekend bridging, because that is where our profession needs to go. Just like you were saying, we need to use the internal. It is an absolutely pivotal skill, but we need to do that and bridge to fitness, and we are not just pelvic PTs. We are pelvic orthopedic PTs that blend everything that we know within our medical training in order to drive a fitness forward message. And so now I am loud and proud that I am an internally trained pelvic PT and I leverage it in my practice every single week. I'm a part-time practicing clinician right now because of my research. and it gives me so much insight. My patients do amazing, but it's not because of my fingers and their vulva. It is because it is the basis of which we build our foundations, just like I'm not going to just do Kegels, right? I'm going to teach the coordination of the pelvic floor to bridge to function. That is the same thing that we are doing in this fitness forward pelvic PT approach. It is why I hope that when I share my story, that somebody resonates with it. Somebody who has hesitated and said, I do not want this to be who I become. And I hope it gives you freedom, that it gives you this unbelievable understanding of the bottom of the core canister. So if you are interacting with someone who has hip pain or back pain or abdominal pain, you are interacting with it. You are interacting with the pelvic floor. And it will give you this idea that the training is not going to put you into this pigeonhole that you cannot get out of. All right, that is end for me. If you are interested in figuring out our internal assessment, we have so many live courses coming up over the beginning of 2024. I'm gonna be in Raleigh, North Carolina. We only have three spots left for that course. This weekend, end of the month, Alexis is doing a course in Hendersonville. And then beginning of February, I am going to be in Bellingham, Washington. doing all things pelvic PT. So if you are interested, let us know. Otherwise, have a really wonderful start to your week and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 5, 2024

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty discusses treating the subscapularis muscle for the fitness athlete. Zach discusses modifications for pressing, pulling, and Olympic weightlifting. In addition, Zach discusses go-to exercises to use for HEP with these individuals. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show, where it is not only the PT on Ice Daily Show, but it is the best day of the week here on the PT on Ice Daily Show, and that is Fitness Athlete Friday. I'm excited to be with you all this week. My name is Dr. Zach Long. I'm a faculty member inside of the Fitness Athlete Division, teaching both our live and advanced concepts course with the rest of the team there. Today, we are going to talk about subscapularis treatment with the fitness athlete. So the subscapularis muscle, I think, gets commonly overlooked in the fitness athlete's shoulder. Alan talked about it last week, so I'm going to follow up his discussion last week with a few other things. But like Alan said last week, this is the largest and strongest of the rotator cuff muscles, and I think it commonly gets overlooked when people are dealing with shoulder pain. And so we're gonna jump into kind of some of the different modifications and treatment strategies that I use when patients have subscapularis pain. Make sure you listen to last week's episode as well. A little quick recap of last week's for you just to set the stage here. SUBJECTIVE EXAM FOR THE SUBSCAPULARIS Subjectively, what I hear most frequently when people are dealing with subscapularis strains are that they have pain with dips, pushups, and the bench press, so with shoulder extension-based pushing motions. And then things like snatches, overhead squats, and kipping pull-ups, where their arms being really stretched overhead in that position. OBJECTIVE EXAM FOR THE SUBSCAPULARIS Alan talked quite a bit last week about testing positions for the subscapularis, and those were absolute gold for ruling in and out the subscapularis. I'm going to throw one more test at you before I move on to more of the treatment stuff. And I like this test because As Alan talked about last week, when you do like IR at neutral, the pecs are such a big muscle working right there that it's not going to be sensitive enough on your subscap. So that's why he talked about like the liftoff test in your arm. The one kind of issue that I have with the liftoff test, I use it with all my subscap people, is for those that are highly sensitive and you know that they're already really irritable, I find at times that just getting into that position really lights them up. So the test that I prefer to start with is that internal rotation at neutral, but we get rid of the pec involvement a little bit. So imagine somebody standing with their elbow right at their side, elbow bent to 90 degrees. You then put one of your hands outside of their lateral elbow and you have them push out like they're doing a lateral raise. You don't let them actually push away from their body, but they're trying to. And then you test internal rotation resistance with the other hand. And you'll find that that little lateral raise push gets rid of a lot of the peck involvement in there and will let you get a positive test for a lot of people that have a subscap strain that your standard IR at neutral would not. SUBSCAPULARIS TREATMENT So let's jump into treatment a little bit and modification. I'm going to say number one, from a manual perspective, like if you made me choose only one area of the body to needle for the rest of my life, and you said you can only needle one thing for forever, choose what muscle. Now this might just be because I treat primarily shoulders, hips, and knees in the clinic, but I would choose subscapularis dry needling over every other area of the body. It has just been the area that I find most frequently gets huge improvements in their symptoms after a quick dry needling session. So if you're not familiar with that, look up Paul iDryNeedle. Paul runs our dry needling division along with Ellie. and the great faculty that we're building over there, but check out their coursework. That is just a money technique to have. From a treatment perspective, so much of my treatment with this comes down to the combination of wanting to build the subscap up, but also wanting to make sure we're not continually overloading the subscap. So I have a lot of conversation with my patients on what sort of modifications they need to be making to their training to not further aggravate the subscapularis. And so, All of these are obviously based on somebody's irritability. So when they strain their subscap, if it's very, very minor, I'm not pulling all of these levers, but if it's very major, I might be. And as y'all know, our goal with the fitness athletes and all of our people in general is to keep them active. We don't want to tell them, stop benching, stop doing pushups, stop doing dips. We want to find ways for them to do those movements or similar movement patterns with less pain. So that's breakout kind of where I kind of go with modifications. MODIFYING HORIZONTAL PRESSING So if we start with like our horizontal pressing motions, which I think are the most common things that I hear people with subscap strains discuss subjectively, that's the dips, pushups, and bench press. I think the reason why those hurt so much is as we take the shoulder into extension, I think you can appreciate as your shoulder goes into extension that you're gonna create a little bit of compression on that anterior shoulder. And as we know, tendons don't like compression. So I think that's why extension is so irritable for these individuals. So one thing that I find myself doing more than anything else in people with subscapularis strains is I actually have them stop doing dips. And we end up replacing dips with, with push-ups or banded push-ups or some variation that doesn't take the shoulder into quite as much extension. When push-ups are pain-free, then we start moving back to dips. But generally, I find that dips are going to be really painful if the push-ups still hurt at all. So that's kind of a general rule of thumb for progression there on the dips. In terms of the pushup and bench press, I find that the most valuable thing we can do for people in terms of modifying is to just adjust the range of motion a little bit. So for the pushup, kind of the two modification, three modifications I make there are a lot of times I have individuals do a pushup down to an ab mat. So that ab mat's just gonna, they touch their chest to the ab mat instead of the floor. We reduce that range of motion, maybe an inch and a half or so with the ab mat there. And so frequently that is enough that we can now still do the prescribed workout with just that slight modification to the range of motion. Other times I find that having them really torque their hands into the ground or keep those elbows close to their side and making it a little bit more like a close grip pushup can help them out quite a bit. From a bench press perspective, very similar. So maybe instead of bench pressing, we do a floor press or a board press. So a floor press is simply a bench press where we're laying on the ground. So when the elbows get to our side, they hit the ground and you can't actually take the arm into extension. That can usually be enough that people can still press really heavy. The floor press is one of the best exercises you can do by far to improve your bench press strength, so it's a great modification in this time period. We can also do a board press where they're on a bench, but they go down and they touch one, two, or three 2x4 boards that are placed on their chest to reduce the range of motion. And then very frequently I also have, especially with more like my power lifters or people that care about bench pressing a lot, I'll use accommodating resistance. So maybe with a lightweight, they can touch their chest and not have that much pain, but if it's really heavy and they touch your chest, they get pain. So that's resist the bench press with bands so that at the bottom, those bands are unloaded a little bit, and then that weight increases as they go towards lockout. So that's a great way to really challenge the lockout, still train full range of motion, but not irritate that already irritated subscapularis. So the big key there is to probably reduce the range of motion a little bit and play with some of those variations to see if you can get people to not continually aggravate the subscapularis but still get in that horizontal pressing stimulus. MODIFYING KIPPING When it comes to kipping-based movements, so toes-to-bars are one that really tend to aggravate the subscapularis, I see quite a bit. I will Usually prefer to just get people to do a really tight kip where they maintain a lot of tension and they don't go into as aggressive an arch position. That is actually a performance advantage in the toes to bar. People will cycle their toes to bar reps a lot faster. So this is a great time to make people do smaller sets because a lot of times they'll fatigue more rapidly with this. but to actually work on a technique improvement that will help them out long-term. So those quick cycled reps with a little bit more tension. If it's more irritated, then we might just do an active hang, knee raise of some sort so that we're still getting the hanging stimulus. We're still getting the ab stimulus, but we're just reducing a little bit of the shoulder demands. And then when it comes to things like kipping pull-ups, if it's highly irritable and I don't feel like kipping is in their best benefit right now, we just turn that into strict band-assisted pull-ups that we maintain that high volume of the vertical pulling stimulus. We maintain those fast reps that keep our cardiovascular system up if we're talking about prescribing kipping pull-ups in a Metcon, but it will unload the shoulder just a little bit to do a strict band-assisted pull-ups versus kipping when somebody has a subscapularis strain. MODIFYING OLYMPIC LIFTING And then the final thing that I often modify is their snatches. So frequently, it's the turnover and the catch of the snatch that really irritate these individual symptoms. So at times, that just means we move to variations where we're not doing the turnover or the catch. So we're doing snatch grip deadlifts, snatch grip high pulls, snatch grip pulls, exercises like that. So we're still building their technique. and working on things that will help their snatch overall. But again, we're just not adding more fuel to the fire there. So that's the main modifications that I make when somebody has subscapularis pain. TREATING THE SUBSCAPULARIS: LESS IS MORE Let's jump now into treatment. And I think from a home exercise perspective, one thing that I'm really big on is that less for your HEP is more. We don't want to overload our patients. So a huge percentage of my patient population at this time are people that are seeing me for a second opinion. And I kind of see three things most commonly pop up when people see me as a second opinion. Number one, they were just underloaded. They didn't get a sufficient enough stimulus, their therapist was on the right diagnosis, but they didn't challenge them enough to actually build tissue strength up. Number two is they're on the wrong diagnosis, which we all see all the time. Somebody thought, you know, that because this person's pain was on the back of their shoulder radiating down to the tricep, they assumed that it was a posterior rotator cuff pain and they didn't do a great job screening out the subscapularis with the tests that Alan talked about last week and I talked about earlier. And so they're treating posterior rotator cuff when it's really the subscapularis instead. And then the third thing is people come in and they have an HEP list of eight exercises that they're doing for three sets. And I look at that and I'm like, man, that's going to take 40 minutes to get done. Less is more here, folks. So the rule of thumb I have here is that my goal, sort of like your post-op ACL that needs a full strength program, My goal with most of my individuals is to try to limit their HEP to 10 or 15 minutes or less, four-ish days a week. I think that that's pretty manageable for most of our people. It gets really crazy when you're asking people to do 30 minutes of work every single day. So to get this done in 10 minutes or less, that usually means that I'm trying to stick to three exercises, maybe four. So in the subscapularis, maybe they do some soft tissue work on their subscapularis. That's one minute. And then we do a nine minute EMOP. So that's 10 total minutes of work. We add in grabbing equipment. They get this done in less than 15 minutes. Less is more with these individuals. Try to really stick to that. And I think you'll see your HEP compliance go up quite a bit. So three exercises, less than 15 minutes, preferably less than 10 minutes is my goal. When I'm looking for exercises, I kind of have four different exercises that we might have in those three of their HEP. Number one is going to be obvious. Like if they have a subscapular strain, we're doing something to try to build that muscle and tendon backup. It would be way too hard for me to really describe these exercises here on the podcast, but if you go to my YouTube channel, Barbell Physio, you can search for all of these exercises. But kind of my general progression here, highly irritable. I'm doing internal rotation at neutral, but I'm going to do it similar to how I did the testing. So I take one band and I'll put it around their arms. So one big resistance band going around both arms. So they have to do that little lateral raise before they do the internal rotation. I'll find that that again isolates the subscap a little bit more than the pecs. Progress that to an IR punch. Progress that to an IR diagonal. Progress that to IR at 90 degrees. That's my general philosophies there. So number one, load the subscap. Number two thing to have in that HEP is to look at any mobility limitations that they might have. Like is their overhead positioning stiff? Is their Tyler test for that posterior shoulder capsule stiff? Do they lack shoulder extension? Does their thoracic spine suck? Does something as far away as their ankle mobility suck? And that's putting them in suboptimal positions for things like overhead squats or snatches. So the second component there is to dial in their mobility, The third component is lat strength. So the subscap and lats have a lot of similarities in terms of their function, but I'd say overall for the athlete doing rig-based gymnastic skills, when they have lat weakness on board, the rotator cuff ends up taking on more of the stress of those movements. I call the lats the glutes of the upper extremity. What happens when somebody has weak glutes in athletic performance? They strain their hamstrings more. They tweak their back a little bit more. Their performance overall goes down. Strong lats are so important to the fitness athlete population. So make sure you're thinking of that with individuals. That's number three on people with subscap strains is to load their lats up. 4. Something to pump a ton of blood into the shoulder tendinopathy, whatever you want to call it. And lateral raises don't bother their shoulders. So we do something like an internal rotation diagonal to directly load the subscapularis. Now lateral raises don't hurt, but we know lateral raises are going to challenge the deltoid quite a bit. They're going to challenge the supraspinatus. Those muscles are all around the subscapularis. So if I then have them do a set of 15 to 20 lateral raises, I'm going to pump a bunch of blood to the shoulder. What happens when we pump blood to an area that's currently injured? We help with inflammatory chemicals that are sitting out in that area. We help with, you know, an overall endorphin release. We just make everything feel better when we add a little bit of blood pump to an irritated area. So that's make that be our final exercise in that little EMOM for them. So I hope those modifications and HEP discussion help you out a little bit more when you see subscaps. Again, make sure you go back and check out Alan's episode. He did a great job discussing internal rotation and shoulder extension and why that's so important in this population as well. Hope y'all have a great Friday and a great weekend, and we'll see you here next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 4, 2024

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the most recent round of cuts to Medicare reimbursements, why reimbursement is cut every year, and potential fixes to Medicare and the American healthcare system as a whole. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. I hope your Thursday is going better than mine. Very, very sick as you can tell. I'll try to get through this. If it's too hard for you to hear me live here on Instagram or YouTube, when I mix this podcast here in about 30 minutes, I will boost the audio and try to clear up some of my raspiness. So hopefully you can hear me better on the podcast episode. So it's Thursday, it's Leadership Thursday. We talk all things business ownership, practice management, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday is a true gutcheck-style workout. The harder you want to work, the sooner you will be done. So what is the workout? Every three minutes on the three minutes, including the start of the workout, so at zero, you're going to perform 40 double unders. you're going to perform 20 ab mat sit-ups, and then any remaining time you're going to do burpees. And you are done with this workout when you hit 120 burpees. So this workout rewards those of you who have unbroken double unders or who are willing to scale, maybe practice for 30 to 60 seconds, or just do single unders and move on. It also rewards folks who want to drop the hammer, especially early on in the burpees and get a big chunk of that work done out of the way. We recommend today that you read the Instagram post for this workout that was released last night to learn how to scale and modify this. What we don't want to see is people just doing double-unders or failing double-unders for three minutes and not getting their heart rate up, really not getting any double-unders or sit-ups or burpees in, and just kind of spending 18 minutes tripping over a jump rope. That's not the goal. So make sure you read that post and scale appropriately. THE FUTURE OF MEDICARE Today, what are we talking about? We are talking about the future of Medicare. So if you are unfamiliar with Medicare, maybe you see patients who utilize Medicare insurance in your clinic, but maybe that's the extent of your knowledge. I recommend you go back to 2023. Look on our YouTube channel. and look up the four-part series, Mysteries of Medicare. And if you're a Virtual Ice subscriber, we're going to be condensing those four episodes into one brand new session for you that's going to actually premiere this coming Tuesday at 8.30 on Virtual Ice. So that's going to be a great resource to prime you for today's discussion. Today we're talking about Medicare cuts. It is something we hear all the time. Those of you who maybe work in cash therapy, I would urge you to continue to listen. I think we have a lot of room in the cash-based therapy space to work with these patients. We can see these patients, take cash from these patients, and have these patients get reimbursed for their visits from Medicare. if we're willing to do a little bit of extra paperwork. So I think this is an issue that affects the entire profession, affects the healthcare system in general, but it's not just something that insurance-based therapists need to deal with. It is ultimately going to affect our healthcare system as a whole. So today we're going to talk about the upcoming Medicare cuts. We're going to talk about the way that Medicare is divided and how that might look for the future of Medicare. And we're going to talk about maybe some potential ways that Medicare could be fixed. MEDICARE CUTS So first, let's start with the cuts. If you haven't seen, we have a 3.4% cut coming in 2024. Those of you who have been practicing for a while, this is nothing new to you. Medicare has been cutting reimbursement for Most healthcare services, but specifically physical therapy, for most of physical therapy's existence. There really has only been one year that we didn't get a cut, and that's because we agreed to a 20% cut for physical therapy and occupational therapy assistance. So, PTs ourselves, OTs ourselves, we avoided that cut. And we passed the burden on to our assistants, which now is creating an employment issue with those folks because they don't get paid as much to do sometimes the same amount of work. So we have a 3.4% cut coming in 2024. And some of you are maybe upset about that. Some of you are maybe proactive and you wrote your state senator or whatever and that's great. But the question we hope to answer today is why should you care? We talked about this in the Mysteries of Medicare series. 10,000 people a day right now are becoming Medicare eligible every day until 2030. This is the height of the baby boomer era, the generation of those folks. hitting age 65 or older and becoming eligible for Medicare or otherwise enrolling into Medicare for the first time. So what we're going to see, and it's now 2024 if you haven't been keeping up the past couple days, what we're going to see over the next six years is that our population is going to go into an inverted pyramid where the vast majority of our population is going to be at the top of the pyramid. What does that mean? What are the implications of that? That means that over time, most of our population is going to become older adults. What are the implications of that? That means the majority of those folks are probably going to be using Medicare insurance for their healthcare needs. That means there's, if we look at it as inverted pyramid, where, let me do a pyramid with my hands. There we go. Kind of, whatever. That means those of us still working, there are less of us still working than there are those who are now drawing from those Medicare funds. And we could potentially be in a situation where both the Part A or the hospital insurance fund and the Part B or the supplemental medical insurance fund that we use in outpatient physical therapy could become insolvent, which doesn't mean bankrupt and we'll talk about that here in a second. So our second point today is what are those two funds and why do we keep seeing these cuts? We keep seeing these cuts because we are trying to stretch what is going to become a decreasing amount of money if absolutely nothing changes in our medical system, a decreasing amount of money over time to the point where maybe Medicare no longer pays for all services, some services, or part of some services. FOLLOW THE MATH: HOW MEDICARE IS FUNDED So understanding how the money works is really important and that's what we're going to talk about right now. Medicare is split into two different trust funds. The first is Medicare Part A, or called HI, the Hospital Insurance Fund. This fund is separate from the Part B, or the Outpatient Supplemental Fund. This fund has enough money right now to be completely solvent, pay for 100% of hospital-based care until 2028, even if every single person working right now stopped paying Medicare tax. Now, that doesn't mean it's going to be solvent forever. It is forecasted that this fund will slowly become insolvent beginning in 2031, unless somehow the money that those of us still in the workforce paying into the system exceeds what those who are drawing out of it for healthcare services slows down, right? If we can get to a place where revenue begins to exceed expenses again. I don't think that's possible. Let's talk about why. We need to understand that those of you and those of us who are in the workforce still and seeing those payroll taxes come out of our paycheck, only 3% of that goes towards Medicare. That means that we only need to pay 40 quarters or about 10 years of that tax into Medicare in order to have 100% premium free hospital insurance also called Medicare Part A from Medicare. What we should know is that also covers your spouse even if your spouse never worked a day in their life. You and your spouse both get access to that. for just paying into that fund 3% of your paycheck every paycheck for 10 years. So let's do some hypothetical math. Let's keep it simple. Let's look at nice even numbers. Let's say that you're a physical therapist and you make $75,000 a year and your spouse has never worked and will never work in their entire life. That means you're gonna get about $2,884 per paycheck, and that means about every paycheck, you're gonna pay $87 towards Medicare for you and your spouse. Across the 10 years, or 120 months, or 40 quarters, or however your brain makes sense of that, that means that you're gonna pay about $10,000 and a half into Medicare. Now already some of you are saying, wait a second, that doesn't seem like a lot of money, especially for potentially two people. And you're exactly correct. Is $10,500 enough to justify the government paying for 100% of your hospital costs from the time you turn age 65? until whenever you die. 70, 80, 90, 100, 108, 115. And even if you're really bad at math, you should know that across 10 or 20 or 30 or maybe even 40 years of living, you're definitely going to exceed $10,000 in healthcare costs. And already we're kind of understanding the problem that Medicare has. So it's expected over time that this hospital-based fund will drop and become insolvent. What does that mean? It doesn't mean it's out of money, it's not bankrupt, it just means that what we're going to continue to see happening is going to continue happening. We're going to see reimbursement be cut, we're going to see more restrictions on folks getting access to care, and ultimately we'll get to a point where the fund is insolvent, which means now 100% is no longer possible. Maybe you go into the hospital and you had a heart attack, and you need a bypass and it costs you $50,000, maybe now Medicare only pays 80% of that, right? And now you owe 10 grand to the hospital, which if you're 80 years old, you probably don't have 10K in cash just hanging out to pay, right? So already, again, you begin to see the compounding of the finances in a way that is not sustainable. The other fund that money goes into is the Supplemental Medical Insurance Fund, SMI. This is also known as Medicare Part B. Those of you working in outpatient, this is what you interact with. This does not get money primarily from our taxes. This is primarily paid for by premiums that you pay to the government when you turn 65. As of right now in 2024, that's about $175 a month or about $2,100 a year. And that works on an 80-20 system. We explained this a bit back in the Mysteries of Medicare series, that if you go to physical therapy and it's $100, Medicare pays $80, the patient owes $20. Now the question again is, is $2,100 a year enough to offset how much a patient may use of outpatient costs? And again, those of you who maybe are even really bad at math and you get nervous around math, you don't have to be a math genius to understand that's not gonna cut it, right? The average Medicare patient consumes $16,000 a year of healthcare money. So is $16,000 more than $2,100? Yes, it's eight times more money, right? That means that the average person is consuming eight times more money from Medicare than they pay into it. Again, we begin to see the compounding financial problem that the math does not check out and has not checked out for a long period of time, which begins to explain why we are continually trying to stretch these funds. as long as possible. What we are doing with these cuts is essentially kicking the can down the road and hoping that something happens in the future where our population increases and we suddenly have more young people than old people that are paying into the system and these funds can potentially become solvent again. CAN MEDICARE BE FIXED? So, our third point, summarizing here, bringing all these points together, can this be fixed? Currently, this is a very broken system for all the reasons that we just explained. The average person consumes more money than they paid into initially or currently pay into with their premiums. We are definitely on track to become insolvent, which means payments are going to continue to decrease and that Medicare is no longer going to be able to cover all or part of some services, which means patients are going to have to pay for more and more out of pocket. What do we know that translates into? Well, when people don't have access to health care, they tend to not use health care. until they absolutely need it, right? They stop going to primary care appointments, they stop going to physical therapy, they only enter the healthcare system when their symptoms are now impacting their daily function. They're now ready to go into urgent care or the hospital, right? So what do we need to happen? We need to have a drastic reduction occur in the costs that we consume from this system in such a way that the revenue begins to exceed the costs again. What does that look like? At the end of the day, that looks like we need to have a significant decrease in how much health care the average American consumes. This is where we make our case for rehab, right? Somebody seeing you one or two times a week for maintenance therapy on Medicare that does not require any medications, any surgeries, any hospitalizations, that person is going to consume way less money than they would on average if they were not staying in shape and working with a physical therapist, right? This is how we justify our utility to the healthcare system. We need to make a significant dent in the chronic disease epidemic if we're ever going to have a hope of fixing this system. Now, I'm not a pessimist. I'm also not an optimist. If you know me very well, I would consider myself a realist. I'm not the person that's going to clap it up for you and tell you you're doing a good job, but I'm also not the person that has a bunker full of, you know, 15 years of canned goods and batteries and solar panels and that sort of thing. I'm kind of right in the middle. The realist in me says that we're not going to be able to turn this ship around in time to fix this. and that if you're listening right now and you're of working age, that you should do everything possible to ensure that you do not need to rely on Medicare yourself for your health insurance. when you will be Medicare age. You should also expect that the age to become eligible continues to get pushed back. It's not unrealistic to think that those of us who maybe are in our 30s or 40s now that in 20 to 30 plus years you may have to be 70 or 72 or maybe even 75 to begin to collect those Medicare benefits. That means you need to be able to provide your own insurance or otherwise pay for your own health care or Humor me, exercise enough so that you don't need to use a lot of health care because it's not going to be available for you anyways, right? And this is the message we need to imprint on our patients, especially if we can get them younger, right? Especially if we can get that 19 year old World of Warcraft player who doesn't like to exercise shake that person Spencer damn it will you please go and pick up some heavy stuff a couple times a week and get your heart rate up because you're looking at a really long life of decreasing quality and quantity of life and oh by the way in your future because you're so young nobody is going to be around probably to help you pay for that so we need to be realistic about that as well we need to understand why these cuts happen and There is absolutely, I believe, nothing we can do to stop or reverse these cuts. They happen across the board. They're beginning to happen to physicians as well. Everybody is being affected because we're getting closer and closer to that time point where these funds are going to slowly become insolvent. SUMMARY So that's Medicare, that's why we have cuts, why we have cuts every year. Why do we have cuts? We are stretching a limited amount of money and hoping for a brighter future to magically stumble along where somehow we start having more children so that our population shifts to have more young than old again, and also maybe a future where enough people take care of themselves to the point where they don't need to consume $16,000 a year on average from the healthcare system. Is it possible? I don't know. Call me in 10 years and check in with me. But I think it's important that we understand this baseline and have a knowledge of this both for ourselves to understand why sometimes in the clinic things happen the way they do and also to better educate our patients Hey, in the future, especially those folks who are younger or middle-aged, there's no one coming to save you. We need to find you something that you like to do every day so that you can save your future self, right? I love what the older adult division says. We're all older adults in training and we need to start acting like it. There may potentially be a future where there are no safety nets for us. It's you against the world. At the end of the day, if you have some sort of issue that causes you to enter the healthcare system, then we need to begin to prepare our bodies for that potential future. So if you're a Virtual Ice member, join us on Tuesday. We're going to talk a really deep dive into Medicare. We're going to talk about why it's relevant, yes, to insurance-based clinicians, but also how cash-based therapists can interact with Medicare patients as well in a legally compliant way that still sees them get paid for working with Medicare patients. So I hope you have a wonderful Thursday. Have a great weekend. We'll see you next weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 3, 2024

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses the top 4 "ins" and "outs" to geriatric practice in 2024. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETT Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of the lead faculty within our geriatric and pelvic health divisions and happy 2024. So I'm really excited because I have been seeing these like ins and outs of 2024 all over social media and I thought they were so fun. And therefore, I wanted to try and do the same thing for geriatric practice. I think it'd be so fun. So in today's episode, I am gonna be doing four ins and four outs for 2024 for geriatric practice. IN #1: HIGH-INTENSITY So the first, we're gonna start with the ins. And the first one that you know if you've been following MMA for any amount of time is we are going to put high intensity everywhere. And we recognize that high intensity is relative, but we have actually updated our content in the last year to just reflect that we cannot ignore intensity anymore. And that doesn't say that we're gonna ignore the accumulated effects of low to moderate intensity exercise. That's absolutely not it. It's that we cannot be afraid of high intensity exercise anymore when we have overwhelming evidence across all life stages and across a variety of different chronic conditions. So when we have octogenarians and individuals with lung cancer and individuals who have had a stroke who are successfully able to participate in high intensity endurance training or aerobic training, We can't ignore it anymore. It's just the evidence is just too strong. And so that is going to be our in is to push every single day to do something a little bit higher intensity than we previously would and play around with intensity as a variable. That's number one, high intensity everything. IN #2: USE OBJECTIVE MEASURES THAT MATTER Number two is that we need to get objective measures that matter. When we teach at MMOA Live, we always look around the room before we start our outcome measures lab, and we try and make outcome measures fun, I promise. I think it's fun anyway. We ask individuals, how many people are having a goal for their geriatric patients that are they need to get objectively stronger? everybody puts up their hands right if you're older adult can't get out of a chair without using their hands like their leg strength is less than their body weight which is a dangerous place for them to be because what happens if they they break their wrist and so that is almost everybody says yes this is what I want them to do when we ask how do you how many people take an objective measure of strengths that they know is that they're prescribing in the right intensity zones, that is usually a lot less. That's a lot less people putting up their hands. And I get it, we think that we have to wonder at max deadlift with somebody and that seems absolutely ridiculous for some of our patients who are maybe seated a lot of the time or have a lot of frailty on board, but that's not the case. That's not the way that we need to do or we need to always think about objective intensity. We have different ways. And so our in for 2024, number two, is that objective measures for function matter. And we are not going to know if we're hitting the right spot. There's always this Goldilocks equation, right? Like I've had people mad at me because I've been a little bit too hot on the intensity, but I've also left a lot on the table from being a little bit too cold. So we have to be able to objectively measure where we need to be and we need to know what we can do in order to hit those targets. So that's number two. IN #3: PRIORITIZING A FITNESS-FORWARD APPROACH TO GERIATRIC CARE Number three is that we need to start prioritizing a fitness-forward approach to geriatric care. And I know, you know, I would probably say that the geriatric space, with so much being involved in balance, false prevention, we're not as manual therapy focused. We always joke at ICE that, you know, which ones are our gericrew, because our hands are just not nearly as good as some of our orthopedic outpatient therapists. But There's this idea when we start talking about kettlebells and heavy bands and barbells that fitness forward approach and geriatric care is expensive. And our MMA crew, we have to just laugh. Like we laugh and laugh and laugh because if you look at the cost of a new step, our clinics are not hesitating to buy a $10,000 piece of cardio equipment but do not want to put in $1,000 in order for them to be able to get some true measurable objective strength training equipment. And Alan tells me, because he's a guru in this stuff, that you can get a lot of that reimbursed through a tax credit. So it is not as expensive as you think, and it doesn't have to be as in-depth as we are thinking when it comes to buying fitness forward equipment. And for our home healthers or those that are traveling, you know, having a heavy road ban and having one or two kettlebells in your car is not a huge investment. And it's absolutely something that we can do in order for us to take a fitness forward approach to rehab. So we have one high-intensity everything, two objective measures that matter, that give us information, and three is just prioritizing that fitness forward approach. IN #4: POST-MENOPAUSAL ACCESS TO HORMONE REPLACEMENT THERAPY And then number four, I have to put my Jerry UI, Jerry pelvic hat on, is that we're going to start removing some of these barriers for women who are post-menopausal to access HRT. There is a big push right now because we see, for example, that topical estrogens can significantly reduce rates of urinary tract infections. Urinary tract infections are absolutely devastating for some of our older adults. And there is a lot of fear. I'm pushing against it every single day in the clinic when I'm working with someone post-menopausal and I bring up estrogen and they say, I talked to my doctor and they said it's dangerous. It's going to give me cancer. they're not prescribing it and that is just so behind the times and that is not where we want to be so in 2023 going into we're going to get rid of it 2024 we're going to be advocates for it and we're going to have our own knowledge to be able to be able to give our clients up-to-date information about something that can significantly impact their health. I was just reading a cross-sectional survey on menopausal women who were active, and it showed that 68% of them, as they went through the menopausal transition, had an increase in joints, aches, and pains, which means that we're missing something oftentimes in our assessments if we're not trying to take into account estrogen status with how they're presenting in the clinic. So there are our four M's, high-intensity everything, objective measures that matter, a fitness-forward approach, and it isn't that expensive, and using HRT for menopausal women who may be eligible for it. OUT #1: DISMISSAL OF COMPLAINTS DUE TO AGE So let's talk about our outs. What are we going to kick out in 2024? Number one is we are going to kick out these dismissal of complaints based on age. We are going to kick them to the curb. Almost every condition in our medical system has age as a risk factor. The longer we are on this earth, the more wrinkles we have on our insides, we have on our vessels, we have in our organs. Yes, it is an increased risk for orthopedic musculoskeletal pain, for different signs and symptoms of functions at different organ systems, yes. but saying that it's because you are such age or that you should not have the expectations to feel healthy and vibrant at 70 because you're 70, that is not okay. We are going to stop dismissing complaints, stop saying things as physios like, of course you have bone and bone arthritis, you're gonna have pain in your knee or you're over the age of 60, pain is never going to be completely gone. You're never gonna be pain free again. Things that I've heard from a rehab clinicians in my area We need to stop dismissing complaints. OUT #2: ELDER SPEAK The second thing is elder speak. We're going to kick elder speak to the curb. Oh, I have a 99 year old. She's so cute. She was a surgeon. She has raised 10 children and has 25 grandchildren and is still a really active part of her family. I hear this on our courses all the time. Oh, I have the cutest 75 year old. It is meant well, but it is dismissing or infantilizing our older adults that deserve our respect and reverence. And so we are going to adamantly hold that line. And kind of our to be to this is we're gonna really focus on using patient first language. So many times when we ask like, tell me who you're going to work with to implement some of these things from MMOA on Monday, we say, I have a stroke that is 75. instead of saying, I have a person who had a stroke, who is 75. And it can completely dehumanize them. And we do it for quickness of communication often, but it is definitely something that we need to be better at in order to allow individuals to not have their disease central to their wellbeing and their identifiers as a person, right? We see this all the time, that individuals start to become their diseases. And if we speak like that, then it becomes so much easier for that to happen, right? We do not want to say you are your stroke. You are a person who is hopefully going to live a very high quality multidimensional life with impairments that you did not have before, but you are not your stroke. So I kind of put that as an elder speak bee, okay? So the first thing we're going to make sure we kick out is dismissing complaints based on age. The second thing is we're going to watch our own communication. We're going to kick out elder speak. We're going to kick out this patient first language, or we're going to use this patient first language. We're going to kick out identifying individuals as a shoulder or a knee, or I have a total joint replacement. Got three knees and a hip on my schedule. We're going to kick all that language out because it starts with the way that we communicate in our minds and with our colleagues, and then it trickles into the way that we communicate with our patients. OUT #3: BLANKET CONTRAINDICATIONS The third thing, this might be a little bit of a lofty goal, but I'm gonna say it anyway. We're gonna start removing blanket contraindications, right? If you've kind of been around our crew, you know that the bed lift twist restrictions after things like lumbar surgery, people go to the bathroom the first day, they're bending right away. They just have to be taught how to bend or something. We know that our hip precautions don't really do anything. And we have all seen that patient that comes in 10 years later after getting a stent done and says, well, I can't lift more than 20 pounds. I had heart surgery in 2014. And we're like, whoa, whoa, whoa, whoa, whoa. What are we talking about here? We need to DC those recommendations. So what we're starting to see over and over again is that blanket recommendations are kind of done based on theory of tissue healing. But we know as rehab clinicians that they all respond to stress. Right, our body needs to gradually reintroduce stress across a graft, across a surgical stalcar, across an injury, and that needs to be done in a nuanced, individualized approach, and these blanket recommendations oftentimes do not really help, and what they do do is create a lot of kinesiophobia. And oftentimes, because of the way that our medical systems are set up, where we don't have appropriate or adequate follow-up, because we're just so overrun with a lot of different medical professions, they don't get discharged. And so we wanna try and be really mindful of that. All right, elder speak, A and B, dismissing complaints, blanket contraindications, and then the last one, and I'm gonna end here, is that we are going to avoid taking a siloed approach to our rehab. OUT #4: SILO APPROACHES TO HEALTHCARE So often, PTs are not tapping the shoulders of our OTs, our speech-language pathologists, our social workers, our nurse practitioners, our pharmacists, and we think that we need to know all the answers. It is funny, the more education that I get, the more I realize how much I do not know. Every time we are doing a course, I get somebody teach me something new and We don't need to. We don't need to know everything because we have our colleagues. We have our friends. Our healthcare system is meant to be a multidisciplinary collaborative. process. And I know you all are looking at me being like, well, you know, it's got to go both ways. And I totally agree, especially with our physician spaces. And that is something that I'm really passionate about advocating for as well, is letting our physicians as well kind of pass the baton and say, I don't have the space, I don't have the knowledge, but this person does. And so what I want to see get kicked out in 2024 is this idea that we are our own island. because it just makes our patients feel so alone or so unheard. because the communication doesn't go back and forth. In our medical professions, we're starting to become so hyper-specialized that sometimes we only look at the tree and we don't see the forest. This is where our PTs, OTs, rehab clinicians, we do a good job of zooming out, but sometimes we put ourselves in these silos too. I'm not a pelvic floor PT, so I'm not gonna talk about your pelvic floor despite the fact that the reason why you're not exercising with me is because you're peeing every single time. I'm not a vestibular specialist, so you're gonna tell me that you're dizzy, but that's not in my wheelhouse, so I'm not going to talk about it, even though it's the biggest barrier to you exercising, right? These are all things that we silo ourselves within our profession, and then we don't often tap on or even look for other clinicians in our area that could be helping our patients. And so we wanna take this siloed approach, kick it out, and kind of an in is that we're gonna really try and lean on relationships with our colleagues. And it's hard in a really busy clinic, I get it, but we absolutely have a role to play and we want to lean on them so that we know what they are capable of. And so we wanna even know their scope of practice. So we have so much, so much work to do. SUMMARY So looping this around, what are our ins? High-intensity everything, objective measures that matter, a fitness-forward approach, and using HRT for menopausal females. What are our outs? We're not going to dismiss complaints because of age and just say, well, you're 80 years old. Nope. We are not going to communicate with elder speak or avoid patient first language. We are going to maybe hopefully get rid of some of these blanket contraindications, take a very gradual approach. And then we are going to kick out the siloed approach to rehab. Alright, if you are looking to catch MMA, our Level 1 and Level 2 courses. Level 1 starts January 10th, formerly known as Essential Foundations. Our Level 2 starts January 11th. If you are trying to see us on the road, our first courses back start the 13th, 14th. So we are in Maryville, Ohio, and we are in Santa Rosa, California, the 13th, 14th, and then the 20th to the 21st, we are in Clearwater, Florida, or you can catch me in Greenville, South Carolina. So hopefully we will see you on the road sometime this year, or we'll see you in our courses. We have some big, exciting changes that are coming around the ICE pipeline. So stay tuned, have a great day, everyone, and happy 2024. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 2, 2024

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses dealing with doubts in the clinic, how adopting a fitness forward approach can help solve a lot of "What if?" problems that arise when trying to pick "the best" intervention, the concept that doubt is bilateral, and how a fitness forward practice style can help build confidence with both patients & providers. Take a listen or check out our full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZAC MORGAN Alright, good morning PT on Ice Daily Show. For those of you who don't know me, I'm Dr. Zac Morgan. I lead in the Spine Division with both Cervical and Lumbar Spine Management. Great 2023 with all of you all on the road. Exciting 2024 ahead of us. So we've got a lot of changes coming with ice, so keep your eyes peeled. You've seen some of the certifications roll out. You're seeing courses pop up there on the website regularly. We will have more to offer there as well. So we're not fully booked with Spine, but we're getting close. So eyeball some of those dates. We'll cover those in a little bit. Let me start off by kind of debuting today's episode. DEALING WITH DOUBT So I kind of want to set the stage with a little bit of an overview of what I'm talking about when it comes to dealing with doubt. And why I think using a fitness-forward approach in the management of your patients with really any musculoskeletal issues or whatever issues they're coming to you with, I think using that fitness-forward approach adds so much certainty in those doubts. So what is fitness-forward PT and how is it different is a good place to probably start. Thinking about the concepts of fitness-forward PT and how that might differ from other approaches, I think this for me is obvious when you see it. Fitness-forward PTs are trying to at any corner to bleed fitness into their plan of care. They're trying to bleed health concepts into their plan of care. So rather than your first choice always being mobilization, or manipulation, or dry needling, or any of those things that we also love, you might see fitness-forward PTs just as equally choose something like isometric loading to reduce pain symptoms, use cardiovascular exercise to reduce pain symptoms. More on those types of things later, but I just think it's important to understand that those things could be utilized for the management, for the modulation of symptoms just as much as manual therapy and in fitness forward care you will see that. So we love highlighting these things. Let me tell you a little bit personally about why this episode is important to me. Early in my career the biggest thing that plagued me, the biggest thing that got in my way of helping patients when I think back to those times It was my own personal doubt. So I had a lot of personal doubt in the approach of care that I was delivering to people. That approach, for me, when I first started in this profession, centered a lot more around manual therapy. That was basically where my head was at, was trying to figure out the right mobilization for that person, doing it in the right direction, the right level of vigor. These types of concepts were always running through my mind in the middle of that evaluation. I wonder if this person would respond to thrust manipulation. I wonder if I should try grade 3 moving immediately. All of these concepts were bouncing around and I'll be honest with you all, what it led to for me was a lot of confusion and a lot of concern that I might be selecting the wrong technique for the person. "DOUBT IS BILATERAL" And what that ended up leading to clinically was doubt that was bilateral. So what I mean by that is that my client, they could start to tell that really what I was doing was somewhat bouncing around interventions trying to solve their problem. The problem was it wasn't solving their problem. So as we switched from intervention to intervention, that client often started to develop some doubt in my point of care. Perhaps just as importantly, if not more, I started to develop doubt in my plan of care at this time in my career. So I wasn't sure what was going on. I knew I was recognizing some patterns in front of me, but whenever I would see them, I wasn't sure exactly what the best solution might be for that person. And so I had a lot of doubt. And I think that then allowed space for that patient to also create a lot of doubt. OVERCOMING DOUBT So let's talk a little bit about dealing with this and what I think this kind of manifests as for most of us clinically. And I think this happens the most at the front end of your career versus the back end, but it happens really regardless. It's imposter syndrome. So if you're not familiar with imposter syndrome, this is that feeling you have where you're not quite sure you're good enough. where you think you might not be the right person for that client in front of you. If they had gotten the therapist next door, they would have been way better off, might be a thought that's going through your mind if you have a lot of imposter syndrome that you're dealing with. And I know I dealt with this tremendously, and all of the newer graduates that I talked to on the road, the ones that we mentor here at the clinic, all of these things, they often lead to imposter syndrome, and we get to the point that we're not quite sure what's going on with the patient, And that leads us to the spot of, I'm not quite sure I can help, and they would probably be better off with someone else. Well, team, we have to pull through that because we all have so much value we can bring to clients. And as you get further in your career, you start to believe that more, and it becomes a little bit easier to somewhat sell that plan of care to the client in front of you, to build them the bike, to get them moving forward. This happens to all of us at some stage. And so I think it's important to understand if you're there, what are the moves that I can make to get out of imposter syndrome? And if you're not dealing with imposter syndrome, it could always come back up. It's something that even to this day, there will be times where I'll have that moment where I'm like, man, I'm not quite sure. So it is something you will deal with clinically and it's something you want to be well prepared for because it has some clinical impact. The clinical impact that I was talking about before of lack of confidence, both for you delivering things to the patient, but also for the patient receiving those things from you. there is no doubt that there's clinical impact to imposter syndrome and we want to get rid of that. That way that clinical impact is all positive. The way I believe that we're going to do this is by shifting the manner in which we manage our patients. MOVING TOWARDS A FITNESS FORWARD MINDSET What I mean by that is if you're not already, you have to move towards a fitness forward mindset. You have to kind of underline your care with fitness forward. The issue with the way I did it early in my clinical career of being more like manual therapy focused. is that you're constantly using all of your brain power to try to figure out which mobilization the person would respond to. To try to figure out what direction, what level of vigor, how long should you do the mobilization. All of these factors are running through your mind clinically. And a lot of times, the answer doesn't live with manual therapy. The answer lives with what that person does for the remainder of the hours of their life when they're not on your table. That's a huge portion of what's driving people's pain scenarios. And the beautiful thing about that is the things that work for all pain scenarios are lifestyle changes. They're these fitness forward approaches. So you take something like cardiovascular training. So getting the heart rate up, whether it's for a short time at a higher heart rate or a long time at a bit lower of a heart rate, that no doubt will reduce symptoms. So in those patients that I'm confused on, I'm not quite sure what's going on, I feel a little doubtful, early in my career I would be trying 10 different mobilizations on them and by the end of that hour They would have got up probably sore, mostly maybe even just from laying in all those different positions while I was troubleshooting different techniques. But overall, they would often get up off the table, they'd be sore, and I'd be confused. They'd be like, ooh, it doesn't seem like Zac knows what's going on. In the back of my head, I'd be going, ooh, I really don't know what's going on. This person seems worse, not better. The way I would approach that person now is completely different, and that's because I've shifted in the direction of fitness forward. Now, when I'm unclear as to what's going on, if it's early, think like really acute neck pain, really acute back pain, those people that move through the door and you can just tell by looking at them, this person's not going to tolerate a whole lot of movement today. In the past, I would have badgered that person with a lot of manual therapy. Now, I'm going to get that person really comfortable and give them a cardiovascular stimulus. Maybe that's standing on the bike where they can use arms and legs. Maybe it's on the rower. Maybe it's on the skier. Could be the arm bike. It could be really anything. Could be the new step. The beautiful thing about cardiovascular exercise, it doesn't really matter how you leverage it. The pump gets going regardless. So as long as that heart rate gets up, you're gonna see some pain drop. I might would choose some isometric loading for this person now. I might would choose some breath work, right? Just having them in a comfortable position, just simply sitting down, thinking about nothing other than their breath, doing some physiological size or box breathing or 478 something to stimulate that parasympathetic output. When you think about this, this is a lot more global on the human than that local joint and how it moves. Do we want to address that local region with even with manual therapy? Absolutely. Does it always have to happen on day one? Absolutely not. And I think that's where it has shifted for me. So rather than being focused on kind of underlying my whole plan of care on did I select the right treatment plan, the right mobilization, the right progression of forces for this person who has a pattern of pain I recognize in front of me. Rather than doing that, now it's how can I get this person fitter? What in the world can I do to get this person to adopt a more healthy lifestyle? And in the short term, I still want to recognize those patterns. I still want to provide those positive stimuli, but at the end of the day, I'm trying to get after the big rocks, the big levers in their lives. FITNESS FORWARD BUILDS CONFIDENCE The reason I think this is so advantageous when you compare it to that manual therapy based approach, or just maybe more focus in the manual therapy based approach that I kind of grew up in in this profession, is it builds confidence. It builds confidence for a few reasons. One, you know that you've provided this person with something that's positive in their life. They may not get any exercise without you encouraging them to do this. you know what you've done for them is helpful and potentially life-changing. Like if you can convince that person to sleep a little better, you can convince them to do a little bit more on their day-to-day with exercise, that may dramatically alter the course of their life. The beautiful thing is, odds are pretty good it will also reduce their symptoms, which is why they walk through the door. Now if you did it the old way, you might be trying to select the right mobilization, the right direction, the right force. All of these factors would be at the foremost of your mind versus how do I get this person fitter. And while I'm okay with you thinking about these things, and I hope you're not hearing down manual therapy, I just don't think it's where your brain should be. Because when you think about it, if that doesn't work, and you get through the session the way I used to, at the end of that hour, the person's often sore. They're often a little achy, and they've lost a little bit of faith in what we're doing here, and so have you. And so that prognosis at the end of the session doesn't sound as strong. But when you know what you're giving the person is something that will be beneficial and positive to them, you can feel really confident when you deliver that plan of care. And team, in watching a lot of young therapists and doing this for a while now myself, I think the delivery of the confident plan of care, reassuring that patient, we see folks like you a lot, what we'd like to do now is X, that moment for patients is more important than what mobilization you selected. It's more important than what manipulation you did. It's more important than the direction you went. We want to create that moment where the patient goes, oh wow, I think they've got me. I think you will feel more confident delivering that moment when you underline your plan of care with fitness forward care versus when you're trying to select the perfect treatment. We have to absolve ourselves and understand no one knows what's going on with our patients. We're never going to have our exact finger on the pulse of precisely what's wrong with that person from a tissue diagnosis standpoint and it wouldn't matter if we did. What we do know is when we get people more towards a healthy lifestyle, when we give them some psychologically friendly understanding of what's going on, when we give them some skilled manual therapy, and when we do that in a fitness forward package, we move that person forward. And that has just given me so much more confidence in my plan of care delivery, as well as just prognosis delivery with those patients. And I see it happen a ton with new grads and folks that I mentor all the time. So I think the last thing I want to say here is if you still feel a little bit of that imposter syndrome and you still feel like, oh man, I'm not quite sure if I'm the right person for this patient to see who's dealing with acute back pain, I want you to think of where else they could go. So, yeah, not only could they not receive a fitness-forward approach, which is a bummer, but on top of that, if they didn't go to you, who may not know what is going on and may be a little nervous about treating this patient, if they didn't see you, they might go to Urgent Care. They might go to the emergency department. Those places are no place for you if you have acute back pain, if you have acute neck pain. You need to be in a conservative provider's office. Now if that conservative provider decides that you need to be elevated into the healthcare system, so be it. But we need to be at the forefront of that. Because think about it. Not only do costs go up, think about the psychological sequela of going to the emergency department first. having that scan done, being told here's what's wrong. Think about the patients you interact with who have chosen this route that right now are probably the most frustrating ones on your schedule. We have to get them out of that muck and if we sit here thinking what we do isn't effective, we'll never be able to get patients out of that muck. We have to be completely confident that what we deliver is the most effective thing that they could get and And that is fitness forward care. And when we deliver that, we can be confident in it. And when we're confident in it, we can pull people out of that muck of the healthcare system. This is the point of today's episode. And so team, I think that's why we, that's the way in which we can deal with doubts and shift away from imposter syndrome. So just quick summary. All of us deal with imposter syndrome. We all deal with doubts. There are times where a patient is in front of you and you go, man, it could be one of these three patterns and I'm just not quite sure. Rather than trying to be perfect and select the perfect treatment every single time, why don't we select the actual best treatment for that person, which is probably to move them more towards health. That may come in the form of fitness, it may come in the form of sleep improvements, perhaps changing some of their dietary factors, dealing with their stress differently. TINA could be any of these factors, but we have to be ready alongside of this person to move them dramatically in that direction quickly, so that when their symptoms start to drop, they associate that with those health behaviors. Once we get that association going in their brain, You just changed the person's life. You didn't just stop at back pain. Sounds dramatic, but it's true, and that's what we're after. So team, the way we deal with doubt is to use fitness forward care. The beautiful thing about fitness forward care is even if you were wrong, you helped the person. You helped them dramatically. So even if you thought it was a derangement, it turned out to be a dysfunction, doesn't matter. That person still left 1% fitter. That person's moving forward, dramatically in their life, you're going to figure that out session over session. So the next time you see the person, it may be a different pattern. That's the point of the symptom behavior model. That's why we gather data. That's why we look at asterisks, so that we know we're helping. So maybe the pattern wasn't perfect on day one, but when you choose fitness forward, the treatment will be. SUMMARY Team, that's all I've got for you all this morning. I just want to kind of last wrap things up with a few quick point outs of where we're going to be on the road this year. So starting in Q1, if you're looking for a little bit more in the clinical reasoning realm, if these words like asterisks and rechecking asterisks and kind of forming that plan of care or things that you're looking to improve on in the new year, I would definitely suggest jumping into cervical or lumbar. That's where we really focus on those clinical reasoning measures. And in February, on February 3rd and 4th, we've got two courses for you. So there's Hazlet, Texas and Wichita, Kansas. be aware Wichita, Kansas only has a couple seats left, so if you are near there and you want to jump into that course, do it soon, because that course is about to sell out. And then at the end of that month, February 24th and 25th, West Coast, Simi Valley, California, so right outside of LA, that one's selling really well too, so there won't be a whole lot of seats available by the end of that. So if you're looking for any of those, jump in. If you're looking for lumbar management, January 27th and 28th, Rome, Georgia, Cincinnati is close to sold out. That one is actually the March 9th and 10th, and then March 23rd and 24th, Milwaukee still has some seats left. So if you're looking for either cervical or lumbar, those will be your Q1 dates to look for. That's all I've got for you all this morning. If you want to continue the conversation here in the chat, I will be on it all day, but thank you for your attention this morning, and I will see you on the road in 2024. SPEAKER_00: Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jan 1, 2024

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan defines interrectus distance and how to measure it, how to functionally measure core strength, and the limitations of focusing on interrectus distance with patients. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALEXIS MORGAN Good morning, PT on Ice. Getting both our cameras going here. Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan, and I am excited to be with you on this morning, this new year. Happy New Year, everyone. And let's talk about measuring IRD or inter rectus distance versus measuring strength. Which one matters more? So to jump right into the topic here, Interrectus distance is a common measurement that individuals are going to be taking in pelvic health. WHAT IS INTERRECTUS DISTANCE (IRD)? So interrectus distance is the distance or the measurement of the linea alba width. It's that linea alba between the rectus abdominis on the left compared to on the right. What is that distance between? That's our interrectus distance. Many people advocate for measuring interrectus distance. Number one, it's measured in a lot of our scientific studies that is looking at diastasis recti. There's a lot of studies that are looking at it. And so if they're looking at it in the studies, well, maybe we should be looking at it in clinic as well. It's also repeatable. We can measure it the exact same way and we can see if there is change. And we like data that we can measure and we can see if there is change. So people are definitely advocating for its use. There are some benefits from measuring change. Obviously, you're here at ICE, you know that we are recommending to be able to test and retest to see those differences in all aspects of care. So, of course, we should be recommending that here, right? Well, we do recommend testing and retesting in this space. MEASURING STRENGTH However, we recommend measuring strength. So, measuring strength entails getting functional with your clients. One of our favorite tests is the sit-up test. We talk about it in our online course, and it is a way in which you can measure how strong an individual's rectus abdominis is. So they're sitting up. How much support do they need from their legs? How much support do they need from their arms? Do they need to whip themselves up or can they control themselves up? Do you need to hold onto their feet or not? This gives you a score. And with that score, we can then track change over time. It's extremely functional. This is what individuals are doing when they're getting out of bed or when they're getting up out of the floor with their little ones. This is also very functional for all populations. So not just the postpartum individual, but this is also helpful for individuals who are post hernia surgery or pre-hernia surgery. This is great for individuals with varying levels of adiposity. You don't have to measure, you don't have to assess something and be distracted or be, oh, I don't really know what I'm looking at because there's adiposity. We're just measuring strength. We're just testing the functionality. LIMITATIONS OF IRD When we think about the limitations of measuring the interrectus distance, Really, I could go on for a long time here. There's actually no known pathological number or centimeter or measurement. There's no known measurement that we all are in agreeance of like, yes, that number is pathological. We don't have that. In 2021, a recent paper came out and actually I believe Rachel did a podcast on this exact paper. So I'm not going to go into all of the details. You can search back to listen to this, but in 2021, a paper came out looking at individuals ages 20 to 90 males and females of all BMI sizes, looking at their CT scans and they measured the interrectus distance. With all of these people, 57% had greater than two centimeters in that interrectus distance. Now for reference, over the last 70 years, much of the data, much of the science that is looking at diastasis is using measurements, oftentimes in centimeters, and they vary. There's no agreeance in these studies. So sometimes there are two, sometimes it's 2.2, sometimes it's 2.5, that that one particular study calls pathological because there's no known pathological. But around that two centimeter mark, Well, now we have this study just in 2021, looking at what is normal. And we see that 57, so over half of the individuals actually had greater than two centimeters. So there's a problem here. We can't call this pathological of more than half of the individuals of all ages, of all BMIs, parity being one risk factor, but BMI and age also being risk factors. We can't use that. Not to mention in all these studies there's a variety of tools that are being used. So measuring with just fingers, measuring with calipers, measuring using a ultrasound machine. There's a lot of different ways to measure and of course those are going to be different between different tools. We don't have any standards. We don't know where exactly should we measure. In all of these studies, sometimes it's a couple centimeters above the belly button, sometimes it's more, sometimes it's less, sometimes it's right at, sometimes they avoid. There is no absolute on where we should measure, nor the type. It's all over the place. And one of the aspects that I think is the most concerning here is that, well, I've just laid out one, the fact that we don't have any agreement on any of this. Why are we doing, why are we measuring? FOCUS ON FUNCTION AND NOT APPEARANCE But number two, when we're measuring, we are perpetuating this focus on the looks. We're focused on what they look like and what that measurement is has nothing to do with their function. We talk a lot in our level one course on diastasis and a big aspect that I'll have to leave for another podcast on another day, or you can join us in our course, but another aspect of this is body image. And many individuals are very concerned and have body image dissatisfaction. If we can help them by shifting the focus to function in our little space, absolutely we recommend referring out to mental health professionals to help with that. But in our little space that is the physical world, If we can help by shifting the focus to physical and to function, then why would we not do that? Especially when there's a lack of evidence for clarity on measuring that inter-rectus distance. Our newest research in this space in the last handful of years, our newest research has shifted in this direction. it shifted in measuring abdominal torque. the rotational torque that is that one can generate power. Why? Because that's functional. Or that sit-up test, like I mentioned, it's functional. Our newest evidence is heading in this direction. Let's not wait 20 years. Let's go ahead and jump on this train and let's start measuring function today, this year, for 2024. Let's measure function and let's focus on what matters. for our clients, and let's follow this research. And when we do that, we know we can absolutely help them increase in their function. We've got no doubt about it. I know for sure if you can't do a full setup, I'm gonna give you the modifications and I'm gonna give you that home exercise program that will allow you to do a full setup in due time. I have no doubt about it. I can sell that so easily and I would hope that you can too. So let's stop focusing on interrectus distance. Let's start focusing on function. Our recommendation is that if somebody comes in and asks for an interrectus distance measurement, if they're asking you to measure, and they fully believe in its importance in their rehab, that would be the only time in which you would use measurement. Other than that, other than they're asking for it and there is a significant belief in its importance, If those two things are not both on the table, then we need to set the measuring IRD aside and focus in on strength. Thank you so much for joining me this morning. I hope it made you think. It's something we've been thinking a lot about, both in reading the evidence and in practicing clinically. And I hope it helps you focus in on what matters this year for your patients. This material and a whole lot more is in our online level one course. Our course starts next week. It's absolutely sold out. We are closing, we will be selling out for the March cohort well before March as well. So if you are wanting to get into this level one course, it's been revamped, all brand new. If you want in, you should go ahead and register for that March cohort. If you've taken our online courses before, online level one before, then you will be interested in our online level two course. And that is a brand new course, which starts April 30th. If you want to catch us live, we're going to be on the road a lot in 2024. All of that's on the website. You can see it. I'll just mention the few that are coming up in January and February. We are going to be in Raleigh, North Carolina, January 13th and 14th, Hendersonville, Tennessee, January 28th and 29th, and Bellingham, Washington, February 3rd and 4th. We are so excited to see you all out on the road in 2024 and can't wait to see you all online as well. Have a great day. Happy New Year. And we'll catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 29, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses assessing & treating for issues related to shoulder internal rotation & extension limitation with overhead movement in the fitness athlete. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning's off to a great start. We're here at Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things fitness athlete, CrossFit, Olympic weightlifting, powerlifting, endurance athletes, and any recreationally active person. we talk about how to address those concerns. I have Dr. Haley with me here today. She's going to be my demo for some hands-on stuff. If you are listening to the podcast right now, I don't know why I pointed to my ear. If you're listening, you can't see me anyway. If you're listening, please switch over to our YouTube channel and watch the video because about halfway through, I'm going to show a lot of hands-on assessments and techniques, and you're not going to be able to see that if you are just listening on the podcast. SHOULDER INTERNAL ROTATION & EXTENSION: ANATOMY Today, what are we talking about? We're talking about the combined motions of shoulder internal rotation and extension in the shoulder, especially its relevance to the fitness athlete. So when we talk about these motions, we're primarily talking about the subscapularis muscle of the rotator cuff and the shoulder blade. So this muscle gets neglected a lot, mainly because most human beings no longer exercise, which means they are no longer vertically pulling and pushing above their head. So they're often not needing to use a lot of internal rotation and extension of the shoulder because they live their life with their arms relatively neutral. But if we look at the actual anatomy specifically of the subscap muscle, we know it is actually the largest and strongest rotator cuff muscle. It takes up the whole anterior portion of the shoulder blade on the anterior side of the scapula and is primarily responsible, yes, for internal rotation, but when the arm is elevated or out in front of the body, It also performs some combined motions of adduction and extension. It functions very similar to our lat muscle. So we have our subscapularis and our lat muscle counteracting all the other muscles of the shoulder and the rotator cuff that elevate our arm above and overhead. Most importantly, from the anatomy is knowing the attachment points. It attaches right on the anterior capsule of the shoulder. And when we see referral pattern, we can see anterior shoulder pain, folks point directly to a spot right on their anterior shoulder. But it also has referral into the posterior rotator cuff and into the medial scapular border. So a lot of times we can chase treating the posterior rotator cuff, especially in the fitness athlete when we actually need to be treating subscapularis. SHOULDER INTERNAL ROTATION & EXTENSION: ASSESSMENT Now how do we know this is a target for treatment? Well that's going to be revealed in our subjective and objective exam. So when someone comes in and I'm gauging their symptom behavior and I'm getting a list of their eggs and eases, especially with a fitness athlete, I'm looking to hear things like pain with dips, pain with bench, especially in the bottom position of a bench press, things like pain in the turnover, or what we call the catch of a bar or a ring muscle up, handstand push ups, again, especially the lowering the eccentric phase, where we're now going from an overhead, flexion, abduction, external rotation. And now we're lowering eccentrically into extension and internal rotation, very similar to the bottom position of a bench press. And then in that pull, that high pull motion that we have in our cleans and snatches with Olympic weightlifting. So when I hear aggs like that, my hypothesis list subscapularis jumps up. I'm looking to assess internal rotation and extension in that athlete, much more so than that sedentary person who comes in and complains of shoulder pain. I'm really not thinking this person is probably having a lot of issues with loaded internal rotation extension in the gym. because they don't go to the gym, right? That is a person where I'm probably going to look to the posterior rotator cuff and maybe the lats for strengthening and the delts for strengthening and just basically get that person's shoulders stronger versus specifically addressing a specific muscle like the subscapularis, which I would with a fitness athlete. So let's talk about how to actually assess the shoulder. So I have Haley here. We're going to demonstrate on her shoulder. You're all probably very familiar with this seated screen. It's something you learned in school. We're going to go through it really quickly. So having Haley lift her arm up and overhead and sitting to look at flexion, coming out to 90 degrees to look at abduction. We can meet in the middle and look at scaption at that 45 degree angle like that. We can put our arm at our side and now we can look at extension. And then we can hold our arm at a side and we can go across the stomach, internal rotation, and then out away to look at external rotation. Now what do we like about that screen? It's a screen, that's it. I hate almost all of that for the fitness athlete. Why? It's really not challenging a lot of true end range positions, especially of extension and internal rotation. The main thing to remember about internal rotation is if Haley's arm is at her side and she's internally rotating, she can palpate on herself. When the arm is at the side, the pec is the main mover there. It's not actually subscap or the deltoid at all. So when the arm is at the side, we're not even challenging actual internal rotation. We're using nothing about the subscap at all. Likewise, if we're seated and we're going through extension, I need to know how can I challenge sheer force to the shoulder like it might encounter in a bench press, a muscle up, a handstand pushup. I can't do that in sitting. SHOULDER INTERNAL ROTATION & EXTENSION: DITCH THE SEATED EXAM So for fitness athletes, we need to ditch the sitting exam and we need to go prone for the shoulder. So I'm gonna have Haley lay on her stomach here. We're gonna look at her left shoulder. We're going to look at internal rotation first. So I want her arm out at 90 degrees, about parallel with her shoulder, and I'm going to instruct her to bring her palm up towards the ceiling. And I want to look at that internal rotation. So we're cheating a little bit here, a little bit of abduction, but we have a really good assessment of internal rotation here. I can overpressure this as well. Haley, don't let me put your hand down. And I can look to see if that's symptom-provoking. So that is how I will assess internal rotation. Is the motion full? Is it provocative with an overpressure test? We can also look at extensions. I'm going to have her scooch a little bit to her right. She's going to bring her arm up at the table next to her side, and then she's going to lift her arm up in the air. And I'm looking to see, again, does she actually have full straight plane extension, or does she drift out into a lot of abduction? Good motion here. Same thing. I'm going to overpressure this. Don't let me push you down. And I'm going to see, is that symptom-provoking? So I'm going to challenge extension in a manner where gravity is providing sheer force through the labrum for me to see if that's provocative. And then I'm also going to overpressure the arm to see if I can overpressure and get any symptom provocation out of the shoulder. The last test that I will do is I'll have Haley stand up and then she's going to turn her back to the camera. We call this the liftoff test. It's also called Gerber's test. Very old test, almost 30 years old now. Tons of great research on it. So I'm going to ask her to pick a hand and I'm going to have her put it in the small of her back. And really I'm going to see how far up her back she can go with that hand. So can she go any higher? Good. Some of you might measure range of motion this way. That's great. I usually see what level of the spine can the thumb get to. Very functional for women, right? Somebody that can't even put their hand in the small of their back is probably going to have a lot of trouble with something like taking a bra on and off. But we get a good measure of range of motion. We know that if she can reach the small of her back, we're primarily now looking at subscap. A really good study by Greece and colleagues way back in 1996 found that if someone can get their hand in the small of their back versus down at their glutes, that just by getting it higher to the low back, we can get 33% more subscap activation. So I know if a person can achieve this position, they have really good range of motion out of that subscap muscle and that we're primarily now looking at subscap in isolation. What do we do now? We do the actual lift off. So I'm going to have Haley lift her hand away. She can lift her hand away and keep it approximately in the small of her back. And then if that's not pain provoking, at this point I am confident in ruling out subscap. Why? This test has 99% sensitivity. If that is negative, I can cross subscap off my hypothesis list and now I can look a little bit deeper into the shoulder. All of that has only taken us eight and a half minutes with a lot of talking. This is something you could probably do in a minute or less in the clinic and immediately rule out the subscap and be really confident that it's not the subscap. So, Haley, go ahead and have a seat. SHOULDER INTERNAL ROTATION & EXTENSION: TREATMENT So, what if it is a subscap, right? What if somebody like me walks in, my left shoulder looks okay, my right does not, Immediately I'm thinking I know which side I'm going to treat. I know which muscle I'm going to treat. We're going to talk about treatment next week. Zach Long is going to get on here. But the main thing is we need to restore that internal rotation range of motion, especially under load. Why? These folks are using this range of motion in the gym or they're trying to use it, which is maybe why they're bumping into symptoms with things like handstand pushups and Olympic lifting and muscle ups and that sort of thing. So we need to restore that full internal rotation range of motion. we need to increase its load tolerance, and we need to, in general, get the shoulders stronger, both delts and lats. But specifically, working on the subscap is going to give a lot of benefit to that athlete. So someone like me, I would needle my own right subscap, try to improve some of that range of motion, and then try to load that internal rotation. We'll talk more about treatment next week with Zach. He's gonna do a follow-up episode specifically on how to treat the subscap for the fitness athlete. So make sure you tune in next Friday. That's all we have for you today. I hope you have a fantastic weekend. Courses coming your way. Head on over to ptinex.com. Remember, all of our courses priced at $6.50 will become $6.95 on Monday. So if you have a course on your list, make sure you buy it over the next couple days and avoid that price increase. All of our courses from the fitness athlete division are on PTONICE.com. Hope you have a fantastic weekend. Have a wonderful new year. See you next week. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 28, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses balancing consumption with creation, the illusion of consumption as productivity, and the need to be authentic to stand out. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MOORE Okay, team, what is up? Welcome back to the PT on ICE Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of ICE, and always thrilled to be here on Leadership Thursday, especially as we go into a new year, and always happy to be here on Gut Check Thursday. And this one's gonna be a little bit different. I present to you our Gut Check Thursday for this week is a 36-hour water fast. So maybe it's a little bit of a pushback against some of the excess of the holidays, kind of pulling that back in, especially around New Year's Eve time. We are going to run our official Ice Physio Water Fast from Friday at 5pm until Sunday at 5am. So it's going to be 36 hours. We're going to break that Sunday morning. Um, for those of you that don't know, um, over at ice physio, we have a relatively large group of us that does a 36 hour water fast every month. And then a prolonged three day fast every six months, which we're actually moving to a four day fast. Um, in the middle of next year. Um, again, that'll be our first four day water fast. Um, that'll be done annually, but, um, lots of thoughts behind this. Um, a lot of things about, kind of the qualities of restraint and enjoying maybe the exact opposite of excessive consumption that we're oftentimes so drawn into, which is the topic of today's episode, but a really good time of year to maybe pull in those reins. So over the next week. See if you can find a 36 hour period where you can just consume water. And feel free to consume it liberally, but I think you'll find it, if you have not engaged in this, to be both a unique experience and a very, very productive one. Not to mention maybe some benefits in longevity and you think about apoptosis and the ability of your body to clear some of that stuff out. Join us. It's both a mental and a physical feat that we think has some great rewards. So that is the Gut Check Thursday. It is not adding on to high-intensity stimulus. Over the busy week, it is in fact going the other direction and see if we can't exercise our restraint for a 36 hour period. So if you have any questions, hit me up, let me know. It's something we do every month and we love it. We'd love to have you join us. We will be going in Friday, 5 p.m. AUTHENTICITY Sequels suck. I think we can all agree with that. So let's dive in and talk about why. And I want to give you an action item as we are about to turn the calendar page to 2024. I want to leave you with a thought to maybe move in the opposite direction of what is too commonly done, not unlike the gut check Thursday this week. So we all agree that sequels suck. The question is why do sequels consistently suck? And of course, there's some exceptions and we don't need to play that game. Generally speaking, they leave a bit to be desired. Why? The answer is that it's impossible to be authentic when you're copying from a template and people connect with authenticity. One of my deepest beliefs is that real makes you feel. If you're wondering why in a certain relationship or when you were listening to a certain speech, you felt particularly captivated, it's because the person was being real. Whether you're delivering or receiving, real makes you feel. is a tried and true reality. There is something unique that each of you bring to any situation to bear that nobody else possibly could because it is uniquely you. When you present or deliver or connect from that space, it is absolutely captivating. Sequels, by design, make that impossible, right? It can't be truly unique because you are intentionally building off a template. And so there is already the impossibility of that uniqueness to fully manifest in that piece of work, which is why we tend to really struggle to connect with sequels. Now, many people have become sequels. This is why a lot of times content is boring. Sometimes I hate to say this, but it's why sometimes relationships or engaging or people themselves seem to lack a bit of sparkle because so many people have become sequels and they're not trying to do this, right? There is just too much information coming at us. If we don't want to become sequels, if we don't want to constantly be consuming all this information and then essentially just building off it in the same way a sequel would, you have to schedule breaks from it. REBALANCE CONSUMPTION AND CREATION What I'm saying is you need to rebalance intentionally consumption and creation. The problem is consumption feels like you're moving forward. This is where most people run into trouble, right? There's so many good things, so many great books, so many amazing podcasts. There's so much out there that you want to consume. And while you're constantly consuming it, you feel like you're moving forward. But there is undeniably a ceiling or an upper limit on where that is no longer a reality. The best analogy I have for you is it's like taking notes on your notes, right? That always used to bewilder me. I would watch people take notes in class or whatever. Then they would go to the library and take notes on their notes. And it's this never ending, right, reading and reading and reading and feeling like you're learning, but you're not. If you really wanna learn, stop. Stop and think about your notes. Stop and actually listen to that person talking and think, man, what do I and don't I believe? What naturally jives with me and where do I feel some dissonance? Now, where that dissonance is, why do I feel that? Get in to the thought and the why and the wonder. Because that's when things really start becoming a part of you. That's when things truly assimilate and become usable. It's not just constantly reading and copying and reading and copying. It's when you stop and say, what do I think about that? How does that jive with what I've known up until now? It's when you pause that the actual learning happens. Even though the constant consumption feels like learning, it's when you pause that you allow the knowledge to change you. And so when you're constantly consuming, that second part never happens. STOP READING & START LEADING Which is why my action item for everybody in 2024 is to stop reading and start leading. Stop reading and start leading. Create between every knowledge acquisition. This is my challenge. And I don't mean stop reading entirely. I mean begin to develop a more balanced schedule between creation and consumption by committing to creating in between every knowledge acquisition. As opposed to finishing the end credits on one Audible book and starting the next one immediately. Give yourself a break. to create, to think about how that, what you just engaged in, altered you, changed you, challenged you, and do something with it. Now I wanna give you an actionable how, because I think sometimes we get into this philosophical space and don't deliver that. My how for you in 2024, if you're trying to rebalance consumption and creation, is to have a forced content schedule. Meaning something that you commit to putting out for somebody Okay, this could be for your business your community your family your gym your church, right? Whatever you're involved in commit to a content schedule being forced to create At a regular rhythm is the greatest way that I know to successively approximate your true self, meaning your unique self, meaning the thing that people are drawn to and captivated by because nobody else could be that thing. Being forced to create at a regular rhythm is the greatest way that I personally know to successfully or to successively approximate your true self. Commit to a schedule. As I kind of look at my world, there's nothing I'm more thankful for than this podcast is a great example, which every week we're having to think about how do we think about things and how could we share that with our community. And I think about things that we do at ICE like hump day hustling or even gut check Thursday, like coming up with that fast this morning, but we are committed to you all. that we're going to put things out for you. And that forces us, if we don't just want to be replicas, to be original and think about what we want to share, what means something to us. And that allows us then to come to these platforms and try to successively approximate our true selves. And that process is really in many ways, in my opinion, anyhow, what life is all about. And certainly one of the things we enjoy most about sharing and receiving is when we do successfully approximate our true selves. So commit to a rhythm. In new years, in this new year coming up in 2024, don't create an endless consumption list. Instead, share your unique creations on a committed schedule. It will force your hand. It will make you say, well, I can't go consume nugget number 7,206 this week. I need to pause because I said I was going to put something out. I need to stop taking notes on my notes and start doing some real thinking because I need to bring something to bear. Commit to creating regular organic content to somebody, to your family, gym, church, business, community, whatever, and decide that in 2024, you're never going to miss one of those marks. You are going to find by the end of the year, that you have learned so much about the way that you think about the constant stream of information coming at you. And it will be that that will carry more value than I promise you any single part of that endless, incessant communication or information stream, because it is your uniqueness you're trying to find and share with the world. And it is that which they will receive most voraciously, I promise you. In 2024, let's rebalance consumption and creation. Team, big alert on the courses. The prices go up Monday. So if you want to grab an ice physio course, all the 650 courses go to 695 on Monday overnight. So you need to grab those courses by Sunday. If you want to save whatever it is, 45, 50 bucks a course, it's not a huge amount of money, but if you're going to grab a couple of courses in 2024, grab those ASAP so you're not paying extra. over at PTOnIce.com is where everything lives. Team, have a wonderful new year. Enjoy the weekend. For those of you joining us on the Water Fast, Friday at 5 p.m., we'll cut off the nutrients, all water, till Sunday morning at 5 a.m. I promise, it's a unique stimulus that is highly productive. Cheers, team. Have a wonderful weekend. Happy New Year. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 27, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses research supporting the effects of high-velocity resistance training on older adults, including benefits for bone mineral density, the effects of detraining, and different ways to implement power training with patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MUSGRAVE Welcome crew to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here with you. Hopefully you have been enjoying the holidays however you enjoy to celebrate over the last few days. Super excited to bring to you really interesting systematic review looking at high velocity resistance training for adults 50 plus. So what we're going to be covering today is you know what are the primary results, what can we learn about dosage when implementing this intervention for adults 50 plus and then we're gonna spend actually quite a bit of time talking about clinical considerations for this type of information and talking a little bit about just the body of research that already exists. So let's get into it team. This systematic review included 25 randomized controlled trials. We had 12 original studies. We had 13 follow-up studies. What they did is they were applying high-velocity resistance training to older adults. People 55 plus and they define this as having a slow eccentric phase with a explosive concentric phase. So in general, we would just reference this as power training, right? Kind of like a broad jump where you're going to slowly load the movement and then you're going to explode. then the other piece of this is having additional resistance with this. So traditionally this is basically just power training. Power training could include jump training, it could be Olympic style lifts like snatches or cleans with dumbbells, barbells, whatever implement you want, kettlebells, any of those type of implements. EFFECTS OF HIGH-VELOCITY RESISTANCE TRAINING ON BONE MINERAL DENSITY So What they did is after they included their studies that met their criteria, they dug in and they had to have pre and post DEXA scans to figure out what their bone mineral density was at the beginning and then also at the end. They also had to have a six-month follow-up One of the studies actually had a 16-year follow-up, which is pretty wild. Being able to get a randomized control trial with a year follow-up is pretty great, but 16 years was pretty wild. So they looked at bone mineral density at the femur, the femoral neck, the lumbar spine, and also the distal radius. Only two of the studies looked at the distal radius to see if there were any changes in bone mineral density. The rest of the studies did not look at that area. Unfortunately, those two studies showed no change. So we'd need to dig into those studies more specifically to look at the loading strategies for those to really try to figure out what happened there because we know Basically, in general, our body's gonna respond to all the load. So if we get proper loading, due to Wolf's Law, we know those osteocytes are gonna start producing osteoblasts, and then we're gonna lay down fresh bone if we get proper loading. So no changes in the distal radius with using high-velocity resistance training. They did, however, find statistically significant results looking at the total femur on the DEXA scan, the femoral neck, as well as the lumbar spine. So there were statistically significant findings there using high velocity resistance training, AKA power training. So that was pretty cool. So we know that that is a modality that would be beneficial. The dosage, if we're moving on from what were the results, so it was beneficial, then the results were the results in the dosage were that twice a week is kind of the minimal dosage to see change in the skeletal system. So at least twice a week is what we should be looking for for dosage. Unfortunately there was so much heterogeneity in our different interventions that they weren't able to conclude a specific loading percentage. We do know just in general when it comes to power training that our percentages are going to be lower than resistance training because we're adding the component of speed. So if we're going to slowly get into that eccentric position to then explode into concentric, it can't be at the same percentages that we use at resistance training. So we know as a blanket statement that it's lower load than resistance training traditionally is. But what that is, there was not any formal consensus found from the systematic review. But they did find that two times a week is the optimal frequency that we're looking for if we're trying to change the skeletal system. they did find because their minimal follow-up was at six months, that if there was no training across that six-month period, that the gains that were created were also lost. THE EFFECTS OF DETRAINING So we want to keep that in mind that detraining, just like for the musculoskeletal system, the skeletal system as well, if you don't maintain those results, you're not going to be able to keep them. A really easy way to think about this is fitness is forever. It's just like brushing our teeth. We don't go to the dentist and say, well, you know, you've done a good job the last 50 years, so you know what, let's just take off the last 40 years. You don't really need to brush your teeth anymore. No, the results are not gonna be sustained and the same thing goes for our skeletal system. So once we get those results, we wanna make sure that we're getting people to be loading their bones at least twice a week. And this to be a thing that it's like, it's gotta be scalable across a continuum, across a lifespan for people, or it's not gonna necessarily be beneficial. We can give them a little bump, but that just makes it so much more important. that we're selling fitness from day one. What are you gonna do once care ends? If you wanna maintain these results, we know we can give you results. We know we can get you there, but you're gonna need to continue this training, kind of indefinitely. So finding fun forms of exercise that's gonna include high-velocity resistance training to help maintain bone density is helpful. Now, where we're gonna spend the bulk of our time is on clinical considerations. So I talked about there being high heterogeneity in our interventions. So the interventions included dumbbells, they included machines, resistance training. I found this very interesting. There was actually a masters football team that was included in this study, which I think is super cool. There were also some Olympic lifts that were being completed. in this study as well. Now, probably the most disappointing part of this study for me was this quote, which I'm gonna read to you. It may be unlikely that older adults are willing to engage in Olympic style lifting or soccer and that performing explosive concentric with slower eccentric movements using machines or free weight style equipment may be more feasible, safe and result in better adherence for the population. Now that was researcher opinion. And I can understand if you've got someone that is super sick, super frail, super deconditioned, it may not be feasible to get them out playing football or playing soccer. But when we're thinking about our active 50, 60, 70, 80 year olds, I mean, we've got people pole vaulting in their 80s. These things are not out of reach for older adults. For them to be doing Olympic style lifting, explosive type movements, Just anecdotally at Stronger Life, we do tons of agility, power, jump training with people all the way up into their 80s with no injuries. So a little disappointed in that statement. I can understand clinical practice, maybe we're talking, you were in the ICU, you're in acute care, you're like, okay, yeah, we're not probably gonna be playing soccer in my sessions. "THE NEEDS OF AN OLYMPIC ATHLETE AND OUR GRANDPARENTS DIFFER BY DEGREE, NOT KIND" But when we're thinking about long-term, we're thinking about strategies for for people that are over 50 like these are not out of reach we can absolutely be doing olympic style lifts and it reminds me of the quote from coach greg glassman who created crossfitted the needs of the of athletes and our grandparents are the same. They differ by degree, not kind. We need these types of interventions for our older adults to help with their bone density. And I would argue that power training, Olympic-style lifting, some of these more explosive-style activities are actually way more fun. I mean, let's think about pickleball, for example. Pickleball has tons of power training incorporated in it. And I would say, although it is becoming more popular in younger populations, I would say 50 plus probably has a market cornered on those style of movements. So the big takeaway there is don't count out power training for our older adults, Olympic style lifting. where they're moving quickly. Now another interesting discussion in there while we're talking about power training is that there were specific adaptations that were special to some of these cutting and power agility type movements that they described as odd stressors. So when we're thinking about the bone, if the load is only in one direction, we're only going to get adaptations, by and large, in that direction. When we start thinking about loading the bone from different angles with different cutting and different movements, then we can get adaptations in different directions, which, by and large, is going to help make our bones more resilient, less likely to fracture if they've encountered load in multiple directions and odd type stressors. POWER TRAINING VS. RESISTANCE TRAINING Now the study was, this systematic review was not strong enough to say high resistance interval training, or sorry, high intensity, high velocity resistance training is superior to high load resistance training. So we can't say power training's better than resistance training. We can't say that those odd type stressors with agility type movements are superior either. So basically this is all modality we should have. It was strong enough results that if you're not doing power based movements, agility, jump style training, Olympic style lifting, you should get that included into your clinical practice for older adults that are trying to improve their bone density. It is clear that it should be part of the approach. Now I will say if you're looking at the overall results, the two different, levels of quality here. We've got a systematic review, which way trumps the randomized control trials I'm about to reference. But if you look at this multi-modal approach, because the systematic review really did not have just high-velocity resistance training, there was strength training, there was balance, there was functional training. There were all these different modalities. It wasn't just high velocity resistance training included in the study. So it was really a mixed modal approach, but a common thread was that high-velocity resistance training was included. Now, some former studies of a lower level of evidence, if we're looking at the Lift-More or the Lift-More-M trials, those are both free access to the public, you can Google those very easily, use this mixed modal approach, but it had a much more specific dialed-in approach to loading. So there was high resistance training, 80% plus of a one rep max included and power training included. That mixed modal approach with a higher percentage of resistance seemed to be very beneficial when we're looking at the Lift-More and Lift-More-M trials. I would say that's one thing that's different from the systematic review is the criteria did not include a minimum threshold of resistance. Now those are my caveats from reading this and kind of thinking about the body of research. SUMMARY So if we're gonna boil this down, we're gonna ask, does high velocity resistance training help build better bones? We would simply say yes. Dosage that we need, two times a week. We know that there's a detraining effect if people stop this training for more than six months. So fitness is forever. We need those training methods, those modalities to continue. Considerations for clinical practice. Can we hang our hat on just high velocity resistance training? No. This was not strong enough to rule out just heavy resistance training. The body of research is larger there for making changes in bone mineral density just in general. It should probably include some power training like Olympic style lifting or agility training as well. That's also going to be beneficial. No clear winner on the type of modality, whether we're going to use dumbbells, kettlebells, barbells, resistance bands. All of those things are on the table, which is actually great because we don't always have those same exercise modalities. So it seems to be more important to hit those thresholds for power training, to hit those thresholds for resistance training, but maybe it's not so important that we just have X equipment in our clinic or at our disposal, which is actually great news. Team, I hope you enjoyed this review. I will have the the DOI listed if you want to look at this article more in depth on your own as well as the ones for the Lift More and Lift More M trials. If you found this interesting and you're interested in coming to see us on the road, I tell you what, live is a great place if you are new to loading bones or maybe you want some new Method styles to load your bones for your older adults. We have a whole impact training lab Lots of resistance training labs where we can help you dial in the dosage for the person in front of you From the ICU all the way up to fitness and masters Athletes, which is wonderful in our older adult live course. The next ones are going to be in Santa Rosa, California That'll be January as well as you can catch us in Marysville, Ohio on the 13th and 14th of January, then we're going to have Clearwater, Florida just a week or so after. If you're looking to continue your journey towards getting your MMOA cert, if you want to catch us in the L1, Previously Essential Foundations, that will kick off on January 10th. In the L2 course, which prior was called Advanced Concepts, is gonna be kicking off on January 11th. I hope you have or are still enjoying your holidays. Love to get your thoughts, comments on this super interesting systematic review. And that is it for now, team. Catch you later. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 26, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the need to assess beyond the physical properties of a scar. Scars can have deep meaning to our patients, and learning the human story behind the scar can help with better understanding a patient. Whether the scar was planned or not, the story behind the scar has value. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How's it going? My name is Dr. Lindsey Hughey. I am extremity faculty, and I'm delighted to be with you here the day after Christmas. For those that are on YouTube Live, unfortunately, that is not working. So I'm just gonna have to send it via Instagram. Today, I'm gonna chat with you all about how scars, and I promised a month ago that I'd be chatting about actual scar management. THE HUMAN SIDE OF SCAR MANAGEMENT But what I didn't tell you last time was that we're gonna focus on the more human side of scar management for our post-op folks. So after surgery, no matter what extremity is involved, whether it's shoulder, maybe it's elbow, maybe it's hip, knee, ankle, maybe it's even back surgery, right, there is a scar that comes along with it. And as physical therapists, we tend to focus on the more physical part of managing that scar. And so what I mean by that is we focus mechanically, right? How's it moving? What's its pliability like? What's the elasticity surrounding that tissue, right? Is it moving well with the fascia? Are there any adhesions? Our scar tissue buildup. We are looking at the pain response of the patient, right? To show if there are any signs of infection. Think red, hot, tenderness, or spreading redness, right? We're looking for the management and guiding education accordingly. In addition, we're looking for any excessive swelling, right? Is the scar raised? Is it flat? And then we're really focusing our efforts on educating, mediating, against infection and then how to keep that scar moving. We aren't often focused on what that scar might represent from the patient. And what I mean by that is some intangible and unquantifiable measures like their emotional and their mental and their social response to having that scar. I wanna share two personal anecdotal experiences with scars that I've had myself to try to illuminate that part that's more unquantifiable, right? That emotional, social, mental piece in our scar management. So I have three kiddos, 13, 12, and seven. Some of you that know me already know this. And they were all born via C-section. C-section was not what I wanted. I had this whole natural birth plan written out, and it didn't really go according to plan. For that first one, it was emergent, and the second one was planned, and then third one was also planned, but there were some complications with actually having Luke, where he needed to be rushed off to the NICU, actually, because of some breathing issues. And I'll tell you, in general, the scar, I focus a lot on its appearance, right? That it's ugly. For those C-section mamas you know, there's like often this like shelf or invagination where that scar is and so tissue hangs over it. And besides it not being kind of the birth plan that I wanted, that appearance part of the scar really bothered me. So it represented kind of two things. Something that I didn't really want to have or how I wanted my birth experience to go and then also just the appearance like that there's this lingering scar that has now like affected my body makeup and how I'm presented to the world and The reason I share that is I don't think we think about that with our patients, right the connotation with the scar. We're again always thinking about physicality. How's it moving and is there any signs of infection and giving them tools to manage that. THE STORY OF THE SCAR IS IMPORTANT Well, when I realized the story is important, I want to share one particular moment that I had with my scar and the management of it. And it actually happened with my third c-section. So About a year after having Luke, I started having like spasms in my rectus when I would laugh and or when I was doing gymnastics work. So not only was the appearance kind of bothering me, it was starting to become painful because I would get these spasms that would double me over into trunk flexion. And so it made me talk with a colleague at the time I was working at Baylor and Dr. Jen Stone actually is a pelvic floor therapist and she offered to take a look at it and literally we're like in between teaching classes um on a break and she's like yeah lay down and i'll assess it and she starts assessing um the scar mobility and i was not a good pt patient and i hadn't done much scar work and so she starts you know telling me it's hypertonic and not moving well and more on that left side and she's just palpating and then she just offhandedly says what was your birth um experience like and I'm starting to tell her the story and I just start weeping. And it was so unexpected because I started telling her, basically, I'm on this OR table, in this Vitruvian man position, you can't get up. And I look over and Luke, you can see his red flashing lights. and his pulse ox was low. And the nurses were kind of telling me like, Oh, he's fine. And kind of pretending like he's fine, but really he couldn't breathe. He was having transient tachypnea, which is come to find out normal after C-section in many babies, because they don't get that birth canal squeeze. So fluid sits around their lungs, but I had never experienced that with the other two C-sections. And so like emergently he's wheeled away from me and I'm still like open on the OR table and so I start telling her this and like I'm crying as I'm telling her this and I get to kind of the end of the story how I never got to hold him like you know that first hour of nurturing time I didn't get and I didn't actually hold him for like 12 hours and we're like when I'm waiting post-operatively to see what's going on they don't really they didn't tell us much so I'm like in limbo thinking like is he gonna die but again Turns out to just be the transient tachypnea, not a really big deal. And I'm recounting this whole story to her how it was like tough. I didn't get to hold him. I didn't get the skin to skin time. And, you know, we're literally were afraid he was going to die. You know, he only needed two to three days in the NICU, it turned out, and he was all good. But in that moment, I realized like Jen gave me permission to tell my story and really unpack it because I'm kind of like a power through type of human, got through that last C-section and went back to CrossFit and thought I was fine and dandy. And it was in that moment where she just, you know, was palpating the scar and took the time to like understand the story behind it. And so it makes me pause and Consider maybe all of the folks that I kind of bypassed thinking like total knee replacement, total hip replacement, and what those scars might have meant. Or someone after trauma think ACL or getting that triad where they have this surgery where it takes them out of their season, right? It's out of their control. Those are two different kind of scenarios, right? I didn't want the C-section, right, in any of the cases. but the C-section kind of chose me. In that case of like a total knee replacement or a total hip replacement, something where we get gradual worsening pain and function and we have to elect to have the surgery. SCARS TELL A STORY OF RELINQUISHING CONTROL I have another personal story to share where even when you elect, so like those three sections not really in my control, There are surgeries we have to choose sometimes because of pain worsening function and or failure of our tissues. And so the second scenario, I want us to appreciate too, because both involve a little bit of relinquishing control, which is tough for our patients. So my second scenario is also another personal story. Having had the three C-sections, right? And we fast forward seven years to the present, I, in this last year, started experiencing a supra-intra-abdominal hernia. So I noticed this mass above my belly button to the left. So because it's asymmetrical, it wasn't like the Linnea Alba issues. It literally, or Diastasis Recti, it literally is a hernia because of that asymmetry. throughout the year kind of started getting bigger. And I consulted with some pelvic floor PTs, and they're like, that's not necessarily pelvic floor, right? Start working on your intra-abdominal pressure to help. But you should get that checked out, because the mass on your stomach is kind of concerning. And come to find out, I put it off for quite some time, at least six months, and I go to this intra-abdominal specialist, and he does, in fact, confirm that it is a supra-abdominal hernia, and that there's subcutaneous fat, and that, right, if you ignore it long enough, this can turn into an issue where there's strangulation, which then can become like an emergent issue if you become sepsis, if it were to triangulate and cut off blood flow or like your intestines, right? The reason I share this story with you is the second part is this was a surgery that I had to opt for, kind of like when someone has to choose that total knee replacement or total hip replacement. I was starting to have some pain associated with eating big meals, and then some exercise-induced nausea with high intensity. It was only intermittent, right? Sometimes, so for at least a year-ish, I had been putting it off. I've since had the surgery, right? December 13th, I had it. And now I'm in this new zone. You can't actually even see the scar, right? Because it's under steri-strips. But what I want you to think about and what has me pausing and thinking from my own personal experiences, this scar, although a little bit out of my control, right? It's abdominal wall failure due to intra-abdominal pressure issues, due to that history of C-sections. It's not really something I wanted to do. I don't want the downtime of not lifting heavy things with my friends. I don't wanna build my gymnastics from the beginning. I don't want this break of time where I'm not lifting heavy and I'm not working intensely, right? It's this forced slowdown. But in a lot of ways, like I chose this, right? I chose to schedule this surgery due to some failure in the tissue and some worsening pain and weakness. The scar, once it heals, it'll represent a pause in my story. But it also represents an opportunity, if I'll reframe it that way, right? An opportunity to work on my intra-abdominal pressure from the start, now that I don't have a 1.5 by one centimeter hole in my fascia, right? And now there's no longer subcutaneous perineal tissue sticking out. SCARS REPRESENT A SLOW DOWN Our patients, no matter their surgery, whether they had you know, a history of various surgeries like I had and have had to have subsequent surgeries like I just needed to have because of those, they are coming to you and they are in a time where there is some uncertainty on board, where they have to slow down in their story, right? Which affects them mentally, socially, emotionally and spiritually, like when they're not involved in the activities that like bring them joy in their life. And They have to give up some things for a time and that can be really hard. And so scars, let's approach them. Let's take the opportunity to not only obviously address that physicality piece, right? and safety about infection, and make sure the scar is moving well, but take the opportunity to understand the story behind maybe why they chose that surgery, or were advised to have that surgery, or maybe why it was emergently, right? If there's some trauma associated around having to have the surgery, that can be tough, and they've maybe never been asked to share that story, and maybe they'll have that kind of emotional release unexpectedly when you ask them that question. What I want you to reflect on is, have you even thought of the human in front of you and the story behind the incision and what that might mean to the patient? Can you take the time to give them permission to tell that story? And it may unlock some sadness and fear and angst. But if you don't invite that opportunity, then you miss the opportunity to help them reframe that experience for the better. you miss the opportunity to deliver control to their story right where they're the heroine of that story. So two real action items today is learn the story behind their scar and their incision from the beginning and then of course create a complimentary rehab program that makes their extremities, their spine, robust and that makes that scar just be in a badge of honor, right? And just a reminder of a moment to get after resilience in their story. A lot of times in our extremity management course, we can't dive into postoperative care. We speak a ton about upper quarter and lower quarter extremity resilience and how you can get after that with your patients. We have so many offerings to dive into that in January. And so if you'd love to learn more about extremity care and resilience, we would love to have you at one of our upcoming courses. We are literally stacked in January, January 13th, 14th. We are not only in Richmond, Virginia, but we are also in Greta, Louisiana, and we are also in Fayetteville, North Carolina. So all of our extremity faculty will be out on the road teaching that weekend. be there at one of those locations. In addition, January 27th, excuse me, I already said that, January 13th and 14th, we also have opportunity. I kind of flipped that actually. Check us out on btoknights.com. The 13th, 14th is when we're in Virginia and Louisiana, and then the 27th is when we have three opportunities. Forgive me for that. Fayetteville, North Carolina, Athens, Georgia, and then Burlington, New Jersey. And then literally most months of 2024, we are somewhere in a city near you. I thank you for taking the time to listen to my story today. And I hope again, that you will consider the patient's story behind their scar. Have a great day, everyone. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 25, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick unpacks the one emotion you are underutilizing during client sessions: "Awe". In this episode, she defines awe, discusses benefits of experiencing awe both as a provider and client and gives examples of how to spark awe during PT sessions. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. APRIL DOMINICK What is up everyone? Happy holidays and welcome to the PT on an ice daily show. My name is Dr. April Dominic. I am with the pelvic faculty today. I'm hopping on to talk about the craft of sparking awe via PT. So what is awe? We'll talk about what it is. We'll talk about the benefits, and then I'll give you some examples of how to spark awe during your physical therapy sessions. DEFINING AWE First off, let's define it. Researchers define awe as the feeling that occurs when you encounter something unexpected, something vast, something extraordinary. And this emotion awe can come across the gamut of types of emotions. It can be positive in the sense of inducing pleasure. It can be neutral in the sense of inducing connection. and it can be negative in the sense of having some sort of uncertainty about it. With awe, what it tends to do is it diminishes the focus on the self and instead reflects it to the collective. So folks tend to be a little more concerned about others, about the grand scheme, about the collective versus themselves. And often people think of awe as if it's this vast, physical, massive thing that has to happen, like seeing the view of earth from space. It can actually be that, but also be something a little smaller or a little more emotionally dense. Some examples of awe, there are so many, we'll go through a few. Awe can be the emotion that's emitted when an orchestra finally reaches that crescendo during a long drawn-out musical phrase. It can also be something very impactful from a social perspective, such as, do y'all remember when we used to clap for the healthcare workers during quarantine around 8 p.m. That was something that was happening across the world that was just very unison in nature. And it can be the sting of a slam dunk of the opposing team with two seconds to go, resulting in a loss during a basketball game. I have a few instances of awe that I'm reflecting on from my personal life, Uh, and one is a couple of years ago, I had the opportunity to say goodbye to my friend from physical therapy school just three hours before she died. And that was a very powerful, impactful way of feeling off for myself in contrast with a very natural, big phenomenon that I got to experience this past year. I was in Iceland chasing the Northern lights. And I just wasn't successful with that. I finally came home and, uh, draw drew the curtains on my Airbnb just one more time at 2 a.m. And lo and behold, above me was this incredible, incredible feat of nature of dancing Northern lights, just neon greens and soft pinks. So vibrant right over my Airbnb. And it was, it was just so incredible. And then it can be something smaller. Like yesterday I was taking a walk in the Texas Hill Country neighborhood and I looked up and across from me just yards away were two brown and white stags just majestic and staring at one another. So those are some examples of awe. They can be big, they can be small. THE PURPOSE OF AWE And what is the purpose of awe? The purpose is to pause. It's to allows time to slow down and to allow us to reflect on understanding an event that just happened to us. So how do we express awe? I want you to know how we express awe so that you can identify it during your physical therapy sessions. We do so via language. Wow. Ooh. Or some might say, oh, that was awesome. or I'm awestruck. We do so with verbalization of wonder. We may, after witnessing an incredible event or listening to a heartwarming story of one of our clients saying, I was finally able to lift my grandkid after having shoulder surgery and I did it with no pain. We may express awe via emotions. It can be tons of tears or, um, laughter or goosebumps even. And we also do so via facial expressions. So it might be a jaw drop or eyes widening. Eyebrows lifting, these are all things you may encounter, see folks do in your physical therapy sessions. And that is something that you can do as well with your own expressions and reactions to them. According to the research team Cohen et al, awe is a universal expression that is distinct from 50 other emotions. And it is also present across 144 different cultures. They, in one study, they looked at 2 million videos of people watching fireworks and individuals seem to express awe in similar forms. THE BENEFITS OF AWE So why is awe beneficial? There are so many benefits to the emotion awe. Mentally, it induces a sense of calm. It reduces anxiety and depression. And per researcher, Dr. Keltner, he has suggested that awe also has a role in the grieving process. This can be grieving of a human, of a pet, or even of a body part, if someone's had an injury or a surgery, or maybe even time, thinking of the postpartum individual who may be grieving her pre-partum self. Physically, awe can show up and it's beneficial from a physical sense in terms of it dials down the fight or flight response. It can increase cardiovascular health and longevity. And then on a transcendental level, the emotion awe helps us feel part of something larger than ourselves. We think of this from our clients perspective in the sense of some of our clients come in and they let their diagnosis just identify them, right? They come in and they're like, well, my fibromyalgia, yada, yada, yada. Right. And they are just blaming everything and, and saying that their existence is due to fibromyalgia. and that is going to get them to perseverate on their injury or their condition. Awe or practicing awe would be an awesome thing for them to do just so that they can kind of step out, zoom out and look at the collective and take the instance of focusing on their own injury or condition away. We can also think about it from what we do on a day to day. We are sitting there listening and working with all different kinds of individuals right then and there. We as clinicians are practicing awe as well as we're focusing on others, not ourselves. And I think that this can maybe even help us with our burnout in our profession. Just remembering and reflecting on those instances of awe. HOW TO SPARK AWE So let's discuss how we can spark awe in our PT sessions through our environment and through our interactions. From the environment standpoint, awe can be induced by just even the music that you're playing. Music has an incredible power in the sense that sound waves activate the vagus nerve. It activates our dopamine a regulation or reward system. It lowers cortisol. So just by turning on music that brings you or inspires all in you or asking the client, Hey, what kind of tunes can I put on for you? And then decorating your clinic with maybe pictures or, um, pieces that represent bring us like, uh, photos of scenes from your travels or photos of your pets, your family, your dogs, all of that can induce awe and help in the client environment overall. And then finally, interactions that we have in our PT sessions via assessments and treatments. I've got a few here. So the first, we can inspire awe by our reactions during session, whether that's a concerned jaw drop or those widened eyes or even dropping a verbal phrase for the client. Since they've said, oh my gosh, I've just started exercising so much now, my frequency has increased. I went and bought that 50 pound kettlebell that you suggested and we can give them praise. and inspire awe in that way. Also, we can use our senses as a gateway to experiencing or expressing awe. With the exception of taste, we tend to utilize all of our senses in our PT sessions. Hearing, we actively are listening to our clients as they share their stories. sight, we're watching them and helping and suggesting different movement patterns for them. We are touching them via palpation, via assessment, via our manual therapy skills. And smell, that may be just for our wound care colleagues. And then in terms of treatments for patients, you can suggest all practices, We can play games during our sessions or encourage them to play games. This is going to ignite that childhood sense of wonder. Every time I think of sense of wonder, I'm thinking of Leanne Ryan's, I Hope You Dance or Leanne Womack. It might be Leanne Womack. She says at the very beginning of her song, I hope you never lose your sense of wonder. And then another lyric is, I hope you still feel small when you stand beside the ocean. All of that reminds me of awe and wonder. So we can tap into our childhood feelings of discovery with our clients and encourage them to do so as well. And then we can suggest all walks. This is something where, you know, maybe we're doing fitness outside of the clinic or we're asking them to do their rehab emoms outside because maybe they'll hear the birds chirping, cute birds chirping, or maybe they'll see a new bloom in their garden from a flower. just different ways to bring out awe. And then we can also use awe as a meditation or mindfulness supplement. In case you want any other resources or you want to dive deeper into the research on awe, check out Dr. Keltner's book on awe, the new science of everyday wonder and how it can transform your life. So to sum up today, we can't all fly to space and take a bird's eye view of earth to experience awe, but there is everyday awe around us, even in the clinic. Awe is an emotion that's extraordinary. It removes focus from the self. and transfers it towards the collective from an emotional bit standpoint, like supporting a client's aha moment when they're saying, Oh my gosh, I think my pelvic pain and my urinary urgency are related to that episode of abuse that I had. Or when a, when we as a PT break down a client's thought virus that they think lifting heavy will result in injury. And then in that very same session, both the client and ourselves experience awe when that client cranks out 12 deadlifts at 80% one rep max, feeling no pain. And they thought they'd never be able to do this because of their bum knee. Awe is perceptible in each of your PT sessions, whether it's with a new client or with someone you've seen for years. Remember, how do we increase awe? We can do so through increasing our own awareness of all happening throughout our sessions. We can do so through facial expressions, watching someone's body language, through the words we say. And remember to use your senses. And we also can encourage folks to utilize awe and seek and appreciate awe inside and outside the clinic. This is all going to help with increasing their mental and physical well-being. So I'm faculty with the Pelvic Division here at ICE, and we have so many offerings that we'd love to see you get some awestruck education with. We've got our weekend live courses starting January 13th and 14th in Raleigh, North Carolina, and January 27th and 28th in Hendersonville, Tennessee. We'd love to see you live or at any of our online offerings, head to beauty on ice.com to check those out. I hope y'all have a wonderful holiday and experience large doses of awe this week. And as you ring in the new year with those fireworks display, know that folks all over the world are expressing similar instances of awe, just like you take care y'all. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 23, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses why & how interval-based training causes positive adaptations, how to assess & program intervals for patients and athletes, and how to help them approach interval-based training. Take a listen to the episode or check out the show notes at www.ptonice.com/blog If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALLGood morning, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday. Currently I have the pleasure of serving as Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, if you're working with that person that is recreationally active, the CrossFitter, Olympic Weightlifter, Powerlifter, the Endurance Athlete, whatever, Fitness Athlete Friday is for you. Today we're going to talk about intervals. I think this is a great topic because what we're going to talk about today can really apply to all of these athletes. Runners, cyclists, swimmers can obviously benefit from interval work, but so can crossfitters and powerlifters and Olympic weightlifters. And we're going to talk about types of intervals, why do intervals work, how do we program these intervals more specifically. to the weaknesses that these athletes need to work on. And then we're going to talk about how to actually approach these intervals as if we were in the driver's seat. Being that athlete, how should we approach interval based training? I'm going to reference a paper today that is just basically a review of a whole bunch of different research articles on interval based training. It's by Oticon and colleagues from 2021. It's the International Journal of Environmental Research and Public Health. and the title is Evidence-Based Effects of High-Intensity Interval Training on Exercise Capacity and Health, a Review. And this is just a paper that consolidates a lot of different research on what is actually happening to the body physiologically when we do intervals, what is the benefit of interval-based training, and then a little bit about adherence and enjoyment as well as we talk about compliance with interval-based training versus other types of training. WHY DO INTERVALS WORK? So let's discuss the first part that a lot of us maybe have questions on, especially if we're explaining to patients or athletes why we might be doing interval-based work, even in the course of their rehab. If they're doing remoms, if they're doing AMRAPs or something with rest, when you have folks doing interval-based exercise in the clinic or in the gym, why do intervals work? The first thing I want to speak to is the concept of excess post-exercise oxygen consumption, often abbreviated as EPOC. For a long time, this was thought to be the main benefit to higher intensity interval training, that somehow, because we were working so close to our max threshold, that as we did interval-based training, our body could somehow not supply enough oxygen to itself during the training, had to pull oxygen from other sources, and otherwise created a large deficit that throughout the day would need to pay down that deficit, would lead to a huge consumption and calorie burn, would lead to otherwise a lot of increased metabolic effects throughout the day after interval training had completed. We know now that has been thoroughly trounced in the literature, The most effective thing you can do for EPOC is actually resistance training, right? To accrue more muscular mass that is more metabolically active, that's going to result in an increased metabolism throughout the day, and actually every day, the more and more mass you accumulate, right? Very large muscular people have very large base metabolisms, and that's related to resistance training, not related to high intensity interval balance, of aerobic exercise. So know that EPOC is really not what we're after. What we're actually after, depending on the type of interval and training we do, is looking at central versus peripheral cardiovascular adaptations. So with central cardiovascular adaptations, we are mainly targeting the heart. We have improvements in ventricular hypertrophy, we have improvements in maximal stroke volume, the amount of blood that gets sent out every beat of our heart, and an overall increase in red blood cell volume. Now, when we do moderate intensity steady state exercises or longer, slower intervals, we primarily get peripheral cardiovascular adaptations. We get increased mitochondria, we get increased capillary density, we see improvements in lactate buffering and transport, converting pyruvate that's broken down during exercise back into lactate to be reused for energy. And the key there is that when you do really long, slow aerobic training, or you do very, very long intervals, you are only really becoming better at doing long, slow aerobic training or really long, low intensity intervals. That really long aerobic training or long aerobic intervals only make you better at long aerobic training as a whole. So when we discuss intervals, especially when we're talking about how to program intervals for maybe crossfitters, powerlifters, or Olympic weightlifters, we need to understand that the kind of craze right now in training for them of 40 minute EMOMs and 60 to 90 minute zone two training sessions has really a minimal benefit for those folks. Those folks need to be doing shorter, higher intensity intervals to get those central adaptations. Literally increasing the size of their heart, their stroke volume, their red blood cell volume, giving them more power and energy for those shorter bouts of exercise that they're conducting, Olympic weightlifter or powerlifter, you know, maybe one heavy lift, maybe a double or triple crossfitters, maybe exercising in the 8 to 12 minute time domain. Those folks are really not going to benefit from those peripheral adaptations from really long aerobic training. So we really don't want to see those people doing a lot of long aerobic training, especially if it's competing with their weightlifting or natural crossfit training. And then translating out of the gym, most human functional tasks and sports exist in a relatively short time domain that's also going to benefit from those central adaptation improvements. So we need to understand that if I do 90 minutes of zone two a day, that's probably not going to help me in a sport like football, in a sport like basketball, which is much quicker, much shorter, short bouts, When you look at a game of like basketball or football, it almost looks like interval training, right? Play for 30 seconds or a minute and then there's rest, right? There's timeouts, that sort of thing. Very different than going for a five mile run or a 10 mile run or a marathon. So if you're not doing long aerobic events, you should steer away from long aerobic training or long aerobic intervals. And then the final benefit of why do intervals seem to work? They seem to work because people really seem to enjoy them. When we look at research around high intensity interval training, we see that exercise adherence and enjoyment is very, very high. And I think we've talked about this before. It's often overlooked, right? Of what do you like to do? We should probably program that stuff because it's going to be stuff that you're going to do more often. And if your adherence, your compliance, your enjoyment is high, you're much more likely to come to the gym or go to the track or whatever and do it. and that consistency is what is going to increase your health and fitness over time. So that's why intervals work. They may benefit central versus peripheral adaptations, and that's going to depend on the athlete in front of you of what adaptations they may be seeking. HOW TO PROGRAM INTERVALS Now, when we're programming intervals, whether it's a patient in the clinic, whether Darlene's in the clinic, or we have Frank the CrossFitter, whatever, how do we program these? Remember, with intervals, intensity is the goal. We're looking for most interval sessions, especially if we really want to produce a lot of those adaptations, to be around 90% of our VO2 max. If you've never done a max effort Bruce treadmill test, looking to find your true 100% VO2 max, it's quite the experience, right? You're running on a treadmill, you have the metabolic heart, you have the oxygen mask on, you're running on an ever-increasing speed and grade until failure. With a true VO2 max test, Failure is when you pass out, right? There are people behind the treadmill to catch you as you pass out. You reach the point at which you can no longer pump enough blood to all of your body and you pass out. That is the true test. So we're not going for that with our intervals, we're not going for 100% blackout, but we are looking for 90% or maybe 80%. So we're looking for very, very, very hard efforts. The type and amount of those intervals is going to be key to facilitate that intensity. That's going to be a combination of work and rest, hopefully working on things that that athlete or patient needs to improve related to time domain and functional tasks. So if intensity is the goal, how do we notify that intensity? If we're not having folks do a treadmill test to failure, well, we do need to do some testing. We do need to have some sort of baseline measures in place to know what sort of paces are we looking for. We can get a metabolic heart in the clinic. We can measure heart rate. But the easiest, most practical thing for a lot of us is just going to be to have somebody do something like a 500 meter row one day and then a couple days later do a 2000 meter row or a run or a bike or whatever. Get some sort of short time domain effort and some sort of longer aerobic time domain effort. And the key there is we're looking to establish fatigue fall off factor. So we know does this individual need to work on speed or do they need to work on endurance? Now, with some of our patients, especially more of our deconditioned patients, we don't need to do a lot of testing to know what they need to work on, right? That patient that barely makes it into the clinic from the parking lot, the 20 second walk from their car to the chair in the lobby was max effort for them. You know where you need to start with that person, right? That person needs to work on shorter intervals. They have no aerobic capacity. Certainly, they're not gonna do well on something like a six minute walk test. Shorter intervals for that person, build them up. But with somebody who's already active, how do we know their weaknesses? We need to calculate that fatigue fall-off factor. How do we do that? I've got it written out on the whiteboard here. I hope you all can see it. I hope it's not backwards, but I'll read it out loud nonetheless. So, I happened to just do a 500 meter row yesterday and find a new PR. It was 133. That's 93 seconds. I already know my 2,000 meter row time. 2,000 meter row is gonna feel a lot like a mile run. it's 648, which is 408 seconds. So what is the time difference? If I think about, if I could hold that 500 meter row four times, I could theoretically get that 2000 meter row done in 372 seconds. However, that's not realistic. Why? Fatigue falloff factor. As exercise bouts get longer, There's some natural fatigue accrual that's going to slow me down more than just thinking I could rock my PR 500 four times in a row. If that PR short distance effort is truly max effort, there is no way you could sustain that for four times as long, right? And that time difference is called fatigue falloff factor. So 372 seconds over 408 seconds is about a 91% Integer there, that means I have about a 9% fatigue fall-off factor. Now, how does this let me program? If folks have less than a 10% fatigue fall-off factor, they need to be working on power and speed. Folks that have more than a 10% fatigue fallout factor, they need to work on endurance. So that kind of tells you right away, does this person need to be working on shorter intervals, more power and speed? Or does this person need to be working on longer aerobic intervals to build up their endurance? And then again, the final key there is, what is this person actually doing in the gym? Because at the end of the day, if they're not doing long aerobic work for training, even though it may seem like they need to train endurance, again, does not make sense for them to train a lot of endurance and vice versa. So make sure we're training the right energy system. I love testing this stuff with patients. I've watched a lot of people row a very slow 2K row just to get that data. Data might not change behavior, but it certainly does inform our decisions when we're gonna start creating some exercise programming. Now, establishing that baseline, knowing intensity is the goal. How do we implement this in the gym and the clinic? For a lot of folks, that's going to look like running or using a machine. Why? Because our bodies are very, very efficient at using cardio machines or running, we get to use our full body, which means we get to get a lot of blood pumping, which means we get to buffer a lot of things like lactate, much more so than if we decided to do intervals of something like strict pull-ups, right? Where muscular fatigue, the lack of muscular endurance or indoor strength is going to affect our ability to do work. Not many people have gone to the point of failure on a bicycle and collapse on their bicycle due to a lack of leg strength pedaling that bike, right? It's always usually at the end of the day an endurance thing. So when we're having folks do intervals, yes, in CrossFit, we can do intervals, but we often do intervals, we mix things up, right? We have biking, pull-ups, and kettlebell swings or something, right? We have enough work where just as we get tired, we move to the next thing, and then we get some rest. We don't just do big rounds of one movement unless we happen to be on cardio machines or running. So make sure in the clinic or the gym, you have a rower, you have a bike, you have a ski machine, whatever, or you have a treadmill or otherwise ability for the athlete to run. So that's how we program intervals. EXAMPLE INTERVAL PROGRAM I want to show you an example now of how I would program for myself based on the data I just shared. So same whiteboard, right? We know that we want to be ideally 90% intensity of whatever we just did. I know my max effort 500 is 133. So that means that if I'm going to be doing rowing, again, my fatigue fall off factor was 9%. I need to be working on power and speed. I'm going to program myself 500 meter row repeats with some rest. Why? Because I need to work on that power and speed. How do I know my pace? Well, I know my PR and I know my intensity thresholds. So I know if I want to be doing these 500 meter rows at 90% I need to be rowing at at least a 143 per 500 pace. If I wanted to work at 80%, I could be rowing at a 151 per 500 pace. And now I can give myself a range. Hey, I'm going to do five sets of a 500 meter row. My range is a 143 on the fast end and a 151 on the slow end per 500 meter row pace. And I'm going to rest three minutes after every round. Why? Because I want to be resting at least as long as I'm working. Now, how do we approach this? How do we help patients? and athletes approach this interval work. Now that we know why we're doing it, now that we know how we program it, first things first, what is the goal? For a lot of our patients in the clinic, statistically 90% of them are completely sedentary, so anything goes, right? They can benefit from both short time domain and longer time domain intervals. They can benefit from doing it on any of the machines. They have room to grow on running, biking, and rowing. With those folks who maybe, again, They clearly do not appear to have any long aerobic system left. You're probably going to be stuck with short intervals in the short term until they start to build that aerobic base up. If we want to improve power or speed with these folks, we want to keep the time domain two minutes or less, right? We want to keep it in that anaerobic time domain window. So if we're thinking rowing, if we're thinking running somewhere between 100 and 400 meters and we want to have relatively short bounce, with longer rest at least one to one rest to really facilitate our ability to repeat those efforts to hit those paces with power and speed. Now on the opposite end, what if we want to improve longer endurance? Well, we're probably looking at running 800 meters or longer, we're probably looking at rowing 1000 meter repeats or longer. We're otherwise looking at exercising longer than the two minute time domain. Here, the bouts are going to be longer, the rest is going to be a little bit shorter, because again, longer effort, lower intensity, we don't need as much rest, so here you could get away with maybe one to two rest. If it took you four minutes to run an 800, you could rest two minutes and then run that 800 again, hopefully in another four minutes or whatever your pace may be. I cannot stress enough that you should match the modality of what the patient wants or needs to get better at, right? If you want to get better at running, you should probably do most or all of your interval-based training running. I hope I don't have to explain why being specific there is really important. But most of your intervals should be on the modality that you want to get better at, especially if we're talking about doing this for performance. Yes, there will be some carryover from the rower or the bike to running and in between. But if you want to become a better biker, you should do a lot of biking. If you want to become a better runner, you should do a lot of running. APPROACHING INTERVAL TRAINING And then the final thing I'll say is make sure that you're actually getting the stimulus. Remember, these efforts should ideally be around 90%. They are higher intensity because they are intervals, because you are eventually going to get some rest. You should not be shooting to get a PR during your training, right? If it's a test day, it's a test day. If it's not, we should not be shooting for 100%. We see this a lot in the CrossFit gym. We will have 400 meter repeats. or 500 meter repeats. And our guidance is these should be at 80 to 90% of your max PR of whatever, whatever distance we're going. And what do we see a lot, we see a lot of people swing for the fences on the first round, and PR their runner row, maybe they puke in the bushes, and then some of them are not able to complete the rest of the training, right? So some folks may even fall short of a PR, they try to get it, they miss it, and then they're not able to complete the rest of the training. Completing the volume of the training at the intended intensity is getting the stimulus and making sure that we're actually trying to get max effort, but we're not going for 100% every time it's time to run a row. On the other side, we make sure we don't under dose ourselves, right? If we're aiming for 80 to 90% of our max, we should not see a slow warm up in those intervals where maybe only the last couple rounds are actually at 80 to 90% of our max capacity. Again, intensity is the key here. All of those benefits central or peripheral come from getting close to those intensities. If we miss those, I don't want to say you're wasting your time, but you're not getting the same benefit you could as if you were really pushing yourself. Interval based training should be very, very, very uncomfortable. You should feel like you need that rest break. You should feel like, geez, I wish I had more of that rest break. If that's the subjective feeling you have with interval training, you are doing it correctly. So interval training, why does it work? Central versus peripheral adaptations, different needs for different patients and athletes. How do we program it? We program it by making sure we establish some baseline testing, find out what our person needs to look at. How do we approach it? We understand if that person needs power or speed, they should be doing shorter time domain, longer rest. If they need endurance, they should be doing longer time domain, shorter rest. And whenever possible, we should be matching the modality. If you wanna get better at running, you should do your intervals as running. Make sure we're getting the stimulus, hitting that 90% mark, and actually getting good effect from our training in the clinic or in the gym. So that's interval based training. Very quickly, some courses coming your way. Your next chance to join the fitness athlete division online will be our level one course that starts January 29th. And then our level two course starts February 4th. Live courses coming your way in January, Portland, Oregon with Zach Long, January 27th and 28th, February 10th and 11th of 2024. Mitch will be in Richmond, Virginia. and then February 24th and 25th, Zach Long will be at home base in Charlotte, North Carolina. So check us out, ptownice.com, click on our courses, see where we're coming your way. I hope this was helpful, hope you have a fantastic Friday, have a wonderful weekend, have a great Christmas, we'll see you next week, bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 21, 2023

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty member Ellison Melrose discusses how to dry needle the occiput to address headache complaints. Elli orients listeners to the anatomy of the occiput as well as muscles to target when needling. She also discusses what stim parameters to use when treating headaches. Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling , Lower Body Dry Needling , and Advanced Dry Needling. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLISON MELROSE All right, good morning, Instagram and YouTube. Welcome to the PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division. We're gonna dive right into things today. I am here to bring you dry needling for the suboccipital headache. And why I say that in quotations is because oftentimes when people are complaining of headaches at the base of the occiput, If we actually take time to palpate those tissues, it's not the true suboccipitals, okay? So we are thinking about the occipital insertion of things like upper trap and semispinalis. Those are our two main culprits when we have patients that complain of the headaches that start at the base of their occiput. So before we dive in, first of all, I have already cleaned the tissue of my patient here. but let's orient ourself to the anatomy of this occipital area. OCCIPITAL ANATOMY So in order to do so, we are gonna start by palpating for the external occipital protuberance, which is the protuberance, which is the nice bump on the back of our head here. So that's going to give us that orientation of where that superior nuchal line is, okay? Superior nuchal line is going to be the superior border of those occipital insertion of upper trap and semispinalis. We can follow that superior nuchal line down towards the mastoid process here. That's going to give us our, again, superior border of where those needles live. If we follow the mastoid process medially, it dives deep, but the inferior nuchal line is going to be the inferior most border of where we're needling today. What I want to do is I wanna take some time to find where the true suboccipitals live as to avoid needling in this area. So in order for us to do that, we're going to, there's a couple ways to find this region. First, we can palpate that EOP, external occipital protuberance, and drop down. The first spinous process we come in contact with is going to actually be spinous process of C2, as C1 does not have a spinous process. So that is going to be the inferior aspect of where the true suboccipitals live. Let's come back towards the mastoid process. From there, if we drop just distal, feeling the lateral like pillars of the neck, that is going to be the transverse, the first thing we palpate there is a transverse process of C1. So the true suboccipitals live between the spinous process of C2, transverse process of C1 and that inferior nuchal line. So we do not want to be needling in that area today, as it's a little bit more of an advanced technique. And I think when we're talking about the headaches that present at the base of the occiput, it's actually not the true suboccipitals. So for orienting ourself to where the muscles are, we have two main muscles, but we have bilateral tissue. So we're going to be treating bilaterally for this headache presentation. We are going to find that external occipital protuberance. If we step just about a finger breadth lateral to that, we can palpate a tootsie roll shaped tissue, and that is going to be your upper trap insertion on the occiput. When we're needling this area, we want to be mindful of some sensitive structures around this tissue. For example, what kind of is around the upper trap insertion is going to be greater occipital nerve. Essential anatomy is going to make it really seem very easy to find and it's not necessarily easy to find. One way that we can avoid too much interacting with this nervous tissue is going to be limiting our pistoning in this area. NEEDLE INSERTION ONTO THE OCCIPUT So for treating these occipital insertion musculature, we want to be using our E-STIM with pain modulating parameters. Okay, so EOP, first step lateral, is going to be that tootsie roll of upper trap. From there, we can take another finger breath lateral to that and we can find semi spinalis muscle belly as well as it inserts on the occiput. So let me do that on the other side. EOP, upper trap, we got a good old tootsie roll here. And then just stepping just lateral to that, we have semi spinalis. There is an area we want to avoid in this area, region as well. And it's going to be, if we find the mastoid process, about one finger breadth medial to that, there's a little sulcus. That sulcus is where the occipital artery lives. And if we go too deep there, we can interact with things like the vertebral artery and such. So we don't wanna be interacting with that tissue there. So we are gonna be keeping, it's pretty small territory here, but keeping our needles about, you know, two finger breaths away from that EOP is where those needles are going to be living. Let's talk about needle application. So in this area, the occiput is kind of diving anteriorly, right? So we want to have a bony backdrop for these muscles, and that's going to be on that occiput. We want to be using a firm palpation to mitigate the sensation of the needle inserting into the tissue. There's a lot of tendinous tissue here, so sometimes it can be a little bit more sensitive of an area to needle. So we can mitigate that sensation with increasing our palpation and our compression there. Our needle angle, let me just grab a guide tube out and we can kind of go over that. Our needle angle is going to be almost perpendicular to that occiput. So if we're thinking about the needle angle is like so. So for upper trap, we're thinking about angling that needle almost towards the eyeball or on that ipsilateral side of that muscle. For the semispinellas, it's a little bit more lateral. The occiput is diving, again, anterior. So there's some 3D anatomy here. We wanna be inserting, again, perpendicular to that occiput. So our needle angle, may look a little bit more flared towards midline, or that needle angle is going towards the contralateral eyeball, okay? So, again, let's orient ourself, and we'll then start placing some needles, because that's why we're here, right? So, palpating external occipital protuberance, stepping just distal to that and lateral, so we're underneath that superior nuchal line. If we are at the level of the EOP, we're going to be in more tendons. We wanna be a little bit more distal between superior and inferior nuchal line. Finding that tootsie roll, that's going to be upper trap. We are using a firm two finger digital compression to rock climber grip that upper trap against the occiput. We're using some short needles here. So I have 30 millimeter needles, and that should be sufficient enough to access this tissue. My needle angle for upper trap is going to be, compress, create a small treatment window between my fingertips, and I'm letting that needle settle. My needle angle is directly towards the eyeball on the ipsilateral side. Firm tap, and then we're going to advance our needle towards a bony backdrop on that occiput. So there we have upper trap on the patient's right side, And then our semi-spinalis is going to look very similar to that. We're just thinking just lateral to that insertion of upper trap, okay? So this is a petite anatomy here, so we don't have a ton of space between that kind of mastoid process and the upper trap needle that we just placed, right? So what we're going to be doing is the same sort of thing, hook, rock climber grip, Now my needle angle's a little bit more flared towards the midline, towards the opposite eyeball. Firm tap needle towards occiput. So now we have placed both upper trap and semi spinalis needle on the patient's right side. For treatment purposes, I would be doing bilaterally. And we can walk through that if, let's do it. Why not? Let's do it again. So, again, we're gonna find EOP, drop just distal to that, just distal to that superior nuchal line, stepping one finger breadth laterally, that's gonna be our upper trap insertion. Needle direction is towards the eyeball, perpendicular with the occiput here. Two finger digital compression, firm compression, creating a small window between our two fingers, firm tap, advancing the needle to a bony backdrop on the occiput. Again, we're limiting the pistoning in this area because we have some sensitive structures like that greater occipital nerve, really close to the upper trap insertion there. We are then going to step just lateral to that to interact with the semispinalis insertion at the occiput. So again, one finger breath lateral to that, avoiding that sulcus between the mastoid process and this muscle tissue, compressing tissue. Now my needle angle is a little bit more towards the contralateral eyeball. And we're again, looking for a bony backdrop here, maintaining that depth as we let that tissue recoil. So again, optimal treatment for these muscles is going to be setting up a circuit for pain modulation, and treating that tissue there. We want to limit pistoning in order to mitigate interaction with some more sensitive structures, including the greater occipital nerve. Again, for these suboccipital headaches, we are not treating the true suboccipitals. We are a little bit more proximal to that. We are thinking we are at the occipital insertion of upper trap and semispinellis. We want to orient ourself to this anatomy by finding the EOP mastoid process, and the region of the true suboccipitals as to avoid that area. We're using a firm compression to mitigate the sensation of the needle insertion. Upper trap is going to be perpendicular to the occiput. Needle direction is towards the eyeball, ipsilateral eyeball. Semispinalis is just about a finger breadth lateral to that, and we are angling the needle towards the contralateral eyeball. So there we have the needling technique for treating the suboccipital headaches. Um, there's actually the occipital insertion of upper trap and semi spinatus So that's all I have for you guys today. If you guys can catch us out on the road next spring We have some upcoming live courses in january. We're kicking off the the new year strong I will be teaching in rochester, minnesota the second weekend of january. I believe that's the 12 through the 14th, and Paul will be up in Bellingham, Washington for our first advanced course that same weekend. Then you can find me teaching the upper quarter in Longmont, Colorado two weeks later, so the last weekend in January. And Paul will be continuing some courses out in Seattle. So feel free to hop onto PTOnIce.com to check out where we are on the road. Again, this is We're starting the new year off really strong with some upcoming courses and our first advanced concepts course that Paul will be leading in Washington. So hope you guys have a great rest of your Thursday and I am signing off. See ya. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 20, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the importance of fracture risk screening & osteoporosis management, including utilizing the FRAX tool & DEXA scans to better help assess & manage fall risk with patients. Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog . If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I'm a member of the Older Adult Division. Excited to be talking to you all this morning all about the big critical piece that is missing from our fall prevention and management frameworks. The big critical piece that is missing from our fall prevention and management framework. So before we get into the goods, I want to let you all know about our courses that are coming up in January because we are hitting the new year just right out the gate. We are absolutely slammed. So our L1 and L2 online courses kick off January 11th and January 12th. And then we will be on the road all throughout the month. So we will be in Columbus, Ohio, We will be in Santa Rosa, California, Clearwater, Florida, and Kearney, Missouri. So we would love to see you in our online courses or out on the road starting the year off strong with us. FRAMEWORKS FOR ASSESSING FALL RISK Okay, let's dive in. I want you all to think of your typical frameworks for your fall risk assessment and your management plan. I want you to think about it. So I want you to think that 70 year old Betty is coming into your clinic or you're going to see her at her home or in her hospital room. She's been referred for strength and balance deficits. She's had a fall in the past. I want you to think about kind of that long list of assessment pieces that come into your head. You know, what you're probably going to evaluate or be thinking about. So when I think about that long list, here are some of the things that come to my mind that are probably coming to your mind. You may do some evaluations and assessments like the short physical performance battery. You may run a tug. You may look at strength. You're probably going to do a gait speed. Maybe you want to do a mini best and check Betty's vision, check her cognition, talk to her about her environment. Maybe you do a medication review or you check her shoe wear. Maybe you're going to check her vitals, right? This list could go on and on. It's definitely not all inclusive, but I would bet that a large percentage of you that for a large percentage of you, the piece that didn't make that list was fracture risk screening and osteoporosis management. FRACTURE RISK SCREENING & OSTEOPOROSIS MANAGEMENT This is our critical missing piece, fracture risk screening and osteoporosis management. So we are going to start by setting the foundation and talk about why that piece is commonly missed. We are going to talk about why as fitness forward rehab professionals, fracture risk screening and osteoporosis management has to be on our radar, especially given the fact that we have the goal, especially in this crew, we have the goal of identifying, seeking out, and absolutely destroying one ret max living in order to make our older adults as robust as possible. And in this specific case, helping to make their bones as robust as possible. And then I will give you guys a few clear, easy to implement actionables that you can start getting after this week that are going to be able to give you a very comprehensive clinical picture of your patient's skeletal health. Okay. So first and foremost, we need to think about why is this not on our radar? You know, why for many of us was fracture risk screening and osteoporosis management not something that came to our minds. And if you're like me, I didn't really learn about that in school. It wasn't emphasized. I definitely didn't learn it out on clinical. And I really didn't address it in my clinical practice. If someone, one of my patients had osteoporosis, I kind of just assumed that it was going to be managed by their PCP or the medical team. And I didn't really have a big role to play, right? And we also have to realize that we understand that falls and fractures are important, right? Like falls and fractures, especially in working with older adults, this is on our mind a lot. And we know that as our older adults age, falls and fractures are going to increase. And we know that This results in years and years and years of disability that our older adults have to live with. So we know that it's important. So we have to start thinking like, why isn't this on our radar? So I want you all to start getting really curious about your patient's skeletal health. And when we look to the literature, we further see that this is an undertreated and an underdiagnosed condition. In the literature, it'll be deemed as the silent disease. And there are so many retrospective cohort studies that show that individuals who sustain a fracture after a fall, a very alarming high percentage of them were never scanned. They never had a DEXA scan. They were not on osteoporosis medication. And a very high percentage of them will go on to have another fracture in a few years. So this is a massive, massive problem that we are seeing and we have to realize that we have a role here and we can be the individuals to help screen and identify this as a problem and interrupt that cycle. So when we start to get curious about our patient's skeletal health, I want you all to think about Betty, right? About 75-year-old Betty who's coming in to see you. And we're really good at looking at Betty and assessing Betty and thinking, like, Betty's got a lot of muscular weakness on board. So if we know that Betty is weak muscularly, we have to remember that it's called the musculoskeletal system, and that those bones also may be very weak as well. So as soon as you identify muscular weakness in Betty, I want you all to be thinking, okay, I need to start thinking, hmm, are those bones weak as well? The other side of this, though, is that Betty may blow that, you know, 30 seconds to stand out of the water. Her gait speed may be great. Like she's really kind of crushing it on her on these outcome measures that we're running. And we may think like, oh, she's thriving. However, we can't automatically assume that those bones are thriving as well because there are so many factors that go into bone health that are not visible to the eye. So don't make the assumption that her skeletal system is absolutely crushing it. You want to continue to be curious and you have to start thinking there's so much more that goes into this. I need to do some assessments and do some screening to really get a clinical picture of what Betty's skeletal health is actually like, right? And we need to start thinking about this in terms of urgency. In the older adult division, the urgent situation is identifying someone who is at one rep max living, and then triaging our fitness forward approach, because that individual needs our fitness forward approach the most. So if you think about it, and Betty is coming in, and you're running assessments on her, and she's at risk for falls, and you haven't even looked at her skeletal health yet, Well, you're going to say, whew, Betty's at risk for falls. I definitely need to really triage a fitness board approach for her. But then if you also assess her skeletal health and you realize that she has weak bones and she's at risk for falls, my God, that is an incredibly, incredibly urgent situation. That individual needs our fitness forward approach the most, but we're not going to be able to know how to intervene, how to appropriately intervene if we don't even know the problem exists. So we have to be able to identify that this is a problem. We are the providers that can make this silent, invisible disease very visible. So how do we do that? Let's talk about some actionables here that you guys can start doing immediately that are going to be able to give you really critical data in order to gain a comprehensive picture of her skeletal health. Number one, it is the lowest hanging fruit. It's the easiest place to start. SCREENING FOR FRACTURE RISK: THE FRAX TOOL You can screen for fracture risk and you can do that by using the FRAX tool. The FRAX tool is so easy, so quick to implement. I will link it here for you. It takes two minutes, but the algorithm gives the 10-year probability of a fracture. So it's gonna give the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture, so of the spine, forearm, hip, or shoulder. In the questionnaire for the FRAX, ask some questions that start giving you an idea of things that affect bone health. So really easy, they're going to be asking just age and height and weight, right? These things you can get from EMRs or your patient. really quickly and then they're going to be asking some questions like have they had a previous fracture? Did one of their parents fracture a hip? Are they smoking? Are they on medications like glucocorticoids? Do they have an inflammatory disease like rheumatoid arthritis? Do they drink excessive alcohol? All of these factors that can really affect our bone health negatively. It will also ask for their bone mineral density. And you do not have to have Betty's bone mineral density in order to fill this out and for it to be to give you a validated probability. The frax has been validated without a bone mineral density value. However, Betty may have her bone mineral density. She may have a DEXA scan, and you can use that value, but only for the femoral neck. It is only validated for the bone mineral density of the femoral neck. So that's the caveat there, right? So really quick and dirty, you can do the FRAX tool. It's going to shoot out a probability. What happens next? This is going to start to give you an idea, like, whew, there's a lot going on here that I didn't realize with Betty. Her skeletal health isn't really thriving. And let's assume that Betty has not had a bone mineral density scan. And you're really thinking, well, I mean, gosh, she smokes, she's been on glucocorticoids, she drinks alcohol, she has had a previous fracture, like, she should probably get a DEXA scan. and you're thinking like, but you know, what are some, like, should I suggest that? The great news is that there are guidelines that tell us if we should suggest that Betty get a bone marrow density scan. I will link the clinician's guide to prevention and treatment of osteoporosis as well for you all to look at, but it just gives some general guidelines. A lot of the things that you have just heard about from the FRAX tool. So, it will tell us that we should consider BMD testing if with individuals based on age, based on the clinical risk factors such as taking glucocorticoids or having an inflammatory disease, individuals who have had a fracture. So we have guidelines to tell us this. TESTING FOR OSTEOPOROSIS So You've run the FRAX tool, you've looked at the guidelines, you are sure, you're like, Betty needs to go get a DEXA scan. So you're gonna communicate this to Betty. But what you're gonna do next is not, hey Betty, I really want you to go get those bones looked at. So schedule that with your doctor. I'll see you next week. That's not what we're gonna do. you're gonna help Betty set that appointment up or call a doctor, right? You are going to help her advocate for herself. You're not just gonna give that piece of education and then peace out, Betty. So what can you do? You can get the doctor on speakerphone during your session with Betty. and you can guide the conversation while she asks to set up an appointment to get a DEXA scan done. You can make sure Betty knows how to get into her MyChart so she can send a message to her doctor and you can help guide her on how she should formulate that message so she's communicating effectively. Make sure that you are a guide during that process and that you're not just throwing an educational piece at her and expecting her to take care of it. Help her through the process. Okay, so let's say we got a DEXA scan scheduled for Betty and she goes and has her appointment. She gets her DEXA scan. She has her results. This is where you can have a major role, not only in helping to deal hope to Betty once we are looking at those results, but it's also gonna be your guide when you start to implement your interventions. And it gives you very critical information, okay? So if you all have not seen a DEXA scan in the wild and what that looks like, I'm gonna tell ya, it's not patient friendly. I have seen one after my mom had to get one before she had a lumbar fusion surgery. It is chock full of scary words like osteopenia, fracture, osteoporosis. There's a lot of negative values, right? Like her T-scores all over the place and there's these negative numbers. It'll say increased risk for fracture. It is not easy to comprehend. and it deals a lot of fear. So this is an opportunity to help Betty interpret what this means. And you can really offer a lot of hope here. So with the DEXA scan, right, and with this data, you can be looking at it, and it's gonna give you that T-score, right? Betty may be looking at this and be like, oh my gosh, this number is so low, this is awful, right? I'm so scared. you can deal hope because you know, based on the law of initial values, those lower T-scores are going to respond to bone loading the best. They're gonna have the best result from starting to load those bones up. That's an amazing thing. You can share that news. So even if that T-score is really low, you can say, Betty, that's all right. That low score, those bones, you're gonna respond the best. And together, we're gonna help get those bones stronger. So right away, you can start dealing some hope. It's also going to tell you where those low T-scores are. The location of where the osteopenia or osteoporosis is is incredibly critical. How many of you have had patients come into your clinic and say, I can't lift that because I have weak bones? And you know, Betty, if it was Betty, she may assume that her weak bones are all over the place. However, that DEXA scan could tell you that the only place where she has weak bones is in her radius. Okay, well, all those squats and the jumping and things that Betty's like, absolutely not, I can't do, they're kind of irrelevant because it's in her radius and not in the legs, right? So to help Betty alleviate some of that fear, you could reassure her where those weak bones are. And that could really work in your favor when you're trying to get her to buy in to do exercise. However, you are also thinking, I need to know where and where is important because you know that bones are going to adapt specifically to where load is put on them. So let's say the low T score is in Betty's hip. You know that you have to load that hip up in order for that bone mineral density to increase. However, you also are taking this information and being cautious to say where it is so that Betty knows, yes, it's weak here. She may be a little apprehensive to load that area. So you know that you can give her the hope of, hey, it's weak here, but your bones are strong in these other places. So we can start loading where those strong bones are. So you can gradually expose her and mitigate some of the fear she may have. The other piece of information that is really important from the DEXA scan that you get as a provider is that it just gives you the severity, right? How low is low in that T-score? Because that is going to determine your rate of loading progression. So you have to know, hey, maybe this is someone where we are not going to start with impact exercises, we're going to start with just resistance exercises. And maybe I'm going to modify where I place that weight based on where that low T-score is. And maybe if we do start impact, or when we start impact, it's going to be upper extremity assisted versus just having Betty do jumping right away. So it's incredibly important so you know where the entry point is of appropriate and safe loading. So the bone mineral density scan, helping Betty interpret that information and you using it as a guide, sets you up to be able to appropriately intervene and start loading those bones up. All right. That is it, that is what I got for you all. I want you to start getting really curious about your patient's skeletal health, and then get after these two easy actionables. Run the FRAX tool, advocate for a bone mineral density test. Once you get the DEXA scan and you get that information, interpret that with Betty, use that as your guide, use it to deliver hope to Betty. After that, it is off to the races with your loading interventions. this framework of how to manage osteoporosis. This is one small piece. We expand on this so much greater in our L2 course. We talk about medical management. We talk about further into guidelines and how to load and what's appropriate to load. And we dig into the research. We would love to see you in that L2 course so that you all can really get a comprehensive really get comprehensive knowledge of how to manage this condition. In our live course, we have an entire lab focused on impact training, so it gives you all the ideas, all the ideas. You get to try them out of how to initiate bone loading for your athletes who are seated and they are non-ambulatory, they're in wheelchairs, all the way up to a very high, highly active older adult. That's what I got for you guys. I would love to hear if you all run the Fractual this week or interpret your patient's DEXA scan with them. I would love to hear how that goes. Have a wonderful rest of your Wednesday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 19, 2023

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses using the "Five A's" model in the clinic with patients to begin to address obesity management as part of a plan of care. Take a listen or check out the episode transcription below. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLEN CSEPE Hey, good morning, everybody. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'll be your host today. My name is Dr. Ellen Csepe. I'm with the MMOA Older Adult Division, whose life's mission is to give grandma gains this Christmas to fight off frailty and level up what it means to be a geriatric clinician. So before we get started today, let's talk about our upcoming courses. We have two courses online that are eight week long cohorts where we talk about discharging the ankle pump and dialing in our skills for dosing in the level one course, which starts on January 10th. January 11th, our L2, level two course, we take it to the next level to really dial in our skills for older adults with specific conditions like osteoporosis, osteoarthritis, and even we have a new segment recently added on cognitive changes in dementia. So we're really glad that you're here today. Our topic for today is gonna be on obesity in the five A's framework. So your job, as a clinician and managing obesity in the Five A's framework. So I don't need to tell you guys, obesity is a growing health concern. Obesity and pre-obesity affect nearly 70% of the American population. This is obviously a big concern for us as a community, as a country, and as clinicians. And believe it or not, most patients believe that this is our job to manage, Managing obesity is something that is within our scope, and talking about the health considerations and health behaviors that contribute to obesity are within our scope as providers. But we have to take on this responsibility with excellence. We do everything here with excellence. And it's unfair to give this patient population anything less than that. And I've been saying this for a while, friends, but Our profession is uniquely positioned not to just add our opinion on how we should manage obesity, but in my opinion, we should be the leaders in health care. for how to manage obesity. We squander so many different resources that puts our profession above others. Things like time. We have more time with patients than any other provider and we often waste that resource because we're not confident in managing this problem well. We spend so much time with our patients and we have the strongest therapeutic alliances with them. We know our patients and spend hours with them as they recover from injury where they're kind of uniquely positioned at a position for behavior change. They're really primed to make the most with their health because they're afraid, unfortunately, because of their injury, because of what happened to them. prime time for us to change behaviors and we really waste that opportunity for lots of different reasons. And friends, we can no longer pass the buck off to other health care providers and say that this is their job. You know what I'm talking about. We ask our patients, does your doctor ever talk to you about exercise? Does your PCP ever talk to you about nutrition? They're like, no, they've got five minutes with me and they didn't do that. And we raise our hands and say, this is the problem with our healthcare today. No, we have a job to play in managing obesity. We have a role in this and we have to do it well because Friends, if you wish to treat obesity, you're responsible for not just identifying it as a problem in your patient population, but knowing what's going to work. For example, if I have a car and my battery is dead and I know my battery is dead and I take it to a mechanic and that mechanic says, yeah, your battery's dead. Good luck. That didn't help me at all. I need a mechanic that can identify the problem and then take the next steps to helping me fix it. We can no longer merely identify that obesity is a disease that causes significant harm to our patients. We cannot just merely identify it, cross our arms, look down the end of our nose and blame our patients. We can't do that anymore. We cannot just watch our patients suffer with a chronic illness and do nothing pragmatically to help support them. With that in mind, that same analogy of a car battery, if you had a car that needed a new battery and you came to me and I was your mechanic, I have no idea how to change a car battery. No clue. But if you came to me and I said, oh yeah, I've got this handled. I can help you out. That's an even bigger problem. We cannot address this concern with merely confidence. We have to have the skills to help our patients manage obesity. We can't just have confidence that we're providers of choice and that we're excellent. We need to have real skill in treating this concern. And friends, patients know that their weight is contributing to their problem. That's not that telling them is not the skill. That's not the skill. We need to be able to create an environment that's free of stigma. free of bias and filled with empathy for our patients that are struggling. Because patients know their weight is contributing to their issue, but in this void, in this vacuum of clinically meaningful discussion around weight and around behavior change, things like fad diets, diet pills, failed attempts at managing weight, ignorance to what might actually work, poor access to health care, and really at the bottom line, addressing their health alone. That's what happens if we don't bring skill to this discussion. If we can't bring skill to this issue, to this massive health crisis, what happens is the flip side. Patients having to figure it out on their own. So what I mean to say is there's a big difference in shooting from the hip and saying, yeah, you know, you'd probably have less pain if you weren't overweight or obese. There's a difference in that versus, can you tell me more about your exercise habits? Can you tell me, have other health care workers talked about how your weight might be changing or your weight might be impacting your condition? There's a huge difference and what that skill, if I could really articulate what that skill is, this skill is the hardest job that we have. The skill that you need is really the soft skills of being a good clinician. That's the hardest job we have. It's way easier to needle somebody's trap than it is to develop therapeutic alliance with them and make sure that they know that you're on their team and that you're an empathetic listener. That is way more abstract of a skill than just being able to do one small part of our job tactically. And I would argue that it might be the most important skill that we have. Patients need empathy if they're facing a health concern. Patients need us to see them as a person and not just as a patient. We need to address our own biases to really be impactful for this patient population. We need to acknowledge that if it were easy to lose weight, everybody would do it, but it's hard. Obesity is a relapsing chronic health condition that's multifactorial and it has a lot of psychological impact or impact bi-directionally that we don't even really fully grasp yet. Obesity is not easy to change and we need to address that first. So the next part of our discussion today, we're going to be talking about the five A's in obesity management. Now, when we talk about workouts, we're often given ideas and options to scale a workout. And so friends, if treating your patients with empathy and understanding and listening and patient-centered language is too big of an ask, I'm going to give you an option to scale this discussion with them. If the 5 A's and treating your patients with dignity and empathy and listening and respect sounds too hard, here's your scaled option for this discussion. You can say, it sounds like you're concerned that your weight is a contributor to this issue. I can refer you to a colleague of mine that has more empathy than I do and can have this discussion with you better. Bottom line, if you don't have empathy for your patients, if you haven't done the work to check your bias and how you might look down the end of your nose towards people struggling with your weight, looking for your help, then please step to the side and let a clinician come in to intervene that can have empathy and listening. Because unfortunately, you're likely doing more harm than good. Patients know that you're biased against them. They don't need you to tell them. Your face says it. And unfortunately, negative interactions with health care providers with weight bias often leads to further binge eating episodes for patients with a binge eating disorder. So no, you're not just telling them what they need to hear. You're actually being supremely unhelpful and likely making their problem worse. So if you can't have empathy, please scale this discussion and relay them to a provider that can actually be helpful. THE FIVE A'S MODEL So what are the five A's? The five A's model originates from the U.S. Department of Health and Human Services where it was developed as a framework for encouraging smoking cessation because, believe it or not, sticking your nose up in the air and saying, you know, those things are going to kill you actually doesn't help anybody quit smoking, shockingly. The same is true for older or for people struggling with obesity. So this framework was really developed to help put the patient who needs to make decision making changes in the driver's seat for their behavior change. So the five A's. ASK The first A is ask. Ask, is it okay to discuss lifestyle factors today during our session? Is it okay to talk about how weight might be contributing to your condition? Is it okay for us to talk about contributing factors like sleep and stress and nutrition? Have other health care workers discussed your weight in a way that was helpful or meaningful? So the five A's first, we want to ask for permission and some patients might tell you, no, that's okay. If somebody says, no, you know what? This really stresses me out. I'm not interested in talking about this with you. I just met you. That is understandable. We don't need to have a wrestling match with our patients. And if you have these soft skills, it should not feel like a wrestling match. It should feel like a natural discussion because again, patients already likely assume that their weight is contributing to their problem. You can ask which factor of their health they want to address today. So whether we know that sleep, stress, weight, exercise, diet, all interweave in regards to behavior change. We know that those things are interwoven and impact each other. ASSESS So our next A is assess. Assess, so you can ask a patient, hey, what do you want to talk about today? There are a few different things about your lifestyle factors that might be contributing to your condition. Yeah, your weight might be part of it. Also, sleep has a bidirectional relationship with weight. Exercise habits, dietary habits, stress, which do you kind of want to dive into today? And then let that drive the next tool of assessment. So if your patient says, you know, I actually don't know how much I weigh, do you have a scale here? Of course, that's within our scope to weigh our patients, to calculate BMI, to look at waist circumference. An important note should be that we do that in a private area because discretion with privacy is super important with this patient population. So we can't make good decisions with bad data. That's from our CEO, Jeff Moore. We can't, give patients and shoot from the hip that they need to lose weight when we don't know anything about their body composition. So weighing patients, providing that information about their waist circumference or their BMI is our next A for assessment. ADVISE The next advise, so the third A is advise. advising patients that sleep, exercise, appropriate nutrition management can be helpful in reducing pain. Most patients come to see physical therapists because they're in pain and so understanding that those factors deeply influence our success with rehab, and those are things that we can modify, that is hugely important for our patients to know. Also, not setting the goal too high. We might say, here's what your BMI window would be if it were normal, but who cares? Our goal initially should be to manage weight for five to 10% because even small percentages of weight change can be hugely impactful on lifespan. There's a lot of discussion about whether or not weight cycling and trying to lose weight only to gain it can be bad for our metabolic health, and meta-analyses recently would show that, hey, even if you lose weight and regain it, that can be beneficial for your overall health long-term, and you can still have a decreased risk of experiencing diseases. Noting that, you know, advising the patients that, hey, if you've tried losing weight in the past and it was a real stressor for you, we can talk about just increasing your activity level. It doesn't have to be a goal to lose weight. That does not have to be our goal. We can advise patients to just increase their activity level or decrease their added sugar, irrespective of weight changes, and that alone can be helpful in managing pain and managing injury. Third A is advise. AGREE The fourth is agree. So this is super important for our patients. We have to agree. We have to come to an agreement as to what we're going to do next. This is a pro tip. Let your patient set the goal. set what they want to do. Being told, okay, we are going to agree for you to stop smoking. We are going to agree for you to cut back to two cigarettes a day. Nobody likes to be told what to do. So asking your patient, what would you like the goal to be for the next week before we see each other again? Let's agree to talk about this again in the future, but I want you to set the goal for what sounds realistic for your life. I'm not going to tell you what that is. ARRANGING And then the fifth A, likely the most important, is arranging. So arranging for services for our patients. This is probably where we like to, you know, shoot from the hip and say, have you tried cold plunges? Have you checked out this latest app? Have you seen this new meal subscription plan? So arranging for our patients to access services is a huge, role to play in a patient's weight management, I would advocate for you guys. Really challenge your biases here. If you had a patient that had a resting blood pressure of 200 over 130, you'd be like, shoot, man, you are in danger. You are not okay. We need to send you to your PCP to talk about blood pressure medicine. That's what it's there for, right? Friends, if we can say that about blood pressure medicine, Why can't we say the same thing about medicine that would help manage obesity? We know obesity is a chronic, relapsing, difficult to treat condition. We know that it's a disease that requires medical management in some cases, and that people with just diet and exercise alone still struggle with success with managing their weight. If we're going to say that our goal is to manage weight for people that struggle with obesity, why are we so against referring them to get medicines. Why are we so averse to referring out to clinicians that would do this better than we would? It's no shame to say that you might need medicine to help manage a chronic health condition. So referring patients back to their primary care doctor to determine if it's appropriate for them to be a candidate for bariatric surgery, or talk with a nutritionist, or talk with a dietician, or be on medications. That is within our scope as well. And you really, friends, have to check your bias. If that puts a knot, a ball of wax in your throat, that you're like, oh, I really don't wanna do that, that's cheating, cheating. It's cheating for a patient to use medication to lose weight. They should do it the hard way. Like, we're not gonna be effective to patients coming at a chronic health condition with that bias. Can people be successful with managing their weight without medicines? Absolutely, but those medicines are underutilized for the people that truly need them and overutilized by Instagram models. So I think that we can do our patients a favor and check our bias when we're talking about medications and other procedures related to weight loss. SUMMARY First, ask. Then, assess. Third, advise. Fourth, agree. Fifth, arrange. So those are the five A's for obesity management and the conversation that we had around them. Friends, I am so honored that you would spend your time with me to talk about how to serve this patient population better. This patient population deserves our best stuff. They deserve excellence. They deserve people who are truly compassionate. And friends, we have a strong role to play in this huge problem in society. You know, it's really easy to acknowledge that chronic pain, um, chronic pain and over-utilization of obese or of opioids is a huge problem in our world. We know that overdosing from opioids is a huge problem that physical therapists can be super impactful in treating. I would argue that we have a much bigger role to play in managing obesity and supporting our patients than we assume. We really don't do enough for our patients because we're often limited by fear. We're often limited by a lack of skill and a lack of knowledge into what we should do. And I am so honored that you would spend your morning with me sharpening those skills. Our patients suffer in the void of these meaningful discussions. Our patients suffer by themselves, not knowing if there's a clinician who has empathy and support for them. I'm so thankful that you listened to this podcast today to really better serve those patients who are vulnerable in our healthcare world. Thank you so much for joining me. Have a great rest of your day. OUTRO Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 18, 2023

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of estrogen in the body, the important role estrogen (or lack thereof) may play in rehab outcomes, assessing menopause in the clinic, and hormone replacement therapy. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. And y'all, the pelvic division has been just really busy over the last couple of weeks, couple of months, heck, the entire year. But if you did not see, we actually just sold out our first online cohort for 2024. And so that is sold out. So our next cohort for our online level one is March 5th. Our brand new inaugural cohort for level two, if you've taken level one, is April 30th. And in 2024, I am going to be in Raleigh, North Carolina with Rachel Moore, January 13th, 14th. And Alexis is going to be teaching in Hendersonville, 27th, 28th of January. And then we're heading over to Bellingham, Washington, February 3rd and 4th. Those are the first three courses of 2024 if you guys are interested in coming to our live course and doing some of our skills check for cert. ESTROGEN & REHAB Okay, so I kind of want to talk about estrogen and specifically estrogen in later life and lack of estrogen and how it influences rehab. So this has been something that I've been really kind of geeking out about over the last little while around, you know, not just as pelvic therapists, but as anybody working with a person going through menopause, if you are working with anybody over the age of 50, a female over the age of 50, you are interacting with a person who is going through estrogen depletion in their body. And As I've learned more about the influence of estrogen on our bodies, the more I am recognizing even outside or maybe even especially outside of the context of pelvic health when I'm seeing people who are postmenopausal, but in my orthopedic rehab, how much it is influencing our outcomes. and just a person, a person who is a female in an aging body, what the lack of estrogen may do for the way that we experience aging. And then I kind of want to cap this podcast off talking a bit about some of the myths and misconceptions around estrogen replacement therapy. or menopause replacement therapy. And we'll talk a little bit about the change in the labeling of these types of treatments and where some of the thoughts around risk for things like sex-related cancers has come up. So to start this off, I want to start with a story. So I was working with a woman who was coming in. She was in her early 60s and dealing with shoulder pain. She had a history about 10 years ago of frozen shoulder. So when it comes to adhesive capsulitis, we know that being a female and being kind of in middle age is a risk factor. And I never really thought about that risk factor being linked to estrogen status or like the beginning of perimenopause. Still wasn't really thinking about it. But she said, you know, that was a really long journey when her shoulder froze. And but it got better, got better over time. She realized that she was going through hormone replacement therapy or she was going through menopause. She got put on hormone replacement therapy. She was on it for 10 years. And then her doctor on a follow up where she was trying to get a renewal said, actually, you've been on it for too long. I'm going to take you off of it, which that That's a whole other ethical scenario, especially because we should be weaning off estrogen replacement therapies, not just going cold turkey. But however, took her off and within a couple of months of that weaning process, her other shoulder started to freeze. I've obviously been in the weeds of this research right now around the influence of estrogen on our body, but I was thinking about and reflecting on how many women I have worked with over my career. THE INFLUENCE OF ESTROGEN ON OUTCOMES I've been a PT for 10 years, so very still early on in my career, but how many have I not recognized the influence of a person's estrogen status on our outcomes? And so when we think about estrogen, we think about fertility, rightfully so. We think about pelvic floor physical therapists kind of specializing in the fertility space, granted, but estrogen, when we have a depletion in estrogen as women go through menopause, it affects every part of our body where there is an estrogen receptor. And I don't think that many orthopedic therapists or people who kind of aren't niching into this space, myself included until I got into this arena, recognize just how widespread that is. And in pelvic health, we've done an incredible job of advocating for individuals in the perinatal space. We still have, of course, ways to go. However, you know, there's this rise of individuals going through menopause who are starting to advocate that we need that same type of education. And too frequently now that I've been asking are my patients saying to me, oh, well, my doctor said it was just part of aging and I shouldn't be on hormone replacement for this long or like have just been dismissed about their symptoms and have not linked some of these other body systems and the experiences that they're having in these other body systems with their estrogen depletion. I have a client seeing me for ankle pain and she's kind of in that postmenopausal window and she said, I am trying to learn a new body that I do not understand. And I think that was such a profound statement because so many individuals are feeling this way and we have a huge role to play in rehab. And I'm not talking pelvic, I'm talking generally. THE ROLE OF ESTROGEN IN THE BODY And so when we think about estrogen, estrogen has receptors in our brain. It has receptors in our joints and muscles. It has receptors in our heart, and it influences our bone, right? Bone is probably the easiest one. We know that individuals who are postmenopausal are at increased risk for osteoporosis osteopenia, that there is an accelerated rate of decline in bone mineral density loss with estrogen as rates of, estrogen helps rates of bone build up. And with estrogen depletion, we see a switch in the slope of the line where bone breakdown exceeds rate of bone growth. And so rates of osteoporosis go up postmenopausally. We also see that individuals who are in an estrogen depleted state have higher rates of joint pain. So kind of an umbrella term of joint arthralgia. and we see links to risk factors around things like adhesive capsulitis in individuals going through perimenopause, but very little research has actually looked at individuals' experiences of musculoskeletal pain in the postmenopausal window. So we could have individuals who are not responding as quickly to rehab, even though we're throwing everything at them that is evidence-based and evidence-informed, because they are going through menopause and it's the influence of their hormones is changing the way that their body is responding to some of our rehab interventions and we don't know about it. Our body also has estrogen receptors in the heart. And so we see that men tend to have a higher rate of cardiovascular disease and heart disease than women, but that change in rate between men and women starts to change in that postmenopausal window. So rates of heart disease start to go up postmenopausally because of the protective effect of estrogen on the heart. What we also see from a metabolism perspective is that there is a change to the way that fat is laid down when individuals are postmenopausal. So where we have the protective subcutaneous fat that tends to be something that is kind of a net, potentially neutral way of laying down fat, the more dangerous fat is visceral fat lay down, and that tends to accelerate in a postmenopausal female because of estrogen deficiency. which then increases risk for a whole bunch of different metabolic diseases, including, you know, heart disease, stroke, Alzheimer's disease, like all these diabetes, all of these things that we know are linked to pro-inflammatory cascades. It accelerates for individuals as they go through menopause. And then finally, from a cognition perspective, we have systematic review evidence that Individuals who go through premature ovarian insufficiency. So individuals who go into menopause before the age of 40 are at an increased risk for cognitive decline. So rates of Alzheimer's are higher in individuals who go through early menopause. And we see that there may be a protective effect, preventative effect of the development of cognitive decline for these individuals who are going through menopause early if they are on hormonal contraception. Which gives a very strong argument for the link between estrogen status and cognition. And when we think about symptoms of menopause, we kind of put them into different buckets. We talk about, you know, vasomotor symptoms, which are night sweats, issues with sleep, sleep disturbances are very high around the postmenopausal or menopausal transition, and hot flashes. Right? And there's kind of like this immediate withdrawal effect of estrogen. Like you could almost think about it as like a drug withdrawal. Like when we get withdrawn from estrogen, those vasomotor symptoms kick up. And then eventually our body gets used to being in that state of estrogen deficiency and those withdrawal symptoms kind of go away. But genitourinary syndrome of menopause is really focused on the aging of the pelvis and its influences. And so when we're in pelvic health and we're talking about estrogen deficiency, we see, you know, adhesions in the labia minora to the labia majora. We see an increase in friability of tissues. We see an increase or a changes to the pH of the vaginal microbiome. And so these all have influences, but the genital urinary syndrome very much focuses on the pelvis. ASKING ABOUT MENOPAUSE And so if you are not in pelvic health, you may not be really considering it a reason to be asking about symptoms of menopause and when you went in through menopause. But if you are an individual who is working with anybody who is a female over the age of 50, you should be asking, are you in menopause? Have you gone through menopause? When did you go through menopause? And menopause is diagnosed as the 12 month mark of not having a period. So when you have not had a period for 12 months consecutively, that is considering being in menopause. Average age is 50 to 51 in the United States. asking around changes in symptoms around the menopausal transition. Did you notice a change to your mood? Did you see a change to your sleep? Did you see a change to your cognition? Did you see a change to all these other things? Because we know that if you're depressed and not sleeping and your joint pain is up, we're probably gonna have a lot of conversations that we need to have around recovery. It's gonna influence the way that our treatment is going to go. And then we can be an advocate for ways to manage. Too often, and there is nothing that makes me more mad. Like when I see individuals who have gone to their doctor and they say, I am suffering with vasomotor symptoms. I am suffering with all of these things. And they say, I have no libido. And they say, well, you are going through menopause. And that's kind of the way it is. Men will get Cialis or other types of hormone replacement for their sexual dysfunctions very readily. And it is met with hesitation when we are talking about female reproductive aging. And I was just at a course where it has some individuals who are part of the military and the military nurse practitioners were there, which is really cool. But they said, you know, we are so willing to prescribe Cialis but we are very hesitant as a division to give hormone replacement therapy. HORMONE REPLACEMENT THERAPY And so the next part of this conversation, one, estrogen affects everything. It's absolutely gonna influence our pelvic floor. It's absolutely gonna influence our pelvic health. But then the next thing that people are asking is around estrogen replacement therapy, sex hormone replacement therapy, and its safety and efficacy. So I wanna do a little bit of a history lesson here around where this risk is coming from. So there is a large longitudinal study called the Women's Health Initiative that has been collecting data on women for a very, very long time. And early, early on in about 2001, a study was released from the Women's Health Initiative that said that there was a 25% increased risk of sex-related cancers for individuals who are on hormone therapy than individuals who are not. This was, potent, like kind of true, but it missed the forest for the trees. And so when we kind of zoom out and we look at relative risk of sex-related cancers, that, well, that translated into, instead of it being three in 1,000, and these are not perfect numbers, I don't remember off the top of my head, it changed to a four in 1,000 rate or incidence of sex-related cancers. When if you think about it like that, that is not the biggest difference. However, that one study came out and it changed everything. It was largely disseminated, many media outlets put it up, and it made everybody very, very fearful of prescribing hormones. So there's a couple things nuanced to this. When we are taking any type of medication and our sex hormones are not anything different, there is always going to be potential risks. Those have to be balanced by the benefits. We see, for example, that individuals who are on replacement therapy have a lower risk of Alzheimer's, dementia, especially if individuals are going through a menopause early. We see sexual health, sexual, satisfaction increases on hormone replacement therapy. We see an increase or rather a decrease in rates of urinary tract infections. And if you are working in the geriatric space, move this into Wednesday. It makes a huge difference. A urinary tract infection can change a person's life. A person can die of a UTI because it can end up, they get in hospital, UTI becomes sepsis, sepsis becomes a full blown, you know, it's now a full blown infection and individuals don't get out of hospital or they see a consistent change in function. All of these benefits for many are going to outweigh that slight increase in risk. Now, we have evidence since then that that risk percentage may have actually been when we replicate a study, which is super important before we're making very broad sweeping statements. There is a range of that relative risk and it actually might be lower. And because of that, we now have good evidence for individuals who are going through chemo to be able to have, because it can irradiate and bring you into a low estrogen state, where they may use topical estrogens. We have more evidence for individuals who are on estrogen receptor blockers, like tamoxifen, to, again, have topical estrogens. Because, obviously, we're not gonna wanna ingest estrogen when we're trying to block it so that cancer doesn't regrow, but to put it on the external genitalia, that would allow us to remove some of those pelvic-related symptoms for individuals being in low estrogen as a consequence of cancer treatment. And this evidence is continuing to grow. NO EVIDENCE FOR AN OPTIMAL HORMONE REPLACEMENT WINDOW The other question, when I go back to my patient that I talked about, is that he said, well, you've been on it for enough, this physician, and I'm gonna take you off. We actually, again, don't really have any evidence around where that window is. Like how long you can be on it before the risks start to outweigh the benefits. And because we don't know, individuals are just creating a risk tolerance zone for themselves and then unilaterally kind of applying it in their practice. And so we still have so much work to do in this space. We are starting to see a change in our language around hormone replacement therapy, and it's being changed to MHT, menopausal hormone therapy. And it is actually encompassing a variety of different treatments. It is not just a systemic pill that you can take that is a natural replacement, there is those. There are progesterone replacements. There are estrogen and progesterone combos. There is evidence for testosterone replacement and testosterone replacement helping individuals with hyposexual disorders. And then there are topical estrogen therapies where individuals who are experiencing recurrent UTI, individuals with issues with labial adhesions, individuals with clitoral adhesions, all these different things can see a huge benefit to this type of hormone replacement. And so, The role that we have to play here, if you were a pelvic clinician listening to this, we have a ton of advocacy to work on. Staying up to date with the evidence, referring back for potential counseling on hormone replacement, and continuing to have those conversations with our physicians is gonna be super important. If you are a person who's an orthopedic specialist, you need to be asking about estrogen status. Have you lost your menstrual cycle? That puts you in low estrogen. Have you recently had a baby? If you're a postpartum and you're dealing with a wrist injury, that low estrogen is gonna impact your ligaments. It's going to make it so that you may be more likely to have things like mom wrist decorvains tendosynovitis. And then if you're working with individuals who are older, then again, we're gonna be asking about when you went through that menopausal transition and how you're feeling. A lot of people feel like, oh, well, I'm going okay through my menopause right now. I don't really need it. The thing is estrogen deficiency is accumulative. So it is also a discussion around the preventative aspect of continuing to have individuals on hormone replacement. I don't know the answer to this, but it is a continual conversation. It is one that is happening in lots of spheres and one where there is a role for rehab. And this has been such an important part of the development of our research base in pelvic and a huge portion of the proportion of individuals that we are seeing in our practice that we have put it into our level one. So we have an entire week on the influence of menopause on the female body and an entire module on the way that we would work towards treating individuals and advocating for individuals who are going through menopause, who are subsequently feeling issues with pelvic health. So if you are interested, get into our March cohort. I could rant about this all day. I'm already 20 minutes in. I'm gonna get off here, but it's important. And it is not just important to our pelvic health clinicians. It is important for everybody who is working with a female body over the age of 50. And we're not even going to go into the perimenopause part because perimenopause could be 10 years before. So if you're working with anyone over the age of 40, this is relevant and it influences our rehab outcomes. All right. I hope you all have a wonderful week. Merry Christmas. If you are off, happy holidays. Whatever denomination you are, please hopefully have some time to spend with loved ones. And I hope that you get some of the rest and relaxation that is just something that you are looking for. I have two little ones, four and two, and the magic of Christmas and the holiday season is so alive and well in our house, and it is such a beautiful thing. So I hope you all get that. You are so welcome for me talking about this. I promise you, I will be diving more into this onto my personal Instagram, and it's definitely gonna come onto ICE because I think it's really important, and I think it's a huge miss that we have. So thank you for listening, and I am so excited to continue these conversations. Merry Christmas, happy holidays, and hopefully you get all of that rest and relaxation for the end of 2023. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 15, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how to adapt the @concept2inc rower for patients & athletes who cannot use both legs, both arms, or seated athletes. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALLAlright, good morning everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Fitness Athlete Friday. We talk all things CrossFit, Powerlifting, Olympic Weightlifting, Endurance Sports, Triathlons, Marathon Runners, Cyclists, figure skating, all that wonderful stuff. If you are working with a person who is recreationally active in the gym, on the road, whatever, Fitness Athlete Friday is for you. Today, we're going to build upon an episode from three weeks ago, introducing you all to the Concept2 Rowing Machine. We're going to build and show you how to adapt this machine for a lot of different folks who might show up in the gym or in the clinic, post-op, adaptive athletes, all that sort of thing. Before we get started, just a heads up about courses coming your way from the fitness athlete division. Your next chance to catch us online for our level one course, online course, eight weeks, entry level course previously called Essential Foundations will be January 29th. So our Clinical Management Fitness Athlete Certification, Level 1 online, prerequisite for Level 2 online, that class begins February 5th. And then our live seminar is its own standalone event. Those are all over the country this coming year, so check out PTENICE.com and look for Fitness Athlete Live for courses coming near you. And then check out our two online courses beginning in January and February. Just a reminder, all of our courses currently priced at $6.50 will jump to $6.95 on January 1st. And really, we don't want to pressure you, but most of our quarter one courses, live and online, are selling out. Our pelvic level one online course just sold out yesterday, about a month in advance. So we're seeing about a three to six month sell out window currently. So if you had an eye on a course, we'd recommend grabbing it sooner rather than later, especially if you can take advantage of saving some money on that price increase. So that's courses coming your way from the fitness athlete division. ROWING 102 So before we get started, I'm going to show a lot of stuff today. So if you are listening on the podcast, and you are a visual person, or you're not very familiar with the rower, I would recommend you stop the podcast, you jump over to our YouTube channel, and continue watching this episode here on YouTube so you can actually see what I am doing. So I'm going to reference two previous episodes as we talk about today's topic. So we're going to get into some advanced mechanics of the rower, how to adapt the rower with different equipment. Go back three weeks, episode 1606, where we talked about the very basics of the Concept 2 rower, how rowing works mechanically, how to put yourself in the best mechanics to row, how the rower itself too works as far as what are the different pieces of equipment, how to clean them to make this machine last you, 10, 15, 20 years, and then also how to use very basic things on the rower like drag factor to understand where you should place your damper on the flywheel, again, to optimize the very basics of rowing. I want you to go back two weeks to Guillermo's episode, episode 1611, to learn a little bit about how intervals, he specifically talked about research on assault bikes, but how intervals on earth machines in a very small time window, two to three times a week, for eight to 20 minutes of work can have a significant increase on VO2max. So never forget, when we're working with patients, working with athletes, especially those folks already active, at the very least, we can help them maintain their current level of fitness, being intelligent with how we use machines, how we adapt the machines, and that's the point of today's episode, of how to adapt these machines. So folks coming in, they can only use one arm, they can only use one leg, they're pregnant, they're postpartum, whatever, how can they get on this machine and at least maintain their fitness as we work through their rehab. 1-LEGGED ROWING So I want to talk about how to set up the rower to row with just one leg. I want to set up the rower and show you how to row with just one arm. And then I want to show you what many people don't know is that the rower actually breaks down in half. Yes, to make it easy to store, but also to get rid of the rail so that seated athletes in a wheelchair can roll up to the rower and row on a Concept2 rower. So the first thing I want to show is very simple, one-legged rowing. So what you're going to want is one of these little things. If you've ever changed your own oil on your car, you know what these are. These are little caddies that roll underneath your car. So they have wheels, six axis, they move in any direction, and they're mainly designed to hold tools and stuff if you're working underneath in your car. So you can get these at an auto parts store for 10 or 20 bucks. You just need one of them and they'll last forever. Alternatively, you can also use a skateboard or something like that. But what we want is we want something that we can place someone's foot inside of that moves, ideally moves what we call six axis, right? Forward, backwards, side to side, and then each diagonal, right? It can potentially move 360 degrees so that as a person rows, their foot can move alongside the rower. So let's set that up. So for example, let's say I can't use my left leg, maybe my left leg is locked in a knee brace, I'm locked in full extension, maybe after ACL reconstruction or something, I can still get on the rower and row with one leg. So I'm going to get on my rower, I'm going to strap in, grab the handle, Until my wife was on the rower last, she cinched the straps all the way down. And now, instead of putting two feet in, because I can't bend this knee, right, it's locked in extension, I'm going to kick it out to the side of the rower, and I'm just going to let it rest in this whale caddy. Now, I can still more or less perform all of my normal rowing mechanics. I can still drive with my right leg, I can still lean back, and I can still pull with my upper body. So this is fantastic, folks maybe working with an amputation, folks locked in a brace, maybe folks that just can't tolerate that loaded knee bend, knee extension with that leg for whatever reason, we can have them still row using something like an oil caddy or a skateboard. So that's one leg rowing. 1-ARM ROWING Now, one arm rowing is totally possible. You're going to want a device like this. This essentially just looks like a hook. You can get this from Adaptive Training Academy. So if you don't know Adaptive Training Academy, we highly recommend them. They have a wonderful course on basically adapting all things fitness for adaptive athletes. So it's a course that has its origins with CrossFit, but now has expanded into the rehab community as well. How rehab providers and fitness professionals can work with adaptive athletes to get them moving, keep them moving. They have a wonderful store full of all sorts of really, really, really cool things to help you work with adaptive athletes. And this is one of the tools they sell. So these hooks are going to latch on to the handle of the rower, and they're going to allow me to row with one hand. If you'll notice on the rower handle, in the middle, it has places technically to row with one hand, but they're not very comfortable. you need to essentially weave your fingers through and then you have the metal chain kind of bashing against your knuckles the whole time you're rowing with one arm. It's also very wide, so you'll sometimes see people row with a neutral grip and that's just not very mechanically advantageous. This is designed to improve that. To bring the handle in so that I can grab it with one hand, I can technically even hook grip this to really get the most out of my grip on my right arm or left arm and row to my chest and maintain my normal rowing mechanics. This is also fantastic for pregnant women who maybe don't tolerate the flexion on the rower anymore because of their stomach or the extension because of the stress it places when they lean back. What's great about these is you can build them on each other and you can essentially reduce the range of motion needed to reach towards that handle. So this can even be great for kids to get them on a rower at a younger age or maybe they literally don't have arms long enough to reach the handle, we can bring the handle to them. So I'll show you what that looks like with one arm rowing. So sitting in the rower, taking the hooks, latching it onto the handle, and now it's reduced the range of motion by about six inches towards me. And now with one arm or the other, I can pull and I can maintain all of the same mechanics of rowing. with one arm. I'm still able to drive with my legs, lean back, and pull the handle to my chest. Again, if needed, I can put another one of these on here and continuously bring that handle closer to me. So this hook is available again from the Adaptive Training Academy store if you want to pick that up for your rowing. DISASSEMBLING THE ROWER FOR SEATED ATHLETES/PATIENTS The final piece is breaking the rower in half. Again, a lot of folks don't know that the rower actually disassembles into two pieces. That's to make it easy to store. It's totally possible to break this rower in half, and if you have a larger car, an SUV, certainly a truck, you could take the rower with you, maybe if you're a home health clinician, and bring it into people's living rooms. it is made to break in half and all things considered once it's broken into half it's not very cumbersome and it's not very heavy. So let's talk about how to do that and then adapt that for the seated athlete. So right here at the base of the foot plates you're going to see a black piece and you're going to see a little handle to lift up. If I lift this handle up you'll see that the rail of the rower is just sitting on metal rod that's connected to the flywheel and the computer portion of the rower. So if I lift this up, I can now disassemble the rower into two pieces. So now the rails here, this weighs almost nothing. This weighs a couple of pounds. Again, this would be very easy to throw in the back of an SUV or a truck. The heavier part, of course, is going to have the damper and the flywheel, and all of the computer parts, but now I have the front part of the rower. Now I can have somebody in a wheelchair roll up to this. We can play with different variables. In the gym, we like to lift it up a little bit, and we like to put sandbags or plates to anchor it down, and we like to sit it on some sandbags or plates. So depending on the type of wheelchair that your patient or athlete has, you may need to bring the rower up a little bit so they can roll up, get into a good position and row. And then definitely, because it's no longer as heavy as it once was, you're going to want to make sure you weigh it down so that as they begin to pull the handle, this thing doesn't move around. But with a little bit of ingenuity, this is something you could even bring into someone's home, maybe wheelchair bound, where they're able to row, maybe do some intervals on the rower. So make sure you understand that the rower breaks down. This also makes it really easy to store rogue fitness. So you can see one over here in the corner, my bench is hanging on it. They make hangers that can be mounted to a wall that can hang either benches or it's designed to hang the front part of your rower off of. If you're thinking you're in the clinic and you don't have room on the ground for a rower, that's okay, you don't need it. You can break the rower in half at the end of the day and you can hang it on the wall. So make sure you understand that the rower breaks in half. That's made for storage, for travel, but also really important to make sure that we can get seated athletes using a rowing machine. So rowing, this is a very versatile piece of equipment. Make sure you understand how to use it. Make sure you understand that you know how to adapt it for different patients and athletes that present to you in the clinic in the gym and get more people rowing, get more people working on or maintaining their current level of fitness as you help them through the rehab process. I hope this was helpful. I hope you have a fantastic weekend. Our very last live course of the year is this weekend. It's happening right now in Salt Lake City. It's a dry needling course with Ellis and Melrose. So if you're there, I hope you have a fantastic time. Other than that, I hope you all have a wonderful Christmas, a very happy new year. Have a great Friday. Have a great weekend. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 14, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses how the pursuit & achievement of clinical excellence solves many problems. Individuals who produce high-level outcomes in the clinic tend to be the ones who get paid more, work less, dictate their schedule, and overall feel a significant return on the time investment they spend in the clinic. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MOORE All right, team, what's up? Welcome back to the PT on ICE Daily Show. It is Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursdays, which are always Gut Check Thursdays. Let's get it out of the way. Let's talk about the workout, and it's a banger. We've got three sets of the following rep schemes and movements. We've got 21 burpees to target, followed by 15 devil's press, Okay, it's gonna be with 35s or 20s. Okay, so going into that deficit push-up, pop into a squat, weights above the head, and then back down. 15 of those, nine burpee into a chest-to-bar pull-up. Then, however long that took you, you're gonna rest one-to-one. So if that took… Let's see, maybe three-ish minutes, right? You're now going to rest for that same amount of time, and then you're gonna fire back up set number two. The workout is three sets with that one-to-one work-rest ratio for time. That, I'm looking at that, I'm gonna need to settle into about 20 minutes or somewhere on that workout. That is going to be rough. Okay, as far as upcoming courses, one thing I wanna mention is that Pelvic Live, I'm sorry, Pelvic L1 Online only has four seats left. I also wanna say a lot of the courses in January are looking that way. Remember, our prices go up January 1st. It's only 45 bucks. It's from, all the 650 courses go to 695, but if you're gonna grab a Q1 course, they're already all on the schedule. Make sure to jump in and grab that course before January 1st, because right now you can buy them all for the $650 price. So if you have any courses you're looking at in 2024, you know you're going to take anyways, just jump on there and grab them before that price jumps up to $695. on January 1st. So you've got a couple weeks, that being said, a lot of them are selling out. So try and scoop up those tickets over at PTOnIce.com as early as you can to save yourself a few bucks going into the new year. So that is my course announcement. EXCELLENCE SOLVES EVERYTHING Let's talk about excellence. So the topic of today is excellence solves everything. And what I mean by that is, There is a threshold of excellence at which no barrier survives to your success. This is where the idea of becoming undeniable feeds in really well. Now, we're going to chat PT, but you can think about this anywhere. Think about that musician who doesn't have a major record label. Think about that busy restaurant in a horrible building or a terrible part of town or bad location, what have you. Think about the individual player with a mediocre teammate who still wins the championship. There is a level of excellence at which once achieved, nothing else matters. That being said, that's very, very high level from a success perspective. Now I want to drill down and talk about a specific thing that possessing that excellence gives you or benefits you or arms you with because it is so relevant to today's practicing professionals. EXCELLENCE DRIVES AUTONOMY Possessing excellence, certainly at a level like we discussed before, allows you to always be deciding. And as I look at why that's so important, it's because autonomy is, from my vantage point, the most modifiable and important burnout variable or job satisfaction variable. Autonomy is the most modifiable. Burnout or job satisfaction variable. I was talking with Adam Fritsch down at South College I work with Adam over at South and that he and his colleagues over at Bellin published a paper I think it was in March of this year titled feeling exhausted how outpatient physical therapists perceive and manage job stressors and in that paper All the things you would expect kind of fell out of solution, right? Like if the workload was unmanageable or perceived to be unmanageable, that was stressful. If cultural differences were present, that's stressful. But what pops out at me in that paper, because it's so directly modifiable, is the lack of control or this idea of not having autonomy. Namely that if people did not perceive themselves to have control, they felt more burned out. Everybody I talk to making their way up the professional ranks, that constantly jumps out at me. Now, let me talk about why excellence takes care of that problem. That is because it allows you to always be deciding and that's what autonomy is. When you achieve a certain level of excellence, You get to always be deciding. You get to always have control. And I think the data shakes out to say that will prevent burnout and maximize job satisfaction. Let me give you some really specific examples of where you get to always be deciding that other folks might not that are going to lead to you perceiving that feeling of control that avoids burnout increases satisfaction. Number one, which insurance is to take? When you hit a certain level of excellence, you're deciding that. You can say to the insurances, look, your customer's gonna come to me either way. They're just gonna be furious that you're not covering it. But they're not gonna make a decision to not come. They're gonna come and then be mad at you. At a certain level of quality of service delivery, you will hit that reality. Right alongside that, how much to charge. You're the one deciding. The solution to burnout is appropriate return on your time investment, another huge variable. You can't balance an equation with the wrong numbers. You need to be able to drive what you receive for your time delivering services. at a certain level of excellence, you get to decide that. You're not thinking about what might this market handle or what's the, you're thinking, this is what I'm gonna charge because this makes sense for my model. Now, you're gonna combine a few things when you do that. Number one is make sure the equation works, but number two is putting that price point in a spot where you actually get to serve all the folks that you want to serve, that you feel called to serve. So, it's multivariate that coming to that number. but you get to come to that number, right? That's the beautiful thing about it. Number three, when to work. There are few things that decrease stress like having complete control of your schedule. This is the one that hits me the most personal. I have no issue giving you massive volume of work days. I have no issue being up at four, 4.30, getting after it, putting out a lot of production. I have no issue with that as long as Right now I'm holding 4.30 to 5.30 because my kids might text this morning they wanna hit CrossFit. As long as I have the autonomy to hold these parts of my schedule that are non-negotiable, I have no issue with the work output on the other part of the day. It's being able to control when you work that I think is probably a bigger variable or a bigger factor than the amount of work and people just haven't put that together yet. But again, at a certain level of excellence, you control that. Because when you say to that patient, I can only see you at seven a.m., if you're good enough, if they perceive you as valuable enough, they're gonna say, well darn it, that isn't a perfect time for me, but there's no way I'm not taking the appointment. They're only saying that if you've achieved a certain threshold of excellence. So now you're deciding when to work. You're deciding how or even if you want to market. You may choose to not spend any time in that space. I wouldn't advocate that from kind of a business consulting perspective, right? All the best companies market when they're busy. That being said, you could decide that. at a certain level of word of mouth demand, right? But certainly when you do market, it doesn't have to be salesy. At a certain level of excellence, you're simply reminding people that they want to come see you. They've already heard from nine other people they should. They've already been thinking about coming in for a long time. Now your marketing simply becomes creative reminders, which is a much nicer way to go about engaging with your audience than always trying to sell them something. So you get to decide at that certain threshold of excellence how or even if you market. You decide whether you stay at your job. You no longer need to stay at your job because you have to. You stay at your job because you love it. Because the people that have created the environment have done a great job. And you can't get enough of the culture. And you're learning a ton. And you're serving people you care about. You're staying for all the right reasons, but none of the wrong reasons. Because you can walk any day. You think to yourself every morning, need this. The people want to come see me no matter what. I'm choosing to stay here because I love it. That's a lot different professional world. You don't feel stuck. You're driven by choice because you've achieved that level of excellence. Excellence is so unique. because it solves all of those problems. Those are all problems that every business guru is trying to sell you an individual solution for, right? How to navigate the insurance market, how to come up with your pricing, right? How to get more control of your schedule. You could find individual products that would try to solve only one of these, all of them. EXCELLENCE: THE CLEAN SWEEP Excellence is a clean sweep. Once you get good enough, every single one of those problems gets erased at the same time with one thing. But there's one other thing before I sign off that I want you to think about that is so unique about possessing excellence. And that is that it travels with you. I don't think enough people think about this. Excellence travels with you. Relationships, local marketing, et cetera, all of those things, if you change where you're working, if you move or relocate, all of the other business hacks, if you will, that you leverage have to be started back up. But your excellence travels with you. It's gonna meet you there, right? Right from patient one, they're going to perceive the asymmetry and the quality of what you deliver, and all of those problems are gonna vanish without you having to restart any of the other machines. Excellence travels with you wherever you go it meets you there. This is why it is hands down because it solves all the problems at once and wherever you go it meets you there, it travels with you. This is why it is the greatest and most urgent investment. I'm not telling you not to leverage all the business tools. I would totally encourage you to leverage a wide variety of business tools and strategies. I'm just saying for the greatest ROI, Get good first. Get good, then busy. Because excellence is the greatest decider to your overall success and certainly the greatest driver of your individual autonomy. And that's what I think results in incredible levels of job satisfaction and very, very low levels of burnout. Get good. You'll get busy, but you'll also solve every other problem in the process. Team, PTOnIce.com is where everything lives. Thank you all for being here this morning. Have a wonderful Thursday. We'll see you next week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 12, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses isometric exercise, in particular, that isometrics are beneficial for more than pain reduction. Mark cites research from the tendinopathy space about the importance of not using isometrics as a quick fix for pain, but as the starting point to gradually reintroduce functional, full range of motion exercise including concentric, eccentric, and power movements in order to fully rehabiliate a tendinopathy. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT What is up PT on ICE crew? Sorry for being a minute or two late here having some technical difficulties over on the YouTube side. So it looks like that is trying to get going as we speak. We will see if that that comes online here as we're talking. What I'm what I'm currently seeing for you YouTube folks is just a spinning wheel of death saying going live, going live, going live for the last three minutes. So hopefully that'll that'll pop up here over the next second or two for you all. So I'm Dr. Mark Gallant, lead faculty for the ice extremity management division coming at you here, clinical Tuesday. We are done with live courses for the year. I believe there's one more live course, dry needling course this weekend. And other than that, we've got a few weeks off. So we'll be sharpening the iron over the next few weeks, gearing up for for the next year of the ice season. And we can't wait to see you all out on the road. So all of our courses, all of our online courses will be kicking off in January. And all of our live courses will be kicking off the first and second week of January. So if you all haven't been on here the past couple weeks, checking in, there will be a price increase for all ice courses starting January 1. If you've been eyeing those courses and you know a course you want to take over the next few months, we would highly recommend popping in, purchasing that now, save yourself $50. ISOMETRICS: CLINICAL VALIDITY & CLINICAL APPLICATION So what I'd like to talk about today is isometrics and their clinical validity, what they're good for in clinic. And isometrics have come up a lot recently. If you've been a daily listener to the podcast, what you'll have seen is Jordan Berry came on here two weeks ago and he talked about using isometrics for specifically for low back pain and then Alan Fredendahl came on last week and he did a podcast talking about how using the rack pull can be a nice way to add isometrics into a more functional movement, getting your folks back towards the gym. So clearly as a company, we really enjoy using isometrics and we believe that isometrics are a key part of clinical practice. However, isometrics have been under fire recently on social media, in the research, because they got touted as being a silver bullet for pain relief a couple years ago. So where this all came from, Ebony Rio published an article in 2015 looking at six male volleyball players who had patellar tendinopathy. And what she found with these six male volleyball players, if they held an isometric contraction at 70% of their max volititional contraction, for five sets, 45 seconds, that we would see a dramatic decrease in pain. And that's what she found. So for these young, healthy male volleyball players who had about five to seven out of 10 anterior knee pain, their knee pain was fully resolved after doing those isometrics and 45 minutes later. And so, of course, as a profession, we got extremely excited, like, oh man, these isometrics are the key to relieving pain. for our tendinopathy patients. We've gotta use these for everyone, so we extrapolated that to not only patellar tendinopathy, but to rotator cuff tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy. We really just ran the gamut as far as tendinopathy goes, looking at this research. Again, it was one study, six healthy males, With that extrapolation, what of course followed was a lot of repeat studies. So this has been looked at about 10 times over the last eight years. So we've had people look at it in the rotator cuff, in the Achilles tendon, in the lateral elbow. We've had a couple editorials written. We've had one systematic review. And what's shaken out is it's been very inconsistent over the last eight years. There were a couple studies that showed very similar to what Ebony Rio showed, that there was a dramatic pain reduction using isometric contractions. And other studies did not get the same magic bullet results when it comes to isometrics. PAIN RELIEF OVERSHADOWS TENDON HEALTH And we really believe that this study has overshadowed the bigger picture with isometrics. and why we really love isometrics. So of course we live in a society that wants that instant pain relief. That instant pain relief is such a central nervous system component and it is unlikely to actually benefit the person who's got a true mechanical musculoskeletal problem long-term because what we see is if you get that dramatic quick pain reduction, although it's great, everyone wants to be out of pain, Oftentimes, that leads to the person not continuing out with rehab over the long term. And we know from a lot of research that most quick changes within the first six weeks are mostly central nervous system changes when it comes to how tissues respond, certainly to pain. And then at that six-week mark, we start to see a lot of muscular changes. And then for tendons, it can really take six months and up to two years to get a dramatic change. And so if we get that instant pain relief, we may actually be doing a disservice to the long-term health of that overall tissue and rebuilding that capacity. I don't like reading directly off of things, especially while we're here on the podcast, and I don't think that I need to defend Ebony Rio. She's one of the premier researchers in the world. listening to a lot of lectures that Ebony Rio has done, listening to her on multiple podcasts, reading basically every article that she's ever published. I believe that her intent was not for these isometrics to, for this small, small case study article to create such a huge wave and ripples across the rehab professions that anytime you listen to her speak, what she really dives into over and over and over again, is that isometrics are a nice starting spot and that we really need to rehab these people fully out with isometrics, heavy concentrics, eccentrics, dynamic speed and power training over a long period of time. So I want to read a quote from Ebony Rio that came out two years after the article with the Patella tendinopathy that sent ripples through the profession. And what the quote says, simply taking away someone's pain with a medical intervention may not result in a positive medium to long-term outcome, it is possible that simply removing pain does not equate to a positive tissue adaptation. So there's Ebony Rio directly saying that that quick removal of pain is not directly correlated to positive tissue changes. If we look at Karin Silbernagel, who's another premier tendinopathy researcher, and her response to the fad of isometrics being a huge pain reducing intervention. She states, a change in focus from improving resilience to a focus on acute pain relief may likely misguide patients and clinicians into thinking there is a quick fix. So what both of these women are saying, who are premier researchers in the tendinopathy spaces, there is no quick fix, that we need that long-term loading regardless of whether we get quick pain relief or not. THE LONG-TERM FIX: TIME UNDER TENSION, INTENSITY, SYMPTOM MANAGEMENT So why, despite all that, are we at ICE still advocating for and sticking with isometric interventions, both with our tendinopathy patients, our low back patients, literally for every region of the body, isometrics can be a nice tool to get your patients moving along the way. So let's break down why we believe that. So when we're looking at tissue care, there are a few things that we know have to be true to move and adapt those tissues in the long term. Number one is time under tension. There has to be enough time under tension for the nervous system in that tissue to respond to adapt. If it's just one quick motion that never gets repeated and has no time under tension, the nervous system doesn't have, isn't easily as easy to adapt to that stimulus. So time under tension is number one. Number two is intensity. There has to be enough of a stimulus to that tissue to create mechanotransduction to have that tissue adapt. And then number three is that we have to manage our patient's symptoms while trying to maximize the other two. So that's what makes us unique as physical therapists is we're creating time under tension. We're creating intensity while we have those symptoms on board to manage. It's really like this seesaw that we're managing. So we have symptoms on this side, we have time under tension and intensity on this side. It may start out that we've got more symptoms at first and we're trying to balance that scale and eventually have less symptoms, more time under tension, more intensity to our interventions. What isometrics, what we've gotten into over the last eight years is Even if you have 7 out of 10 pain while you're doing this, go ahead and do it because it's going to eventually reduce your pain overall. And we just need to get that time and attention. Well, what that creates with someone who's got fear of exercise and apprehension is a lot of yellow flags. So that's when you get people saying things like, I hate going to physical therapy. Oh, it's so uncomfortable. I really don't want to do this. And they start avoiding their intervention. The first thing we want to make sure is whatever that stimulus we're giving to the person, that they feel psychologically ready to tolerate that. Are you cool with exercising into three out of ten pain? Oh, you're not? One out of ten pain would be more tolerable to you? Okay, let's find an intervention that we can do there. So those are the three big components. Getting their symptoms, getting a stimulus that puts them in a symptom range that they can tolerate, creating a lot of time under tension, and creating enough intensity. ISOMETRIC EXERCISE: CONTROLLING MULTIPLE VARIABLES The reason we love isometric so much early on is because it's a much easier intervention to control all the variables that will allow you to balance those scales. So we go back to a podcast I did a few months ago talking about the guitar amp and things that stress tissues out. What we really are looking at is our knobs that we want to play with is the overall work volume, how much work has been going into that tissue over the course of a few days or a week. How much load has been going into that tissue? What is the actual weight on the bar, the body weight, the resistance of the band that you're looking at? What is the compression and strain on the tissue? So is that tissue all the way compressed in like that or is it strained all the way stretched out? That's gonna be one another way that the tissue can be stressed out and then the speed of the the speed of the intervention so if i do a heel raise versus sprint that's going to put a definite a very different type of force through that achilles tendon so again we've got overall work volume we've got the actual load on the bar we've got compression or stretch or strain and then we've got speed as all ways that that are going to manipulate and change the stress of the tissue. The beautiful thing about isometrics early on and why we're recommending them is you can control all of those variables much easier. So the overall work volume, you're going to be able to very cleanly set that with your patients. I want you to do five sets of 45 seconds or five sets of 30 seconds. whatever the agreed-upon work volume can be, and then it's clear with that isometric. It's very well set. As far as the load, that's not going to change with the isometric. You're going to determine with your client or patient, okay, I want 5 pounds on the bar, I want 10 pounds on the bar, I want 15 pounds on the bar, and then that becomes static. For compression and strain, you're going to find the range of motion they can tolerate. Okay, it's in a mid-range, that angle does not change. So we are no longer getting a change in compression or strain or say we bend it to 90. Now that's the new angle. There is no change during the actual intervention in compression or strain. So we have now controlled that variable. And then for speed, the speed is literally zero. Once you get that weight and that load into the position you want it, it's not moving for the remainder of that intervention. you can really control all the variables quite easily with the isometrics so that you know when something gets challenged or something gets flared up, well, ooh, it's really only these one or two variables that we're manipulating, and so you can much easier control the progression of treatment. So if we're looking back at Alan's example from last week, it's like, okay, Julie, we're gonna hold five sets for 30 to 45 seconds of this rack pull. We know very clearly that you can tolerate 135 pounds of weight. We know the angle of the hinge that you do well with is at about your knees pulling up there. And then once you start pulling, you're immediately going to get the block of that rack. So those angles are not going to change. You're not going to get any change in compression, stress, or speed from that movement. And then as you move that person on, okay, we can progress. Let's change the angle a little bit. or maybe we're going to change the load a little bit, and you can very isolated change these variables until that person's symptoms reduce enough, where then you get into your concentrics, your eccentrics, then you can progress them to your dynamics. So we are not looking at isometrics as this silver bullet of dramatic pain relief early on in tendinopathy. We're looking at it as a nice entry point into giving enough time of retention, enough intensity to a tissue while managing symptoms, because we can control more of the variables. And once those symptoms come down and we don't need to control those variables as much, then we can get more into our concentric eccentrics, more into our dynamic exercise where our buoys are a little bit wider. So Hope this helps. Hope this explains why we've been so excited about isometrics over the past couple days. For those of you on YouTube, sorry about that. I'm still getting the spinning wheel of death, but wanted to make sure that I got on here. Again, to repeat, isometrics, if they work for your patient as a dramatic pain reduction, that's wonderful. That's a home run. Make sure they understand that they've got to continue loading over the next six months to a couple years to get all of those positive tissue adept patients. If you do not get a dramatic reduction, it's six out of 10 pain down to zero, not to fret. As long as you can control their symptoms with the isometrics by controlling all the other variables, it is a wonderful entry point into moving those patients forward. Hope you all have a wonderful rest of the year. Have a happy holidays. Can't wait to see you on the road. Make sure you get those tickets to courses before the prices increase in three weeks. Have a great new year. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 11, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to better educate patients on prolapse, including a three-step framework focusing on education, risk factors, healing timelines, and empowerment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL MOORE Good morning, PT on ICE Daily Show. My name is Dr. Rachel Moore. It is Monday morning, which means it is pelvic day on our podcast here. So, we are going to dive in today. Our topic is using words that heal to talk to our patients about prolapse. So we want to make sure that when we are talking about our patients that have prolapse or maybe have been given this diagnosis of prolapse, that we're using words that are going to empower them. So we're going to dive into that today. Before we do that, a couple of housekeeping things, just letting you guys know the courses that we have coming up within our pelvic division. So we are done for December, nothing left in 2023, but we are kicking off 2024 strong. We've got two courses on our live docket in January. So we've got one January 13th and 14th in North Carolina. We've got one January 27th and 28th in Hendersonville, Tennessee. And then February 3rd in Bellingham, Washington. So we've got three chances within the first like month-ish of 2024 to catch us on the road. um on the those live courses that's where you'll be taking your certification test if you're interested in having that pelvic certification which includes taking all three we now have three of our pelvic courses our next online level one cohort starts january 9th and the sign up for our level two is now officially open so if you want to hop into that cohort it starts april 30th and that will be the first cohort of our level two so Really excited to kick that off and just kind of get that rolling. TALKING PROLAPSE So without further ado, let's dive into our topic of the day. We talk a lot about ICE or talk a lot at ICE about using words that heal, not harm. We preach it a lot and sometimes it can be really tough to figure out how to explain like difficult diagnoses. Especially things that are maybe controversial when it comes to the postpartum space and we're gonna see that with things like diastasis or prolapse and a lot of times our patients are coming in and maybe they've been given this diagnosis by another provider and it's not really explained very well and so they go down this scary Google rabbit hole and they come in and with all of these preconceived notions um oftentimes mostly negative preconceived notions from all of this research that they've done and they feel like they're empowering themselves with knowledge but in reality there's a ton of negativity and fear-based messaging about these topics so today we're going to talk about prolapse later on in a future episode we're going to talk about diastasis and i really just wanted to talk about some actual quotes that i use with my patients or kind of an outline or a framework of how we can break these scary diagnoses down, especially if you're newer to the pelvic population, you haven't had a lot of reps practicing talking about this, so that we can make sure that all of our patients are leaving their sessions feeling very empowered and excited to be working with you. EDUCATE So the first step of our three-step framework is going to be educate. I can't tell you how many times I have people come into the office and they're sitting there and they're squeezing their legs together because they are so terrified that if they aren't constantly contracting their pelvic floor and squeezing their legs together that their bladder is going to fall out of their vagina because they've been told that they have a bladder prolapse. with no other explanation this happens so often people will go to a provider the provider maybe will be doing a well women's exam or a check for whatever reason postpartum follow-up whatever and they tell them you have a bladder prolapse or you have a rectal prolapse and then that's it and they don't really tell them anything else and maybe they don't even really prescribe them physical therapy and they just wander into your clinic um on their own but there's not a lot of follow-up in most cases. So the very first thing that I'm doing when I'm sitting down with patients is breaking down. Okay, you were told you have a prolapse. Did anybody explain to you what that is? And usually that's followed with no, I went on Google and I saw a bunch of scary things. I'm like, okay, great. Like we're going to undo all of that. And even sometimes if they were explained, it maybe was using a very medicalized definition that can be, again, terrifying if you don't really know what's going on. So I'll bust out a whiteboard and I will draw out the pelvic organ. So if you're watching on Instagram or YouTube, you can kind of see with my hands, but if you're not listening, just visualize. I'll draw out, like, here's our bladder, here's our uterus, here's our vaginal canal, and here's our rectum. All of these organs sit within our pelvic bowl. When we have pelvic organ prolapse, essentially what that means is there is a descent of one of these organs or a drop down that pushes onto the walls of the vagina. at this point usually i'll take a minute to explain to people that the vagina is not a hollow tube it does not look like this it actually looks more like sides of soft tissue coming together most people don't realize that because every picture we've ever seen of a vagina in a textbook in anatomy books anything Looks like a hollow rigid tube. So a lot of times even letting them know like hey your vagina is not like this It's like this you'll see a light bulb moment where they're like, oh Okay, so maybe that's not a prolapse that I'm seeing maybe that's actually just my vagina. So that alone can be really helpful We'll talk about the fact that the vagina is not a hollow tube and that it is soft tissue and with that it is influenced by other things around it and so then we'll kind of break down here's your bladder maybe you have a descent of your pelvic organs and we see this kind of drop down if vaginal canal is here and our bladder is dropping down slightly and pushing onto that vaginal wall what we may see is a slight drop down of that vaginal wall oftentimes we're doing this test on our backs Oftentimes gravity is pulling everything down a little bit more and so when we take this person who's upright like this and put her on her back, our bladder drops down and we can kind of see and maybe feel that drop down sensation. When we layer in gravity with standing, we're upright, we drop down, we can sometimes feel that heaviness sensation from the vaginal wall not necessarily supporting that drop down quite as well. It is really important to highlight and differentiate an organ falling physically out of the vagina which can happen if we have a uterine prolapse where the uterus is dropping down into the vaginal canal versus an anterior wall or a bladder or a posterior wall or rectal prolapse where it is not the physical organ dropping down, it is just the wall of the vaginal canal dropping inwards. That education is huge. You will see people have this like weight lifted off of their shoulders knowing that their organs are not actually falling out of their bodies. Education is important. DISCUSSING RISK FACTORS Talking about risk factors is also incredibly important. Letting them know what the top risk factors are. Genetics and connective tissue immobility, BMI, chronic constipation, which comes along with that straining, that consistent straining mechanism where we're bearing down repeatedly over time, pregnancy or parity, and vaginal delivery. A lot of those aren't things we can necessarily control for, but what's important to let them know is that exercise is not one of those factors. We want to make sure that our patients know that they didn't cause their prolapse by doing too much too early, especially if they're in the postpartum space or if they have this like shame associated with, I have a prolapse and I did it to myself. That's not the case. More often than not, if a prolapse or a pelvic organ position change is going to happen, it's going to happen in a vaginal delivery after a pregnancy. And it's not necessarily something that they're causing by doing activities later on. Letting them know that they didn't cause this thing to happen, again, can be huge for somebody's mental state. If they're feeling like, oh, I did too much and I caused this, that can kind of cause this negative spiral of fear for movement in the future. DISCUSSING TIMELINES Finally, we want to talk about, on the education standpoint, timelines. It doesn't make sense to have somebody at six weeks postpartum come in and say, yep, you got a grade three prolapse. Your bladder is dropped down and your anterior wall is coming out of your vagina. We expect there to be changes. we expect that after a vaginal delivery, those tissues aren't just going to pop back and get to their original position or even a new baseline for a longer timeline. So talking about the fact that early postpartum is not the time to be diagnosed, quote unquote, with a prolapse or to even really be concerned about where things are. Instead, we want to talk about ways to talk to them about um body mechanics and um their strategies for bracing we want to talk about bowel health and making sure that they're not continuously straining and bearing down and let them know that when we layer these two things in And then we allow time as a factor. Where they're at at six weeks postpartum is going to look different than where they're at at six months postpartum, even if that was the only things that they did. So education is huge. Educate them about what prolapse even is, educate them about what the risk factors are, and more importantly, are not, and talk to them about the timelines for healing. The next step in our little three-piece framework is going to be normalize. there is so much conversation happening in the pelvic floor PT world that a prolapse or a like a grade one prolapse which is just a slight descent of pelvic organs might be normal in the postpartum population. Just like we don't expect our breast tissue to look exactly the same after breastfeeding, we can't expect our pelvic organs to be in the exact same position after they've undergone nine to 10 months of low load, long duration stretch that creep has set into those tissues. And then we also potentially layer in a vaginal delivery. A grade one might not be a big deal at all. That might just be a typical postpartum change. On top of that a grade two might even be somewhat of a normal finding I have not yet seen a grade zero quote-unquote after a vaginal delivery I think it's a unicorn that actually doesn't really exist and we've had a lot of conversation about this within our pelvic crew of has anybody ever seen that The consensus so far is no. And so if you guys have, drop it in the comments. I'm curious. But we want to talk about normalizing this change. We expect physical changes in our body after pregnancy. We expect physical changes in our body after vaginal delivery. It's OK to look like you've had a baby. It's OK for your body to show those signs. this can be a big thing for people to wrap their heads around because there's a lot of talk within our culture about bouncing back to what your body was before and Switching up that conversation to we're not worried about what it was before We're getting to a new baseline and that might show changes that have happened and that's okay Normalizing the fact that our bodies are going to change during pregnancy after a delivery is important The other part that we want to normalize is that in the early postpartum timeline, those muscles are recovering, especially following a vaginal delivery where they've had a stretch injury, they've been stretched out, elongated, they're returning back to their resting state. We expect those muscles to have a lower threshold for activity than they did before. as pts this makes sense as patients it not it doesn't necessarily um come to the forefront of the mind so reminding them these are muscles think about any other muscle in your body maybe you've pulled a hamstring maybe you've pulled your quad maybe you've overstretched your shoulder those few days maybe weeks afterwards it took less activity for you to feel something in that area in this case specifically what I'm really kind of preaching to people is that if you get up and you're feeling good one day and you go for a walk with your kiddo around the block and that's the farthest you've walked and then later in the day you start feeling some heaviness you didn't cause a prolapse likely those muscles are just tired. They worked harder than they have all this timeline leading up to this. And so they're fatigued. And just like every other muscle that fatigues when it fatigues, it doesn't work quite as well. And so we feel that heaviness sensation. normalizing that heaviness sensation. I love to do this when people are pregnant, set that expectation. Hey, look, as you start moving more, you might notice that you feel a little bit of heaviness. It's not a big deal. That's kind of our buoy lets us know where we're at. You're not causing any damage. It's going to be okay. That heaviness will resolve and over time you're going to build up your capacity where that heaviness sensation comes on later and later and later normalizing what a prolapse is, normalizing what the grades are, normalizing the changes of our body that happened during pregnancy and postpartum and normalizing recovery of those muscles and potentially having an onset of symptoms. FINISH WITH EMPOWERMENT Finally, we want to empower our patients. This is where our bread and butter lies. This is what we are here for. We are all about empowering women in this pelvic space. we have evidence that we can reverse a prolapse up to one grade. So that means if somebody comes into the grade two, then potentially we can get them to a grade one. Realistically though, at the end of the day, I don't even really care about that. What I'm really harping on more, really focusing on more with my patients is that We know that the degree of prolapse or the descent of those pelvic organs and how much they are descended has no correlation with your symptoms. You can have a grade three and be highly sensitized and feel everything. You can have a grade three and have no idea that you even have a change on the flip side. You can have a grade one and feel like things are falling out. so talking about the ways that we can directly impact that by calming down the system giving them tools like laying on their back with their feet elevated adding in some bridges to get some muscle activation kind of taking the pressure off of the pelvic floor so that they can decrease that symptom of heaviness discussing things like bowel health, like we chatted about earlier, avoiding straining, using a squatty potty, making sure that they're drinking enough so that they're not falling into this chronic constipation camp, and then talking about body mechanics. That's one of the biggest things that we really want to focus on. We have to know what they're doing when they brace. We have to know what they're doing when they bear down. We have to know what they're doing when they do a pelvic floor contraction. we need to collect that data. We need to calibrate to make sure that they're not dropping down with their pelvic floor and increasing that heaviness sensation with their daily tasks. That is a huge piece of the puzzle. So our three-step framework, when we're talking about somebody coming into the clinic day one terrified that they have a prolapse. The first thing we're going to do is educate them. We're going to talk to them about what a prolapse is. We're going to talk to them about the risk factors and what potentially caused it and what definitely did not cause it. And we're going to talk to them about timelines. We're going to normalize. We want to make sure that they leave feeling like their body, their vagina, their pelvic floor are normal. And even if you have somebody come in with a grade four, We're still normalizing. We're still talking about all of the ways that we can help. We can work on prehab. We can take those same tools and improve things so that going into a potential surgery, they have better outcomes. And anything less than a grade four, you better believe I'm normalizing. You might have a change in your pelvic organ position, but you know what? That's totally normal after having had a baby and a vaginal delivery. The third step is we're going to empower. We're going to make sure that our patients feel confident in movement, feel confident in that bracing strategy, feel confident in what they're doing in their daily lives so that we can build a stronger and more resilient human being who can tolerate more things before symptoms come on. I hope you guys enjoyed this. I hope it helped clear some things up, especially if you're newer in the pelvic space and you really understand what prolapse is, but you're just not quite sure how to talk to patients about it. It can be intimidating, but I trust that you guys have got this. If you're not confident in treating heaviness and pelvic organ descent, um, and that sensation of heaviness hop into our live course, we spend a ton of time going over bracing. We talk a lot about what prolapse is, We have a whole matrix and kind of framework about treatment approaches for each of these little camps, whether they have symptoms objectively or subjectively and what the combinations are. I hope you guys have a great Monday. Get out there and crush it. Thanks. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 8, 2023

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZACH LONG Good morning, everybody. Welcome to the PT on Ice Daily Show. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible. TESTOSTERONE REPLACEMENT THERAPY Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training. UNDERSTANDING TRT DOSAGE And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT. THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT. TENDON HEALTH ON TRT And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health? INJECTION SITE MATTERS WITH TRT And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 7, 2023

Alan Fredendall // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO & Fitness Athlete Division Leader Alan Fredendall discusses utilizing the rack pull as a way to begin to load the spine isometrically. Alan demonstrates the rack pull, how to set it up, how to modify & scale it, and how to prescribe & dose loading of the rack pull. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL PT on ICE Daily Show, happy Thursday morning, hope your day is off to a great start. My name's Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer and a faculty member in our Fitness Active Division. We're here on Technique Thursday, that means it's also Gut Check Thursday. This week's workout, we have a 15 minute AMRAP, so a little bit more chill than previous weeks. We have an ascending rep scheme of American or overhead kettlebell swings, 5, 10, 15, 20, so on and so forth. Recommended weight, 53 pounds for guys, 35 for ladies. And then you're going to pair that every round with 10 back squats. We're going to do that at 135, 95, and then 30 double unders after every round. So a good goal there is to get maybe four or five rounds deep into that AMRAP. accumulate a good volume of everything. You're going to end up at about 50 to 75 reps of the kettlebell swings, of the back squats, and of the double unders. So that's Gut Check Thursday. Courses coming your way. We are basically done with live courses for the year. We have live courses this weekend, but they're all sold out. And then our very last live course of the year is next weekend in Salt Lake City with Paul for dry needling. So if you're trying to make a course before the end of the year, that's the last one you can sign up for. All of our other courses starting up in 2024 are on our website, ptenice.com. Remember, price change going into effect January 1st. Our rates are going to go from $6.50 per course to $6.95. So if you already have an eye on a course, make sure you sign up before January 1st and save yourself 50 bucks. MASTER THE RACK PULL Today, Technique Thursday, what are we talking about? We're talking about the rack pull. So I want you to go back to last Tuesday's episode with Jordan Berry, episode 1608, Spine Isometrics, to talk about all the research and the clinical reasoning supporting something like a rack pull. I want to take a deep dive into this, because on the topic of spine isometrics, I think this is a very effective exercise to use in the clinic with patients with low back pain, folks who are having trouble deadlifting, to really build a strong, robust low back, so that bending over and picking up stuff from the floor is no longer bothersome. Today I want to talk about why we're doing this, I want to talk about keys to success, and most importantly I want to talk about how to load and dose this and prescribe this to patients. WHY THE ISOMETRIC RACK PULL? So, why do we do this? First of all, it's simple and effective. It's essentially a very small partial range of motion deadlift. It is very scalable based on your patient's presentation. Somebody who's very irritable has very severe low back pain, we can move the safeties and the J-hooks to maybe above the knee, maybe right below level of hip, so we have a very small range of motion that we're contracting through. And we can scale that back down though as somebody starts to feel better. We can take that all the way down to a rack pull from mid-shin as if somebody was lifting from the floor. We can meet our patients where they're at with the scalability of that. The nice thing, like Jordan said last week as well, the key to a lot of isometrics is that most people can do these at home. A lot of folks have a squat rack. or a barbell in plates in their garage or the gym. So they can set something up close to this at home and be able to do that for home exercise. Those individuals already active in the gym already have access to this equipment at the gym they go to, so they can also do this as part of their home exercise program at the gym. Now that's why we do it. KEYS TO SUCCESS What are some keys to success? The keys are The setup here is everything. So you'll see I have a pair of safety bars here and a pair of J-hooks. My preferred way to do this whenever possible is to set it up like this. Whether I have two pairs of J-hooks or cups in the rig, I have a pair of safety bars and a pair of J-hooks. I have basically two start and stop points that's gonna let me control that range of motion. So setting it up is really, really, really important. So set up your environment correctly. The J hooks should be upside down. So what we'd like to see is that they're actually upside down so we have more surface area to lift the barbell against. So I'm going to show you a rack pull right now. and show you what it should look like. So, in this example, I'm starting right at the top of the knee. The goal with the rack pull is not to finish the deadlift. If I'm standing at the top of my deadlift, there is no tension here, there is no work needed out of the low back. I need to somehow stop myself short of full range of motion, so my back has to work to keep myself in the position. So, from mid-shin, a nice hinged position, and now I'm gonna lift and pull up against the J hooks and now I can't reach full extension and here my low back is just working to keep this barbell in place and then when I'm done I don't have much room to go to set it back down. So again the issue with the J-hooks put into the rig like normal is that that barbell can actually roll off in a way and lifting a bunch of weight off like that, surprisingly, can upset some people's low back. So if you're going to use just J-hooks, again, take them, turn them, and then flip them upside down. Now we have more surface area. We also have kind of a framing here of the J-hook so that the barbell can no longer slip down, out, and around the J hook. So that's setting up the rack pull. Again, meet your patient where they're at. Adjust the range of motion as needed. If you don't have two pairs of J hooks, by a second pair or what you can use in place of two sets of J-hooks, you can place the barbell on some plates as the lower edge of your range of motion and use the J-hooks to stop the top motion. Again, the key here is that this is an isometric exercise, so we wanna be pulling up against something for 45 seconds. All the benefits that Jordan talked about last week, the stress relaxation response, strengthening, blood flow, pain relief, and then being able to reproduce this in the gym or at home. Now finally, why do we do this? How do we set it up? DOSING THE RACK PULL How do we actually dose this? Again, that's gonna depend, what is it gonna depend on? Your patient's current level of irritability. Somebody that is very flared up, maybe you're thinking about starting with something like a reverse Tabata, so you're gonna do eight rounds, 10 seconds on, 20 seconds off. progress them maybe to a full Tabata, where they're now doing eight rounds, 20 seconds of work, 10 seconds of rest. And then for me, my ultimate goal, following some of the tendinopathy literature, is to get to that 220 seconds time under tension. I like to see patients be able to progress to five sets of 45 seconds of work, and then really however much rest they need. 15 seconds is probably too short, so an EMOM timer is probably not appropriate. I like five seconds of 45 on, 45 off. 5 sets maybe of 45 on, a minute, a minute 15 off, so maybe you can set every 2 minutes for 5 sets on your timer. Something like that though, building to that 220 seconds time under tension, ideally showing the capacity to be able to hold that rack pull for at least 45 seconds. So meet your patient where they're at, progress them, progress them, progress them, time under tension. Now what about loading? This is a partial range of motion that you don't need to lift from the floor. What does that mean? That means this should be quite heavy. This should be near, at, or maybe even above that patient's deadlift max, if we know it. Again, we don't have to lift it from the floor. The hardest part of the deadlift is done for us. It's already sitting above our knee. All we need to do is just a little lift and then hold. So, that means that this should be quite heavy. How heavy? whatever weight they can feasibly hold for maybe that reverse Tabata, and then that full Tabata, and then that full 45 seconds on with the rest coming. The key human beings who come into your clinic are not gonna be challenged by an empty barbell rack pull, even if their low back pain is really irritable, so keep that in mind. SUMMARY So the rack pull, why? We like that it's scalable. We like that it is easy to set up. It basically requires no thought or mechanical skill to be able to get into that position, We'd like that we can transfer this to home. A lot of folks have access to a barbell and the setup needed to do this rack pull. We'd like that we are really easily able to make people successful with this by just modifying the environment, setting up with plates as blocks and J-hooks as the top limit, two pairs of J-hooks, squat safety bars or J-hooks, whatever. This is very easy to set up and be successful with it. And then we like that it is easy to dose. We can see patients make progress from maybe 10 seconds on, 10 seconds off for a couple sets, to a full reverse Tabata, through a Tabata, and then maybe into somebody who is probably now ready to start deadlifting from at least the knee through a partial range of motion, if not from the floor, is somebody that can come up here, lift and hold for sets of 45 seconds. Five sets of 45 seconds really seems to be the sweet spot for the back to start feeling good, for the back to start feeling strong, and to now reintroduce full range of motion deadlifting, things like kettlebell swings, back into a person's exercise routine if they're already doing, or now, maybe for the first time, instruct that patient in the deadlift. So, the rack pull, easy to set up, easy to mess up too if you don't have a lot of attention to detail, but relatively easy to set up, load, dose, and prescribe as homework for our patients. So try that out. Thanks everybody, have a great Thursday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 6, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the scary stats of sarcopenia: increased risk of falls, fractures, loss of independence and the list goes on and on. Dustin emphasizes that rehab providers have HUGE opportunity in this department but often leave so much on the table. Listen in as Dustin shares some new research about Sarcopenia and it's implications for our work. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. DUSTIN JONES Alright Instagram, good morning, good morning YouTube. This is the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about leaving nothing on the table when it comes to sarcopenia. Leaving nothing on the table when it comes to sarcopenia. We're going to be covering some new literature that looked at the variations of intensity of different exercises with and its impact on sarcopenia and what that means for us as clinicians or fitness providers. Before we get into the goods, I do want to mention CERT-MMOA is rocking. CERT-MMOA is for those that complete our three MMOA courses, our online level one and level two. then our live courses. We have shut things down for the rest of this year but I want to let you know as soon as 2024 kicks off in January we are hitting the road hard. Both of our online courses are gonna be starting that second week of January and then we've got a few courses I want to mention that are gonna be absolutely awesome in that month of January. We got Santa Rosa, California January 13th, 14th. On the 20th, 21st we're gonna be in Greenville, South Carolina the 27th and the 28th we are going to be in Missouri. So we'd love to see y'all on the road. SARCOPENIA So let's talk about this, sarcopenia. So sarcopenia, for those that are not familiar, is age-related loss of muscle mass and strength. Sometimes now you are going to see the word function or physical function be thrown into that definition, but by and large, most of the time when you see this, it is age-related loss of muscle mass and strength. This is very important for every single person listening to this podcast because the vast majority of y'all are treating older adults in some way shape or form. But what we're seeing is that the term sarcopenia is starting to apply to individuals that may not have that older adult tag on them. Maybe those folks that are south of 65, maybe those folks that are in their 50s, sometimes even their 40s that are gonna qualify based on the criteria of sarcopenia. So this is a big issue and it impacts a large, broad audience. Just some stats, just so you are aware of how this could impact the folks that you're serving. 10 to 40% that's a wide range, but estimates are saying that 10 to 40% of community dwelling older adults have sarcopenia. All right. So 10 to 40% of folks, independent older adults that are walking amongst this, out in the community walking into your outpatient clinic would be categorized as having sarcopenia. And we would argue that that number is largely artificially low, that there may be even more. If you are a clinician that is working in a more acute setting out of the community, right, like acute care, home health, skilled nursing facility, this number goes up exponentially. So for you all, the vast majority of individuals, particularly older adults, would fall into that category of having sarcopenia based on the diagnostic criteria. So all to say, a lot of folks across the whole healthcare spectrum would fall under this category. SARCOPENIA: WHAT'S THE BIG DEAL? Now why is this a big deal? This is a big deal because if you have that label sarcopenia, you are at 60% increased risk of falling, If you fall, you're at an 84% increased risk of having an injurious fall or with a fracture. Those are big statistics, and we know the negative implications of those health outcomes. It is a big deal. It is an absolutely big deal, and it's important for us to understand how big of a deal this is, but then also to know what to do with it, all right? And this is where this new research, this new literature that was just published comes into play. There's a recent systematic review and a network meta-analysis that was published in the European Review of Aging and Physical Activity that looked at randomized controlled trials that use exercise in different intensities of exercise and how that impacted different outcome measures with folks that have sarcopenia. So they found that there were about 50 randomized controlled trials that totaled of about 4,000 participants. And all of these studies looked at the following outcomes. They looked at muscle mass, which we're usually measuring with something like a DEXA scan, right? Muscle strength tested by hand grip strength, chest press, and then a leg press on a machine. And then physical function, functional outcome measures, five times sit to stand, 30 seconds sit to stand, timed up and go, short physical performance battery, which is, you'll commonly hear us refer to it as the SPPB, the six minute walk test, and gait speed. All right, so these studies were measuring a lot of things that have huge implications for a lot of physical therapy and even fitness outcomes. All right, so all these studies were looking at those things. and they performed exercise at different intensities. So they performed exercise potentially at light intensity. This is categorized as at zero to four out of 10 on that modified Borg score where we're looking at relative intensity or RPE, rating of perceived exertion. that could also equate to under 49% of someone's one rep max. So typically what you saw in this meta-analysis is that the randomized control trials that were using that light intensity, they were often using aerobic-based training. So we're going to throw that in, kind of that light intensity category. Then we had moderate intensity. So this was that five to six out of 10 on that RPE. kind of 50 to 69% of a one rep max was considered to be moderate, and then vigorous, six to eight out of 10, and kind of that 60 to 80% of that one rep max. All right, keep in mind the updated ACSM recommended guidelines are calling, particularly for sarcopenia, are calling for 60 to 80% of someone's 1RM. They're calling for vigorous exercise, in particular resistance training for these individuals, all right? So they had those different intensities and they saw, all right, what's going to happen here with these folks that have sarcopenia? And the interesting thing to think about this is there's a lot of individuals, particularly when someone has sarcopenia on board, that the main focus is that, hey, this person may be relatively sedentary. They have low physical activity levels. Let's just get this person moving, right? Let's get them started in some type of physical activity. Let's bump up their overall physical activity. That's going to be a huge win. I would agree with that. Anytime that we move someone from being relatively sedentary or low physical activity levels and we can bump that up, we are going to see some positive benefits. We cannot deny that there's good in getting people to move more. STOP STOPPING AT LIGHT INTENSITY But what we need to acknowledge, especially after these results, is we cannot stop there. That is the first part of the journey to pushing people to more activity, but more intense activity. So what they found with this meta-analysis is the individuals that only received that light intensity, the only improvements that they saw across all those different outcome measures that I mentioned before was they did see some improvements in their hand grip strength. Awesome, that's great. That's a great correlation to lots of health outcomes, right? It's not a bad thing to have an improvement in hand grip strength. Great, that's awesome. There's a point for light intensity exercise. Now, moderate intensity exercise saw improvements in hand grip strength and important outcome measures like a 30 second sit to stand, a timed up and go, and leg press. Awesome. That's a few points for moderate intensity. We should probably be giving more preference to that than light intensity. And then the vigorous intensity crew saw improvements in all of those things previously mentioned that the light and moderate intensity experience, but they also saw improvement in muscle mass. They saw improvement in gait speed along with 30 seconds at the stand, five times at the stand, timed up and go, hand grip strength, leg press, chest press as well. They saw significant improvements across that broad spectrum of outcome measures that I talked about before. They get 10 points for those types of benefits, right? So if we're to rank them, the vigorous benefited tremendously much more than the moderate and the moderate benefited more than the light. So what this is basically telling us is that these folks that had that sarcopenia tag, which is based on, you know, a DEXA scan, but then also, you know, SPPB under 8 out of 12 or hand grip strength under 26 kilograms for males and under 16 for females. That's what we would typically look at, right? SARCOPENIA NEEDS VIGOROUS INTENSITY Folks that have that diagnosis that we need to be giving them vigorous intensity activities, particularly resistance training. If we do not give them vigorous exercise, we are leaving a lot on the table. Yeah, they're going to get better. They're going to improve on some of these outcome measures, but we leave so much potential benefit on the table that we're ultimately doing a person a disservice. So based on this research, I wanna focus on three main takeaways that we should walk away with after coming across some literature like this, all right? The first one, particularly for the ICE crew, you have such a unique opportunity that you spend so much time with these individuals, comparatively more time than any other healthcare provider, that you need to be well-equipped to screen and identify when sarcopenia is on board. We cover this extensively in MMOA level one and in our MMOA live course, but you need to be able to run an SPPB. You need to be able to run a hand grip strength. You need to be able to interpret those results and let that influence your course of care, particularly for the outpatient clinicians, because why do people come to you, right? What is a primary driver for your services? People are typically coming to you for pain, which you need to focus on, but that may not be the biggest issue. All right. So one we're screening, we're identifying number two, we are leveraging intentional under dosage. You've heard us talk about this podcast before. We've done whole episodes on this. So I'd encourage you to search that if you had, if this is a new term for you, but we need to leverage intentional under dosage because that is typically we're lowering the barrier of entry for individuals. So they're going to partake in particularly a new activity, right? For so many of these folks, they have not exercised before, they've not performed any intensity of resistance training. This is completely new territory for these individuals that we need to make it approachable. And so we may typically underdose initially. SHORTEN YOUR UNDERDOSAGE But in light of this evidence, that intentional underdosage period needs to be as short as possible. We don't have a lot of time here with these individuals and we need to make the most of our time. The quicker we can get to that vigorous intensity level so we get all those benefits that this meta-analysis discusses, the better, right? So that intentional under-dosage period needs to be as short as possible. That's a very vague thing, right? For some individuals, you may have their first visit where it may be intentionally under-dosed for their capacity. and then the next visit based on their response, their trust in you, their willingness to perform maybe a more challenging activity, that intentional under dosage period may be the span of one visit, right? But I know for me, particularly in home health, I've had intentional under dosage periods that have been well into the months. based on the person that I'm working with. Whatever it is, make it as short as possible. So we screen and identify, we leverage that intention on your dosage. And then number three, and I think this is something that we really need to grasp, is the clinical urgency in this situation. that if you continue with your light, with your moderate intensity exercise with these individuals, you're leaving a lot on the table. And ultimately, you are harming that person. You are robbing them from the potential benefits that we've seen in this meta-analysis, that they see the big improvements in the functional outcome measures, in their strength, in their muscle mass. These people have the capability to get those kinds of results. And if we waste our time and spend too much time in that intentional underdosage period where we're doing that sedentary, doing light to even moderate intensity activities, you are doing that person a disservice. You are doing that person a disservice. It is a dangerous situation that you're playing with. We need to have a sense of urgency when we're talking about sarcopenia. All right. I'm going to drop the link to this meta-analysis at Open Access. Really good read. It gives you a good idea of kind of the big body of literature around sarcopenia, but what they found in terms of these outcome measures. I'll drop that in the comments. If you have a tough time getting that link, just shoot me, DustinJones.dpt or the ICE account a direct message and we'll get that over to you. But this is a big conversation for many of you. You all are seeing tons of folks that would have that sarcopenia label put on them if they were properly screened and identified and you have a huge opportunity to give them that vigorous intensity, that amazing dose that is going to give them huge benefits across such a broad spectrum of outcome measures that have a huge implication for their quality of life. Alright, y'all have a lovely rest of your Wednesday. Go crush it. I'll talk to y'all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 5, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses recent research supporting the effectiveness of conservative care compared to invasive care, but in particular, the efficacy of chiropractic care compared to physical therapy care. Zac postulates that being hung up on the concept of spinal manipulation is often to blame for reduced PT outcomes when it comes to spine pain. He challenges listeners that the majority of patients are going to seek out & receive spinal manipulation for their pain, so the best course of action is to learn spinal manipulation, practice daily, and understand how to explain treatment to patients in a manner that does not facilitate dependence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course , our Cervical Spine Management course , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ZAC MORGANAll right, good morning PT on Ice Daily Show. I'm Zach Morgan. I'm lead faculty here with the cervical and lumbar spine management courses and lead that spine division as well. Wanted to bring forward some content this morning. So the title of this episode is the deck chair on the Titanic or deck chairs on the Titanic. But before we jump into the actual content and kind of unpack what we're, what I'm talking about with that metaphor, I wanted to start out by kind of pointing you all in the direction of the next courses that you can jump into from the spine management side. So we're wrapped up for the year, but if you're looking for next year, two options in the middle of the country for cervical spine on the weekend of February 3rd and 4th, we've got Wichita, Kansas, as well as Hazlet, Texas. So if you're in the middle of the country looking for cervical spine, those will be good options. At the end of that month, we'll be in Simi Valley, California on February 24th and 25th. If Lumbar is the one that you're looking for, there's one in January. So Rome, Georgia, 27th and 28th of January. And then March 9th and 10th, Cincinnati, Ohio. And then March 23rd and 24th over in Brookfield, Wisconsin or right outside of Milwaukee. So several offerings there to start the new year for cervical and lumbar. If you haven't looked into the ice ortho cert, do so. So we've, we've revamped our website and you can go on there and kind of look at what all is included. Um, but that cert is kicking off. We're testing people out on the weekends already and it's been a really good kind of, uh, initial rollout here. So if you're looking for an orthopedic cert, um, check out the new ice cert and let us know if you have any questions. FIRST PROVIDER SEEN FOR ACUTE LOW BACK PAIN I just wanted to kick off today by actually unpacking an article. This article was published in the PT Journal back in September. It came out of the University of Pittsburgh, so that's probably the crew that does the most looking into back pain, at least in our profession. University of Pittsburgh is pretty famous for a lot of their back pain research. Essentially, this article was titled, First Provider Seen for an Episode of Acute Low Back Pain Influences Subsequent Healthcare Utilization. So definitely a bit of a wordy title, but essentially looking at who do people present to first and how does that influence downstream medical costs. And this was from Christopher Baez and his colleagues over there. Anthony Delito was on this paper as well. So if you're familiar with Anthony Delito, he's definitely done a ton in the low back space as well. So really good university, really well done study here, published in our journal here just very recently. So very recent data that we're looking at here. And let me just kind of talk briefly through what they did with this article with the method standpoint, and then we'll talk about the outcomes. And then we'll unpack the metaphor and end with some action items this morning. So really what was done for this article was a retrospective analysis. So they looked back at cases of acute low back pain, meaning that the person had not been to any sort of a medical provider within the last three months for back pain. So they looked at acute cases of low back pain and they looked at where they presented and then those downstream medical costs and how those things were affected based off of where they presented first. So they were looking at chiropractic care, physical therapy, primary care physician, emergency department, and so on, and basically comparing the outcomes downstream depending on where the person went from one of those professions. As far as outcomes, what were they looking into? They were looking into things like episode length, future CT MRI use, how often did those patients wind up getting that advanced medical imaging, how often did they opt for things like injections or opioid prescriptions, specialist referral downstream, getting to a spine surgeon, those types of referrals. Actual surgery was one of the outcomes they looked at, and then just unplanned care. So they looked at all these variables, retrospectively after these people had presented to the health care system one way or the other to see if there was any difference in the variables over the following year after they had that first episode of acute low back pain. And two things really jumped out to me as I was reading this article. So there's two very obvious things to me. CONSERVATIVE CARE OUTPERFORMS INVASIVE CARE First, conservative care definitely outperforms more invasive care when it comes to the reduction of those expenditures. So physical therapy and chiropractic would be the ones we would lump into conservative and physical therapy and chiropractic significantly outperformed basically the emergency department primary care physician any of the other places that patients would have presented, which makes a lot of sense to us as the conservative care crowd. We know that a lot of times getting that patho-anatomic diagnosis is not helpful at all and often drives a lot more care. So if a person ends up getting that type of a diagnosis early on, often they're going to end up in the health care system for longer. as physical therapists and then even often as chiropractic work, we're more targeting symptom behavior versus anatomical diagnosis, so it makes a bit of sense that conservative care outperformed non-conservative care. CHIROPRACTIC CARE OUTPERFORMS PHYSICAL THERAPY CARE But the second thing that jumped out to me as I was reading through this paper is that chiropractic care significantly outperformed physical therapy. Basically, at pretty much everything other than use of radiographs, which is not overly surprising. Chiropractors have the ability to prescribe radiographs. But if you look at things like episode length, they got us by a couple days. If you look at CT, MRI use, injections, opioids, surgical referrals, actual surgery and unplanned care, The chiropractic profession outperformed the physical therapy profession within that conservative care chump pretty significantly. I'm not really trying to pin our professions against one another. What I'm more trying to point out is they pulled their weight. Whenever we look at this data set and we see essentially how this course of care went through for the patients, it's clear the chiropractors pulled their weight. Yes, we helped from the physical therapy side as well, especially compared to non-conservative care, but within conservative care, I would say we left them stranded a bit and didn't do as good of a job as they did. And so I couldn't help but start to think about why wow, we've really got to step it up as our profession. Like if we want to be in this conservative care battle, it's not enough for us to not contribute to that side of the fight. We have to step it up. We have to pull our weight in this fight. So let's talk a little bit about maybe some of the ideas as to why PT didn't do quite as well as chiropractic care in this study. Because they didn't postulate too much on that in the actual article, but I have some thoughts surrounding it. And so I just want to talk through those things a little bit. WHY ARE WE SO AGAINST SPINAL MANIPULATION? Let me just start by saying, team, every year since I've been a PT, even from school till now, things like spinal manipulation have always been super challenged within our profession. So it's very clear when you look at medical practice guidelines, when you look at our clinical practice guidelines, when you look at most of the clinical practice guidelines, especially for the management of acute low back pain, they have suggestions for spinal manipulation. But within our profession, what I've always witnessed is anytime we, as I put out posts about spinal manipulation, we get a decent amount of kickback from our own profession. we get all sorts of commentary on those posts suggesting potentially that it's not as safe as it should be or maybe it's going to create dependence or things of this nature and I think in our profession we argue about that a lot and it winds up plaguing us when it comes to the execution of those techniques or even feeling okay about using those techniques on patients and team This is something we have to get rid of if we're going to contribute our share to the fight with conservative care for the management of acute low back pain. ARGUING AGAINST MANIPULATION IS LIKE ARGUING OVER DECK CHAIRS ON THE TITANIC I don't remember when I first heard the metaphor about arguing over the deck chairs on the Titanic, but it really fits in my mind to this current conversation. It doesn't make any sense to argue over the deck chairs on the Titanic, right? But imagine that. Imagine the ship is sinking, it's dropping underwater, it's hit the iceberg, And you're up at the nose of that ship that's going to sink last, arguing about where the deck chairs go, which table they go out, how you want to orient those. That makes no sense, right? The ship is sinking. So I think in our profession, we tend to do this. We tend to argue over the deck chairs on the Titanic. Let me unpack that a little bit. What's the Titanic in this metaphor? The Titanic is that people are going to have their spines manipulated when they have acute pain. You can like that or not like that, but the fact is true that patients or just our communities seek that intervention out in relatively high volume when they have acute pain. That's happening. What are the deck chairs that we're arguing about as a profession? That's where these things like Will it create dependence? Does it work? Is it safe? These types of questions are arguing over the deck chairs. We know it's safe, right? Like that has become very clear. If you look through the literature, when spinal manipulation is done well, it's a very safe and effective technique, especially relative to other techniques that people might would choose or even other medications that people might would choose for the management of their acute pain. So we know it's safe. We know it works well for acute pain. We've got enough data to show that it works well. Also, I mean, I would say even empirically, just looking at how many people are driven towards that intervention, I think empirically we know it works. And then, does it create dependence? I think that comes a lot more from the narrative for how it is presented to the patient than it does from the actual technique. So I don't think it has to create dependence. And we sit here and argue over these types of variables. Meanwhile, people are going to have their back manipulated regardless of whether we come to some sort of a conclusion or not. And that conclusion doesn't really influence the end result of those people seeking out that intervention because they think it'll be helpful to absolve some of their pain scenario. So it's very clear to me that we need to start pulling our weight here. We're too busy arguing over meaningless variables. START LENDING A HAND What we actually need to do is lend a hand in this fight to our chiropractic colleagues who are doing a very good job managing things conservatively. It's time that we take some action here. So team, I wanted to end this podcast by talking about what that action might would look like as a profession and hope that over the coming years we can start to shift to the profession in this direction. I do feel the wave of that currently and it's really exciting to see that more and more therapists are starting to utilize interventions that their patients want to meet that patient expectation and help create a narrative surrounding it. But I wanted to leave you with just a few action points. So first things first, I think you have to learn how to thrust manipulate. I understand there's a lot of argument in this space, but if you aren't able to do the intervention, the patients will never hear these arguments. So if we leave them stranded, or even leave them to just seek out all sorts of other health care, when what they want is spinal manipulation and if you could provide that to them, you could then help them understand the mechanisms, those underlying mechanisms that might make them feel more robust about their body versus feeling weaker or feeling fragile. We want to learn to do it so that that way when patients need it, we can provide it and we can also provide a supportive narrative that creates independence, not dependence. And this is possible. And so I think we have to learn to manipulate, otherwise we have no fight. Nobody's going to listen to the data. They're going to need to see it empirically. And so I think for us, we've got to get them in and actually do these interventions with them. To get good at that, I think you have to practice daily. So first, learn to manipulate, then practice daily. So whether that's on your spouse, on a family friend, or practicing on patients that are in front of you with no contraindications and perhaps even some indications for doing those techniques, I think we should practice these techniques daily so that you can get good at the psychomotor skills. Once you've mastered them, of course, focus on other things. But if it's still a skill set that you're refining, I would do those speed drills that you pick up in classes. I would practice on your colleagues and friends and patients. And then lastly, I think we have to, while doing these techniques, support a better narrative surrounding why they work. We want our patients to feel more empowered by feeling better following thrust manipulation, not to feel dependent by feeling better. So I think changing that narrative requires the learning of techniques and ability to execute the techniques well. That way the patient is actually interested in what you have to say. If you can't do the technique and you tell the patient that the technique doesn't work, a lot of patients are going to leave feeling like, well of course they think that, they're not able to do it. So I really don't think we can win any sort of battle of decreasing the dependence on things like spinal thrust manipulation without being experts ourselves in doing it. SUMMARY So team, that is just kind of the overarching thoughts on that article. It just jumped out to me that It was really nice to see the conservative care on the whole did really, really well. But I was just disappointed because I feel like I would love to carry more of the load alongside of our chiropractic colleagues and not leave them out there to fight this battle on their own. And I think a decent amount of professional infighting creates challenges surrounding actually learning these techniques and then utilizing them on patients. And I think we have to stop the professional infighting. We have to stop arguing over the deck chairs on the Titanic and just accept the fact that the ship is sinking. And it doesn't matter the orientation of those chairs. We have got to quit arguing over these factors and we've got to get to where we can actually do these techniques to people that are in pain so that we can help the chiropractic profession start to reduce a lot of those long-term costs that get associated with also not just costs but worse outcomes for the humans in front of us. You can criticize it all you want, but at the end of the day, what we're trying to avoid are things like opioids, things like injections, things like advanced medical imaging. These things, not just within 12 months, create a lot of expenditure and a lot of disability, but within the rest of that person's life, they do the same thing. So that's all I've got for you this morning, team. Let's tackle this problem together. Let's get out of the way. As far as the profession is concerned, stop arguing over little things and start to add these valuable interventions to our patients with acute pain. Hit me up if you have any questions, comments, or concerns in the thread here. I'll be checking it all day. Happy to further the conversation. But that's all I've got for you this morning. Take it easy and have a good Tuesday, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 4, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick as she wraps up her series on postpartum depression. In this episode, she will focus on first line of defense treatment for PPD including including medication, psychotherapy and exercise. As well as how to support someone with PPD as a friend or healthcare provider. She concludes with some important resources for emotional and mental health support that are free and extremely helpful to share with someone who is postpartum. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. APRIL DOMINICK Hello and welcome PT on ICE. My name is April Dominick. I am part of the faculty for the ICE pelvic division. And today's topic is all things treatment support strategies and helpful resources for postpartum depression. This is the final episode in my three part series on postpartum depression. So I am excited to dive in. But first I wanted to remind everyone of our array of course offerings in our pelvic division. Our first few live courses of 2024 are in Raleigh, North Carolina. That's going to be January 13th and 14th. And then Hendersonville, Tennessee, January 27th and 28th. And let's not forget about our not one, but two online eight-week course offerings. The level one cohort is going to start January 9th, while our brand new level two advanced concepts course will take place April 30th. If you've got someone asking you for some gift ideas or asking you to let them get you a birthday present, if you have a winner birthday, then have them help you out with some courses for ICE. That would be such a great gift of learning. And you can head over to ptonice.com to secure your seat in one or all three of those offerings, which is what is needed for our brand new ice pelvic certification. TREATING POSTPARTUM DEPRESSION All right, let's dive in today to the treatment section of postpartum depression. So one of the most common ways to treat postpartum depression is with antidepressants and psychotherapy. For those who are lactating, the conversation may include discussing the benefits of breastfeeding and known risks of antidepressant use during lactation. A lot of folks have concerns with the side effects that can occur when starting antidepressants. These concerns are totally valid and really excellent questions to bring up with their physician. For some, not being on the medication and leaving symptoms left untreated from a medical management standpoint could be just as risky in terms of their mental health and emotional health as well. For those who are concerned about the interactions that breastfeeding would have with antidepressants, or for those who would not prefer to take antidepressants, Psychotherapy is actually the first line of treatment. When looking for a mental health provider, we want to remind our clients, if possible, you want to find one that lists some sort of training in or special specialization of perinatal health as they will be really well-versed in the unique challenges that a postpartum individual faces. EXERCISE AS A FIRST LINE TREATMENT Now, Let's talk about a treatment that is within our PT scope of practice, and that's going to be exercise. So exercise is a great alternative or supplement to treating postpartum depression. Now, as a postpartum person, finding time to exercise while caring for a newborn, as well as taking care of the rest of life's demands, including chores or a job, That can be incredibly difficult and is a huge barrier for many to either return to or begin exercise in the postpartum period. When I was searching on the American College of Obstetrician and Gynecologist website, just seeing what all they have in terms of resources and recommendations, they didn't really have exercise as readily mentioned on their main pages when they were discussing how to address postpartum depression symptoms. And rather, they had like the medication and the mental health therapy, which was the greater focus, which is wild given that it Exercise is an excellent treatment offering that's conservative, it's generally accessible, and non-pharmacological. Not to mention, some of the forms of exercise can be cost-effective. And this may be a gap that we as rehab providers can remind our physician colleagues on the latest research that we know about of the effects of exercise and depression. and reminding them that, hey, we're those musculoskeletal experts in your community, and we are willing and able to help guide their clients in starting or continuing exercise, as we know, improving the postpartum individual's physical well-being and directly supports their mental health and well-being. THE EFFECTS OF EXERCISE ON DEPRESSION So what do we know about the effects of exercise in general on depression? Exercise helps to increase levels of endogenous endorphins and opioids, all of which have positive effects on mental health. And the team from Singh et al published a paper in 2023 on an overview of systematic reviews on physical activity for improving depression. they found that physical activity had medium effects on depression compared to usual care. So specifically, they suggested that aerobic resistance and yoga exercise was the most beneficial and exercise with higher intensity was associated with greater improvements. And then there was another study that was published in September of 2023, and this one was by Zhao et al. And they aimed to determine the association between seven lifestyle factors and lots of other body functions to see what their impact was on depression. They studied data from 290,000 individuals across nine years, with about 13% of those individuals developing depression. We love that length of time for data collection. Some of the seven healthy lifestyle factors that they found were associated with a lower risk of depression were healthy sleep, about seven to nine hours, that reduced the risk of depression by 22%. Frequent social connection that reduced the risk of depression by 18%. it was the frequent social connection was the most protective against recurrent depressive disorder. And then the other two of the seven healthy lifestyle factors was regular physical activity that reduced depression risk by 14% and then low to moderate sedentary behavior. When it comes to our postpartum population, we have to recognize that seven to nine hours of sleep is extremely unrealistic for most, but we can offer suggestions for improving the quality of that sleep, curating the best environment with maybe the control of limited noise. Can we make the room colder when we are going down for two to three hours, start to nap, uh, darker, uh, light or like less light and then cooler temperatures. Um, So those were some of the studies that looked at the effects of exercise and lifestyle behaviors on depression overall. What about the role of exercise in prevention and treatment of the postpartum population with depression? A little more niche. When it comes to aerobic exercise, there was a qualitative systematic review from 2023 by Xu et al. And it actually just came out last week. And it was studying the efficacy of aerobic exercise in preventing and treating postpartum depression. They found that compared to standard care, aerobic exercise, particularly 30 to 45 minutes of moderate intensity, three to four sessions a week, had a significant effect in treating postpartum depression with a greater emphasis on prevention. Many of the studies we have on exercise effects on postpartum depression, look at aerobic exercise. But what about resistance training? So in a study by Le Chemin et al. from 2019, the group examined the influence of resistance training in women during postpartum depression. They found that compared to a stretch-based program, those who engaged in resistance training reported a significant decrease in their depressive symptoms four months postpartum. compared to when they measured immediately postpartum. We also have data from our very own ICE faculty, Dr. Christina Prevett, who did a study that looked at the impact of heavy resistance training on pregnancy and postpartum health outcomes. And compared to the national averages, those who lifted heavy showed lower rates of perinatal mood disorders as well. So there's quite a bit of heterogeneity in the method sections of these studies that these systematic reviews are looking at when it comes to exercise and depression. This makes it difficult to specify any sort of intensity or specific type of exercise or timing frequency domain for what is best practice, what is most effective for using exercise to help with reducing depression. The SHU article was one of the first that I had run across giving a specific time and frequency domain for exercise in the postpartum depression period. It would be interesting if researchers could look at the effects of exercise alone, as many of the studies look at the combination of the treatment of psychotherapy, medication, and exercise. I'd also be curious about, hey, does it matter the specific time that someone returns to exercise postpartum. As in, is it most effective if someone returns to movement within two weeks, four weeks, six weeks? What makes the most difference? So while we're waiting for more dialed-in research in the clinic, If you're going to create a program or suggest a rehab EMOM for someone with postpartum depression, make sure that you're including a mix of aerobic exercise, resistance training, and mobility, as well as some sort of reconnecting with their breath and body, just to help tap into that downregulation of the nervous system and hit those preliminary time guidelines from Shu et al. of 30 to 45 minutes, three to four sessions a week. So to sum up treatment, while there are multiple options to address postpartum depression currently, our first treatment approach is usually a combination of the treatments of antidepressants, psychotherapy, and exercise. So that was treatment. SUPPORTING PATIENTS WITH POSTPARTUM DEPRESSION Now I want to talk about how do you support someone who has postpartum depression as a rehab provider or a friend. Overall, validation, education, and reassurance and psychosocial support go a long way in helping someone experiencing postpartum depression. Making the new mom feel taken care of. Everyone has shifted focus to the baby, so how about asking how the mother is doing, checking in with their needs or whoever the postpartum person is. So there are so many ways to support a new parent and these are just going to be a few suggestions for how providers or friends and family can support that person. As a friend and provider, highlighting and celebrating the wins is key. Small, big. How they have made a huge impact on caring for their child and supporting their family. How their baby needs them, the postpartum person, to be consoled and that that person is able to console the baby and how they are learning what their baby needs are and recognizing the needs for comfort, for food, for diaper changes. As a friend, if you're looking for a way to help them that may not have as high a financial ticket as some other ways that folks can help, offering to drive the postpartum person to their appointments or to sit in the stay with a baby so they can get out of the house or get in some exercise without being interrupted by the baby waking up. Or as a friend, offering to help them with some chores. Bonus, you'd get some quality time together. And then another option as a friend is just communication. A simple message can make someone's day offering consistent check-ins, text messages, phone calls, FaceTime, snail mails. You can share something funny about what you just experienced or maybe you just thought of them and wanted to share that with them. As a provider, brainstorming with the postpartum person, how they can ask for help from their support system and help offload their mental and physical demands. Um, maybe they could create a meal train or ask, um, friends to set up a grocery delivery or, uh, ask for some gift cards to a favorite restaurant or self care services like physical therapy, um, a massage, a facial or a haircut or a babysitter. Obviously those come with a little bit higher price tag, but just options to, um, suggest for the, uh, postpartum person to tap into their support network. And then as a provider, reviewing and sharing some resources with the client that are particular to postpartum depression, such as phone support lines, community groups, or even providing them with some postpartum depression related pamphlets so that if it's a hard conversation that they don't want to have, then they could read it on their own time. RESOURCES FOR POSTPARTUM DEPRESSION So I'll go over some resources now and put them in the caption for you to reference. That is my cat. She is joining and also wants to hear the resources. So the first one is the Postpartum Support International website. It is one of the best resources overall that I've encountered. It is good in that it is going to be helpful for connecting folks with local resources in their region, offering emotional support during pregnancy and postpartum. with online support groups and they also have live phone sessions every Wednesday and I think they're capped at about 15 to 20 people. They also have perinatal trained medication providers or therapists or community groups and tons of blogs with others sharing their stories and so Folks can also use the Postpartum Support International's directory of trained perinatal mental health providers on folks who are specialized in postpartum anxiety, postpartum depression, and they have a director specifically for those humans, which I think is awesome. The next resource is the National Maternal Mental Health Hotline. They provide free conventional support confidential support resources and referrals from professional counselors to help pregnant and postpartum individuals facing mental health challenges. And this is also available 24-7. They also have interpreter services that are available in multiple language, which is huge. The third resource is the 988 Suicide and Crisis Lifeline. It provides free and confidential emotional support to help people in suicidal crisis or emotional distress. This is also available 24-7 and individuals can call, they can chat, or look up all the different educational information on their website. The fourth resource is the Postpartum Progress website. It is just chock full of information on the postpartum period in general, with a big section on postpartum depression, They have a provider list, including a black mental health provider list. And, uh, one of their extras was a Spotify playlist, uh, called warrior moms, which I love the strength and energy behind that. And then finally another, um, uh, resource, which is on the ACOG website. Uh, it is an infographic on anxiety and they do a beautiful job of, um, pretty much going through all of my, uh, podcast series, but for anxiety. about the prevalence, what is postpartum anxiety, and what are some treatment methods, what are some resources, just kind of sharing information because it's helpful to know that other folks are going through the same thing and that there's help out there. This pamphlet is a great idea to put up in the clinic, put up in bathroom stalls, maybe even have on your clinic website, but making one for postpartum depression. So we as PTs, we are perfectly positioned to help break the silence of folks with postpartum depression who may also be unaware that they're even dealing with this condition. We can make a difference in these clients' lives. Combined with educating ourselves, we need to be educating the birthing individuals, their support system on what postpartum depression looks like and ways to prevent it. then actually informing the individual on a number of treatment strategies available to them, including the combination of medication that is right for them, psychosocial mental health therapies, or alternative therapies like aerobic or resistance training exercise, whichever of those treatment strategies makes sense to them. And of course, speaking with their medical provider for the medication and psychotherapy piece. Oftentimes finding the right care support and gradually adding in movement, physical movement, aiming for good quality sleep, which is so tricky with this population and addressing nutrition can be huge steps in treatment of postpartum depression. But there's so much more. The essential pieces are asking someone about their current ecosystem in their postpartum world, allowing them space to share the tough things and knowing when to refer out for postpartum depression. as well as encouraging them different ways that they can lean on their support system or offering them the free resources such as the support groups or hotlines I talked about. And those are available in the caption. So treatment for postpartum depression, remember it's not a one size fits all. And individual specific situations, their preferences, they all have to be taken into account. If you miss the other two episodes in this series that go over the prevalence, risk factors, how to screen and what to say to someone who you suspect has postpartum depression, check out episode number 1553 and number 1572 to learn more. And thank you so much for your time and attention today. And I hope you find some brightness in your day. And as a bonus, if you have anyone who is recently postpartum, send them a warm message and let them know that you are thinking about them. Take care, everyone. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dec 1, 2023

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses one of the most effective and efficient ways to improve VO2max/fitness/endurance/conditioning both in the gym as well as in the clinic for your fitness athletes (and all clients). Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. GUILLERMO CONTRERAS Okay, live on YouTube and live on Instagram. Good morning, everybody. Welcome to the PTI Daily Show. My name is Guillermo Contreras. Happy to be here with you on the best day of the week, Fitness Athlete Friday, talking all things fitness athlete and improving overall fitness in the individuals that we work with on a daily basis, in our clinics, in our gym settings, et cetera. Before we dive into the topic at hand, Let's go ahead and talk a little bit about the fitness athlete courses coming to your area as well as online. Fitness Athlete Live is going to be on the road over the next three months, quite a bit. Next weekend, we're going to be in Colorado Springs, Colorado, the weekend of December 9th and 10th. The weekend, and that's it for 2023, right? But 2024, we jump in right back onto the road. January 27th and 28th, we're going to be in Portland, Oregon. February 10th and 11th, Richmond, Virginia. And then February 24th and 25th, we will be in Charlotte, North Carolina. So plenty of options, whether you're in the mountains on the West Coast or on the East Coast, we're going to be traveling throughout those areas in the next three months or so. So feel free to check out the website, ptinex.com to find out how you can sign up for those. As a reminder, courses in price at the end of this year. So if any of these courses look like something you can get to, you want to get to, you can travel to, you're going to make a plan to get to. Snatch that course up now because right now courses are $650 and they're going to be bumped up to $695 in 2024. So take advantage of the lower price now. Get yourself signed up for those courses and then find a way to get to these courses but just check those out on the website for where those are going to be. And then fitness athlete level one online. The next cohort is going to start up on January 29th. Currently in the middle of a cohort right now. Started finishing up week four right now. So four more weeks there, a little short break, and then we kick back up on January 29th. And then fitness athlete level two, or what is formerly known as advanced concepts, that kicks off on February 4th. Those courses always sell out. We rarely have anyone that wants to get into it that can't get into it after they sell out. So if it's something you've been looking to do, if you're looking to become certified in clinical management fitness athlete through that certification process, then you need to be able to take a one, take the L2, take the live course. And again, that L2 only comes twice a year. So if it's been on your bucket list, something you want to take, sign up now sooner rather than later, because as I mentioned, those courses, All right. Um, so that is the introduction there. That is what we have on the docket. Um, as I mentioned, again, my name is Guillermo Contreras. I'm a physical therapist, uh, over here in Milwaukee, Wisconsin, and a part of the fitness athlete team here with the Institute of Clinical Excellence. THE ASSAULT BIKE FOR VO2MAX DEVELOPMENT The topic today, uh, the title, uh, is VO2 assault or assault on your VO2. I don't know why I wasn't too creative today, but there's there's a reason we're talking about it is The assault bike or the echo bike or like any air bike right we're talking about like this this beast This beautiful thing we have back here the assault bike I have here in my office Is one of the best tools that we can use to work with individuals in the clinic out of the clinic in the gym trying to improve overall cardiovascular conditioning, fitness, metabolic stress, like all these different factors that we can improve upon using a simple piece of machinery. This piece of machinery costs anywhere between $700 for the Assault bike, the standard or the original, I believe is what it's called, up to $840, $850 for the Echo bike, which you can get through Rogue, the Rogue Echo bike. It can go as low as, if you're really just kind of want to pinch pennies there, a couple hundred dollars, maybe $100, $150, or a Schwinn Airdyne. And those Schwinn Airdyne bikes, right, those are, like we used to have one of those from like the 90s that still worked like it was new. They last forever. they work forever, easy maintenance if you just take care of the chain with the rope echo bike a little more expensive because it's belt driven and again that lasts forever very little maintenance so they're just really really nice pieces of equipment to have. The weight limit then on them is around 300 for the soft bike 330 pounds for the echo bike and probably sure a little bit less for just your standard twin airdyne but they make like the airdyne pro that i'm sure has a 300 pound weight limit as well. last and survive through the apocalypse. That's how good these things are. Not only that, but in the clinic space, they are fantastic for working three limb conditioning. If you have any a knee injury, a hip injury, something that does not allow them to do something like running or standard biking or skiing or rowing, right? They have a limb that they cannot use. You can rest that limb and work the other three in a very effective way that increases conditioning overall. And the reason I'm saying all this, and the reason I'm touting up the Assault Bike, the Echo Bike, right, is because there is no reason that we should not have a piece of equipment like this within our clinics. And if we have something like this, there's no excuse for us not using it with our patients. Especially if you work with an athletic population. When you look at the NFL right now, how many people are getting injured? How many injuries are you seeing on a weekly basis? You've seen an excessive amount of Achilles tears, knee injuries, high ankle sprains, all those things. And one of the biggest things you hear when an athlete comes off of what they call the injured reserve is that, are they in game shape? Like they have the strength back, they have their motion back, they can handle the stress on whatever was injured, but are they truly in game shape? Do they have the ability to withstand rep after rep after rep on the field? And honestly, when it comes to conditioning, there is no better device. in a more efficient way than this behemoth, this beast right here, this monster, this thing we love to hate in the fitness athlete realm, in the CrossFit sphere, and in pretty much anywhere you see this bike. EFFICIENT RESULTS WITH THE ASSAULT BIKE This is proven in a wonderful study where it took 32 individuals and it put them in three different groups. The control group was given moderate intensity cardiovascular training. 30 minutes of 75% heart rate max, cardiovascular cycling, 30 minutes rate of 70, 75% of heart rate max. Group number two was given what we know as a Tabata or a half Tabata. They had to do 10 seconds sprints, five seconds of rest for eight sets. They then rested for two and a half minutes and repeated that whole cycle three total times. Group number three was given a standard Tabata, three sets, of eight repetitions of 20 seconds of work at 10 seconds rest. That is your standard Tabata 20 on 10 off eight rounds. They had to do that three sets with a five minute rest between each uh three set round you call it there or each eight set round I'm sorry eight round set. All in all the modern intensity cardiovascular training group did around three The 10-on-5-off group did around 72 minutes of work per week, so around an hour, a little over an hour. And the standard Tavada group, that three, or the eight rounds of 20-on-10-off, did around 144 minutes of work, or just over two and a half hours, sorry, around two and a half hours of work per week. What they found at the end of the study was that there was no significant difference in improvement across all three of them. All three showed improved time to fatigue, improved VO2 max, improved conditioning, and improved ability to create force, improved MET, M-E-T-S, M-E-T-S. But the big picture here, gang, right? Like what we see there is like, okay, like that means we can pick any of those and get someone more cardiovascularly fit. Yes, that is true. You can kind of pick your poison whichever way you want to do it. What we're talking about here is that the short group, the 10 on, five off, 72 minutes of work per week, one hour of work per week, that group was 250% more efficient in the use of their time to improve their cardiovascular fitness, to improve their conditioning, to improve their power output, to improve their time to fatigue than the other two groups that doubled and six times the amount of work. And how we can apply that is like when we're looking at individuals in the clinic, we probably don't have six hours of week to add to their program, to their plan of care, to get their conditioning up. They might not have six hours additional per week to jump on a bike and do 30 minutes of work three times a week as well. And if we want to get someone more conditioning, better shape, better heart health, improve health markers, blood markers, all those things, while also improving pain, reducing pain, improving function, increase in range of motion, whatever our plan is or whatever our goals are for them in the clinic, this device, the AssaultBike, the EchoBike, a nice quality Schwinn Airdyne bike, that is the way we can do it in a very effective, efficient manner. If you can do the same If you can have the same results in less time, people are going to buy in. If you can show somebody, hey, we're just going to do 8 sets of 10 on, 5 off before we start the session. I'm going to jack your heart rate up. I'm going to get your blood flowing. We're going to not only improve your overall cardiovascular fitness, we're not just going to improve your overall health markers. We're not going to just improve your conditioning, which again, if you're looking at working with athletes, whether it be in professional sports, amateur sports, high school sports, whatever it is, you need to build up their conditioning space or their conditioning ability. SHORTS BOUTS; GREAT RESULTS But across all populations, we can all benefit from this. We can all benefit from having better heart abilities, better cardiovascular fitness, better VO2 mass to be able to stand and do things for longer with less fatigue. So by using this device, using short sprint intervals, things like you see behind me, things like 10 on, five off, or eight rounds, three sets, two and a half minutes rest, or simply one set, one set of eight repetitions of 10 on, five off, right? We can have these small things that can affect individuals. It's also something they can easily do for a home program. if conditioning is an aspect they need to work on. If we're trying to get their VO2 max up, we can give them, hey, I want you to jump on the assault bike, jump on the echo bike. I want you to do 10 rounds. Just go as hard as you can. Rest five seconds. Do that eight times. Do that a few times a week. When you're looking at individuals who have Achilles tears, knee injuries, something where they cannot use that limb or it's uncomfortable to use that limb, they can still get after it with three limbs. They can use left leg and both arms and get after it on a soft bike. Again, effort is what matters here. Intensity is what matters. And when we're talking about working with individuals, trying to give them the most effective, efficient way to get better, get stronger, get healthier, and we're thinking of a fitness-forward approach to everything we do, this device, these tools, these strategies, these techniques, in doing that. and nauseam about getting people fit or getting people strong, using intensity as the way to do that. And if you're curious how it works and if it works for you, simply get on an assault bike, get on an airdyne bike, push yourself hard for 10 seconds, work a five seconds rest, repeat, rinse and repeat for eight rounds and see how you feel after that. See how the improvement comes upon there. Hope to see you on the road, gang. Hope to see you online. Thank you for tuning in. Have a wonderful weekend and we'll see you next time on the PT on ICE Daily Show. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 30, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses the origin of the term "fitness-forward" and how developing your "nose" for the essence of your business principles can help clarify your mission while helping your brand. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MOORE All right, team, what is up? Welcome back to the PT on Ice Daily Show. Thrilled to have you here. My name is Dr. Jeff Moore, currently serving as the CEO of ICE, and always thrilled to be here on a Leadership Thursday, which is always a Gut Check Thursday. Let's do the workout, let's chat about some courses, and then I can't wait for today's topic. I've been waiting a long time to do this one, so I can't wait to jump into it, but first, the workout. Gut Check Thursday, it is Lynchpin Test 14. It's quick, but it's painful. It is 15 clean and jerks at 135/95, then you're going to go 30/20 on the fan bike, and then right back to 15 clean and jerks. Relatively simple couplet, but one can be certain that second set of clean and jerks is going to feel nothing like that first set of clean and jerks. You're going to be exhausted from the first set. And if you went big on the bike, Lord knows you're going to be feeling every bit of that energy on every rep of that second set of clean and jerks times. Probably five six seven minutes. I mean this should not be a long workout Especially if you really put out on that bike, so please tag us ice physio Hashtag ice train get them up on Instagram Let's all suffer a bit together here on gut check Thursday as far as course is coming up I want to say two things number one The first couple weeks of January are going to be packed with all of our online courses. We have six of them firing up in the first couple weeks and darn near all of them in the first month. But in the first couple weeks, we've got Injured Runner, Persistent Pain, Brick by Brick, we have Pelvic Level 1 and Older Adult Level 1. We also have Older Adult Level 2. Now what I want to say is, if you're going to jump into one of those, remember that prices go up to $6.95 on January 1st. So buy your ticket before January 1st. It's only $45 or $50, but save a little bit of cash and snag that ticket at some point here during December. If you're jumping in early January anyways, you might as well save yourself $50. So hop on the website, PTOnIce.com, and get that done. FITNESS-FORWARD: THE ORIGIN OF A TERM Let's talk about fitness forward, specifically The origin of the term. So I get this question all the time. Where did that term come from? What does it even really mean, fitness forward? So I'm gonna answer that once and for all. I'm gonna give you some clarity on that. But I also wanna share a branding lesson while we do so. So if you're not overly concerned about where the term fitness forward originally came from, stay tuned because I hope that by the end of this, you see a significant branding pearl that you can incorporate into your own business or practice. First things first, to understand the origins of this, you have to know a little bit about kind of our company's evolution. And if you look at it over the past 10, 12 years, there have been kind of what I look at as three really significant changes that fostered our evolution that really helped us solidify the who and the why we exist. STRENGTH & CONDITIONING ACROSS PHYSICAL THERAPY The first one is a huge increase in strength and conditioning principles across the professions of physical therapy, occupational therapy, chiropractic, especially around like the early 2010s, like 2012, 13, 14. I was out there teaching almost constantly. I mean, every weekend, every other weekend. And we were teaching, you know, kind of traditional manual therapy and patient expectation and sales stuff. and things to level up your practice. But the questions that I was getting was so oftentimes not so much around those things, but more around, OK, cool, how do I incorporate strength and conditioning principles? What about after the fire's out? How do I keep people on my schedule and really deliver above and beyond just making them feel a bit better? How do I incorporate strengthening and resistance training into injury prevention? And it was very clear to me during those years that that was where the profession wanted to go. That was where a lot of the more exciting research was coming out. Even things around like longevity and healthspan and life quality and all of these things around lifestyle behaviors, resistance training, strength and conditioning were just flooding the research and everybody rightfully so was so excited about it. What nobody had though was answers for them, myself included. I remember looking around thinking, I really don't know where this stuff lives. It certainly doesn't live in PT schools. It still really doesn't. It wasn't in traditional residency and fellowship programs. Those were a lot more focused around the exciting manual therapy research of the early 2000s. They were built from that space. So it didn't really exist out there. Nobody seemed to have the answer. So watching this interest grow, is what led me to reach out to Mitch Babcock and say, big guy, you got to show the profession this stuff. Like this is in your DNA. You live and breathe this stuff. You got to build a course that shows the profession of physical therapy, occupational therapy, chiropractors out there, how to move a barbell around. how to get fit, how to get other people fit, basics of programming, how to work around injury. There is a clear desire for this information that if we had, it could lead to significantly better lives for our patients, but we don't know what we got to build it. So that's where the fitness athlete curriculum started, right? Started off as that first, what we used to call the essential foundations course. It's now level one. And of course, over the years, it's now built into advanced concepts, the live course, the entire certification. But that's where it started. And as it was building, first of all, the reception from our profession was unbelievable. Like, we totally underestimated the demand for that material. To have a concise course that showed people how to do these lifts, how to program them, how to get people fit while getting themselves fit, we underestimated demand. The enthusiasm was incredible. but it wasn't just the students. We as faculty were learning along the way. We were getting more and more into it. Becoming fit and living that life and being about it became more and more important to all of us. As it did, we were hiring people who were already living and breathing that life. And so the compilation of the ICE faculty was moving in that direction as we were learning and teaching this content. Well, what happened then was really important. As we all began to get more excited about it, live, breathe it, demonstrate it, we really started to understand the power of be about it. As we started swapping stories with each other, we began to realize the impact that us working out and being fired up about the stuff at courses was having on participants. We were getting emails of people who said, hey, great class. Love the content. But I also want to say, hey, thanks for the workout. I've been slipping a bit in that space. And that really called me back to action. It really motivated me. Here's what I've done since that course. I've gotten into the gym. I've gotten my family into the gym. And we started realizing this is where the magic's at. DEMONSTRATING A FITNESS-FORWARD LIFESTYLE: PEOPLE FOLLOW PEOPLE It's actually demonstrating this stuff. It's actually living, it's being an example. Well then, we all carried that kind of from the classroom over into our clinics. And we got louder about it in the clinic. We started sharing workouts for the community. And we really realized this is where it's at. Being about it is the answer. People don't need more education, they need more inspiration. That quote kind of came from this evolution of like people don't need more knowledge, they need an example to follow. If you lead people, they will follow you. It's not about education, it's about inspiration. As all of this came together, our growing enthusiasm ourselves, the enthusiasm in our students, then the enthusiasm in our patients and our communities, we realized, and I can point to one moment when it all kind of crystallized, it was in 2017, the very first ICE sampler. We were sitting on Justin Dunaway and Morgan Denny's patio in Portland, Oregon. And we're sitting there throwing around these stories of people who had come to our courses and had this great experience working out, how fired up they were, how their lives are better off now for it. And I'm sitting there on the patio, and I said, that's it. From this moment on, you never go to an ICE course that doesn't have a workout. It's mandatory. It's who we are. And I remember it felt so right to say that it was now, we were already doing it organically, but it was now baked into the process. This is who we are. If you engage with the ICE community, you get fitter because of it and all the beautiful sequelae that come along with that. So this evolution really helped to solidify our mission. We now knew exactly what we taught and what we did. We managed symptoms to maximize fitness for every age and stage. That's it. We know now exactly who we are, what we're teaching others to do, and the wording of all of that is really important, right? The order of that. We manage symptoms. We don't need to erase symptoms. We don't need to cure symptoms. We need to manage them. We need to improve them when they can, but we need to work around them at times. But we manage symptoms for the higher goal of maximizing fitness. Because when you maximize fitness, you don't just change back pain, you change lives. I mean, you transform that individual's life. That's why it's in that order. You are totally managing symptoms, and your efficiency at doing so is critical. But it's for the goal of maximizing fitness, and it's for every age and stage. If you look at our course catalog, that's who we are. We're breaking down barriers for older adults, right? It's old not weak and it's avoiding one rep max living. We're taking it to the pregnancy and postpartum space and getting rid of those myths, right? And debunking all that stuff that you can't lift heavyweights further on into your pregnancy. That you can't do things at more of an individualized timeline afterwards before the generic six weeks. We're breaking down barriers because everybody gets fitness. And we're going to find a way to make that happen. Quotes like, you don't leave the gym, you use the gym. You work around the injuries. The point is, this evolution through fitness being incorporated into our company is what allowed our mission to be solidified, that we manage symptoms to maximize fitness for every age and stage. FINDING A NOSE FOR YOUR ESSENCE OK, but why the actual term? So you get the importance of fitness now within the ice culture, but why the term fitness forward? It still sounds kind of funny. The answer to that is kind of funny. So before I became a physical therapist, my first professional love was wine. So I managed restaurants. I sold wine. I learned everything I could about wine. I love wine. I have not drank alcohol in years. I still love wine. I love everything about it. I love how it brings people together. I love how it's cultivated. I love literally everything about it. Not to get too technical and go into a big wine lesson, But an important thing about enjoying wine… is understanding how to savor the nose of the wine. Most of you are familiar with this idea, right, of swirling your glass, right, and making some of those aromatics volatile so you can put your nose in the glass and you can take in some of those beautiful senses, right, of the different smells and characteristics and the heat of the wine, right? It's beyond just smell. By the way, not to get really technical, but if the wine is high alcohol, don't put your nose so far into the glass, right? I see this all the time. If you've got a big cabernet that's 13.5% and you swirl the glass, if you bury your nose way in there, it's just going to be hot. Because that alcohol is going to be so like, whoa, so upfront, you're not going to really enjoy the nuances of that experience. Higher alcohol, keep your nose closer to the brim of the glass. You have a lower alcohol, you got a German Riesling, 8.5% or something, by all means, dive in. But higher alcohol, just give yourself a little bit of space to make sure you enjoy all the complexities. Now getting back to the podcast, the point is that nose is kind of what you walk away with when you think about a wine. It's the essence, right? I looked up the term essence before this podcast, the actual definition. The essence is a property or group of properties of something without which it would not exist or be what it is. To me, when you're getting the nose of that wine and you're getting that really subtle tone of leather, right, or some of that French oak, right? And you're like, oh, I can really catch that. That really jumps out at me. Without that, it wouldn't be the same wine. That's what you walk away with. It's the wine's essence. The nose, if you will, of ice is fitness forward. Right, no matter where you engage with us, it comes through. It's the essence, it's the thing that's always there. I hope when you see our logo, things like Be About It, Lead From The Front, Old Not Weak, I hope all of these are almost synonymous with that logo. I hope that's what our essence is and you can feel that. Now the brand lesson I was talking about with you all earlier is that's what you wanna create. SOLIDIFY YOUR BRAND BY CLARIFYING YOUR ESSENCE The goal of solidifying your brand should be clarifying your essence. You should all know exactly what it is that no matter where somebody engages with your product, that comes through. That is a beautiful thing. And when you think about really bonding people around a common purpose, knowing what that is and then clarifying it and solidifying it, that's where the magic happens. To fully answer the question, where did the term come from? Well, that's the details. But when did I first say it? I said it in early 2018. It was after that Portland Sampler. It was the next year we were rebranding our ICE logo. And Ryan from THINK Marketing asked me, dude, in one sentence, What is ICE? Who are you? And I said, dude, we're the and, not, or company. We are fitness-forward, manual therapy skilled, and psychologically informed. And as soon as the words fell out of my mouth, I said, that's it. That's who we are. And now you've seen the logo, right? It's got all three of those things on there, but that's where it came from. And I know that fitness forward came out of my mouth first because that is our true essence. Now, what's our goal for you, right? Let's get away from us for a second. What's our goal for you? Our goal is that your practice becomes fitness forward, right? That when you, if you engage in our content long enough, your practice transforms in that direction because that's where people are going to make the most life-changing gains. So we love when we walk into your clinics, and we see all the things, right? We see the squat racks, we see the mats, we see the barbells, we see the kettlebells. We know that people are challenging themselves in a way that's actually going to transform them as a human, not just ameliorate their back pain. It's part of it, not all of it, right? We hope your practice patterns move in that direction, your equipment moves in that direction. But honestly, to wrap this show up, we hope you move in that direction. We hope that your life becomes fitness forward. Not to get too philosophical on you here, but while I deeply love all the comments and emails about, hey, ICE really transformed my practice, this, that, and the other, I love that stuff. That's the core of what we do. But I'm not telling you the whole truth. If I don't say that, what means the most to me is the note that says, hey, I gotta tell you something. I went to this course with a few of your faculty, and they really made this fitness lifestyle approachable and non-threatening, but also relevant and meaningful and emotional in a way that made me change the way that I live my life. And I wanna tell you a bit about why I'm different now than I was before I went to your course. I wanna tell you the effect it had on my family, on my team. If I zoom all the way out, that, that's what I hope. Us being fitness forward in whatever evolution we took to get here, that's what I hope the outcome becomes at scale for every single one of you and every single one of the people whose lives you touch in turn. FOREVER FITNESS-FORWARD We are forever fitness forward. We know who we are and we know where we're trying to go. And I'm so thrilled you're all going with us. I hope that explains the term ptiice.com is where all the goods live. Thank you so much for joining me this morning. Take care, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 29, 2023

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses her personal experience with end-of-life care, comparing different scenarios between family members who had hospice/palliative care and those who did not. Christina challenges listeners to step back and recognize if they are being mindful of the patient's choices when nearing the end-of-life, and respecting the dignity of those choices as it relates to physical therapy treatment. Christina also reminds listeners to always advocate for their patients and be a resource, especially with hospice/palliative care as it is often not recommended as an option for patients. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETTHello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division. We are in full-blown, like end-of-the-year mode. I hope you all had a wonderful Thanksgiving. We are getting ready for a really big 2024. Our next online courses are level one and level two, running January 10th and January 11th. And then we have two courses left for MMOA Live, Chandler, North Carolina, this next weekend, and Portland, Maine, that have maybe one or two seats left in them. And then, oh, hi, Hospice Nursing tuning in. We are really getting going for January so we are in Santa California Santa Clara on January 13th and 14th And we were in Maryville, Ohio that same weekend. Sorry, Santa Rosa and then I am in Greenville, South Carolina the 20th and 21st All right. HOSPICE CARE Let's get talking about hospice. I graduated from PT school about 10 years ago and there always are some moments in your education that really stick out for you. And the one that to this day sticks out for me was we had a panel that came from a hospice that talked about end-of-life care. There was a nurse, there was a social worker, a PT, and a physician who all worked in nursing and they all worked in hospice. And this session about respecting the dignity of end-of-life care was so powerful. I left that session thinking, about what a job, is like to be able to facilitate that person's dignity and respect at the end of their life. I remember thinking about the people that were on that panel and they all loved their job. but you could see that there was some sadness behind their eyes because they've seen a lot of beautiful and tragic transitions into the end of a person's life that can be really difficult to manage. And I have been lucky, three out of the four of my grandparents, this is gonna be kind of a bit more of a personal episode, three out of the four of my grandparents have In my mind died of natural causes my grandmother on my mom's side died at 89 my grandfather on my dad's side died at 93 and my grandmother on my mom my dad's side died at 97 she was almost 98 and I truly believe she was gonna live to 100 but um She ended up with stage 4 cancer, but you know mutated growth at 98. I feel like it's natural causes And they all had different variations of their end-of-life care. And my grandparents, my grandfather and grandmother on my dad's side, both ended up with hospice care and they received different types of hospice care. So I kind of wanted to speak a little bit about what hospice care is, palliative care in general, and just some of the personal experiences about how beautiful that transition in hospice care can really be. WHAT IS PALLIATIVE CARE? When individuals think of hospice or palliative care, they think that an individual is dying imminently. And this was true with my family as well. When I suggested that my grandmother, who was diagnosed with stage four cancer, be given hospice care, my dad thought that I believed that she was gonna die tomorrow. Hospice and palliative care is when the prognosis is not great when there are no thoughts for intervention, or when the person has decided that they are not going to intervene to try and change their diagnosis. And that was kind of what happened with my grandmother. So she was diagnosed at 97 with stage 4 cancer and she said, you know, what am I gonna do? She was of sound mind and she said, I'm not gonna fight this thing. It's gonna make me feel really bad. I'm almost 98 years old. I do not want any intervention. She was very clear in that. And that was really hard for my family because she was the matriarch of the family. She had been so healthy. We literally all had her that she was living past a hundred and she decided that she did not want any interventions. And when she decided that I made the recommendation that we go to a hospice or we put her on the palliative care list here in Canada. And it was a really tough discussion with my family because they believed that, you know, she had a lot that they could still do, and it always came back to this discussion of, in palliative and hospice care, they are going to respect the comfort level of the person that is with them, and they are gonna respect their wishes that they're not gonna do any extraneous interventions to try and change the cancer. COMFORT & DIGNITY AT END-OF-LIFE They're gonna make her comfortable, give her dignity, and allow her to continue with end-of-life care. And I said, you know, as soon as she gets on the list, you know, we may not be accessing, you know, pain management and all those things right now, when that time comes, she's gonna have the capacity to be able to access those services, access those individuals, hospice, support personnel of various forms that are going to be able to help her. Then she was able to access a hospice care home when the time was coming that she couldn't be independent anymore. And so for her, she declined and there was a lot of conversations back and forth about, let's try this ultrasound, let's try that ultrasound. And I was very adamant about coming back saying that this was not what she wanted. She wants to be in palliative hospice care and be comfortable and surrounded by family as she starts to transition to the end of her life. And there was a time when pain was starting to come up because her cancer had transitioned to her bone and she was having a hard time toileting independently. It was around that time that our family had a discussion about putting her into hospice care. Again, my family had a really tough time with it, but when she was in hospice care, she was able to have visitors. There were not tons of lines and tubes and monitoring that was happening. The room was so quiet. She was able to have all the pain management that she wanted. I'm probably gonna tear up at this, but when it was her time, they did this beautiful pass through this archway that had angels and a cross, she was religiously inclined, and it talked about creating this pathway to the end of her life. And it was a beautiful thing. And I remember thinking that there are so many people who don't have that beautiful experience at the end of their life because they are surrounded by so many lines and tubes and sometimes that's just the nature of what happens at the end of a person's life. But I felt so fortunate that my grandmother was able to have this transition to her afterlife in a way that was so respectful. My grandfather was 97, and she passed away just recently. And my grandfather, he was 93, and it was kind of the same thing that was happening. He was starting to decline, he was generally unwell, but he was 93, he didn't really want any interventions, but he did not want to go into the hospital. And so we were able to access palliative care at home. And so by accessing some of those services, we were able to get a hospital bed in the room at that point in Everybody's life we were able to do round-the-clock care. We had hospice Palliative nurses and palliative care physicians coming in and checking in on them. But the same thing we didn't have was he didn't have any lines and tubes He gradually kind of slipped into a coma. We didn't do any extraneous measures except for pain management and he was able to die surrounded by his loved ones at home and again, that was something that I So kind of different versus going from a, you know, into a home of hospice versus transitioning into the afterlife at home, but still two very calm, very peaceful transitions into the end of a person's life. And so I kind of lead with those two, one of, you know, peacefully dying at home, the other around, peacefully passing in hospice care. And I want to kind of contrast that with my other grandmother. So I had a grandmother at 89 who honestly just did not want to live anymore. She had lived a long life. She had been widowed for a long time. And the love of her life, she never really recovered from that. All of her kids were grown. They were all doing well. And she just started to generally decline. She just wasn't doing that great. One of her kids, she had 10 kids, and one of them called an ambulance. She was just kind of not thriving at the hospital. So they brought her to the hospital. Her labs were kind of all over the place. She wasn't really doing that well. And she just didn't, she wasn't really doing great. They couldn't really figure it out. They had decided not to do any invasive therapy. She ended up transitioning to a long-term care home. Now. This is not to say anything negative about long-term care though in Canada There's a lot of conversation about how to create a better environment in long-term care. This is to speak a little bit more to like the medical side, you know So she was kind of getting around-the-clock care and she was on kind of hostilities hospice palliative, it was a very different experience where It just felt like, it felt a lot more lonely because she didn't have that same type of support that my other grandparents had had. And she was, she ended up passing away in long-term care, which was adamantly what she did not want. She wanted to pass away at home. And she didn't know when she was kind of just feeling unwell that it was the last time she was going to see her home ever again. She was very upset by the fact that that decision had been taken away from her because now she was too sick to go home and they wouldn't let her go home. So there were a lot of sad emotions around my grandmother on my mom's side transition into a long-term care facility that wasn't kind of in the same bucket as hospice or palliative care. THE REMOVAL OF DIGNITY AT END-OF-LIFE And so why do I kind of bring all these things up? One of the things that I did not recognize as a person in geriatrics is how I was gonna be confronted with a lot of things around end-of-life care that I would not have expected going in. You know, you kind of go into PT a lot of the time thinking that you're interacting with pain, and you are, but you're gonna have these situations and circumstances where a person that you're interacting with will take a turn. When you go into acute care, you will be having these individuals who were doing fine the day before and then you come to their room for PT and they've passed away overnight or OT overnight and they've passed away. And it makes you think a lot about end-of-life care. And Atul Gawande wrote a book called Being Mortal and he talks about our medical system. It was a book that had a profound impact on me, especially being a person whose loved ones have had different experiences at the end of their life. He talks about how our medical system takes so much work of metrics of safety and length of stay in hospital, things that are very, many times business-driven or a removal of risk, a removal of dignified risk-taking really in a lot of different ways and how there's so much that we can do differently. One of the things that I think we have done right is having these beautiful people in hospice and palliative care who are really changing the way that a person is experiencing end-of-life care. As a geriatric physical therapist, when I'm interacting with individuals whose parents may be having a decline, if I'm talking to family or to individuals themselves, I am just a massive advocate for hospice and palliative care and what that may mean for them. And I think it is a wonderful way for us to be able to have discussions around end-of-life and not be afraid of those discussions. We are always trying to optimize a person's resiliency and keep them living healthier for longer. But there are going to be people that we interact with where that is just not the goal. And that is, we are trying to create comfort. We are trying to move limbs to prevent stiffness and pain in those limbs. we are interacting in a very different way. And by leaning into some of these conversations and being able to have some of these really candid discussions, I think it is a really beautiful thing. As a family member who has had a lot of different experiences with grandparents and thinking even about my own aging experience, and what I would want, I think having those discussions is super powerful. And we have a lot of therapeutic alliances. We have a great role and rapport with many of our patients and we can answer a lot of questions. So I hope that you found this helpful. It was more of a personal kind of anecdote, but I've been reflecting a lot on it. Kind of as we go into the holiday season, you think about loved ones a lot. And so I hope you've had any positive experiences with hospice or negative, I would love to know what your thoughts and feelings are. If you can put them in the chat, I would love that. If you were listening to the podcast, if you want to reach out, please do. Otherwise, I hope you all have a wonderful end of your week and we will talk to you all soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 28, 2023

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry discusses the top 5 reasons to begin to utilize more isometric exercises for the spine: they can be scaled based on any level of irritability, they produce a lot of natural pain-killing chemical, allow for the "stress-relaxation" phenomenon, allow for specific targeting of weaknesses, and are easy for patients to replicate outside of the clinic. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JORDAN BERRYWhat is up PT on ICE Daily Show? Good morning this is Jordan Berry lead faculty for cervical management and lumbar spine management courses. Today is clinical Tuesday and we are talking about isometrics for the spine specifically the lumbar spine but really any area we're talking about isometrics for the spine. Now before we dive into that, I just wanted to mention a couple of the courses that we've got coming up to end the year. We've got, let's see, we've got one more cervical management course that is going to be in Hendersonville, Tennessee, and that's this coming weekend, December 2 through 3. We also have two options for, well, one option left for lumbar management. We've got Charlotte, North Carolina this weekend as well, December 2nd through 3rd is sold out, And then we also have Helena Montana has just a few spots left, also December 2nd and 3rd. So we've got three courses for the spine division coming up this next weekend. And then the first chance to catch cervical management in 2024 is out in Wichita, Kansas. That is February 3rd through 4th. And then lastly, the first chance to catch lumbar management in the new year of 2024 is January 27th through 28th in Rome, Georgia. ISOMETRICS FOR THE SPINE All right. So let's dive into our topic today. We're talking isometrics for the spine and why I believe that this type of exercise for the spine is underutilized across the board for a bunch of different presentations and, a bunch of different levels of irritability. I want to chat just for a few minutes about how we can use this effectively in the clinic. So just to make sure we're all on the same page, when we're talking isometrics, we're talking about a hard, prolonged, sustained muscle contraction. with no movement of the joint. And when we think about using this type of exercise, we're pretty comfortable overall using it in the extremities. You know, we've got tons of research now showing the benefits of isometrics in patellar tendons and Achilles and glute med glute men and rotator cuff. So a lot of those main, you know, tendons and tendinopathies that we're seeing every day in the clinic, we're utilizing quite often some variation of an isometric. But in the spine, however, it's used significantly less. And, you know, there's not as much research geared towards specific tissues in the lumbar spine. with isometric loading, but we can take some of the concepts that we see in the tendinopathy research in the extremities and apply them to the lumbar spine. So I want to chat about our top five reasons why I believe that isometrics for the spine is a go-to exercise in the clinic. ISOMETRICS ARE APPROPRIATE FOR ANY LEVEL OF IRRITABILITY Okay, so number one, they're appropriate for basically any level of irritability. So obviously when someone comes in and they have really severe, really acute back pain and the irritability is really high, you're not gonna have as much freedom for exercise selection, right? You're gonna have to find things that are appropriate for that specific individual. And when someone's super flared up, it can oftentimes be really hard to find an exercise that not only what we're going for is relieving symptoms, but that doesn't flare that person up, And we try to get around this by using really low-level exercises like the cat-cow, like the bird dog, like the bodyweight glute bridge, which is not necessarily bad. I mean, oftentimes for acute low back pain, those can be really good movements to keep that person moving, to decrease fear during the first few days, but it's typically the movement of the spine if anything, that's gonna flare the person up. And so what I see is that we can potentially have not only more aggressive exercises early on, but more of a pain-reducing effect by utilizing isometrics. So again, imagine the person that comes in two or three days of really acute flared low back pain, where the actual movement of the spine, whether that be flexion, extension, side bend, whatever, is the thing that flares that person up. Well, we could use something like a Chinese plank. where the person is laid out in that reverse plank position across two benches, two boxes, two objects, and they're just holding a really hard, sustained contraction. They're contracting the glutes, they're contracting the hamstrings, they're contracting the lumbar spine. Or a back extension machine where you're locked in and you're just holding your back in a set position. Or the reverse hyper. We talked about the benefits of the reverse hyper a few weeks ago, but what about just getting in the position and holding in a straight line in that reverse hyper machine or even something like a GHD holding your body out in a straight position these are all examples of isometrics and what you'll find is that even individuals that have higher irritability they can tolerate a form of an isometric because it is the actual movement of the spine that flares their symptoms. We eliminate that problem entirely here. They get the benefits of the load, they get the benefits of the blood flow, but they don't get any of the potential negative side effects of taking that irritated tissue through the full range of motion. So number one is it's appropriate for any level of irritability. Now obviously if someone's lower irritability, we have a lot more options. We can do it way more aggressively, but usually, it's the higher irritability that can be more challenging to find an appropriate exercise for. PAIN-REDUCING EFFECTS OF ISOMETRIC EXERCISE This leads us to point number two, which is the pain-reducing effect of isometric exercises. And so again, we're going to take some of the research that we've seen in some of the extremity tendon loading research studies like the patellar tendinopathy research around the 5x45 is what so many people either use as a starting point or are basing some of their exercise prescription on. In the older study, they were utilizing five sets of a 45-second hold at somewhere around 70% MVIC. And what they saw in that study for the patellar tendon is that progressive sets decreased the pain significantly. By the end of those five sets, we saw a really significant pain reduction but we did not see that in the other forms of exercise. And so clinically, I'm taking that research and applying it to the spine. And so when someone starts that isometric loading, they might have some pain. You know, let's take the Chinese plank again, that reverse plank as an example. When someone's got significant lower back pain and they lay over those two objects, two benches, two boxes, whatever, that first set might cause a bit of pain. But you'll see that progressive set, set two, set three, set four, set five when they're holding that 30 to 45 to a minute prolonged sustained contraction, that you see this oftentimes this nice pain-reducing effect with each set after. And by the end of it, they have significantly reduced pain by actually challenging and loading their spine. And what a very empowering type of exercise for someone with pretty significant pain to realize that loading the spine and actually challenging it in a way can actually reduce the pain. And so if we see that change in the clinic, I'll just tell the person, this is your new painkiller. Okay, this is your new ibuprofen, this is your new Tylenol. And the cool thing about isometrics is they can often be done not only daily, but multiple times throughout the day. So if you're feeling like the pain is increasing or something is making the spine a bit more irritable that you're doing throughout the day, you can use this as a tool, hit a few sets of these isometrics, those long sustained contractions to be able to reduce the symptoms. So number two is the pain-reducing effect. STRESS-RELAXATION RESPONSE Number three is the stress relaxation response. So again, we see this in some of the extremity tendon research, like the patellar tendon, where we see this, what's called the stress relaxation response. And basically what that is, is the benefit that happens with long-duration isometrics, specifically once you hold a sustained isometric for at least 30 seconds, you see the stress relaxation where the fibers in the tendon have this progressive relaxation until a steady state is reached, essentially the load is being dispersed throughout the entire tissue, throughout the entire tendon. And so the way I apply this clinically to the spine is to take someone that has either excessive or limited motion at a specific level in the spine. Think about your older, middle-aged, stiff golfer who really lacks motion in the thoracolumbar junction, the upper lumbar spine. or take the opposite where you have that young mobile gymnast who has a ton of motion in the thoracolumbar junction, the upper lumbar spine, almost a hinge point right into extension. So those areas in the spine That hinge point, for example, are getting a ton of stress. Oftentimes, a lot of the movements throughout the day, they're using that specific area to move. When you're utilizing these isometrics, you get that stress relaxation response where the load is now being dispersed throughout the entirety of those tissues instead of just moving at these specific hinge points. And so it's cool to now have an exercise to be able to not just isolate the spot that they're oftentimes over-utilizing, but now we can load the entirety of those tissues and disperse some of the force. SPECIFIC TARGETING OF WEAK AREAS Number four targets weak areas. So think about your person that comes in with low back pain and you're screening out the deadlift as one of their aggravating factors. And they oftentimes have this spot in the deadlift that's the weak point. That's the spot of breakdown where when either the technique fails or the pain occurs, it's because they have a weakness at a specific point in the lift. Well, we can utilize isometrics as well to eliminate those specific weak points. So you could have someone, for example, do a rack pull, and you're putting the bar right at the spot that's their sticking spot. You can have them perform isometrics in those specific positions to build strength where the technique starts to break down. And you could hit that at any point in the deadlift, right? It could be six inches off of the ground, right, when they're initiating the pull. We could hold that position. or we could do a rack pull right after the bar crosses the knee and they're struggling to get to that full lockout position. You could use isometrics at any point during someone's movement to build capacity and strength in that specific position to eliminate that weakness. ISOMETRICS ARE EASY TO REPLICATE OUTSIDE OF THE CLINIC Last, they're easy to replicate. So I'm always looking for exercises in the clinic that are easy to do, that you don't have to be at a specific location to do, and take minimal equipment. And isometrics will typically check those boxes. So again, let's take the Chinese plank as an example, the reverse plank that we've been talking about. You can literally do that anywhere. All you have to have is two things you're laying your upper back around your shoulder blades and your heels on. In the gym that could be two boxes, that could be two benches, that could be a bench in a box, it could literally be two tables, it could be a chair in an ottoman, it could be literally anything that you could lay your body across and perform that isometric. Same thing with a reverse hyper. Yes, the actual reverse hypermachine is the gold standard, but you can mimic the isometric anywhere. I mean, you could lay on a table and have your hips hanging off and just raise your legs, keep your legs straight, and hold that position. So I love the isometrics because they don't take any equipment. You can do them anywhere and they're easy to progress because you don't necessarily have to have weight, at least in the start, you can just increase the time. So someone could go from 3 sets of a 15-second hold to 3 sets of a 30-second hold, to 5 sets of a 30-second hold, to 5 sets of a minute hold. You can progress this HEP very easily without having to have equipment or progressively increase the weight. So those are my top five reasons why I am using isometrics very consistently, very frequently throughout the clinic. So just to review, number one, they're appropriate for any level of irritability. So from the lowest of irritability to the most acute and irritable. you can oftentimes find some variation of an isometric that not only is going to load their system and not flare it but oftentimes will reduce their symptoms, which is number two, the pain-reducing effect from isometric. So multiple sets you will oftentimes see a more powerful pain-reducing effect from each set. Number three is the stress relaxation response. So we see that stress disperses throughout the entirety of the tissues when we hit that 30-second mark. So we can load parts of the spine, parts of those tissues that aren't typically getting loaded throughout the day. Okay, number four, it targets weak areas. So if there are sticking points in any movement, we can use that to eliminate the weakness. And lastly, they're easy to replicate. Very little equipment, very easy to progress. That's all I've got, team. I appreciate you hanging out, sticking around, listening to that. I would love to hear from anybody about how you're utilizing isometrics for the spine, either in the clinic, from a rehab standpoint, or more from a performance standpoint, either on yourself or a potential client. Other than that, have an awesome day in the clinic. Thanks for sticking around for Clinical Tuesday, and if you're coming to a lumbar or cervical spine management course, I will see you soon. Thanks, team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 27, 2023

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses subjective & objective measurements to use to track & manage urinary urgency, as well as tools and techniques to utilize in the clinic with patients who are actively symptomatic. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JESS GINGERICH Good morning. I'm sorry about that. I think I was having some difficulty with my internet. Welcome to the PT on ICE daily show. My name is Dr. Jessica Gingrich and I am on faculty here with the pelvic division at ICE. I hope everyone had an awesome Thanksgiving and was able to spend some time with some family and enjoy some downtime. Today, we are going to talk about some clinical pearls of urinary urgency. How can we get objective data to track this progress? And some powerful interventions to help get this under control and really get your patients their lives back. So this can be something that really holds people back from living their life, whether that's at the gym or really doing anything, going out and doing fun things with family and friends, going out shopping. It can really be controlling. So before we get started, we're gonna talk about some housekeeping items. Our next online cohort begins January 9th. So head over to the website to sign up and secure your spot. We have a few more live courses to round out the year. So if you are looking to dial in some of your internal assessments and then treat that higher-level athlete, Head over to ptonice.com to sign up. We also have some certifications rolling out in the new year, so keep a lookout for what you need in order to become ICE-certified for whatever division you're interested in. URINARY URGENCY So, no one talks about bladder habits that we should or really maybe even should not be paying attention to. No one tells us that some of our favorite things like coffee and carbonated beverages, alcohol, can be negatively impacting our brain's ability to tell us when we're full or even if it's irritating to the inner lining of our bladder. We learn to pee just in case or to ignore our first urge and replace it with something other than water. So again, caffeine, carbonated beverages, et cetera. We learn habits that allow our bladder to control us rather than us controlling our bladder. So urinary urgency is a strong and sometimes uncontrollable urge to urinate. This is something where it is smacking someone in the face. They have no heads-up. It is zero to 60. This may or may not be accompanied by urinary frequency. and or urinary urgency so urinary frequency is just going to be peeing a lot in your day we oftentimes get the question of is this what's the magic number really is it's if it's affecting them and if they feel like uh it is controlling them and then urinary incontinence is just um peeing in your pants being unable to control your bladder and there are different forms of that as well So we're going to talk about three objective measures which are interesting because they are subjective objective measures to track progress and then four tools to help give your clients their lives back. So it is important to know if they are experiencing any other symptoms with urinary urgency because as we start to train this we need to be mindful of those symptoms and also how comfortable they are potentially experiencing those symptoms. For example, if they are peeing in their pants and we are now training this, do they have things like a pad? So when they are trying to hold their bladder a little bit longer and they leak a little bit, are they gonna be okay with that? These other symptoms include leakage, feelings of heaviness, constipation, and urinary frequency. Other subjective data includes daily habits like whether are they drinking or how much are they drinking. Are they drinking enough? Are they drinking too much? Timing of what they drink and if they notice any foods or specific beverages that increase their urgency or if they pee just in case. So three objective data points and again like I said these are more subjective but they are so very meaningful so when you go to follow up if these are um changing that is going to be a really big deal. TRACKING STRENGTH OF URGENCY So When their first urge presents, how strong is it? Is it like, Oh my gosh, I cannot control this? It's kind of like, ah, it's more of like a medium or is it more light? Like, yes, it's there. Um, but I'm able, to push it out a bit. Are they able to hold it? So with that urge, are they also leaking or are they just having the urge and no leakage with that? And then do they notice anything that triggers this urge? So for example, some common things that I hear are gonna be seeing a toilet. So they walk into a bathroom, they see the toilet and it is like, whoa. Walking into your home, that kind of like key in the door trigger. Running water or even being in the shower. So a lot of people will pee in the shower and it becomes this thing where you are in the shower and it hits you really, really hard. So when you are confident that they are experiencing urinary urgency, it's time to teach them to remain calm when they have that large urge. Then you're going to teach them how to do a Kegel. Show them what it means to be up in the attic and then also relax on the first floor. When they are able to do a Kibel, we can teach them an urge suppression technique. I'm going to go over that here in a minute. Then once you have the urge suppression technique down, we can start to train them in the presence of triggers. I call this trigger training. So urge suppression looks like this. So there you're going to educate them to when this happens when the urge hits them to stop what they're doing, They can sit, they can stand, whatever it is they're going to stop what they're doing. They're going to take five deep breaths. Do five Kegels, then take five more deep breaths. Then you're going to talk to them about finding a way to distract themselves. This may be, getting back to work. This may be doing a load of laundry, um, playing with their kid, something to distract themselves. After a few times of practicing this, be sure to track when their first urge presents. Is it less or more than what they came in with? Are they able to control it? Are they able to continue what they're doing or does it stop them? And are they able to do it in the presence of those original triggers? So give this a go. Have your patients try this for a week or so. Check-in with them about those objective measures, and subjective objective measures. And we'll see you next Monday. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 24, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the Concept 2 rower, including each key component & how to perform basic maintenance on it. Alan also coaches rowing technique, including how to use the monitor to establish the ideal "drag factor" so that patients & athletes understand their optimal damper setting as well as strokes-per-minute (spm). Finally, Alan discusses how to improve rowing performance, including testing & retesting established benchmarks on the rower. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL Hey, what's up? Good morning. Welcome to the PT on ICE Daily Show. I hope your morning is off to a great start. We're here early on Fitness Athlete Friday out in the garage to talk about rowing. Fitness Athlete Friday, if you're not sure, we talk all things related to CrossFit, Olympic weightlifting, powerlifting, running, biking, swimming, today, rowing, everything related to the recreational athlete, that patient or client who is getting after it on a daily basis. Before we get started today, let's talk about a couple of quick announcements. Courses coming your way from the fitness athlete division, we have no more courses that you can take in 2023 unfortunately. All of our live courses between now and the end of the year are either done or sold out and all of our online courses are finished or have already started towards the end of the year. Your next chance to catch us is going to be in January on the road for our live seminar Your next chance to catch us online is going to be January 29th for Fitness Athlete Essential Foundations, or February 5th. We also call that course Level 1 Online Now. Your next chance for our Level 2 Online course, previously called Advanced Concepts, will be on February 5th. What are those courses? Those three courses compose the Certification and the Clinical Management of the Fitness Athlete, or known as CERT CMFA. Our level one online course is all of the basics. It is a lecture-heavy course. It is a course heavy on clinical application, not only to the fitness athlete but also taking the principles that we teach, how to properly dose and prescribe load, how to increase the intensity of your physical therapy sessions, taking concepts, not only applying them to the fitness athlete but all of your populations, everybody that could potentially come into your physical therapy clinic. Our level two online course, previously called Advanced Concepts, gets a lot deeper into the weeds with a fitness athlete. So if you're looking to learn about advanced Olympic weightlifting, advanced gymnastics, such as those found at CrossFit, muscle ups, handstand walking, pistol squats, all that sort of stuff, and then a super incredible thorough deep dive into programming, then the level two online course is for you. That is for the person who is looking to regularly work with fitness athletes in the community and be the provider of choice in their region. And then our live seminar is focused almost entirely on moving, about understanding what it means to perform a one rep max or a sub max test to predict a one rep max, what that feels like for you to do it so that you better know how to apply that to your patient population, but also how to program based off of that, how to work different therapeutic exercises together to facilitate both intensity as well as recovery during physical therapy. So those three courses compose the CERT CMFA. So p10ice.com, click on our courses to find the next live or online courses coming your way. And I will say this morning ahead of an announcement that you're going to see via email and social media that our prices will be going up per ticket on January 1st. So you heard it here first. Our ticket price will be going from $650 for the majority of our courses live and online to $695 on January 1st. If you were looking to grab one of our courses in 2024, I would do it now. Save yourself the 50 bucks. So that's what's coming your way from the fitness athlete division. ROWING 101 Today we're talking about rowing. We're here with the rower. I love this piece of equipment. I think it's a very versatile piece of equipment. I've had the chance to spend a lot of time on the rower when I first began CrossFit. Was not really able to run. I was so overweight. Spent a lot of time on the assault bike, and a lot of time on the rower. I've done a lot of endurance stuff on the rower, a lot of different programming on the rower. I've rowed two full marathons. So I want to share today the very basics of a rowing machine, what it is, how it works, and how to take care of it. If you're really thorough with your maintenance, even a couple of minutes per month, this is a machine that could last you your entire career without really needing to purchase any repairs or even possibly replace it. And then we're also going to get into the basics of rowing technique and how to get a little bit better at rowing. COMPONENTS OF A ROWING MACHINE So let's start from the top. and describe the rowing machine and all of the different parts, and also some tips and tricks for maintenance. So first things first, the question that most people have about the rower is how does it work? It works with sensors in the damper, which is a flywheel, with a computer monitor here, and then calculations are performed by the computer every pull to give you outputs of a pace of meters or calories, some sort of output of your work. So there are sensors in the chain and sensors in the flywheel. Starting from the front of the rower and working our way out, we have the damper. This houses the flywheel. This is where the resistance from the rower comes from. This handle on the side toggles between 1 and 10. What that does, is the higher the setting, as you approach 10, you're allowing more and more and more air to flow into the damper and create resistance against the flywheel as you row. So you are in charge of a combination of letting more or less air into the damper and pulling the chain you kind of control how the rower feels. A lighter damper is going to feel like a smooth row on really smooth water and a high damper is going to feel like in a really aggressive row maybe through really rough water or something like that. Far and away the majority of people are going to want to row somewhere with a damper setting between four and six. Now you do get more work awarded for a higher damper setting. That being said, it is much more challenging and fatiguing to pull. So the higher the damper goes, you need to be a stronger human being in general, especially with your pulling capacity, and you need to be a more experienced rower. You'll see folks trying to break world records, row at a 10. That's not the majority of human beings who are using a rower. Most folks sitting down on the rower, especially a longer effort, are going to be somewhere between a four and a six. We can calculate the exact damper setting that is best for each individual using a setting on a monitor called the drag factor, and we'll talk about that in a little bit. Taking care of the damper and the flywheel housing is really simple. Take a vacuum, suck the dust out, blow the dust out of there some way to clear the dust so that the flywheel does not get a bunch of gunk accumulated in there. Very easy to maintain the flywheel. Next is the chain. Pretty simple. When you are storing a rower, even if you're storing it horizontally, Always place the monitor down and release the chain. That takes tension off the chain. That's going to let your chain last a lot longer, and it's going to let the screws that hold your monitor upright last a lot longer as well. The chain is pretty simple. It's a handle attached to a metal chain that again pulls on the flywheel. So normally when we're using it in class, we have it out and racked in the handle, but when we're storing it, put it away and take the tension off that chain. Very easy to maintain the chain. Just keep it away as a solvent, not a lubricant. Find an actual lubricant, something like white lithium grease, to grease up that handle, keep it moving nice and smooth, and keep it from rusting as well, especially if your rower is stored somewhere that's not climate-controlled. A CrossFit gym that doesn't have air conditioning, in your garage or something, where it's gonna be subjected to humidity, keep that thing lubricated so it does not rust. Very easy to maintain otherwise. Our footplates, this is where our feet go, pretty simple. We're going to adjust the foot plane based on the length of our foot such that the strap, we want the strap somewhere about mid-foot. We don't want it jammed up in our ankle crease and we don't want it out on our toes either. We want to be able to plantarflex and dorsiflex our ankles and not be restricted by the straps. Taking care of the straps is pretty easy, they're just fabric, use some sort of fabric conditioner. Maybe in the winter, some fabric conditioner so they don't crack and fray. Once a month, again, a few minutes of maintenance and the machine is going to maintain it. And then just clean the footplates. Keep the footplates clean of junk, dog poop, whatever. Otherwise, very easy to maintain the straps and the footplates. The seat, the biggest thing here is that the cleaner you keep the track, the smoother the seat is going to go back and forth on the track. You can coat this with a little bit of grease as well, but the main thing is, especially if you've jumped on here and you've rowed for a longer distance, the pressure of your butt on the seat is going to kind of grind against the track a little bit. It's going to leave little black particles, and a little bit of residue. If you clean that up, it's going to keep the seat moving nice and smooth. And again, maybe once a month, add just a little touch of grease and work it into the metal of the track. Pretty easy to maintain the seat and track. And then the most important component of the rower, the component that is the most expensive when stuff goes wrong, is the monitor. So the monitor is where we keep track of our work. It is battery-powered. It works a lot like a car. It's got C batteries in the back. As you row, you are transferring a little bit of energy from the battery to the rower, kind of like an alternator in a car. And then just like a car, over time, the batteries will decay. These are C batteries. They will decay a lot faster than a car battery. And you may need to replace the batteries every few months. That's far and away going to be your largest expense with a rower. making sure if you're running low on batteries, that you change the batteries out. Now the rower will run without batteries, but it will only run as long as you are actively rowing. So if you stop rowing at any moment, the monitor will shut off. So not something you want to happen in the middle of a workout, especially a longer row. The biggest thing with maintaining the monitor, do not directly spray any sort of cleaning solvent on the monitor. Just like you would not spray it directly onto a laptop computer, You would maybe put it on a little rag and just kind of wipe it. Make sure that you're not putting a lot of chemicals inside of this. Again, it is a computer. So that's taking care of the monitor. So those are the key components of the rower. MECHANICS OF ROWING Now let's talk about the mechanics of rowing. So I'm going to turn sideways here so you can see my side profile. putting our feet in. We want to have tight straps, but we don't want them to be excessively tight on our feet. Again, we want to have the strap somewhere, maybe midway between our ankle crease and our toes. We want to be able to plantarflex and dorsiflex our toes. Tighten it enough so that if you lift your shoe up, you can easily transition on and off the rower. That's how tight the strap should be. Now the mechanics of rowing are very simple, however, they require knowing that rowing is a leg press primarily. Your legs are doing the majority of work on the rower, not your arms. A lot of folks get on here and they do really short strokes and they really do an arm-heavy stroke. and they find that their arms get fatigued, their grip gets fatigued, that should not happen on the rower, even if you jump on here and you commit to rowing three to four hours to get a marathon. You should not feel like your grip strength is a limiting factor on the rower because your legs are doing the majority of the work. So how we like to coach rowing is we like to say legs, lean, and pull. So as I have the handle, I'm thinking about a big leg press, almost like I'm going to deadlift. Legs, then I'm going to carry that momentum forward, lean, and then I pull with my arms. So full speed it looks like this. Legs, lean, pull. Legs, lean, pull. And that should allow a nice smooth rowing pattern. I'm going to let the damper stop for a second so you can hear me. If you hear a lot of slapping, When someone is rowing, that means that their handle is not moving smoothly back and forth. Something is probably wrong with their rowing form. For some reason, their rowing handle is going in an elliptical pattern instead of a straight line. Just like anything else in physics, Straight lines are astronomized. So we need to fix what's going on. We should be using legs, lean and pull. We should be moving as one continuous unit and that handle should be moving smoothly in and out of the rower. So that's the basics of rowing mechanics. A lot of folks can use a lot of simple peeling or more of a lean- back. We're not excessively extending the spine. However, we do want to use the momentum generated by our legs to transfer into a little bit more posterior chain activation to get a little bit more out of the handle. The longer the handle, the more credit you're going to get meters or calories on that rower. DRAG FACTOR Now let's talk about the drag factor. I'm going to turn this rower around again. Drag factor is a calculation of an imitation of what it would feel like if you were actually in a rowing boat on the water. How much drag would you perceive rowing through the water? An ideal drag factor is going to be 115 to 135. How is that calculated? It's going to be different for every person based on how hard they pull the rower and the setting of the damper. How we get to it, it's going to be in the menu on our rower. We're going to go to more options once the rower is turned on. We're going to go to utilities and it's the setting under display drag factor. So it's going to say row to display drag factor. Now what you're going to do, this is again, this is individual to every person. Every person, based on their specific damper setting, based on their rowing mechanics, based on how strong of a rower they are, it's going to be different, but we're shooting for 115 to 135. So if I get on the rower, I'm just going to start rowing, and it's going to tell me my drag factor. So right now, after a couple of pulls, it's telling me 99. I'm at a dip or a 4. I'm going to bump up to 5. I'm going to do a few more pulls. And now I'm at 121. So I'm between 115 and 135. What does that mean? A damper setting of 5 for me is going to get me right where I want. So the most important thing, especially if somebody's going to be using a rower a lot, for our CrossFitters who are probably going to be rowing every week, For maybe a patient who has a rower at home in the basement, working on drag factor can really help them know when they sit down, no more mystery about where to put the damper setting. You're going to be able to say, you know what? For you, damper four, damper five, damper six. Maybe for a very tall, very strong, very experienced rower, maybe they are at damper seven or damper eight. That's going to be rare, but also not impossible. So drag factor is really going to help folks know when I get on the rower, where should I put that damper based on my mechanics, based on my experience and strength with rowing. MAKING PROGRESS ON THE ROWER The final point I want to talk about aside from the components, maintaining it, mechanics, and drag factor is making progress on the rower. A lot of folks want to get better at the rower. The unfortunate truth is to get better at the rower, much like anything else in life, you should do more rowing. So, rowing is a great accessory thing to add in, especially for our CrossFitters. It's unloaded. It's not going to be as tough on the body as maybe adding in an extra session of Olympic weightlifting or running per week. Very easy to add in an extra maybe 30 minutes of rowing a week to try to get better at rowing. A lot like anything else with monostructural work, with cardio, with running, rowing, biking, The answer to the question how do I get better is where are you weak at on the rower? Are you weak under fatigue in the middle of a CrossFit workout? Are you weak at very short sprint efforts about getting on a rower and rowing 500 meters? Are you weak as the fatigue fall-off factor sets in and you row maybe a 2k or a 5k row as you get into longer endurance rowing? Where is your weakness? If folks say, I don't know, that's a great time to establish some benchmarks. A lot like wanting to know somebody's 400-meter run time, Their mile run time, their 5k run time, we can do the same thing on the rower. We have established benchmarks on the rower. A lot of them are pre-programmed in the computer. What is your 500-meter row time? What is your 2k row time? Your 2k row is going to be equivalent to a mile run. What is your 5k row time? that's going to be fairly equivalent to a 5k run. A lot of folks are going to be faster on the rower than running, but that's about equivalent as well. So establishing some benchmarks, looking and seeing how far speed falls off going from 500 to 2k, from 2k to 5k is going to let you help that patient or athlete better program that accessory rowing to get specifically better at the energy system they need to work at. Getting better at rowing too is recognizing where my paces at. Pacing on the rower is per 500 meters. That's the pace that you usually see pop up on the screen, two minutes per 500, two minutes and 20 seconds per 500, and so on and so forth, and understanding each person needs to learn what is a fast, maybe a PR pace for my 500-meter row pace. If there's a workout that has maybe three rounds of deadlifts, pull-ups, and a 750-meter row, what pace should I look to establish if I want to hit that fast? What pace should I establish if I want to hit a sustainable pace that I can hold for maybe a longer effort, like a 750, and then what does a recovery pace look like? If we have a longer workout that maybe has some 1000-meter rows, we had a workout this week that was 50 burpees, 2000 meter row, a one-mile run, and a much longer endurance-focused workout, what should my 500-meter pace look like on the rower for a longer effort, a 2000 meter effort, and understanding when you get on the rower you settle in what pace am I hoping to hold here based on the outcome that I want. Do I want to get on and off this rower as fast as possible, treat it like a sprint effort, Do I want to get on here and sustain a longer effort, or is this maybe a very long effort, a 2,000 meter row in the middle of a workout, and I'm thinking about primarily using this as recovery until I recover a little bit, and then I can begin to pick up the pace again. So understanding where your benchmarks are at, where your paces are at, and what the goal of the goal we're at. where it is in the workout, it's very important to get on here and not go too slow and give up the workout, but also not jump on here and just burn out and be that person on here that looks totally miserable because you started off way too fast and now you've wrecked yourself and you still have a long way to go. So the rower, the damper, the chain, the seat, the foot plates, the monitor, what they do, how to take care of them. Rowing mechanics, it's a leg press, not an arm pull. Legs, lean, and then pull. Drag factor, different for everybody. Very important to understand to get on there and play with drag factors so that you understand for each person, and they understand for themselves, why and how I'm choosing the damper setting that I am, and then how to make progress. Test benchmarks, train rowing, get more comfortable being on the rower, especially for long distances, and then reassess those benchmarks. So I hope this was helpful. Join us in a couple weeks, we're going to go over some more advanced rowing, how to turn the rowing machine into a skier, and then how to use the rower for adaptive purposes for adaptive athletes, or just for folks who come in the clinic, who maybe can't row because they're only able to use one leg or one arm or both, how to use a bunch of different equipment that you probably already have around the house or the clinic to get those people rowing. So hope you have a fantastic Friday. Thanks for joining us. We'll see you next time. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 23, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the "golden triangle" or the foundation of personal & professional success where time, money, and autonomy overlap. Alan shares research supporting a direct relationship between money earned & happiness, as well as the importance of respecting time & autonomy in the workforce. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALLTeam, good morning. Welcome to the PT on ICE Daily Show. Happy Thanksgiving. We hope your Thursday morning is off to a fantastic start. We're here on Thursday, Leadership Thursday, talking all things small business management, practice ownership, that sort of thing. Thursday, Thanksgiving Thursday, still means it is Gut Check Thursday. This week's Gut Check Thursday is a little bit of a tradition around here at ICE. We are gonna do a hero workout called Burp. This is a very long bodyweight workout. Starts with 50 burpees, a 400-meter run, 100 pushups, a 400-meter run, 150 walking lunges, a 400-meter run, 200 air squats, a 400-meter run, and then now we're going to come back down that pyramid. 150 walking lunges, 400-meter run, 100 pushups, 400-meter run, and then finally finishing with 50 burpees. So, very long workout. This is gonna take most human beings about an hour to finish. Obviously, you can tell a lot of redundancy in there with the running, the lunges, the air squats, and then the burpees and the pushups. So, if you do not have an hour today to work out, scale this. Cut all the gymnastics reps in half. Maybe cut the runs down. If you know you're a better biker than a runner or something like that, sub out a rower or a bike for the run. Obviously, the more you reduce the volume, the less time it's going to take. This workout is not for the faint of heart. This is going to make your upper body and lower body sore between all the lunges, squats, pushups, and burpees. But it is challenging. We love how simple it is. You don't really need to warm up or really have any sort of particular skill or range of motion to do this workout. So that's why we love Burp. Courses coming your way, I don't want to bother you with those today. Check out p10ice.com, click the Our Courses tab, and see what's coming your way. We do have a couple more weekends of live courses starting back up again next weekend before we take our final holiday break over Christmas and New Year's. So check out ptonice.com and click on our courses if you're interested in jumping into a live course before the end of the year. THE GOLDEN TRIANGLE Today I want to talk about a concept that I call the golden triangle. Talking about when folks reach out and they describe maybe an employment situation that they are not happy with. This is kind of how I evaluate what I think of the three pillars to success when you are not only working for someone else but just working in general. Even if you are self-employed, even if you do run your own business, carefully managing the three sides of this triangle, I believe is really important for your own personal and professional success, but also for those of you leading others in charge of others, I think even more important to fundamentally understand these concepts. So those three concepts are money, time, and autonomy, and we're gonna break each of those down here in a little bit. I want to start here though first, and this may be a weird place to start, but I promise we'll bring it back around again. I want to talk about what is the role of the human brain. A lot of us may think the human brain is for high-level computations and calculating the physics of a black hole, but that's not how most people's brains work. That's how very few amount of people's brains work, but for most of us, Our brain is a survival mechanism. It is a comparative analysis engine. And it's really good at making comparisons. Your brain is making one billion billion calculations per second. That's a one with 18 zeros. That is a million times faster than today's standard cell phone laptop or desktop computer. We call that an exaflop. It is the most powerful processor on the planet. It is always gathering data, both internally and externally, and making comparisons. Am I hot? Am I cold? Am I hungry? Am I thirsty? Am I not making enough money? Is my coworker making more money than me? Is my boss doing better than me because I noticed that he just bought a speedboat? Those sorts of things. Yes, very basic survival mechanisms, but also higher-level stuff. And that kind of brings up the next point of Maslow's hierarchy of needs. If our brain is this comparative analysis engine, what is it really focusing on? Well, psychologists would say it's focusing on comparing ourselves on this pyramid, this hierarchy of needs, where at the base we have our physiological needs. Am I hungry? Am I thirsty? Am I tired? The next level up is safety and security. Do I have a safe place to rest and sleep at night? Do I have a place maybe that in my mind when I compare to others I call my home? The next level up, the third level, love and belonging. Do I have friends? Do I have a family? Am I raising children? Not only do I have them, but do I feel like I'm thriving in those relationships? And now as we get to the top of that pyramid and we approach that peak, the fourth level is esteem and the last level is actual actualization, self-actualization. So do I feel like I am doing something meaningful, and do I feel like I'm doing something meaningful very well basically You know what is my life's work, and how am I doing at that? And now the brain is always comparing both to environmental factors and to other human beings where we sit on that hierarchy. Trying to chase the top tiers before addressing the bottom, I think is the cause of a lot of dissatisfaction in our daily lives. So shelving that for a little bit, the brain is a comparative analysis engine and hierarchy of needs. Let's get back and talk about the golden triangle. MONEY The first I want to address is money. Money is uncomfortable for some people to talk about. It's often a pain point for almost every single one of us. I think really understanding that about three-fourths of people live paycheck to paycheck and about half of all people now work two or more jobs. really helps us understand that we're not alone in being concerned about money. Most people are concerned about money, but also that it's okay to be concerned about money, right? That kind of sits at the base of that pyramid of those physiological needs, that safety and security. We do need money in modern society to do things like buy food and pay the rent on our apartment or the mortgage on our house. There's often an adage of don't focus too much on money because money can't buy everything or money can't buy happiness. And I would refute that. I would say that that is categorically untrue. We have some really interesting research from the 90s and 2000s that found money and happiness do correlate. There seems to be a plateau, at least in the earlier research, of around $100,000. Research from the 90s and early 2000s found that if you make about $100,000 a year, The more money you make. beyond that doesn't really seem to increase your happiness. Now, the thing to recognize is that if you're not making that, there is room for happiness between that and $100,000. New research, specifically from this year, an article from Killingsworth, I love that name, Dr. Killingsworth and colleagues, this year, March 2023, from the Journal of Psychological and Cognitive Sciences, titled, Income and Emotional Wellbeing, a Conflict Resolved. Strong title, I like it, let's talk about it. These folks repeated the studies, some of it their own research from the 90s and 2000s, and they're looking specifically at the relationship between income level and happiness. What they found this time is interesting that folks tend to fall into categorization buckets. Hey, we know all about that in physical therapy, right? What are these buckets? Well, human beings tend to fall into three different buckets. The first bucket is what they labeled as the least happy group. These were folks who kind of demonstrated the same results as the initial studies, where these folks seem to have a happiness plateau at about $100,000. What does that tell us? That tells us this group of people is probably motivated enough by money that once those initial levels of the pyramid are met, they're able to feed themselves every day. They're no longer worried about their next meal or making the rent or paying their bills. Beyond that, they don't seem to get any more happiness from an increased amount of income, right? So this could be somebody who, I imagine these people is the folks from the documentaries that have to you know free climb El Capitan or summon a mountain or something of that's really what drives their brain and kind of their intrinsic motivation and having enough money to do that stuff gets them to the level of happiness where they can pursue other things. The next group of people they labeled, the researchers labeled the medium happy group. These folks had a linear increase even beyond $100,000 a year with happiness and income. And then the highest happiness group had an exponential increase with income beyond $100,000. They could not seem to get enough money. Money on the opposite side of the least happy group, these folks seemed to be almost entirely intrinsically motivated by accumulating wealth, right? So these are our oil barons and our real estate moguls, our Warren Buffets maybe, folks who have a high value on money and its worth in their life. And then most of us are probably in that medium happy group. As we continue to make more money, we're able to buy nicer things, but it doesn't necessarily define us, but we do like to have that money. All that being said, there is a direct relationship between money and happiness. It's really important we recognize that paying people well, of feeling like the work that you do is rewarded with the amount of money that you place value on, is recognized both yourself personally, but also when you're leading others. What I found over my career Keep in mind, I've been working full time since I was 12 years old for about 25 years, is that the folks who tell you there isn't money for a raise, there isn't money for bonuses, or even that they maybe need to take money away from you, are telling you that because they don't want to give you more of the company's money, right? There is always more money, especially in the context of physical therapy, for an increase in your wages. We all have what we would refer to as a revenue-neutral position, which means the revenue you generate from the work you do is creating more wealth than what you are taking back from the company. I can't imagine a situation where a physical therapist would be getting paid more than what the clinic is collecting in revenue for those patients being seen. So it's really tough to talk about. I recognize that it can be awkward. It can be weird. It can be upsetting to personal and professional relationships, but I promise you when you draw a firmer line than the sand around what you're paid, when your comparative analysis engine is telling you, you're not being rewarded for the time you're putting in. That can be a pain point for dissatisfaction and the research would support that you are not wrong in believing that the money you're currently being paid and the money you think you would like to be paid is creating a happiness gap. It literally is, right? Killing's worth 2023. Messing with people's money on the leadership side is a recipe for disaster. It is never okay to cut someone's pay, to inflict some sort of monetary penalty aside from something catastrophic, right? Dave accidentally drove his car into the clinic and destroyed the clinic. Okay, Dave, you got to pay for that, right, man? But aside from really rare, unbelievable, catastrophic stuff like that. There's no reason to inflict a monetary penalty on someone or to take their benefits away. An example I have of this is my time in the army where if you messed up, if you were late to duty, If you didn't shave, you could be punished monetarily for that, right? It was called in Article 15, it is non-judicial punishment. That means usually you have to work extra duty and it usually means that they cut your pay that month. And that really puts a strain on people, especially in the context of the military where they're not already making a lot of money. And I fondly remember watching people have half their paycheck, all their paycheck taken away, and just instantly how it ruined that person, it ruined their career trajectory. So without a doubt, as a leader, that's something you do not want to mess with. We saw that mess with a lot during COVID-19. We saw pay being cut, and we saw benefits being removed, and then not returned. And it's no surprise that now, several years removed, we have the era of time that we now live in, what we call the Great Resignation, where folks are more than happy to say, give me a raise or I'm leaving, and they will literally leave, right? And for us as practice managers and owners, that's devastating. Attrition is one of the highest costs you can encounter, and you need to avoid it at all costs. When someone leaves, it's going to cost you $3,500 for every $10,000 that person makes. That's money you won't get back on maybe trading you did with them, time you spent with them, money and time you're now going to need to spend trading somebody else. And then of course lost revenue because that person is no longer working for you generating revenue. So keep that in mind when you're thinking, I'm going to withhold raises, I'm going to withhold bonuses, I'm going to otherwise inflict some sort of monetary penalty. It never goes well. And again, it's okay if money is a pain point for you personally, and if it's a pain point for the people underneath you that you're leading. Pay should always increase over time to match inflation at the minimum. I have said this a thousand times and I will say it a thousand times more. Every year you do not get a raise, you are taking a pay cut because everything in your life now costs more money to buy. So keep that in mind. I will beat that dead horse until we're all on the same page about that. And finally, I think this is something no one wants to hear. Both those of you who are maybe unsatisfied with your position because of the money and those of us leading others it is okay for people to leave a position if it's not working out for them financially, right? You cannot feed your kids with the promises of potential future money. Your landlord will not accept the ambitious dreams of your clinic owner and payment for your mortgage. and you cannot get any sort of retirement return on zero dollars invested. So it is okay to move on if this is a pain point that doesn't seem to be addressed. So money is the first part of our golden triangle. TIME The second part is time. Time is a finite resource that we're all running out of. I think every day now the moment I turn 37, I am statistically halfway dead. And statistically, every day beyond that point is that much time left I have on Earth. Time is interesting. Some folks don't feel the value at all. Some folks tend to place a great emphasis on it, maybe even more so than anything else. Humans are the only creatures that can perceive time, so I think it's unique that we're able to perceive the flow of time, and we're kind of aware of moments where we have maybe too much time that we might call boredom, and moments where we feel pressed for time. A lot of us, the majority of the human race, will spend most of our lives using our time to generate money and then trying to use some of that money to buy some of our time back. And that's the way it is, even if it is a little bit sad. But I think recognizing that that's how most of us are going to move through life is important. For some people, time will always be more valuable than money. It does not matter how much you offer someone, how much you may offer them for overtime, whatever, their time doing other stuff is important. There are those people, the clock strikes five, they're out of there and we need to understand and respect that that is one of their values and work around that in whatever way we can. Very few people though, even folks who maybe don't seem to value their time a lot, very few people do not like to have their time wasted for no reason. And this happens a lot in life. It happens a lot in day-to-day life. It happens a lot in the workplace. Think of every situation where you've shown up early or stayed late for a meeting or some other event that was canceled delayed or rescheduled even without notifying the people currently sitting and waiting there for that to happen. Every time someone schedules a meeting with me and doesn't show up, that's a strike in my mind against that person. Very few of us have the tolerance to have our time completely wasted in that manner. but it happens a lot and it happens a lot in the context of the physical therapy workforce. Think about how many times you've come to work and the first two patients on your schedule have canceled or rescheduled, right? And you're thinking, what the heck? Why didn't anybody text me or call me, right? I could have gone to the bank or I could have sat and had breakfast with my kids at home or any, literally anything else would have been a more valuable use of your time. We also, are often asked to work in situations where we know it's not a good use of our time, right? I think of every time I have been asked in the past to work on Christmas Eve, right? Especially in the context of patient care. I know as soon as I'm asked to work on Christmas Eve that no one is going to come to their appointment on Christmas Eve. I remember it's burned in my brain, I spent one Christmas Eve with a completely wiped-out schedule, laying on a treatment table, and I watched all six Rocky movies in a row, right? I watched like eight hours of Rocky movies and did not see a single patient. What a monstrous waste of my time, and the clinic's money, just a bad situation for everybody. The Japanese have a term for that. It's called "Isogaghii" is the act of pretending to be busy. Even when you have nothing to do, we hate that. That is not something that we should encourage. If you don't currently have something to do, don't be here. I live my life by that model. When I catch people sitting in the clinic and they're just kind of pushing buttons on a computer, I always ask, what are you doing here? Oh, you know, I'm, you know, final, I'm like, okay, go, go home, right? Go away. No "Isogashii". We do not need you to sit at your computer doing nothing until 9 pm just to appear busy. So that's money. That's time. AUTONOMY The last part of the triangle is autonomy and independence. It's important to know that we developed this very early, and we all have a strong sense of it, even if we don't voice that it's one of our values, right? I think of my son, he's about to be 11 months old. A couple of months ago, we were hand-feeding him, already he has that sense of autonomy. Now when I go to feed him, he slaps the food out of my hand, and then he grabs it and feeds himself, right? He's already expressing, hey, I'm not a baby. I don't need you to hand-feed me. I can feed myself, right? And that's already present in very, very small children, right? Those of you with toddlers, you know, that independent streak starts and doesn't stop. Those of you, especially with teenagers, you know, it gets more aggressive. And then obviously all of us as adults, have a very strong sense of autonomy. Again, even if we don't express it explicitly as one of our values. Just like time, autonomy is violated on a very regular basis in very unfortunate manners. This happens a lot in the workplace. A lot of you work for employers who control how you're allowed to dress. how you're allowed to speak and talk with your patients, how and when you're allowed to perform very basic physiological functions about when you can eat food. Some of you work for employers that don't let you eat or drink at work. You have to leave the building and eat outside by the dumpster like an animal because you're not allowed to eat in the building because the owner or the manager doesn't like the possibility of crumbs. That is a huge autonomy violation. We also see this in our workflow as well. A lot of us are performing unnecessary documentation so that someone can check our work, right? So that someone can audit our notes just for the purposes of having a checklist where they audit our notes, right? It serves no actual purpose as it relates to helping the patient by documenting what we did with the patient. And for those of us who take insurance, create a claim that goes to the insurance company. There is no point where it's required that all of these extra processes that we add to our workday are mandated. Nonetheless, many of us work for an employer who has all of this extra work, all of these extra checks on our autonomy just to have extra checks. That's very insulting and it creates a lot of redundant work that also simultaneously affects our time. So we are getting a one-two punch of time and autonomy when we're doing a bunch of busy work that doesn't respect our time. It doesn't respect that we're independent clinicians who have often been working a while with a bunch of advanced education. The final thing I'll say here is that what you'll unfortunately find is that leaders who micromanage more, and who place more limitations on autonomy are often the same leaders who have minimal or no restrictions on their own autonomy, right? The person who is a stickler about a dress code is often the person in the office in shorts and a t-shirt and sandals working on the computer, right? So be mindful of those things. As you are maybe seeking out a new position or evaluating your current position, there's no double standard on autonomy. THE GOLDEN TRIANGLE AS A ROBUST BASE FOR SATISFACTION So the golden triangle, the interdependence between these three things builds a very robust base personally and professionally. However, I think it's very important to note that if we take our comparative analysis engine in our brain and compare it to Maslow's hierarchy of needs, What some of us are doing is trying to aim for the very top of the pyramid, aiming for esteem, aiming for self-actualization, and trying to become the best physical therapist that can be when those other bases of the pyramid are not being met, right? We don't have our basic needs met because we don't have enough money coming in. We don't have control over our time. We don't have control over our autonomy. We talked last week about the pitfalls of social media, trying to make you think that the reason that you're unhappy is you're not buying enough stuff or consuming enough content. With that stuff in that content, mainly being focused on trying to push you to the top of the hierarchy of the needs when really what you need to do is address the base, meet those basic physiological needs, safety, security, love, Make sure that time, money, autonomy are on board before you consider purchasing that $10,000 self-help retreat or the mentorship program or the mindset program. I think a lot of our perceptions of concepts like burnout or imposter syndrome are really just the result of our comparative analysis engine and our skull recognizing differences and asymmetries between what we're doing every day and the results we're either achieving or not achieving compared to other people. And when we look and step back and look at this golden triangle, we see, okay, I am not making the money I think I should, especially compared to my peers. My time is not being respected. I'm working more than I think I should to make the money I'm making. And oh, by the way, I'm being treated Like an infant at work by having a dress code and having all of these extra redundant Processes at work that I need to do that consume more of my time and we are always again It is part of our survival. It's hardwired in our brains to make these comparisons. We're always consciously aware of the time and the work and the money and the autonomy compared especially to other people and kind of comparing again back to that hierarchy of needs. And that if we allow one or two or all sides of this triangle to be violated, that's where we find a lot of frustration, and trying to jump your way to the top is not going to get you there. You need to address that base. When folks reached out and they described their appointment situation, I used to be a lot more polite with my thoughts when people emailed us and said, what do you think? I'm seeing 20 patients a day. I'm making $62,000 a year. And every month that I see more than 250 patients, I get a $500 productivity bonus. What do you think? I used to be a lot more polite when answering those emails. I am not polite anymore, right? A lot of the dissatisfaction, a lot of the burnout, I hate that term, a lot of the burnout, though, can probably be addressed if we're a little bit more firm and reinforcing and adhering to our values of Again, money, time, autonomy, are all of those things in place? Okay, now we can begin to look more up that hierarchy, begin to pursue maybe specialization, become the best physical therapist we can be, or even if that's not something you value, the best whatever you see yourself becoming. But again, we can't get there if we don't address the base. Doing anything else is just addressing the symptoms. It's not addressing the root cause, right? We need to address the root cause first. We can't just keep treating the symptoms by buying stuff and taking vacations and that sort of thing to try to solve the unhappiness that we're perceiving. We need to know that it's all related and that we need to address it first before we can begin to kind of reach beyond the top of that pyramid. So I hope this was helpful. I would love to hear any feedback or comments you all have. I hope you have a wonderful Thanksgiving and we'll see you all tomorrow. We're gonna talk about rowing. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 22, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses how to balance infusing patient care with hope with the reality of their recovery. Take a listen or check out the full transcript with show notes on our blog (www.ptonice.com/blog) or on your favorite podcast app. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JEFF MUSGRAVE Welcome to the PT on ICE Daily Show, my name is Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here on a Geri Wednesday. Geri on ICE is what we like to call Wednesdays, all things older adults. So today's topic is going to be all about a question I got this weekend while on a live course. So I had a student raise her hand, the reality of clinical practice here, and ask, how do we balance providing hope for our patients while still setting realistic expectations? How do we balance providing hope while setting realistic expectations? This is a reality of clinical practice for older adults when treating older adults. Lots of factors, and lots of things to dig in there. Before we get into that, if you're looking to see us on the road in 2023, your last opportunity is on December 2nd. That will be in Candler, North Carolina. Our other December offering already sold out. So that's your last shot in 2023 to see us on the road. Otherwise, we're coming out strong in January, team. We're going to be all over the map. We're going to be in Florida, California, Missouri, Ohio, and South Carolina in 2024. So we'll be coming in strong if you're hoping to see us live on the road. L1, previously called Essential Foundations, the next cohort is going to be on January 10th. then advanced concepts will be on January 11th. BALANCING PROVIDING HOPE WITH SETTING REALISTIC EXPECTATIONS Okay, so the question at hand is, how do we balance providing hope while still setting realistic expectations? important that we get this right. This is especially crucial for older adults. I want you to think about their history, and what their interactions are typically like in the medical system. A lot of people don't really give them the time of day. Their visits are rushed. People are throwing $10 words like idiopathic non-diabetic peripheral neuropathy that's what's wrong with you all right get out of my get out of my office kind of thing but we have a lot more time with our patients in comparison to a lot of other providers in the medical system and want to really leverage that time well. So as I've been chewing on this question, I gave the short answer during the live course, but I'm doing this podcast to give you the long answer for those that are interested. So it's like trying to find the narrow path, walking down a tightrope. We think about this journey with our patients from beginning to end. And the two factors that we're trying to balance here, if you can kind of imagine someone walking across a tightrope, they usually have this big pole that they use to balance. HOPE VS. HARD FACTS I want you to imagine on one end of this pole, we've got hope and this positive outlook, Because we know as physical therapists treating older adults, there's a lot we can do. A lot of people leave things like fitness and strength training, and power training. They have not incorporated any of those things. They need us. We can give them a lot of value. We can really do a lot of things to change their life. So we've got hope on this one end. And then we've got the hard facts. the realities of what's coming if they don't change, the reality of what is going to happen to them if they continue down this path. And we're trying to balance these two factors as we're walking with our patients down this path to recovery. So, long story short, the balancing act we're trying to do is we want to give a crap, make it clear that we care, we want to help, and we can help, without going so far that it sounds like we're full of crap. It's like, yeah, that's not possible, and exaggerate too much. But we want to be very clear that words matter. And if we go too far, too far on the hard facts, we can really shoot ourselves in the foot when it comes to recovery for older adults. You know, just a quick overview of some of the research. So Rebecca Levy, a researcher out of Yale, has done a lot of really interesting studies where she's looked at the power of positive beliefs in our belief systems, what we believe about aging, whether that's negative or positive, and how that may change our health outcomes. HOPE AS A POSITIVE TREATMENT FACTOR So she has done multiple studies looking at things like recovery from injury, like people that are hospitalized, if they are able to recover fully or not and she's found that people that are 50% more likely to recover to prior level function if they have a positive outlook on aging, talking about older adults here specifically. She did another study where she looked at people who had a predisposition for dementia if they had a positive outlook, even though they should have had an exponential increase in risk that should have led to them going on to have dementia if instead, they had a positive outlook on aging, they did not go on to get dementia as much as the rest of the cohort that all had that same predisposition. So there was an isolating factor of hope. And we think about when we have hope, we're gonna make different choices. If we believe we're in control and we are the ones charting our course in life versus life is happening to us. So hope is a very powerful tool. To summarize this, there's a great quote from Dr. Justin Dunaway out of our persistent pain course. And he says beliefs and expectations are the foundations on which outcomes are built. beliefs and expectations are the foundations on which outcomes are built. I love that. There was another really interesting study that came out of Harvard in 2007 and what they did, was they had several females, it was I believe it was about 45, don't quote me on that. It was somewhere around 45 to 50 females who had a very active job. They all worked in a hotel system where they were the people who were cleaning and turning over rooms. So they're moving all day. and we would say that they were physically active, they weren't getting fitness in, they weren't hitting ACSM guidelines, they weren't hitting Surgeon General's guidelines for fitness and lifting heavy things and hitting high intensity like we would recommend to truly be healthy. So they split this group to figure out if half of them were told that they were meeting the Surgeon General's guidelines and half were told they weren't, would there be any changes to their actual health measures? So they measured things like the hip-to-waist ratio. They also measured their BMI, their blood pressure, their body fat, and their overall weight. So they told one group, hey, the work you're doing, it hits the Surgeon General's guidelines. You're doing everything you need to do to be healthy. You don't need to exercise. And they told the other half, you're not meeting the Surgeon General's guidelines. You really need to exercise. This is not enough for you to be healthy. And what they did is they met back in four weeks and repeated all their health measures. They found that the placebo group had physical changes. They improved their weight, they reduced their body fat, their BMI was better, their blood pressure was better, and their hip-to-waist ratio was better. The power of words was tremendous for this group. None of them changed their behaviors. They were just told by a trusted source they're doing what they need to be doing and you should expect good things. Really incredible stuff. So we want to keep in mind providing hope is very important, especially to our older adults. They don't typically get a message of hope and we need to provide that because we have valuable tools. There are mountains of evidence showing that resistance training can help people get stronger in the early and late stages of sarcopenia. It's very important to provide someone with some hope. We don't want to take that too far and be completely full of crap, right? We don't want to tell our patients, oh yeah, you know, you can do these adductor ball squeezes, these leg kicks, and you're gonna be fine. You're gonna be prepared and protected for what life has coming at you. We know that is not true, and we're not suggesting that you grossly exaggerate, but we do need to give a healthy dose of hope. CONTENDING WITH REALITY So on the other end of the spectrum, we still have to contend with reality. What is a reality for our patients? What's the reality of the recovery going to look like? How much time should they expect the recovery process to take? And then we need to take a really honest look at what part of the journey we're going to be able to take them through. If you are an ICU clinician, if you're in an acute care setting, you may only see someone once or twice. You're going to give them hope and hopefully help them chart a path. Like, hey, this is going to go from here to home health. You need to find a good outpatient clinician. I know this great team. As soon as you're safe to get there, you need to get there. They will get you hooked up with a gym. And if you really want to change your life and stop coming back to the hospital, you can do that. You have every ability to do that. People have done it before. I've seen them change their lives. If you want to be another person to do that, you're going to have to commit for the next year. But then the decades to come are going to be way different than how your life has been the last month. Those adventures, those fun things you are planning to do, those can happen. That can be a reality for you. And that 45-second conversation could change someone's life. It may not always be, okay? We're not going to wear the rose-colored glasses, but your job is to plant those seeds. You still have to plant those seeds and let them know. Throw them a rope. They're still going to have to climb out of that hole, okay? So, we've covered the hope piece. We've talked a little bit about that scaffolding, but you need to create some scaffolding with reality in mind, okay? We know that there are tissue healing timeframes. that are on a range. We need to scaffold this up, that we need to know that we can get better but it's going to take X number of months and then inject yourself as to how far you're going to be able to take that journey. And day one, plant the seeds for what happens after. What happens after PT, after acute care, subacute, or if you're an outpatient clinician? What are their fitness options? You need to have these people on speed dial so you can bridge the gap, okay? And let them know. Just give them the whole story. Our older adults can handle it. They're used to getting tons of bad news. This is probably, even with a healthy dose of reality, some of the best news they're going to get because it's clear you care. There's hope. There's a path for them. But they need to know the realities and be prepared. What's coming ahead? So use science. Use the realities of tissue healing time frames to help them know, hey, this is how long this journey is going to take. Let's start thinking about these transitions moving along. Team, if we give too much reality and not enough hope, we're going to crush them. We're going to be kicking them while they're down. They're already maybe at a really pivotal point in their life. We give them no hope in all reality. They're going to quit. before it's time to get started before the real work begins. So based on the research that I just covered, based on the realities of being a human being, I would give a healthy dose of hope, and get them started, but we gotta balance that out just like you're walking that tightrope. You go too far either way, you're gonna fall off the path. We're gonna lose therapeutic alliance with our patients. They need enough hope to be ready that they're gonna have to struggle, they're gonna have to work hard, and it's gonna take a while. But there is hope they can truly change, that you've got the skills that you can provide, you know the people to make the transitions, and I think that is what's gonna lead to the most success for our patients, is balancing out science realities with tissue healing timeframes, knowing the person in front of you, and giving them a scale based on how much buy-in they're gonna give you. Are they willing to come into the clinic twice a week? Do they have a plan that supports that? Do they have the financial resources to support that? Or do we need a completely different plan where they're now motivated to do it at home and we need to spread this out and stay connected because we don't have good resources in the area? Alright team, I wish you the best of luck with your older adults managing those two factors, balancing hope and reality to get the best outcomes possible for our patients. I'd love to hear your thoughts in the comments. Have a happy Wednesday and I will catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 21, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses the concept of "DUDS" and "STUDS" when working with patellofemoral pain syndrome. Mark describes three outdated treatment paradigms or "DUDS" including an overemphasis on imaging, patellofemoral tracking, and VMO specific-strengthening. Mark encourages listeners instead to focus on the four "STUDS" of patellofemoral pain treatment: assessing current work demands on the knee vs. current tissue capacity, addressing power & not just strength of the knee, working in motor coordination & skill training especially when reintroducing functional movements like jumping, running, or squatting, and finally, ensuring load distribution across tissues is as equal as possible by working on range of motion. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MARK GALLANT All right, what is up PT on Ice Daily Crew? Dr. Mark Gallant here, Clinical Tuesday, coming at you the Tuesday before Thanksgiving in 2023. So first off, I want to say super grateful to have the opportunity to be on this podcast, rapping to you all and going around the country talking about these topics. So thank you all very much to anyone who's listened to this podcast or anyone that's caught us on the road. But before we dive into today's topic, last couple opportunities to catch the extremity crew crew on the road for 2023, we've got Cody is going to be in Newark, California on December 2nd and 3rd. So so a nice West Coast opportunity. And then Lindsey is going to be in Windsor, Colorado, December 9th and 10th. So those will be the last two for the year before we we take a little break and then we will kick off the second weekend of January for a full slate in 2024. So if you're trying to catch us on the road this year, those are your last two opportunities. And then make sure you grab those seats for 2024, because courses are selling out now and hitting max capacity. So make sure that you get those sooner than later. In addition, tonight on our Vice, so if you're signed up for the Vice program, our virtual ICE, Paul Killoren is gonna be on talking about peripheral dry needling. If there's any topic that pairs well with what the extremity crew is typically saying, it would be the ICE dry needling department talking about peripheral dry needling. So definitely catch that one tonight around 8.30 Eastern Standard Time. DUDS & STUDS FOR PATELLOFEMORAL PAIN SYNDROME All right, for today's topic, what we wanna talk about is duds and studs when it comes to patellofemoral pain syndrome, or what I would prefer calling kneecap pain. So what are the things that we've known over the years or we've tried over the years with kneecap pain that the research really does not shake out very favorably for? And what are the things with kneecap pain where it's like, Ooh, that that's something that we definitely want to pay more attention to. So I'm going to list all the duds and all the studs off, and then we'll break each one of those down individually. So for the duds, we've got imaging to the kneecap as a dud specifically for chondromalacia patella, patellar tracking and trying to impact patellar tracking would also be a dud, and then specific strengthening or specific loading or an attempt at specific loading to the VMO or the oblique fibers of the vastus medialis. So those are our duds and our studs are going to be building work volume capacity or looking at that person's work volume compared to their current capacity and making adjustments in their training. We have specific strengthening or building capacity to that anterior knee with both strength, endurance, and power. We have skill training or motor coordination, and then we have mobility towards the anterior knee and surrounding structures. So those would be the three duds, the four studs. DUD #1 - IMAGING OF THE PATELLA Now let's break each one of those down individually. So for most body parts, We now know that when we take asymptomatic folks and we image that region of the body, we're going to find as many tissue changes as we would for those folks that are symptomatic. Historically, we've called these abnormal tissue findings. Again, these are fairly normal findings for asymptomatic individuals, again, in every single region of the body. What we see with chondromalacia patella, so softening of the cartilage of the posterior patella, What we see when we look at that is if we take a bunch of asymptomatic individuals and symptomatic individuals, run them all through the MRI tube and say, who's got signs of tissue softening to that cartilage of the back of the knee, that number is equal or close to equal for both the symptomatic group and the asymptomatic group. So it would be hard to say that the finding on the image of chondromalacia patella is driving kneecap pain in any considerable way. DUD #2 - PATELLOFEMORAL TRACKING The second dud is patella femoral tracking. So there was this theory for a long time that the lateral structures of the patella or the structures that attach laterally to the patella are pulling that patella off track or creating some level of tilt or compression to the patella that is driving that anterior knee pain. What we now know is that this is not the case typically. The other thing with that was that the VMO was weak and not allowing that even force. We now have studies, it's a pretty cool study, where they took a group of 14-year-old women, they asked them all about their knee pain, how much pain are you in, and then they used imaging to track how their, to look at how their patella was tracking. So they got all that data at 14 when those individuals were at their peak symptom level. They then followed up with those individuals four to five years later, so now they're 18 to 19 years old, All of these individuals had significantly reduced pain. So the patella femoral pain or the kneecap pain had relatively worked itself out. And then they re-imaged and retracked how that patella was tracking. What was interesting is most all of them had a full reduction of symptoms. the knee was tracking the exact same way. So they found no difference in how the knee was tracking, yet that person had significantly reduced symptoms, which again, hard to say that that knee tracking is one, are we even able to intervene on it? And two, does it mean anything if all of the symptoms become reduced despite that knee tracking changing? DUD #3 - SPECIFIC TRAINING TO THE VMO And along those lines, the third dud, is specific training to the vastus medialis oblique fibers. What we now know is it's incredibly hard to isolate those fibers. When we activate the quads, we're getting the whole quad, all of the heads of the quad. And even if we did attempt it, we have no proof of correlation that those specific fibers are driving the symptoms. So our three duds, looking at imaging to drive treatment, specifically with Chondromalacia patella, being overly concerned with with patella tracking and trying to impact that patella tracking with the one thing that we've shown the good research that impacts patella that that would be theoretically impacting patella tracking is that medial knee taping mcconnell taping what we now know is that is much more of a symptom modulator and has no long-term impact on that patella tracking. And then VMO, specifically training the oblique fibers of the quad. What we now know is getting the quads more robust and resilient is the way to go, being far less concerned about those very specific fibers that are very hard to isolate anyway. So those are our three duds. STUD #1 - WORK VOLUME VS. TISSUE CAPACITY Our four studs are going to be looking at that person's overall work volume compared to their capacity. So this weekend is a prime time example. We're going to have tons of folks going out for turkey trots. We're going to have a lot of folks going out and playing backyard football with their family on Thanksgiving. They may not have been doing any training over the last four to six months to prepare their anterior knee. for that capacity. Family members might say, hey, I'm jumping into this turkey trot, and then Bill says, you know what, I'm gonna jump in with you, even though I haven't run since 1968 when I was training for Vietnam. That individual may encounter some anterior knee pain because the capacity of their anterior knee is not matched to the work that it's about to do. So anytime we've got one of these pain symptoms, syndromes, kneecap pain, looking at, okay, what is it you're doing? and what is the capacity of the knee currently, and trying to figure out where those gaps are. STUD #2 - TRAIN POWER, NOT JUST STRENGTH Along those lines, the second stud is can we increase the load capacity, the capacity to handle speed or power, and the capacity of that anterior knee to handle endurance. What is your ability to produce load or to tolerate load in knee extension or squat? What's your ability to sustain that over long periods of time for high repetitions or high time intervals? What is your ability to generate power with those things? Dustin Jones came on here a couple weeks ago and talked about how we may have named the wrong enemy when it comes to deconditioned older adults that it may be more power instead of strength is the problem that a lot of folks actually have load capacity tolerance to their tissue. What they lack is the ability to handle that load while generating high speeds or force. We see the same thing when it comes to kneecap pain. We're getting better at getting people stronger to build that load capacity. We also need to make sure they can handle that at fast speeds. Our box jumps, our broad jumps, our cleans, our snatches, or sprinting, those sort of activities, we need the same sort of intention to build the tolerance. So building the local strength capacity or building the local tissue capacity of the knee. STUDF #3 - MOTOR COORDINATION & SKILL The third stud is skill or motor coordination. The law of specificity has reigned true in strength and conditioning since it was looked at. If you want someone to get better at running, train them in running. If you want to get them better at squatting, they need to train the squat. If you want their step up to look better, they need to be working on step up variations. So this has a very much skill component like any other skill in life. It takes repetition, It takes breaking it into chunks, it takes slowing it down, speeding it up. If we want their step up, or their step down, or their running, or their squatting to look better, making sure that we break those things down individually and look at it in addition to the first two components. STUD #4 - RANGE OF MOTION And then the fourth piece that's a stud is range of motion. What is the range of the tissue surrounding the anterior knee that's gonna dictate how much force is going through that knee? So a couple of the big ones are, what is ankle dorsiflexion like? If that person significantly lacks ankle dorsiflexion, we know those forces are going to go up the chain, often landing on that anterior knee. So attempting to impact or offload dorsiflexion will help with that anterior knee pain. What is the length of the rectus femoris? What is that quad length like? If that tissue is super gummed up and tonic, we may want to work some eccentrics to improve the mobility of that tissue overall. And along those same lines, what is that individual's hip extension looking like? If that person lacks significant hip extension, again, they may encounter more force to the anterior knee. DUDS & STUDS FOR PATELLOFEMORAL PAIN So again, for our studs or duds, looking at the three duds, looking at imaging or being overly concerned with imaging, specifically chondromalacia patella, being overly concerned with patella tracking and trying to impact it, and being overly concerned with the VMO. Those would be our three DUDs that we want to spend less time addressing or no time at all. Our four DUDs are going to be looking with the patient at what is their overall work volume compared to their current capacity. What is the ability of the anterior knee to tolerate loads from a load capacity or strength perspective, from an endurance and from a powers perspective. What is their skill in the movement that they're trying to perform? Do they need to become a better runner? Do they need to get better at squatting? Do they need to get better at step ups? Looking at that specific motion. And then finally, looking at any range of motion deficits of the lower quarter. Specifically, what is that quad length like? What is their ankle dorsiflexion? And what is their ability to extend their hip? Hope this helps. Hope you all have a wonderful Thanksgiving and get some good relaxation and time with your families. Lindsay and Cody will see you on the road in early December. I'll see you on the road in 2024. Hope you have a great week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 20, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. APRIL DOMINICK What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking. THE PELVIC FLOOR & PHONATION I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause. THE ANATOMY OF PHONATION Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece. THE PHYSIOLOGY OF PHONATION Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm. THE MECHANICS OF BREATHING Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies that show, hey, via EMG activity, there's actually some pelvic floor activity prior to resisted expiration. And this is cool because it demonstrates that maybe the pelvic floor has some sort of neural pre-planning during the expiration phase. So I know that was a lot of information, so I'm going to put it all together for you in terms of respiration, what's happening from head to floor. During inhalation, the vocal folds are open to allow the air to flow in. The external intercostals are going to elevate the ribs up and out. The SCM lifts the sternum. and clavicles, the diaphragm contracts and descends downward, the abdominals expand outwardly in response to the displaced organs, and then the pelvic floor elongates inferiorly. Whereas exhalation is more of a passive process of the muscles relaxing. But it can be a forced process as well, like during exercise or playing an instrument, or if we're under any stress, So now I'll run through the muscle responses during passive expiration, which is essentially inhalation in reverse. The respiratory diaphragm and inspiratory muscles relax, the pelvic floor and abdominals, synergistically contract, and there's this beautiful parallel lift of the pelvic diaphragm and the respiratory diaphragm upon exhalation. And then finally, those vocal folds, remember they stay open. so that air can exit the body. So that is respiration. It is the foundation and the power source when it comes to phonation or talking. As far as phonation goes, the entire body is a vocal organ. So the next time someone asks you at a party, hey, do you play any instruments? Be sure and tell them, heck yeah, I play this little thing, the voice. So next I'm going to detail the symptoms or systems involved in voice production. And I'll point out the differences in function of the two major muscles between respiration and phonation. As I said, the voice is a highly complex instrument involving many different body parts. THE FOUR SYSTEMS OF PHONATION And so we're gonna think of phonation as comprised of four major systems. And these systems are like a four-legged stool. When they're all working in sync, that stool or the voice is nice and stable. When one leg of the stool is a little off, then your whole stool is wobbly and your voice is a little wobbly. Another key thing to remember is that phonation occurs during the exhalation portion of respiration. So the first of the four systems is the air pressure system. It's going to manage pressure and flow. It sets vibration in motion. We can liken that air pressure system to a musician's breath as they are playing the saxophone. In the human body, the structures that are involved in the air pressure system are the trachea, the chest wall, the lungs, diaphragm. Then we move on to the second of the four systems, the vibratory system. It's made up of material that can vibrate when activated. So if we're thinking about the saxophone, we're thinking about the reed as the vibratory system. This creates pitch. In the human body, the vocal folds, are what create pitch. They open and close, and that lets short puffs of air come through the glottis at high speeds. And the number of vibrations per unit of time is what creates pitch. Low pitch is the result of the vocal folds shortening and vibrating more slowly. Whereas high pitch is created by lengthening the vocal folds and vibrating more quickly. Loudness is determined by the subglottal pressure which is generated by the abdominals and modulated by the pelvic floor. And then we have our third system, the resonators. They are going to amplify the vibrating sound. It's the actual physical saxophone itself. They affect the richness of the vocal tone. In the human body, that's going to be the throat, the oral and nasal cavities. This is what is going to create someone's recognizable voice. Then the final and fourth system is the articulators. They are unique to the human voice. So there is no analogy for an instrument here. Articulars add quality and timbre. They modify sound shapes as they leave the mouth, which creates recognizable words. And these are the tongue and the soft palate, the lips. So in summary, for phonation or voicing, the voice is produced via the interaction of those four systems. Subglottal pressure creates sound pressure and intensity, via rapid oscillations, the vocal folds produce sound pitch. Via the vocal tract, the glottal sound is articulated, adding in someone's unique voice timbre. And then intra-abdominal pressure is controlled and generated with the rest of the core canister. And that's going to be mostly the pelvic floor and abdominals helping out with that piece. So during phonation, the primary muscles and their actions involved in the inhalation portion remain the same. So prior to speaking, we usually inhale and then we talk, talk, talk. The exhalation portion of respiration is like I said, when we phonate. COMPARING EXHALATION TO ACTIVE SPEAKING So I'm going to talk about the two differences between quiet exhalation and actual phonation or speaking. One is that the vocal folds don't stay open like they do in quiet exhalation. During phonation, they are doing the vibration, opening, and closing through the different frequencies to produce pitch. Second, when it comes to the pelvic floor, there's very little research on what it's actually doing when we are phonating. Aliza Rudofsky is paving the way in these uncharted waters when it comes to research on the pelvic floor, phonation, and the voice, A study she published in 2020 looked at the glottis and the pelvic floor via bladder displacement. So they used 2D ultrasound imaging and folks without pelvic floor dysfunction. She had participants in a standing position. We love that because most singers stand or most people when we're talking, going about life, we're either sitting in an upright position or likely standing. And she had participants, she cued them to do a pelvic floor contraction, to do a pelvic floor strain, as if they had to go to the bathroom. And she also gave them some cued phonation tasks, like saying, ah, for three seconds at different pitches. She also had them take a note and go from low to high. And then she had them do some grunting. She found that during the pelvic floor contraction, the bladder moved cranially, or upwards, and during straining, the bladder moved caudally, or downwards. This is what we would expect. Interestingly, for the phonation tasks, she found that the bladder displacement was significantly different than that that she saw with the pelvic floor contraction. And remember, with pelvic floor contraction, we tend to see more of a cranial displacement, but with these glottal tasks, she found there was more of a caudal displacement towards the feet. And again, that's different from what we normally see with expiration. So this was some novel information about what's happening with the pelvic floor during phonation. She also recently did, and Aliza did an interview in August 2023, and she talked about some of the research she's currently conducting, still doing data collection, but she's having folks without pelvic floor dysfunction say on one exhale, one, two, three, four. And what she's finding is there again is a tendency towards pelvic floor lengthening that's happening and there's also this buoyant nature of the pelvic floor with a specific up and down response to each of those numbers. So again, that's early data collection, but really cool to hear about what could be happening that's a little different than what we would likely hypothesize with the pelvic floor and phonation. And to me, that buoyancy kind of likens to running. So in running, we know that with repeated impact, the pelvic floor is responding like a trampoline. It's going up and down. It's automatically doing this. And so this sounds to me very similar to that. Quiet respiration requires much lower subglottal pressure than phonation. So per Aliza's work, in those without pelvic floor dysfunction, as subglottal pressure demand increases, with the task of voicing, the pelvic floor has an overall tendency towards lengthening and then potentially going up and down with each voicing. Clinically, we can use these results to coach and educate patients, maybe those who are pre-abdominal or pelvic surgery or during pregnancy. We can talk to them about what may happen to the pelvic floor if it's unable to support those higher subglottal pressures that occur with certain phonation, like yelling or even singing. The pelvic floor system may give way in the form of urinary or fecal incontinence, pelvic pain, and feelings of heaviness. especially in that immediate phase, postpartum, vaginal delivery, or cesarean section because we just don't quite have those muscles or that muscular support to help with managing the intraabdominal pressure. And now I want to wrap everything up because that was a lot of information. So in terms of respiration and phonation, We can agree that those are both very complex systems of the body that use a number of body structures that start from the glottis and make their way down to the pelvic floor. Respiration is the process of inhalation and exhalation. During inhalation, the vocal folds, stay open, the SEM and external intercostals lift, the diaphragm contracts, and descends down, the abdominal slightly expands, pelvic floor elongates. Exhalation is either passive or forced, and generally the reverse process. When it comes to phonation, there are four main pressure systems in place. The air pressure system, the vibratory system, the resonators, and the articulators. They all work together to create unique vocalization. During the exhalation portion of phonation, everything stays the same with the exception of those vocal folds, moving back and forth, opening and closing, and then the pelvic floor showing a tendency towards lengthening with a potential buoyant response to each individual vocalization. The inability to support the intrabdominal pressure generated by these tasks with higher sub throttle pressure, such as phonation, may result in pelvic floor dysfunction. Clinicians can use this data as a preliminary sounding board for blending the intricacies of the vocal respiratory and pelvic floor systems, especially when they're treating someone who's coming in for pelvic floor and or vocal dysfunction, as we eagerly await even more research for these systems. Thank you so much for listening. And if you all celebrate Thanksgiving, have a wonderful week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 17, 2023

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel introduces the concept of an off-season for runners in order to focus on physical recovery, mental recovery, strengthening, and rehab. Rachel lays out a structured off-season approach for clinicians to use when working with runners. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL SELINA Good morning, everyone, and welcome to the PT on Ice Daily Show. Okay, I'm happy to be here as your host today. My name is Rachel Selina, and I'm a TA within our Endurance Athlete Division. So I TA for our Rehabilitation of the Injured Runner, both our live and our online courses. Our online course starts again on January 2nd, so if you're hoping to get into the next cohort of that, registration is open now, you can jump in online. It'd be a great way to kick off your new year Um, so we'd love to have you there again, January 2nd is when we start that next cohort. Um, so today, today we are going to dive into some running related topics. THE RUNNING OFF-SEASON I want to talk about the running off season and kind of what it is, how it could be structured and really at the end of everything, like why we should take one or why we should encourage our runners to be doing an actual off season and what that could look like. Why do we need this? It's a big missed opportunity. I don't think many of our runners are taking an actual off-season, even though in almost any other sport, we see an off-season that has a particular structure that looks different than our typical in-season, pre-season kind of training. But we don't often see that in running. And here I'm mainly talking about our recreational runners. So not our elite, elite, highly competitive, like they're getting paid to run. Um, but our everyday person that has goals has things they're trying to achieve with their running. Um, but again, not quite that high end elite athlete. Um, and it's really not what I see people doing. Okay. So what I often see. And I live in Michigan, so this is a bit skewed for kind of our timeline, but the same kind of like concept applies. I live in Michigan, so most people end up having like a fall goal race. And that might be a like a marathon or a half marathon. But they train a lot over the summer, building up to that race. It happened in the fall. And maybe they're using that race as a like a they're going for a goal. They're going for a PR or they're using a lot of people are trying to qualify for Boston. OK, so either way, that that fall event is something that someone is really training for, has a specific time goal, and is pushing, usually pushing their limits to get there. After that, right, event happens, and then people usually take one to two weeks off totally, like no running. And then usually I see it as people kind of taking that totally off of like anything. And then after that two week period, I kind of jump back into running, back into training, maybe slightly less volume, right? Long runs aren't going to be quite as long, but I typically see people kind of jumping back into the same type of schedule, like training five to six days a week. I'm still usually working in some like sprints or hill work, track work, something like that. Um, so really not a, apart from those two weeks immediately after not a clear, like differentiation from what their training was prior to that race. On the flip side, I see some people where they do the race and then they're just done running. Like I don't want to run in the winter. Um, so I'm, I'm not going to run it all after my goal race until spring. Can I argue both of those probably are not our ideal situation. So I think, like I said, it's a missed opportunity and I think it's missed because there's a lot of benefit in doing an off season. Primarily four reasons we're going to cover. So I'm going to take this down a little bit. PHYSICAL RECOVERY I think the first one is physical recovery, right? Someone typically, if they're building up to a goal race, has just spent the last three or four months, like progressively overloading every single week, building, building, building mileage, right? It's a continuous training cycle that adds up to a lot of fatigue. Some runners, right, we can encourage to take recovery weeks during their training, which can be helpful to like mitigate a little bit of that fatigue. But for the most part, people are constantly building their mileage, increasing their mileage and intensity over that three to four month period. So by the end of it, right, that's been a big stressor on the body, whether someone feels like recovered after their one to two weeks off of running, right? There's probably a little more going on underneath that the body is not actually fully recovered where they could jump back into full-on training and expect to do well. Okay. MENTAL RECOVERY So physical recovery and then also mental recovery. Training to that extent, having to put in that amount of mileage and time into running to train well, right? Means we have to say no to a lot of other things during that time. We maybe have to say no to some family obligations or time with friends or just other activities that we like doing that aren't running, kind of everything takes the back burner. So it can also be really just mentally fatiguing and draining. So coming off of that, being able to have a period of time where we can be a little bit more flexible, be able to do different activities, not have to say no, and also be able to prioritize sleep. or like how many people are trying to fit in their running around a work schedule, family schedule, right? So often we compromise on sleep to be able to make that happen. So having a period of time where we can really build back some of those recovery practices is huge. And I think what we miss. And then it also gives us kind of that third point. STRENGTHENING It gives us an opportunity to really help our runners do a full on strength training cycle, like intentionally trying to build strength. Um, we talk about this in the running, our live running course about trying to have runners incorporate strength training into their train, like into their endurance training, um, separate sessions, but concurrently meaning they're, they're doing aerobic training and then they're also in a separate session doing strength training. And we want that because it can help reduce the risk of injuries, but it can also help improve their performance. However, in that in-season cycle, that preparing for competition, most people aren't able to load to the intensities needed to really build strength. And it kind of takes second place to the running training. So having a two to three month period, where we can switch that narrative and make strength training the focus can be super helpful to actually help someone build the capacity in their tissues, right? Here's a two to three month period where strength training is going to be kind of our priority. We can actually build the capacity of your Achilles tendons, your quads, right? Your glutes. And make sure that when you go into that next training cycle, you're actually coming in more resilient, ready to train. Your tissues can tolerate more load. ADDRESING REHAB & PREHAB NEEDS Sweet, and then our final thing I think that we could use off season for is really having a period of time where we address nagging injuries, right? Oftentimes we're seeing people come in, they're in the middle of training, their goal is to do this race. So we might let some things go or people might avoid addressing some issues because they want to finish their race. So having, again, having a period of time where we can fully address that injury, not just kind of do what we need to do to reduce symptoms and get someone to the starting line, um, could be a really helpful thing so that it doesn't become this chronic, um, you know, it goes away when I stopped training a little bit, but then it comes right back because I've never actually addressed it. It's also a good time to address our running mechanics, right? Sometimes when we're in the middle of like a really high volume training, We might want to make some changes to mechanics, but those mechanics, when we change them even a little bit, can have a big impact, which can be good, but it's also hard when the volume is so high. So having a period of time where our volume is lower lets us adapt to that new running pattern, whatever the changes that we're making in the gate mechanics, without it being such an overload because the volume's lower. Right. So we can kind of ease into that new pattern when we go back to our like building cycles for running, we're able to kind of already have that, um, but like internalized and have our body adapted to it. So it's kind of the, like the, the big pillars of what it could be, but then what that would actually look like, like, okay, that's great. STRUCTURING THE OFF-SEASON How do I actually help my runner to structure an off season? If we go back to that initial goal race, race happens. And then we do want to encourage people to take that next one to two weeks off of running, but that doesn't have to mean off of all activity. So I'd encourage runners to focus more on active recovery, not running, but maybe they're doing some light cycling, swimming, yoga, anything else that kind of helps them to recover. But then also really focusing on refueling, right? Making sure we're sleeping enough in that time, just kind of replenishing the body after everything we depleted it from, from that baby vent. So that would be like one to two weeks. And then having another one to two weeks of a reverse taper, which is where we go from not running in those two weeks off and kind of gradually build the running volume back up, um, to kind of just a moderate level. So if we think of an actual taper before a race is the opposite where we're, we're at a higher volume, we kind of drop over one to two weeks. Um, and that purpose is to allow the body to be fully rested going into a race. So that would put us about a month out from a goal race, a month after it. And then I would encourage you to ask your runners to take two to three months after that of an off season. Okay. And that would look like keeping the volume at like no more than 60 to 70% of what they were previously running. Like as their, like their top training weeks or kind of their, their average volume week over week. So if someone was training 40 miles a week in preparation for, say, a marathon or half marathon, having them drop down to where they're not doing more than 24 to 28 miles a week. And that might look like going from training five to six days a week, running training, to dropping that down, running only three or four days a week. And that extra time, again, it doesn't have to be Like you just have to rest. Um, but filling it in with other activities that someone likes to do strength training, maybe it's CrossFit or swimming or yoga or climbing. Okay. And then finally, the intensity of this time should also be dropped down. Okay. We don't want, this isn't the time to like be working on our hills, our hill repeats, our sprints, our interval work, our track work, right. Keep the pace. low enough that it's like easy running. Okay. And then when the body is actually fully recovered, we can enter into that next cycle, ready to go, ready to push again and actually see benefit because the body's recovered and able to adapt to that new training stimulus. So the, the only other, um, It's kind of different situation here. Like what I've been talking about is someone who running is their main thing. Like they like to run year round, they're maybe doing a couple of different races in a year. If we have someone who's a true like multi-sport athlete, where they'll run during say like summer and fall, but then in the winter they switch, maybe they switch to skiing. Okay, that person's going to maintain their aerobic training, from the skiing, and they might not really wanna run at all, which I think we also need to have a bit of caution there, using that other sport as the off season, because running has such a different training load, right? It has that impact that differentiates it from any other activity. So we don't want someone's tendons and tissues to become unadapted to that stimulus of loading and running. So even if someone is taking their off season to pursue a different sport, still encouraging them to get like two to three, at least exposures to running or plyometric training. And it doesn't have to be long, right? Maybe it's asking your runner to do like, can you give me two 20 to 30 minute runs a week, right? Even with your other like skiing training. If they're like, nope, I don't want to run at all. Can we at least get some plyometric training? Can we work a little bit of jump rope in there? Can we work some just other kinds of jumps, box jumps, drop jumps, anything like that to still get exposure to impact loading? And I think like a lot of that can be more coming from a coaching perspective, but I think it's also important in the clinic, especially if we think that most people, when they have a running injury, they don't come to us until it's a big deal. That's kind of our typical pattern, which usually can look like someone coming to us shortly before a race, right? So our focus there to help them meet their goal has to be a little more on kind of like putting out the fire, helping them get to the starting line for their race. But if we can set patients up with the expectation, hey, this is going to help you get to your race. But then afterwards, like I want you to come back and see me. so that we can really address what's going on, right? I want you to take, especially if someone's dealing with an injury, I want you to take this off season afterwards. We're going to work through to make sure you're 100%. We're gonna drop your running down a little bit, make sure you recover so that when you go back to that next cycle, you are actually ready to go. This issue is no longer nagging you, you're stronger, you've had adequate recovery. So I think it's a big point for in the clinic, just the same as it can be outside as we're thinking about maybe our non-injured athletes. Perfect, I would love to know your thoughts, so you can throw them in the comments. Let me know if you're taking it off season, if you encourage your runners to do so, or just any kind of thoughts you have around the topic would be great. So thank you for tuning in, have a great weekend, and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 16, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE Chief Operating Office Alan Fredendall discusses how and why behind more carefully curating the digital & social media content you consume on the internet. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ALAN FREDENDALL Team, what's up? Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day's off to a great start. Glad to have you here on the PT on ICE Daily Show. My name is Alan. I'm happy to be your host. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty member in our Fitness Athlete Division. Leadership Thursdays, we talk all things practice management, small business ownership, and general leadership tips for all of you out there who are leaders in your own way. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday couldn't be more challenging but also simpler than getting out there and hitting a 5k run or if you can't run hit a 5k row. Great aerobic test. As I get more into endurance running, I would argue I've been learning to hate 5Ks the most if it's a really uncomfortable distance to settle into kind of a longer, slower pace of, you know, you're setting a good pace on the first mile. Dang, I'm almost a third of the way done. Second mile, third mile. can be quite an aggressive distance. It's the most commonly programmed CrossFit workout if that surprises you. I've posted some benchmark times as far as percentiles for both the 5k row and the 5k run to kind of compare yourself to where I stack up against the general population. So have fun with that one. It's good to test that at least once a year and see how your 5k has changed, especially if it's a goal for you to get your aerobic, your longer energy system a little bit more efficient, and specifically to get better at maybe 5k runs. Some courses coming your way. Before we talk about these courses coming up before the end of the year, I want to challenge you that if you are in the market for an ice course, and you're able to purchase a course before the end of this year, you should do that. Wink, wink, wink, right? There might be a change being announced soon that would make you regret not purchasing now. So you'll see that maybe an announcement coming soon. courses before the end of the year we're almost done we have some courses this weekend but that's probably too late for you we'll be off next weekend for Thanksgiving and then we have just three weekends left of live courses in 2023 December 1st through the 3rd that weekend you can catch Paul up in Bellingham Washington for dry needling upper body You can catch Zach down at his home base at Onward Tennessee for cervical management. Christina will be up in Halifax, Nova Scotia, A for Pelvic Live. Ellison will be down in Tampa, Florida for dry needling lower body. Cody will be on the road for extremity management out in California in the Bay Area in Newark, California. Brian Melrose will be in Helena, Montana for lumbar management. and Julie Brower will be on the road in Candler, North Carolina for Older Adult Live. That's right outside of Asheville. The weekend of December 9th and 10th, we have Fitness Athlete Live. That's your last chance to catch that course this year. That'll be with Mitch Babcock out in Colorado Springs, Colorado. You can catch Extremity on the road again, this time with Lindsey Huey in Fort Collins, Colorado. And Older Adult Live, your last chance this year will be in Portland, Maine with Alex Germano. And then our very last course of the year, of course, we expect nothing less than a person of Paul's caliber to be the last person working this year. He will be in Salt Lake City for dry needling his upper body. That'll be the weekend of December 15th, 16th and 17th. That's a three-day course. So if you're in a state that needs a lot of hours like Washington, or Maryland, that'll be a chance to catch a three-day version of that course. A course is coming your way from us here at ICE. YOUR TRIBE DICTATES YOUR VIBE Okay, let's talk about today's topic. Your tribe dictates your vibe. You've often maybe heard the other way around. Your vibe attracts your tribe. How you carry yourself, your personality, your values, kind of attract the people around you that are maybe in your friend group, your colleagues at work, that sort of thing. I want to talk about it from the other angle your tribe dictates your vibe, of the people you choose to follow, whether they're actual in-person people or specifically today's topic, of the people you follow on social media can really dictate not only how you feel about yourself, care yourself, but of what you might begin to spend your time and money on for the worse or for the better. So I really, really, really want to stress that social media, I think, is destroying our society for the worse. Certainly, it has value in things like this and sharing information and education. from one person to a large group of people. But I think overall, we can begin to follow people who appear really relevant to our lives. But actually, if we do a really deep dive, we understand they actually have very little in common with us. And then ultimately, at the end of the day, we're in charge of who we follow. Many of us are not on social media against our will. And so that the emails you subscribe to, the social media accounts you follow, all of this digital content that you consume can have positive or negative effects on you. And to really stress, if you take nothing else away from this episode, to be really diligent in the streams and feeds that you begin to curate as you begin to follow email newsletters, social media accounts, and the like. THE PITFALLS OF THE INTERNET: TALKING TOUGH & SOUNDING SMART The first point I want to make today is The pitfall of the internet, as it's always been since its inception of consumer-based communication, is that it's super easy to talk tough and sound smart on social media. We live in a very impatient, rapid-fire, fire-and-forget type of world now. You may not know, but certainly, if you work at all in customer service, you experience, that the average expected response time to an email or social media message is now 10 minutes or less by the average customer. That's a study from Forbes from this year in 2023. I could say a whole bunch of crazy stuff right now on this podcast. I could say it in a social media post and I would have almost no side effects come to me because our society now is so rapid-fire, so fast, so consumable that you would consume this. Maybe what I'd say you would resonate with, maybe it would make you upset. It doesn't matter because you will forget about it in three minutes when you scroll on to the next piece of content. on your social media feed or the next podcast episode that you queue up. The only regulation on what we say is from you all, from the consumers. What's noticeable on social media is that the people who tend to be the most aggressive and make the largest blanket statements are often those who do so without any sort of evidence or support. They're also not the people who tend to engage in the stuff that they create, right? They're very aggressive. They fire something out there. They know it might make you upset. You might actually make a comment. And that's kind of their goal, right? That drives their engagement up. That shows their post to more people. Maybe it further upsets people. It gets more comments. And what we need to realize is that cycle is kind of what fuels those people to have large follower bases, to be able to advertise different things to you. Hashtag, you know, ice barrel, try out your hashtag toe spacers, right? Those people are trying to strike a nerve on purpose to get more engagement, more followers, more followers, engagement equals I can make more money selling sponsored things to you. So we need to be aware of that trap that is out there for us on social media and be aware of the pitfall of the internet and social media itself of this very consumable temporary transient content and recognize if you're falling for that trap of if you are getting upset and making comment or if you're following people who make kind of outlandish, unsupported statements. If that makes you upset, again, the whole theme of this episode is why are you following accounts like that. YOU HAVE NOTHING IN COMMON WITH THE MAJORITY OF PEOPLE YOU FOLLOW The second point I want to make of why are you following accounts like that is that you have nothing in common with the majority of people that you follow and obtain content from. You're making less money than you want to. You're working more hours than you want to. You're not feeling as physically well or as fit as you want to. You're not happy with how your body looks. Maybe you're not happy with how your marriage is going how you're raising your kids how your sex life is going, and how your postpartum recovery is going. You name it, you're being told that whatever is wrong with you, X is Y with you. Y is the solution, right? You are not having a good life because you don't wake up at 4 a.m. and do a 6-hour morning routine. You're not having a good life because you don't wake up and do a gratitude journal, use toe spacers, do yoga, meditate, do a cold plunge, or a sauna, or any of these other things that you're told are the difference between this apparently very successful person and you. But often when you do your research, when you look behind who are these social media influencers, you're often being sold solutions by people that are usually millionaires and who are usually millionaires, not because of the stuff they're telling you that they do, but because they're convincing people like you to buy the stuff that they're selling. And that's how either they are making their money or they're maintaining the level of income that they already have, right? Or maybe they started out in life and mom and dad footed the bill for college and for grad school and for their first house and they don't have a lot of debt and so they have a lot of extra time, they don't need to work as much to become this social media influencer and begin to sell you supplements and Toast Facers and all this kind of stuff. And the more you listen to those folks about what's wrong with you is that you're not consuming this stuff, the more money they actually make and the bigger that asymmetry actually comes. What's not said is that a lot of those folks have made their money by living what they're doing right now, which is a very imbalanced life of working more than you want to in order to try to pull yourself up the socioeconomic ladder. You're told that you're burned out or whatever and really the cause of their success is doing what you're doing right now and eventually getting to the point where their success comes to a level where they no longer need to work as much and maybe now they have more time to show you a video of them working out on the beach in Bali. And by the way, use my promo code Stephen10 for 10% off, whatever. And again, the more you consume that, the richer that person becomes. But at the end of the day, you do not have a lot in common with that person, yet you are trying to model your life after them, even though that's not how they currently live their life. And maybe that's not how they ever lived your life. These people are happy, healthy, and fit because they don't have to go to work anymore. Or maybe they never had to go to work. They can wake up and do their morning routine and go surfing because they're able to afford a full-time nanny to take care of their kids. Or maybe they don't even have kids and they get 12 hours of sleep because they have a night nurse. Or again, maybe they don't even have kids. And you get my point that they are living a very different life than you and maybe they never lived the life that you did. So it doesn't make sense for you to spend a lot of your time consuming their content and buying the stuff they're selling to somehow try to fix your life. Follow people who represent you, who represent your values, who are honest about where they made their money or how they got to the level they are at. I tend to follow people who are very upfront about how they got where they're at by pulling themselves up from being very, very, very, very poor, working a ton, and pulling themselves up the socioeconomic ladder. Is that ideal? No, but sometimes that is life, as true as it can be. And I resonate a lot more with those people who say like, look like this was the way that worked for me. It may not work for you. And I appreciate those people who are honest that look, it was a lot of years of 100-hour work weeks, working multiple jobs to pay off my debt to afford a house, to raise kids, and kind of get to where I'm at now. And I really, really appreciate that transparency, especially more as life goes on. So, what can we do about this of recognizing that Social media is meant to be fire and forget, instantaneous, consumable? It's meant to sell you things. It's meant to show people who maybe have nothing in common with you that you want to see yourself become only if you buy these products. If that's the way it's designed, what is the solution? CUT THE CORD The solution is to cut that cord, right? Take a serious examination of the accounts you're following, of the newsletters you subscribe to, of in general the content you consume digitally via social media, email, whatever, and stop following stuff from people who make it seem like the only reason you're not obtaining the fulfillment you want is that you aren't buying enough of the stuff that they're selling. Stop following accounts that tend to speak on best practices, but speak so dogmatically. Manual therapy sucks, it has no value. On the other side of the continuum, manual therapy cures diabetes, right? Stop following that stuff if you don't actually believe that stuff. Some of us follow that stuff just to watch the comments and watch people argue, or maybe you're even that person, spending your time that could be spent better elsewhere, arguing with people on the internet. I'll be very honest, I used to be that person. If you knew me a decade ago, I was that person. I was that person yelling at people on Twitter. and Instagram and all the other social media platforms, and I've talked about this before, one of the biggest shifts in my life was meeting Jeff Moore, our CEO, who one day sent me a screenshot of all these comments I was making, all this time I was spending on the internet, on social media, and just said, is this the best use of your time to advance the field of physical therapy? And of course, if you really ask yourself that question, then the answer truly is no. So stop following that stuff. Stop following those accounts. Stop following people who tell you that the way you're treating patients is wrong. If they are people who maybe don't currently treat patients or have not treated patients in a long time, five years, 10 years, 20 years, or maybe people who have never treated a patient ever, right, that person who went from PT school, maybe right to a Ph.D., or a consulting job, or to work for an insurance company as an adjuster, and has no actual real-world experience. Why are you following content like that? Knock that off. Follow people who are in the clinic every day, who are trying to make it all happen, who are trying to blend manual therapy, patient expectations and beliefs, and fitness-forward lifestyle, getting people loaded, getting people addressing their sleep and diet. Follow people who put out content like that, not content that maybe just makes you upset at the end of the day. Follow accounts that make your life easier. Follow accounts that give you resources that you can provide your patients so you don't have to work as much making that stuff yourself, right? Follow, obviously, I'm biased. I can't not have any bias here. Follow us, right? Go to PTonICE.com, click the resources tab, and look at literally an endless list of ebooks, workshops, of patient resources already created for you to make your job in the clinic easier so that hopefully you don't have to spend as much time making the money that you're currently doing. You don't have to work as hard doing it. Follow people in a manner that sees you working less and making more and not just buying more gadgets and $10,000 mentorship programs. THERE'S NOTHING WRONG WITH YOU And I think finally, what I want you to resonate from today's episode is to recognize deep down that there's nothing wrong with you. If you work more than you want to and get paid less than you think you should, you are not damaged. You are a normal American, right? 77% of Americans live paycheck to paycheck. Half of all Americans work two or more jobs. It is totally common to work more than you want to, to try to get ahead. Again, some of us are trying to pull ourselves up a huge deficit, right? We're trying to close a large asymmetry. We're trying to go from the poor person who grew up in a trailer park to maybe the first person in your family to finish middle school or high school or undergrad and grad school and be the first person to own your own home and be the first person to maybe have a retirement account and actually be able to think about retiring. We're trying to pull ourselves up multiple rungs. And I think for most of us, we believe that working a bunch is not how we get there. And I think when, again, we follow people who are more transparent in how they have their success. You'll find that's how they also got there, right? They didn't toe space and cold plunge their way from the trailer park to owning their own home starting a family paying off their debt and being comfortable in retirement. So recognize that there's nothing wrong with you. CHALLENGE YOURSELF TO CURATE BETTER CONTENT Okay, challenge you. If you look at my social media account, if you look at my Instagram, you'll see I have tens of thousands of followers. I don't know who most of those people are or why they follow me. Yet, look at that ratio. When you look at the ratio of people who follow to followers, it is my belief that you should only follow people that you want to see content from. What you'll see when you look at my account is that I only follow a couple hundred people, right? I follow close friends and family members. and people that I want to see content from. Again, my goal with social media is to curate a feed that makes my life easier with different tips and tricks about physical therapy, coaching, leadership, business, about all the different spheres I'm involved in. That's how I curate my social media feed. I don't follow people back who follow me if I don't think they post any content, that's certainly possible, or content directly relevant to me. And I think it's okay if you have to unfollow those people. Some people may think that means they follow you. Well, hopefully, they follow me because they find value in what I post and I think it's okay to not reciprocate if you don't feel the same way. I'm sure the people who follow me that I don't follow are nice upstanding people who treat their spouses and their children well hold the door for people to pay their taxes on time and leave a nice tip at the restaurant for the waitstaff, right? Not saying there's anything wrong with them. It's just I don't believe that the content they create is beneficial to me, and otherwise, it just becomes an endless blob of noise that maybe as you start to follow and compare yourselves to, you start to feel bad about yourself. So take a step back. Why am I following these people? Is it beneficial to me? It's okay to unfollow people, I promise you. I'm giving you permission, I'm giving you the blessing to do so. Cut that cord, recognize that you don't have as much in common with most of the people that you follow, as you think you do, and recognize that a lot of those people are relying on showing you this grandiose awesome life in order to sell you stuff so that they can continue to live that awesome life of working out on the beach in the Caribbean and living in their mansion in Costa Rica and using dye-free detergent and eating organ meat and all the stuff you're told is the reason that you're not doing as well as you need to. Consider, that your tribe dictates your vibe. Who you follow can really make your day or ruin your day. It can make you feel bad about yourself. You could get caught comparing yourself. So just knock it off. Cut that cord. Hope you have a fantastic Thursday. Have fun with Gut Check Thursday. We're going to be at a live course this weekend. Enjoy yourselves. I'll be back here on Thanksgiving Day. So I'll see you all on Thanksgiving Day. If you won't be joining us, I hope you have a wonderful Thanksgiving. Have a great Thursday. Have a great weekend. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 15, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer as she discusses that the problem with patient education lies in the tendency of healthcare professionals to overwhelm patients with excessive recommendations, mistakenly believing that this approach is effective. They often act like a "fire hose," bombarding patients with information without considering whether it is truly understood or has a positive impact. This ineffective method of simply talking at patients, providing detailed explanations, or presenting long to-do lists is often learned from clinical instructors and perpetuated without recognizing its limitations. To enhance patient education, healthcare professionals should adopt a three-step framework. This framework involves "show and tell" by combining education with action and intervention, clarifying and recapitulating information to ensure comprehension, and following up and following through with patients to establish mutual accountability. By implementing this framework, healthcare professionals can avoid overwhelming patients and ensure the effectiveness of their education. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I am a member of the older adult division. Excited to be here with you all on Wednesday where we jam on all things older adults. Excited to be talking to you all this morning about patient education. Our topic specifically is patient education finish the drill. All right, so what we are going to talk about this morning is the problem with what many clinicians perceive to be effective patient education. And then I'm going to unpack a three-step framework that you all can use to level up your patient education interventions. And I'm going to then share a few really detailed examples of how you can implement this going forward using clinical scenarios that many of you all experience pretty frequently. The goal here is that we just walk into the rest of our week doing 1% better, okay? THE PROBLEM WITH PATIENT EDUCATION: THE FIRE HOSE All right, so what is the problem with patient education? The standard. Too often, we act like a fire hose. We flood our patients with too many recommendations, and we think that it's effective patient education. Team, we cannot fool ourselves. that simply talking at our patients, right? So explaining the very detailed pathophysiology of their condition or explaining their fall risk profile after running your outcome measures or giving them a 10 item to-do list of safety and lifestyle recommendations that they have never heard before and assume that we are making a positive impact. Many times I think this comes from the fact that we didn't really learn in school how to be effective at communicating to our patients and providing education. And then we just kind of followed what our CIs did, right? I am so guilty of this. I remember as a new grad going into a patient and you're so excited because you want to tell them everything in your brain that you know, you want to share your knowledge. And I remember I would just fire hose, fire hose for 10 to 15 minutes and I would walk out of that room and be like, man, I crushed it with Dolores. Like she just learned so much. I just did an awesome job. And then I would sit down and write literally a paragraph of all the things that I educated my patient on. And for some reason, because I wrote an entire paragraph of my educational interventions, that must make it good, right? Like I perceived that I did this awesome thing. So I think that's a scenario that we find a lot. The other scenario, which I've also been here, and many of you have probably been here too, is that you constantly have this productivity being shoved down your throat, or you are just so freaking burnout and so exhausted, you look at your clock and you're like, I gotta get this last patient in. I gotta get this last patient in. I'm exhausted. I don't have a ton of time. I don't know if I'm going to get a second set of hands to get them up to do any exercise interventions. So what am I going to do? I'm going to go into this room and I'm going to sit there and I'm going to educate. I don't even know if I can stand up to do it. So I'm going to just stay in my chair, educate and type as I'm there. I know a lot of us had been there, right? I know a lot of us have been there, but are we really helping our patient? Do we really think that just by sitting there and telling them a bunch of stuff, it's going to cause any positive impact? We have to really start to dig in there. So I want to offer you all a solution. I'm going to explain this three-step framework. So what does finish the drill mean? It means one, we're going to show and tell, Two, we are going to clarify and recap. And then three, we are going to follow up and follow through. So let me unpack each of those. SHOW AND TELL, CLARIFY & RECAP, AND FOLLOW-UP & FOLLOW-THROUGH Show and tell. Are we pairing our education with action on our part, an intervention, a demonstration? Are we facilitating action on our patient's part? Show and tell. Next, clarify and recap. Are we ensuring that the education that we are giving, the literal words, the process, the steps that are coming out of our mouths is actually being understood? Are we ensuring that the message we are sending is being received in the way that we intend? Are we asking the patient to recap what they heard? Are we asking questions to clarify misunderstandings or gaps in knowledge transfer? And then lastly, follow up and follow through. Are we following up with the patient after we make those recommendations? Are we following through with a caregiver or the next provider? Are we holding ourselves accountable and the patient accountable? That is what it means to finish the drill. Show and tell, clarify and recap, follow up and follow through. Okay, let's go through a few scenarios to give you guys a very detailed, clear example of how you can implement. I have a massive list of these, but I'm just gonna give you three here this morning, okay? All right, for you acute care clinicians, You have Dolores on your caseload. She has just had a lumbar fusion surgery, and you go in to evaluate her. Instead of just telling her, Dolores, you have movement restrictions. No bending, lifting, or twisting, right? We all know the BLT restrictions. What we know is that restrictions can cause a lot of fear. A lot of patients never discharge them and they walk around like they're in straitjackets for a really long time. So instead of just telling Dolores what she can't do, let's show and tell. Let's show Dolores how to hip hinge safely. and distinguish that from actually bending and flexing at the spine. So how do we do that? If many of all have been following ice for a long time, you know this awesome hack. You can take the toiletry bucket that is in Doris's room. You can go take some towels, roll them up, soak them in water and put them in the toiletry bucket. You can put that toiletry bucket on an elevated surface like the bed or the chair, and you can show Dolores how to safely hinge. Let's clarify and recap. Let's ask Dolores, hey, Dolores, do you have any questions about moving your back safely and rebuilding its strength? Let's have Dolores recap the points of performance of that hinge motion and demonstrate it for us. Lastly, let's follow up and let's follow through. If you are lucky enough in acute care to see your patient twice, let's say it's the very next day, or maybe it's later in the day, on the same day, you can ask, Dolores to set the environment up. Show me how to pick this up. We are checking for Dolores's ability to have those points of performance and be able to form that hinge movement. Let's follow through, which is very hard to do as an acute care clinician because many times you have no communication with the next provider. You don't ever get to see Dolores again. How can we do it to the best of our ability? We can follow through by talking to Dolores, maybe putting it on her phone or on a piece of paper. I need you to show this to your outpatient PT. And what does it say? Can you please teach me how to deadlift? Right? We are planting a seed, passing the baton, trying to make sure she stays in that fitness forward lane because we don't want her back on our caseload. Maybe we even take it a step further and we actually recommend to Dolores a specific fitness forward PT in the outpatient setting who we are going to want Dolores to go to. Finish the drill. Okay. Let's talk about a home health example here. So let's say you have Dolores in home health. We know that her visual acuity is impaired, right? Maybe you have done an acuity test. You know that her prescription on her glasses are really outdated. Let's not just tell Dolores about the importance of vision, helping her balance to prevent a fall. Let's not just tell her to make that eye appointment with her doctor and then walk out the door and hope that she does it. Let's show her how to send a message via MyChart. Guys, systems are starting to charge patients for MyChart messages. Let's start to show them how to send appropriate messages via MyChart, right? Let's make this actionable. What if we call the doctor, put them on speakerphone with Doris, guide Doris how to schedule her own appointment to increase her self-efficacy? Let's clarify with Dolores by asking, are there any barriers that you can perceive getting to this eye appointment? Let's follow through by contacting a caregiver to schedule with them. Hey, this appointment, Dolores has a eye appointment this day, this time. Are you going to be able to take her? Let's make sure it's on both of your all's calendars, right? Or maybe we plan ahead with a service like Go Go Grandparent so that we know that the transportation piece that was a barrier is now something that is facilitated and that we have taken care of that. Okay. Lastly, let's talk about an outpatient example. All right. You're working with Dolores, an outpatient. She lives with her partner at home. She's got some balance issues. She has had a fall. So you are treating her. Let's not just tell Dolores to take up her rugs and put nightlights around her house. How often do we give that cookie cutter recommendation of let's remove all your rugs, right? Instead, How about this? How about we make this actionable and we get Dolores or Dolores' partner or a caregiver to get a video walkthrough of the pathway from Dolores' from the edge of her bed into the hallway, into the bathroom, into the living room, out her front door, whatever her normal pathway is for the day. What if we get a video so that we can actually see what her home environment looks like? And then we can say, okay, Dolores, that rug, that one, the one with the tassels that you know she's probably gonna trip over or she has tripped over. Can we get rid of that rug, Dolores? Why don't we clarify by asking, Dolores, are you willing to get rid of that rug? She may, older adults, we know this guys, right? It's really hard to tell them to get rid of rugs. They may be really resistant to that. So Dolores, are you willing to get rid of that one rug? Because you have gone through and you've triaged out of all of the rugs, that's the one that's gonna cause us the most problem. What if we ask Dolores, what are your feelings surrounding getting rid of your rubs? And you dig a little deeper there. Let's follow through with talking about how we're going to actually get this done. Because maybe Dolores may not have the capability to get down on the ground and remove her rubs. So what if our follow through is calling nephew Johnny to ask him, Hey, will you, within this week, come over to Dolores's home and help her take up her rubs? Right? What if, We don't just tell Dolores to have those lights throughout the home. Now that we have the video, we say, Dolores, the lights would be most helpful if you put them here, here and there. Here is the Amazon link of some cheap but effective ones to buy. Let's put it in your cart right now. That is how we follow up and follow through and make this actionable, right? Then we can say, Dolores, here's your follow-up. Bring in a video in the next week and show me what your pathways look like now. So you are able to see that we have followed through with this recommendation. The nightlights are where they're supposed to be and the rugs are taken out. Guys, this is what it means to finish the drill with our educational interventions. Show and tell, clarify and recap, follow up and follow through. I would love to hear you all take this framework into the rest of the week. And while you're with your patients and you're starting to just fire hose and spew out those recommendations, I would love for you to pause take the pause and really think how you're going to finish the Drew. How are you going to show and tell, clarify and recap, follow up and follow through? All right, team, that's all I got for you today. Lastly, let's talk to you all about our courses that are coming up. We have some sold out courses, which is wild to have at the end of the year. November, we have a sold out course in Illinois. In December, we are sold out or we're very near sold out in Portland, Maine. And then we have another chance for you all to catch us on the road in Asheville, North Carolina. In January 1st of the year, we are going to have both of our online courses, our Level 1 and Level 2, formerly known as Central Foundations and Advanced Concepts, that are going to be starting up on January 10th and 11th. You know where all that info lives, ptinex.com, mmoa.online. Hit us up if you have any questions. Go out there and start to make those educational interventions. Just 1% better team. All right, y'all. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 14, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses various approaches to promote system-wide healing. One key aspect highlighted is the importance of education in the healing process. Lindsey emphasizes the need to educate patients about their condition and what to expect during their recovery journey. This includes providing information about tissue healing timeframes and milestones for progress. By equipping patients with this knowledge, healthcare professionals can help them understand their recovery process and make informed decisions. Mindfulness is another approach mentioned in promoting system-wide healing. Lindsey suggests that practicing mindfulness techniques can help reduce stress and promote a calm mind. This can be achieved through activities such as breathing exercises, journaling, or spending time outdoors. By incorporating mindfulness practices into their daily routine, patients can support their overall healing process. Exercise is highlighted as a crucial component of system-wide healing. Lindsey emphasizes that exercise should not be limited to traditional rehabilitation exercises but should also include activities like walking programs. For instance, in the case of total knee surgery, she suggests starting with a 10-minute daily walking routine and gradually increasing it to reach the recommended 30 minutes per day. Engaging in regular physical activity can improve overall fitness and support the healing process. Diet is also mentioned as a factor that can promote healing, especially after a trauma such as surgery. Lindsey emphasizes the importance of nutrition in supporting tissue healing. Specific dietary recommendations may vary depending on the type of surgery and individual patient needs. However, healthcare professionals are encouraged to promote a healing-focused diet that provides the necessary nutrients for recovery. Lastly, sleep is highlighted as a crucial element in promoting system-wide healing. Lindsey acknowledges that getting enough sleep can be challenging during the early stages of healing. However, they suggest providing patients with sleep hygiene tips, such as turning off electronic devices before bed or maintaining a cooler room temperature. By facilitating good quality sleep, patients can support their body's healing processes. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. LINDSEY HUGHEYGood morning, PT on ICE daily show. How is it going? It is clinical Tuesday. I am Dr. Lindsay Hughey from Extremity Management. I led that along with Dr. Cody Gingrich, Dr. Mark Gallant, and Dr. Eric Chaconas. So happy to be with you all on a clinical Tuesday. It's been a little while. Today I'm gonna talk with you about fitness forward post-op considerations for extremity management. It's a topic that often gets asked about on our weekends and our weekends don't actually have the bandwidth to hold those questions. So I'm gonna start sharing on PT on ice a little bit more here. So I'm excited to talk with you about that. But before I do, I want to share some upcoming courses that Mark, Cody, and I have because there are only a couple more opportunities left to catch us this year. And for those courses, we are getting close to 30 for each. And so spots will run out. So if you're on the fence, consider purchasing that in the next couple of weeks. So Fremont, California, Cody will be there on December 2nd and 3rd. And then the final opportunity this year is at CrossFit Endure in Fort Collins, Colorado, on December 9th and 10th. And that one's going to be a blast and numbers are growing. So please sign up now. If you miss those two opportunities just because family stuff's going on, know that we have offerings early in January as well. So Mark in Richmond, Virginia, on January 13th, and 14th, that same weekend, we're also offering a course with me in Louisiana. So please check out our calendar. We hope to see you on the road soon. A FITNESS-FORWARD APPROACH TO POST-OP EXTREMITY CARE So today's topic at hand, we're going to dive into what a fitness-forward approach looks like when we are managing extremities post-operatively. So I want to first just talk about the framework generally, and then use an example. And the example today we'll talk about is total knee replacement. But there are five underlying pillars that I see that are required if we really want to have an all-inclusive approach that is fitness forward for these folks. So number one, we have to be really familiar with tissue healing timeframes of that condition and what to expect and not expect for that patient along their healing journey. So we have to be intimately acquainted with what's normal and what's not, and then be willing to educate the patient about that. So that second pillar is really education. So letting the patient know in whatever surgery they have, whether upper or lower quarter, what's really gonna facilitate healing? What are the expectations for recovery in regards to milestones that they need to hit by certain times and what milestones allow them to progress? There are certain timelines that we can't violate and range of motion precautions based on that specific surgeon. So really make sure we educate the patient and they are fully aware of those precautions. As Zach Morgan said in one of his podcasts recently, we have to catastrophize rest. I'm really letting someone know that rest will never be the thing here post-operatively. Yes, we might have to rest that directed limb, at times, but our body needs movement. It needs blood flow. And so really getting that message early that just because you just have surgery doesn't mean you'll just be sitting and laying around. We actually need to move to promote blood flow and healing to that extremity. Number third pillar is the protocol. Really being intimately aware of whatever protocol the surgeon gives knowing the timelines and actually reviewing them with your patient. Not all surgeons will have a protocol, right? Every surgeon's a little different, but find an evidence-based one based on that surgery and compare a couple of them if the surgeon isn't giving you one. It is really important to kind of sit down with the patient and briefly review that so they really understand, again, what's normal and what's not, knowing what safety precautions are on board from a range of motion and active range of motion versus passive range of motion perspective, and then again, those milestones. Pillar four, system healing. How do we promote system-wide healing? Well, I already mentioned a little bit about our education, about how we're going to catastrophize rest, right? We are going to keep our humans moving, but here's where meds will come in again. And if you've heard me on the podcast, you know, or even seeing my reels, you know, meds is something I'm really passionate about. Mindfulness, exercise, diet, and sleep. And really unpacking what each one of those is for your patient, right? So mindfulness, something that kind of soothes their stress and mind or soothes their soul, helping that connect them with that, exercise, keeping that human moving in whatever way possible, diet, promoting nutrition that promotes healing, especially after a trauma, even though it's a controlled trauma, surgery is traumatic on all of our tissues. So make sure the diet matches that, and I'll unpack some of those things that promote healing as we talk about our total knee example. And then sleep, really helping facilitate ways to help a good deep sleep, that seven to nine hours, and it's so hard in those early healing stages, but giving the tips that you think will help. And it could be as small as turning your phone off an hour before bed, right? Or keep the room a little bit cooler, around like 65 degrees to help them sleep, just giving them those sleep hygiene tips. more on that as we talk about the total knee example. And then the final pillar when we're thinking about fitness forward postoperative care is capacity rebuilding. And what I mean by that is considering all tissues involved in the surgery. So think muscle, think tendon, Think ligament if that's on board. Think skin integrity, right? Because there's an incision on board. And think bone. All of these are challenged. Their capacity is challenged because there is a period where there needs to be some precautions and rest on board. And there needs to then be a period where we gradually build up that capacity as it's going down. And it is our job to prevent loss of capacity as much as possible, and then also build it up as efficiently and safely as we can. And so there are three subsets in this capacity rebuilding phase. So consider when we're thinking about like the muscle, intend and think working locally, but then also think globally right. We don't want to be just so focused if it's a shoulder surgery just on the shoulder right. We also want to be thinking about scapulothoracic muscles. So local and global considerations are key. The second subset is nervous system offense. I think unless someone complains of numbness, tingling, and vague pain sensations, we kind of ignore the nervous system. But consider the nervous system is extensive, and our muscles, ligaments, bones, and tendons are all mechanical interfaces of the nervous system. So we can use the nervous system to promote intraneural healing and blood flow offensively. So consider using your nerve glides early more for tissue healing blood flow and intraneural nutrition. So thinking about it offensively prevention. In addition, consider central sensitization prevention, right? Again, this is a controlled trauma. And we know that folks who have surgeries or injuries are more predisposed to getting injured again. So consider that things like two-point discrimination training, laterality training, and pain pressure threshold are something we should both check on and possibly train if we see impairment side to side. And I'll tell you, in those initial early stages, that four to six weeks, there is definite nociceptive pain damage on board, but consider as we get towards the end, halfway through to the end of our care, we have to make sure central sensitization hasn't occurred in those tissues or become widespread. So check and then train if necessary. And then finally, the third subset of capacity rebuilding is functional pattern training. So consider we want healthy full body patterns. And what I mean by that is initially thinking of getting someone independent in their ADLs and IADL functions. Initially, they might need some assistance, but then eventually we want to normalize those patterns so they don't need any kind of assistance, whether that be a brace or an assistive device. And then we want to prepare humans not just for daily living, normal daily living, but think of job and sports demands. ultimately functional patterns will train those good functional patterns without assistance but then think about preparing for the unknown as well because things in life and sports will happen right maybe our older adult after total knee prepare for falls right think about our person after a meniscal repair like pray prepare for unstable landing. So that's what I mean when I say prepare for the unknown, right? Prepare for real life, which we'll do in a multi-segmental compound way. So to summarize, The five things. Tissue healing time frames. Two, educate your patients. Three, know the protocol and review it with your patient. Fourth, give a meds education for system-wide healing. And then five, think about how you're going to build up capacity in muscle, tendon, ligament, bone, nervous system, and then full body capacity. I wanna briefly take you through a total knee example, how we'll apply these five pillars, just so you can consider how you can apply this really to any post-operative condition. So let's think about someone with a total knee replacement, uncomplicated. TISSUE HEALING TIME FRAMES So tissue healing timeframes, considering just the timeline of care initially, it's gonna be anywhere from four to 12 weeks. And we're really usually seeing them right for those two to three months. letting the patient know, that that's a realistic timeframe. And that there are multiple things on board, right? We have an incision to heal, a muscle to heal, and then bone. And so that four to 12-week timeframe really encompasses that and lets that human know that this is just not a quick rehab process. POST-OP EDUCATION In regards to our education for someone with a total knee replacement, considering our first education strategies really need to be about signs of infection, right? And anybody postoperatively, this needs to be on board, but specific to this total knee replacement, right? If there is red, hot, and warm redness that is spreading outside of that incision. Here's where we make that circle around, we see that redness, and if it spreads outside that, that becomes an emergent thing that they need immediate medical assistance for. Consider letting them know the systemic temperature. If they're running a fever greater than 101 Fahrenheit, they need to, again, get to their doctor quickly. These are things we don't wanna mess with when we think about infection associated with the prosthesis. If there are dramatic increases in pain that are debilitating, another coinciding sign of infection. So that needs to be a part of our initial early stages of education. And then obviously we're educating about our HEP and its importance, but then we need to get into some of that nitty gritty of what facilitates healing. And I can't keep echoing Zach Morgan enough that we need to catastrophize rest, that letting that patient know that they shouldn't be sitting or laying around more than 30 to 60 minutes at a time. They need to keep moving so that systemic healing can happen. Giving them specific movement HEP parameters about exercise, and we'll talk more about the specifics on this in the med section for holistic wellness, but walking, a walking program, or cardiovascular program is crucial with someone with total knee replacement because we know of the underlying metabolic disease that coincides those. that are getting a total knee replacement. And then again, in our education bucket, expectations for recovery, which includes the protocol, and then just specific functional milestones. POST-OP PROTOCOLS That third pillar is protocol. When we think about our total knee replacement, there aren't the very hard and fast range of motion precautions we would have in like a meniscal repair. But there are some must-have range of motion milestones achieved, like in that first year to two weeks, things like there should be independent mobility and getting in and out of the home. That should be all independent or modified independent, right, where they're using an assistive device. In that two to six-week mark, they should be at zero degrees of knee extension, right, to promote that terminal knee extension in gait. Anywhere from zero to about 105 degrees of flexion is that goal in the first two to six weeks. around the five to eight-week mark, we should be progressing past 115 degrees of knee flexion. So using these as buoys and goals is something that we not only want to have in our mind but also help encourage the patient that these are like milestones we want to achieve to keep them progressing. And then when we're past that eight-week mark, we should really be close to within normal limits for range of motion. Now we know not every case goes perfectly like this, but these are overall goals. And by the end of our time in therapy, so think that 12-week mark and this is where you can really set up the patient, here's where we're headed, is a normal step through gait pattern, right? That doesn't require an assistive device ideally. Reciprocal stair climbing, step over step, unrestricted standing, and walking to complete life tasks. If this is an athlete, getting them back to their athletic demand because we do have some of our total knees are in fact, athletes. So don't hold them back if they are, but consider them for our everyday human that just wants to get back. Let's think about Betty getting back to her, taking care of her grandkids, and gardening. We need to make sure that she can get on and off the floor, that she can kneel on that prosthetic, and feel confident in that to get up and off the floor for her grandkids. So consider those timelines. when we think about system-wide healing for the person with a total knee. And this part also applies to anyone who's had a post-op or has had an operative condition. TAKE YOUR MEDS (MINDFULNESS, EXERCISE, DIET, AND SLEEP) Mindfulness, I already mentioned, right? Some kind of stress relieving strategy, whether it's breathing, journaling, or maybe it's just sitting or walking outside, but giving them something that kind of soothes the soul and the brain. Exercise. This is not just the HEP, right, working on specific impairments. It's not just about quad sets and straight leg raises. This is actually working through a walking program for someone with a total knee. You know, in the beginning stages, it might just be in phase one, working on a 10-minute walking daily. But then we want to eke our way to that 30-minute mark, right? Because we want to meet that minimum of 150 minutes a week of daily activity. Again, think about underlying metabolic disease. The person with a total knee replacement has to build up to this to help fight systemic implications. And so whether that is, ideally it is walking, getting their walking tolerance up to that, but it could also be biking. Think cycling and or swimming. Nutrition. So when we think about diet, that D in meds, we're thinking about nutrition that promotes healing. Make sure they're eating enough protein to heal that incision and help heal the trauma associated with the surgery. They're getting hydrated enough, half their body weight in ounces. that they're eating foods rich in collagen. Think bone broth, sardines, and organ meats, because collagen has been associated with improving healing. Things that are vitamin C rich. Think of citrus fruits like oranges which are cruciferous. Veggies like broccoli Brussels sprouts and tomatoes are another good source of thinking about vitamin C. Bromelain, eat pineapples. This helps reduce pain and swelling. Assuming this is okay with their doctor and nutritionist and their pharmacist, right, not interacting with any meds, all of these natural foods will help boost healing. So just giving that general knowledge, can be really helpful in the healing process. And then I already mentioned sleep, the importance of seven to nine, hours of sleep, giving sleep hygiene. And you can see past podcasts that talk about sleep hygiene tips, or even just message me and I'll send you some. But in the person with total knee, it's not just about how to get them to sleep better, but it's giving them some education like, don't put a pillow under your knee so your knee is flexed all night. And then you're fighting to walk into that terminal knee extension we've been fighting for with the quad set multiple times a day. If you're going to put a pillow under the leg, make sure that the knee is straight, right? Think about maybe talking to them about a wedge pillow so that they're elevating that limb above the heart to help with the swelling that is ongoing in that total knee replacement, but that doesn't put that knee in a flexed position. So when we're thinking about sleep hygiene for the person with total knee, it matters how you sleep, those positions of rest. and don't fall asleep with the ice machine on. This is asking for ongoing stiffness. And if it's cold enough, possibly even does some damage to the local skin tissue. So we don't want that. So, your education on sleep is a little bit different from that person with total me. REBUILDING TISSUE CAPACITY And then finally, because I'm running out of time, and this is a topic that is rich and I don't want to take any more, but capacity rebuilding after this last point. So think about, the muscle, tendon, bone, and nervous system. So when we think local, think about skin integrity and prescribing scar massage as soon as that incision is healed, really working on scar massage, think working along as a T and an X, and then specifically focusing on that distal one-third of the incision, it's going to be really paramount in care and getting that knee moving. For local exercise or local muscle, we're thinking of exercising the quads and hamstrings, right? For global, we're thinking above and below the knee. Think about working the glutes, glute max, glute med, but also your hip flexors and to work on your stairs, and then think below also your plantar flexors. For stair climbing and think ankle mobility for squats, When we think about nervous system offense, this is one where I think it's an untapped source, but for that intraneural healing and blood flow, think about using sciatic nerve glides for all that posterior tissue tightness and or those folks that actually have complaints, right, of pain going down the leg. Often it's a secondary result of just an antalgic gait pattern, but get them doing that early so that doesn't become a problem. Even some of our folks have some femoral nerve or saphenous issues. So think about doing some femoral nerve gliding if there are medial and lower leg issues, just that on-off pumping. And then in regards to preventing central sensitization, just consider checking and screening our two-point discrimination, our pain pressure threshold, and our laterality training as we get further out in our rehab and closer to discharge to make sure that this isn't impaired. And if it is, then we train it. And then finally our functional pattern retraining for someone with a total knee. We in the early stages will teach them in a modified way to be independent in their ADLs and IEDLs. But then we wean off of that, right? We want to normalize their gait pattern. Think we go rolling walker to cane to independent ambulation. Even in our sit-to-stands, initially, we'll allow that kick out, right, when someone's going to sit down, but eventually, we want them to use that knee flexion. So we'll have them keep that leg in place and no longer kick out that leg. So consider a functional pattern changes throughout the healing process, but eventually, no matter what, we build up. squat pattern, deadlifts, we prepare for falls by fall training and we prepare for that human to kneel as soon as that incision is healed and they feel comfortable. This is how we train in a multi-segmental way for life after total knee I have usurped my time on the PTL Night Show 21 minutes in. So this is just one small example of someone with a post-op extremity condition and how you can approach it in a fitness-forward way using the five-pillar framework. No, in a total knee, there are minimal precautions, but there are a little bit more precautions on board in other conditions. I appreciate how you can apply this in both the upper and lower quarters. Join me in a month, the day after Christmas actually, to talk about post-op incision management. I appreciate all your time to listen today about a fitness-forward approach to post-op care. Happy Clinical Tuesday, folks! OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 13, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore describes pelvic varicosities & varicoceles. Rachel breaks down the difference in how these present in both male and female pelvic physical therapy patients as well as how to conceptualize treatment in the clinic. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. RACHEL MOORE All right, good morning PT on ICE Daily Show my name is Dr. Rachel Moore I am here this morning. It is Monday morning. That means it is our pelvic day here on this podcast So I'm here with the pelvic division and I am super excited to talk to you guys this morning We're gonna be kind of diving into varicoceles and varicosities, vulvar varicosities, and the way that those are actually incredibly similar in our treatment approach, whether we realize it or not. Before we dive into that though, if you missed it, we've officially rolled out all of our certifications here at ICE. So we have certifications, we've had them before in the clinical management of the fitness athlete division and an MMOA, but now we have new ones. So we have orthopedic, we've got dry needling, we've got an endurance athlete, and then what we are super excited about in the pelvic division is we have our pelvic cert as well. So this is three courses, two online, a level one and a level two, and then one live course. If you're looking to get in on that certification, our upcoming courses, we actually have one this weekend in Bear, Delaware. That's going to be with myself and Alexis Morgan. So super excited about that. Still, time to hop into that if you want to buy yourself a plane ticket and get out there. And then we also have one on December 2nd. If you are north of the US border in Canada and Halifax, Nova Scotia, Christina is bringing those live courses to Canada. So we're super excited about that. Our next L1 cohort kicks off January 9th, and then our L2 you can already sign up for. So if you want to be in that first cohort of that L2, it kicks off April 30th. So if you're interested in getting that cert, all of the options are out there. Hop into one of those courses. We're excited to see you in them. VARICOSITIES AND VARICOCELES Let's dive into our topic for the day. So a lot of times those of us in the pelvic space if we are maybe majority see women a lot of us tend to maybe start there and then maybe branch off into seeing men but if we are in this kind of blinders-on situation where we're like no no I only see women sometimes we may be uncomfortable or unsure if somebody gives you a call and asks about a certain diagnosis or maybe you have a friend or somebody that you know that is struggling with something and asks for advice on the pelvic space and you're trying to figure out how to get them into your clinic. And so I wanted to draw a parallel this morning between two diagnoses that we see as fairly common that actually are very similar in the way that we treat them. So that is going to be varicoceles and varicosities. So in utero, the reproductive tissues of males and females begin developing similarly. If you guys remember that from PT school, when we were learning about the brief amount that we cover these types of topics, once testosterone starts being released, that's when the reproductive organs shift and either develop into male organs or continue on the path of female organs. And so if the testosterone is there, then the tissue that is becoming the scrotum becomes the scrotum. But if the testosterone is not there, then that tissue continues on to turn into the labia. So when we think about our tissues and our anatomy, we often talk about how male and female anatomy really aren't that different. It is similar parts arranged differently and maybe to different sizes and proportions. But when we look back all the way in utero, we can see that developmentally these things start the same and there's a certain point where things branch, but we have these kind of analogous, um, uh, tissues within males and females. So, We know that the tissues are similar between the scrotum and between labia. When we're talking about varicosities, this is important for us to know because these are two diagnoses that we tend to see come up fairly frequently. VARICOSE VEINS IN THE PELVIS So before we dive into the specifics of varicose veins in the pelvic area, let's talk about what varicose veins are. Varicose veins, if you're not familiar with them, are enlarged twisted veins. So oftentimes this comes from damage to the valves in the veins. So our veins have one-way valves that help push blood up and prevent backflow back down. If there is damage to the inside of the vein and the valves are damaged somehow or maybe are not operating at the capacity that they need to be operating, we can see kind of a backlog of blood and that can lead to this kind of inflamed or swollen look to the veins and that blood just kind of pulls in there. The causes of the damage, quote-unquote, Inside of the vein can be known. So this can be something like high blood pressure or it can be unknown Things that increase your risk for developing varicosities are gonna be things like being female So that's always fun when gender is one of the top things can't control for that genetic predisposition so if you have a family history of varicosities then this might be something that you're really keeping an eye on and older age as we get older maybe those valves within the vein become a little bit less competent increased body mass and then in pregnancy we'll dive into that here in just a second and then also interestingly having a history of blood clot that's really important to kind of keep in mind on our radars not only in our post-surgical patients but we're starting to see blood clots kind of popping up more and more um and so if you have somebody who might be not hitting any of these other risk factors but has a history of blood clots it's still something that we want to kind of keep on our radar varicose veins aren't a medical emergency by any means but they can cause some like uncomfortable unpleasant symptoms like heaviness aching pain and then swelling. VARICOSITIES Let's dive a little bit deeper into varicosities of the pelvic region so in our biologically female counterparts we see vulvar varicosities this is varicosity that develops on the vulva so anywhere along the outside of the vagina so that tissue of the vulva It can happen on labia majora, labia minora. It can be going towards the inner thigh, more into that groin area. Really just kind of depends on the area that is affected. The risk factor for this specifically is pregnancy. So we see this come up in pregnancy for a few different reasons. One reason is that we have an increase in blood volume during pregnancy in order to support the baby. So that increase in blood volume means that our veins have to work harder to push more blood up. we also know that we see relaxin circulating and that does have an effect on all tissues and then we have an increase in pressure so we have increased pressure from both the weight coming down of baby placenta amniotic fluid and all the things but then if we also think about like the anatomy of a pregnant belly as people progress through pregnancy get into this maybe anterior pelvic tilt their belly maybe drops low it can cause some congestion or some backup within that system which then leads to less efficient drainage. This is something that we see pretty often in the clinic really and you might be familiar with this if you're in the pelvic space. but what we tend to not really think about is how this parallels varicose seals. So a lot of times we're pretty confident and comfortable with vulvar varicosities, but then somebody comes in with a little bit different anatomy, and we kind of get thrown for a loop. So a varicose seal is a varicose vein that's located within the scrotal sac. This can actually develop during puberty because blood flow to the genitals increases during puberty. As those tissues are maturing things can just get a little thrown off, but it can also happen as a result of surgeries So think about vasectomies even though those are like minor office procedures surgeries vasectomies or trauma to the scrotum They're surprisingly common, especially in the adolescent puberty side of things. And just because you have a varicocele doesn't necessarily mean you'll even know it, aside from feeling it, potentially. So the biggest way or hallmark of this is called the bag of worms. because within the skirt sack that varicocele feels like a thick ropey worm and so as people are feeling around checking testicles for different things then you might feel that bag of worms type sensation or that that feeling with your fingers and other than that you may not have any idea However if you have a varicose seal that is causing problems We can see swelling pain and heaviness as I talked about earlier and if this is left alone and becomes severe it can actually impact fertility in men because it can lead to decreased sperm in the ejaculate and so it can be something that if it happens in adolescence and somebody is trying to conceive later on in life with their partner and they're struggling, it's an area to look at. Just like vulvar varicosities, we see an increase in symptoms when we're standing for prolonged periods, but uniquely to this population, we can see potential pain with ejaculation. So with vulvar varicosities, we might see pain with intercourse because of the pressure on the outside of the vulva during intercourse. But with this population, it's going to be more so during ejaculation that there is pain. WHAT TO DO ABOUT VARICOSITIES AND VARICOCELES We have our person in front of us, male or female, who comes into your clinic, some varicosity of some sort going on. What are we supposed to do? Jess actually did a really fabulous episode on this topic. It's episode 1198, so if you want to go back and listen to that, she talks specifically about varicosities during pregnancy, and those same concepts can be applied to varicoceles in men. So I highly recommend giving that a listen. We're going to dive in just really briefly touch on some of those topics and then I'll let you guys really dive into justice. External support can be a game changer for these folks, especially those with varicose heels whose anatomy is already putting things in a gravity, um, disadvantageous position for drainage. So giving some type of support, whether that is like when you're getting up and moving using your hand to support or getting some type of support garment. There are specific support garments that are made both for males and females for varicosities. soft tissue massage and when we think about this we're really thinking like mimicking lymphatic drainage I talk about this all the time with breast tissue and engorgement but the same thing we're thinking about this like congestion within the pelvic region and so we want to think about clearing more proximally up Towards the iliac vein so that we can kind of promote that drainage and then work our way down Rather than coming down to the bottom and just shoving everything up and causing more congestion Superiorly, so we're starting closer to the midline Draining quote-unquote that area. So if you're watching on Instagram, we're saying we've got a guy in and he's got varicose heels maybe we're starting here and then we're working lower and then working lower and until we get to that most distal tissue. From an exercise intervention standpoint, the pelvic floor muscles, of their functions are a sump pump. So when they contract and relax, they push fluid out of areas. So teaching our patients how to do pelvic floor contractions, how to lift up and contract into the attic, relax down and go into the basement, get that pumping mechanism going, and then teaching them belly breathing on top of that to help facilitate that as well. Finally, from a positional standpoint, we can have our patients if at the end of the day, they're super symptomatic and they're feeling rough after being on their feet, laying on their back, propping their legs up on the couch, or on a wall to get some passive decrease in gravity pressure on the pelvic region, and we can even take that a step further, have them plant those feet on that surface and do some bridging where they're squeezing their glutes, maybe adding in that pelvic floor contraction, layering that in, so we've got gravity coming down, we've got our muscles contracting and relaxing, really everything helping to push that fluid up and out into the drainage system to go bring that blood back to the heart. So, if you have somebody come in your clinic tomorrow, and you are a pelvic floor PT who traditionally treats females, and a guy walks in and he's like, I have a varicose seal, I don't know what to do. I hope that you can put your cap on, thinking cap on, and realize like, you got this, you know what to do. At the end of the day, we have to remember that our males and our females, although the anatomy is arranged a little bit differently, and proportions are a little bit different, they are similar tissue. So keep that in mind. You guys are rocking it out there. Have a happy Monday. Thanks for having me. Bye. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 10, 2023

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance of cadence in running, variables that may affect a runner's cadence, the relationship between cadence & speed, and finally the "optimal" running cadence. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. MEGAN PEACH, PT, DPT, OCS, CSCS Alright, Instagram. Here we go again. YouTube, we're on. Okay, finally. Sorry about that a couple minutes ago. I think I actually got it to work this time. Okay, we are live on Insta. We are live on YouTube. I am Megan Peach, probably the most technologically challenged person next to Jason that we have in this community. So, I apologize for the previous live feed that didn't actually work. Again, I'm Megan Peach and this is PT on Ice, your daily show. I'll be your host today. I am one of the lead faculty for the endurance division and specifically in the injured runner course, both the live and the online courses. And although our courses have wrapped up for this year actually, We are super looking forward to next year. Over the next couple of months, Jason and Rachel and I are basically doing like a big revamp of Rehab of the Injured Runner online. And so that course is going to look entirely different come January than it does right now. If you haven't taken that course and you've taken the live course already, or even if you haven't taken the live course, this is going to be a great time to hop onto that course, just because the material is going to be really complimentary to the live course, even more so than it has been in the past. And then if you have taken Rehab of the Injured Runner online already, it will be a really good time just to check in because it's going to look entirely different in terms of the material and what's in there. Remember, if you've taken that course already, you have lifetime access for as long as that course exists. And so check in with us in January for a full revamp, full update. We're super excited about it. RUNNING & CADENCE Okay, so to get to today's topic, I wanna talk about cadence. And cadence is something that I think if you treat injured runners at all, if you have in the past or you've taken one of the courses, This is a topic that's pretty familiar. It's a running gait retraining tool that we use probably more than any other tool that we have in our gait retraining toolbox. And it's used for a variety of different injuries. We could use it globally for injuries like patellofemoral pain or IT band syndrome. exertional compartment syndrome. There are even prospective studies that have looked at healthy runners and the risk factors for their injuries. And they've seen that low cadence is a risk factor for things like bone stress injuries, things like medial tibial stress syndrome. So we can use it not only to treat injuries, but then potentially as an injury prevention tool as well when somebody has a really low cadence. And then we can also use cadence retraining as a way to treat really specific gait abnormalities or mechanical faults after we've done a running gait analysis. And so typically when we are using cadence as a gait retraining tool, we're increasing the cadence by at least 10%, at least that's the goal typically. And when we increase somebody's cadence, what we typically see are first, changes at the knee joint. At least those are the most prominent changes that we would see in a runner. And the changes we see at the knee joint are things like increased knee flexion at initial contact. We see a decrease in stride length, or a decrease in foot to center of mass, in terms of where the foot falls in relation to the center of mass. We also see changes at the ankle joint, not as prominent as the knee, but we still see them there. We see with an increase in cadence, we see a relative increase in plantar flexion. So whereas we might see a lot of dorsiflexion with a very slow cadence, we see relatively less or more plantar flexion as that cadence increases. Or you could look at it as less angle of inclination as well. We also see changes at the hip. Again, not as prominent at the knee, but they're still there. With an increase in cadence, we will see increased hip flexion also at initial contact. Not only do we see kinematic changes, but we can see kinetic changes while somebody's running as well. And so some of the kinetic changes that we'll see are decreased vertical loading rate with an increased cadence, as well as decreased vertical center of mass, which can then translate to decreased overall loading for that runner with each foot strike. And so while some of those kinetic variables aren't always accessible to us in a clinical setting, typically they're just lab-based variables. we can still use cadence retraining and still make some of those assumptions that it is going to affect some of those kinematic variables as well. So we can not only use cadence as a gait retraining tool to treat specific injuries, we can use it to treat kinematic variables, but we can also use it to treat kinetic variables. VARIABLES INFLUENCING HABITUAL CADENCE What I want to talk about and spend the rest of the time today talking about is some of the variables that might influence somebody's habitual cadence that we don't normally discuss or sometimes don't even consider when we are using cadence as a gait retraining tool. And so somebody's habitual cadence, it just means that the cadence that they're running at normally, without any outside influence, without anybody saying, you should run at this cadence, or you should run at this cadence, or you should increase your cadence. It's just their normal everyday cadence that feels good to their body. And so some of the variables that might influence that are leg length, running experience, BMI, as well as speed. So leg length plays a role in that somebody with a shorter leg length, typically has a faster cadence, and somebody with a longer leg length typically has a slower cadence. Okay, now there's obviously a very wide range of a spectrum there in terms of cadence and leg length, and so these variables are typically related to cadence only at, or I guess more strongly, at the ends of the spectrum. So somebody with either very short legs or very long legs their cadence is likely a little bit more related to their leg length than somebody whose leg length sits kind of right in the middle or maybe that like middle 50% range. And so none of these variables are going to apply to everyone, obviously. The next one, so running experience can play a part as well. Somebody who has less experience running, so like a novice runner, typically has a slower cadence. I've definitely found this to be true in clinic versus somebody who has a lot of experience running or who is a very high level runner, maybe even a professional runner, typically has a very high cadence, upwards of mid 180s, upper 180s, maybe even low 190s, depending on that runner. I've definitely found that variable to be true within clinic, but again, Take that with a bit of a grain of salt because the ends of that spectrum in terms of novice versus experience tend to ring more true with a relationship with cadence than the middle of that spectrum for experience. BMI can also play a role in that somebody with a greater BMI tends to have a slower cadence versus somebody who has a lower BMI tends to have a bit faster of a cadence. That one, clinically, I really can't speak to that one, but that's what's in the literature. SPEED & CADENCE All right, and speed is the last variable that I wanna talk about because I think intuitively, we know that speed is related to cadence, and that's true to a certain respect. And intuitively, if we think of as somebody speeds up their pace, then their cadence is going to speed up as well. And that's true, but only to a certain extent and really only to higher speeds. And so for most people, their cadence is going to speed up only as they approach sprinting or a very, very fast run. And so when we think of speed and we think of running pace, We have two different strategies that we can use to increase our running pace or our speed. And one of those strategies is to increase the stride frequency or increase the cadence. So we increase the number of times our legs turn over, and that alone can increase the speed. The other strategy to increase speed is an increase in stride length. So rather than increase the stride frequency, we can also increase the stride length. And when we increase the stride length independent of any other changes, we can actually increase the speed even when we're maintaining the same stride frequency or cadence. So if we are using these variables independently and considering them independently, most humans are going to take the stride length strategy first up until they get to a point where they're almost sprinting. So a very fast run, a very high intensity run. And at that point, then they're going to employ more of a stride frequency or a cadence tactic to increase their running pace or running speed. So let's think about when you have an injured runner on a treadmill and you're choosing to use a cadence gait retraining tool to address either their running-related injury or certain gait mechanics, and you get them back on the treadmill, and you're having them run at their 6.0 mile per hour, whatever they did their running gait analysis at, and you say, okay, I want you to run at this new cadence, and you've increased their cadence, and now you have it on a metronome, and you put the metronome on the treadmill, and they hear that click, click, click, click, click when they're running, and the first thing they do I think you've all experienced this. If you have treated injured runners before, the first thing they do is that they increase the speed on their treadmill, right? So why we don't want them to do that is that if they increase that speed on the treadmill, chances are they're also going to employ this increased stride length strategy to increase the speed. They may also increase their cadence as well, but we have to remove some of those variables. If we keep them at the same speed that they did their running gait analysis, which should be a fairly comfortable speed for them, something they would run just an easy run, or even a moderate run, but let's say we have to keep them at that same speed that we use for the running gait analysis while we're using that increased cadence, then they have no choice but to increase the cadence rather than increase their stride length. We don't want them to do that. If they increase their stride length by increasing the speed on the treadmill, what's going to happen is that they're likely going to reach out further, meaning they're going to increase their over stride, which is definitely a variable we don't want to influence negatively. We want that over stride to reduce. They may get increased knee extension at initial contact, which again, not a gait mechanic that we want to encourage. We want to encourage more knee flexion at initial contact. We also want to encourage more or less dorsiflexion at initial contact, more plantar flexion, relatively speaking, which is likely also going to increase in the negative direction if we increase the stride length by increasing the speed on the treadmill. All of these variables are very much related in terms of the gait mechanics and the speed of the treadmill and which strategy they employ to actually increase that running gait speed. But if we take out the speed component and just leave that pace at the same pace on the treadmill, then they have no choice but to then change their cadence to match the cadence that you've chosen. And in turn, what we're hoping to see is a positive change in their gait mechanics. "OPTIMAL" CADENCE" Now we often get a question in both courses of what's the optimal cadence for a recreational runner, and really there isn't like a set in stone, everybody's gotta run at this cadence. It's a range, anywhere from mid 170s to mid 180s is typically what we kind of range for for a recreational runner. It may go higher than that. For a more experienced runner, I find that they can tolerate higher cadences, for a very novice runner, generally sometimes they don't even tolerate like a mid 170s and so although it might be a goal, it's something that we may have to work up towards in the future and with different gait retraining strategies. Okay, so I hope that helps. I hope that clears things up for some cadence questions that we commonly get in both the rehab online and the rehab of the injured runner live. I hope you have an awesome Friday and a great weekend and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 9, 2023

Dr. Christina Prevett // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE faculty member Christina Prevett emphasizes the crucial role of understanding statistics in making clinically relevant decisions. While staying up to date with the literature and being evidence-based are often emphasized in healthcare, Christina points out that it is not enough if one lacks the ability to comprehend the meaning of statistics and their application in a clinical setting. Christina acknowledges that interpreting statistics can be challenging, even for individuals with a PhD and experience in the field. This understanding leads the host to empathize with clinicians who may find statistics intimidating. It is recognized that being evidence-informed and evidence-based requires clinicians to possess the skills to understand and interpret the data they encounter. To make statistics more clinically relevant, Christina suggests utilizing systematic reviews and meta-analyses as tools for interpretation. Specifically, she delves into the interpretation of a forest plot, which graphically represents the results of a meta-analysis. By understanding how to interpret and analyze the data presented in systematic reviews and meta-analyses, clinicians can determine if the findings are significant enough to drive changes in their practice. Christina also highlights the importance of considering clinical relevance when interpreting statistical findings. The concept of the minimum clinically important difference (MCID) is introduced, which refers to the smallest change in an outcome measure that is considered clinically meaningful. An example is given of a statistically significant improvement in a timed up-and-go (TUG) test, but it is explained that it may not be clinically relevant if it does not meet the MCID for the TUG. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. CHRISTINA PREVETTGood morning everybody and welcome to the PT on ICE daily show. My name is Christina Prevett. I am one of the lead faculty in our geriatric and pelvic health divisions. So usually you're seeing me on Monday and Wednesday, but today I'm putting on my PhD research hat to talk a little bit about statistics, which I know sounds really boring, but I promise I'm gonna make it really exciting. But before we do that, we have a couple of courses that are coming up across our divisions. So MMOA is in Wappinger's Falls, NY this weekend. Extremity Management is on the road in Woodstock, Georgia. And Cervical Spine is heading to Bridgewater, Massachusetts. And so if you are looking to get in some Con Ed before the end of the year, we still have a couple of opportunities across all of our different divisions. And so I encourage you to go to ptinice.com and take a look at some of those opportunities. Okay, so a little bit about my kind of hat outside of working with ice is that I recently finished my PhD at McMaster University at the end of this year. I just announced that I'm doing a part-time postdoctoral fellowship at the University of Alberta looking at resistance training and its interaction with pregnancy and pelvic floor function. BUMPING INTO STATISTICS What that means is that I am bumping into statistics all the time. And I'm going to like kind of start this off and say, I've been asked to do some webinars and things around statistics for the ice crew for a while. And to be honest, it's been really intimidating for me to do that, despite the fact that, you know, I have a PhD and I'm interacting with this stuff all the time. Um, statistics is hard and, you know, discussing statistics in a way that makes sense is also challenging. And when I reflect on that and the fact that you know, I feel uncomfortable sometimes with interpretation and you know, I did a part-time PhD for seven years and I'm in a postdoctoral position. I recognize how challenging it can be for clinicians. And, you know, we get told all the time, like, you know, stay evidence-informed, like it's important to be evidence-based. It's important to stay up to date with the literature. But your ability to stay up to date with the literature is only as good as your capacity to understand what it is trying to tell you. And I mean that in the best way possible, that it is so tough for us to gain insights from what the statistics mean into what is clinically relevant for us to understand and be able to bring into our clinics. So today I'm trying to take our statistics and make them clinically relevant to you. SYSTEMATIC REVIEWS WITH META-ANALYSIS One of the first ways that I want to do that, and if you like this type of podcast please let me know, and I'll do more, is around the systematic review and meta-analysis and then trying to kind of deep dive into interpreting a forest plot. So when we're thinking about a systematic review, this is the highest level of evidence when we have a systematic review of intervention or prospective studies. When we take a systematic review, we ask a very specific question. And I'm going to use the example, I'm working on a systematic review right now on resistance training and pregnancy. And I'm going to take some of that to make this relevant to how this happens. This is where we're trying to get an idea of the state of the literature. So we use a PICO format, which is the population that we're trying to look at. So in this case, it's individuals who are pregnant. The intervention is what you are trying to see if there's a positive or negative benefit or whatever that exposure may be. And that for me is resistance training. The comparison group is to usual obstetrical care. And then the outcomes, we are looking at fetal delivery, pregnancy, and pelvic floor-related outcomes. So we're looking at the investigation of resistance training on incidents of gestational hypertension and preeclampsia, gestational diabetes, rights of cesarean section, the size of babies, and babies more likely to be too big or too small. What does their birth weight look like? How long are they pregnant? And then are they at increased risk for things like urinary incontinence, pelvic organ prolapse, diastasis recti, or pelvic girdle pain? So that's kind of the format of a systematic review we're trying to answer a very specific question. From there, we go to the literature and we want to make sure that we encompass as much literature as we can. in our search strategy. So that is usually why you'll see a list of PubMed and OVID, CINAHL, Sports Discus, like these types of different big searching platforms that are looked at. And then you're going to get a Prisma plot that you're going to see in the first figure. And that kind of describes a person's search strategy. So how many hits were given when this search was done? How many were excluded because of duplicates? How many were excluded from the title and abstract because they were done in rats instead of in humans? Or they were looking at an acute effect of resistance training versus being on a resistance training program like you're going to have a lot of those that are excluded. And then you're going to have kind of what is included in your systematic review, and then what is included in your meta-analysis if a meta-analysis is indicated or possible. When we're looking at a systematic review, we're looking at a qualitative synthesis. And what we mean by that is that we're trying to figure out, you know, where the state of the literature is. And when I'm reporting on something like the systematic review portion of a paper, You're seeing things like, you know, how many studies were done in resistance training in pregnancy? How long were those interventions? Were they done in the same cohort of individuals? What was, how many of them were statistically significant? What was the dosage of that intervention? Those are things that kind of come under the systematic review umbrella. But I would say really now the emphasis is being placed on the meta-analysis and that is the quantitative combination of these studies and that is what gives us this forest plot. So when we are going through and doing a meta-analysis, there are a couple of things that we need to make decisions on very early on. So the first thing is on a random or a fixed effects model. This is kind of getting into the weeds, but almost all papers are going to be a random effects model, which means that we're going to expect some variability in the population that we are working with, and we're going to account for that variability in the calculations that we're using for our forest plot. PRIORI SUBGROUP ANALYSES The second thing that we are looking at is a priori subgroup analysis. And so I'm going to use my research study to describe this. Before going into this meta-analysis and putting this forest plot together, we have to brainstorm around where possible sources of skew or bias would come into a forest plot. For example, in the resistance training intervention, it would be very different when we have resistance training in isolation versus resistance training as a component of a multi-component program. And so one of our subgroups analyses a priori we discussed was that we were going to subgroup studies that were only resistance training compared to our big meta-analysis, which included our resistance training in isolation or as a multi-pronged program. Another example in our systematic review is that some of our studies were on individuals with low risk at inception into the papers versus those that were brought into the study because they were diagnosed with a complication like gestational diabetes. we could think that the influence of resistance training on a person who has not been diagnosed with gestational diabetes versus those who have could be different. And so we did a secondary subgroup analysis where we looked at the differences between studies that looked at only individuals with gestational diabetes versus those that didn't. And so when you are looking at a forest plot, you will see the big analysis at the top, including all of the different studies. And then after that, you will see different subgroups where there's a repeater of what was in the main group, but it's a subsection of the included studies. And that's what we see. And then we try to see, you know, is resistance training and isolation positively associated with a benefit? versus multi-component or is there no difference and that gives us a lot of information too? So that's that subgroup analysis. Then you go into the results of the paper and there is a forest plot that is there and this forest plot has a bunch of different names of studies It has the total number of incidences and the weight. It has a confidence interval with a number around it. And then on the right-hand side, there's like dots with lots of lines and then a big thick dot at the bottom. I'm trying to explain this to our podcast listeners so that you can kind of understand. And I hope you're kind of thinking of a study in your mind that you have seen in the past. But we're going to kind of explain each of these different things. Okay, so when we're looking at what we are trying to find, it is going to depend if we are looking at a dichotomous variable like did gestational hypertension get diagnosed or not? And if it is a dichotomous variable, what we're looking at is an odds ratio with a 95% confidence interval. So if we are thinking that no difference between usual care and resistance training is one, then a reduction in risk for gestational hypertension with resistance training would be an odds ratio that is less than one. When it is less than one, it becomes statistically significant when the 95% confidence interval encompasses all numbers less than one. When the confidence interval, say for example, our odds ratio is 0.8, we can say that there is a 20% reduction in risk, because a one minus 0.8, of getting gestational hypertension because of resistance training. I'm making these numbers up. But that is only statistically significant if the confidence interval is 0.7 to 0.9. then we can say there's a statistically significant reduction in risk for gestational hypertension with resistance training in this systematic review of this meta-analysis. Where we cannot say it's statistically significant is if the odds ratio is 0.8 and the 95% confidence interval is 0.6 to 1.2. That crossing of one means that there is a higher likelihood that there is that variation is because of chance and not because of a true difference. And so what you see is that when you're looking at the odds ratio, the combination of all of those odds ratios from the individual studies are then pooled in that bolded line at the bottom of the forest plot to give us the confidence that we have based on all of the studies combined, that there is a true effect of resistance training in this example on gestational hypertension. I-SQUARED HETEROGENEITY The other kind of statistic that we're looking at is the I-squared statistic or the amount of heterogeneity. So when you're looking at that forest plot and you're seeing all the dots and those lines, the heterogeneity is basically saying how close are those dots? How much spread is there in those dots? And so if the heterogeneity is low, we can say that not only did we have a statistically significant result, but across all of the studies, we tended to see a trend in the same direction. So it allows us to have more strength and confidence in the results that we are getting. If we see a high amount of heterogeneity, so like there are some that are like really favoring control and saying that resistance training is bad for gestational hypertension, and then some are having really positive effects of gestational hypertension on resistance training, that I square statistic would be high, and then we would probably have to be doing more evaluation, and that's where we would rely really heavily on the subgroup and say, Well, is there certain subpopulations of this group that are skewing the data in one way or the other where their results may be different than the results of other individuals? And so that gives us a bit more information. So the odds ratio is when we're looking at the presence of an event and it's a binary variable of yes, this exposure exists or no, this exposure didn't. When we are looking at continuous variables, we are looking at like a time on an outcome measure, like the time to up and go, we are looking at a mean difference score between resistance training and a control. So the mean difference is going to be in the measurement of the outcome measure that we are looking at. So the target would be seconds. So then from the pool, it would be plus, Six seconds or mine I guess minus six seconds would be in favor of resistance training and that your tug score is six seconds less in a resistance training arm than a control arm or if it goes against resistance training it would be plus six and Again, we're looking at that 95% confidence interval. That average, that mean difference is also something that we would push against what our clinically relevant difference is. So we may see something that's statistically significant at a two-second improvement, but we know that the MCID for the TUG is four seconds. So while yes, it's statistically significant, it may not be a clinically relevant finding. So that's kind of where we build in clinical relevance. And then again, we look at that 95% confidence interval, see what that spread looks like, and look at that I squared statistic. Where it gets a little bit more complicated is when we have things that are measuring the same thing, but measuring it in a different way. So an example in the systematic review that I did on resistance training and lower extremity strength is that there are a lot of different ways for us to measure lower extremity strength. Some people may use an estimated one rep max, and Some people may use a five-time sit-to-stand as a conduit for functional strength training. Some people may use a dynamometer for knee extensor strength. There's a lot of different ways for us to do that. We can still do a meta-analysis on this, but what we have to do is transform all of those variables into one type of measure. And that's when we would see something called a standardized mean difference, an SMD. And in that SMD, we're essentially taking the impacts of all these different types of measurements that are telling us the same information and putting it into an effect size. And so the effect size gives us the amount of confidence that we can see in the influence of the intervention resistance training on the outcome of lower extremity strength. So an effect size using Cohen's d statistic would be that less than 2 is no effect, 2 to 5 is a moderate or minimal effect, 5 to 0.8 is a moderate effect, and 0.8 and above is a large effect. And so in my systematic review on lower extremity strength and resistance training in individuals with mobility disability, we saw a standardized mean difference of 3, which means that we can be really confident there was a large influence of resistance training on the development of lower extremity strength. So kind of pulling this all together, I know I threw a lot at you. When you were looking at the forest plot, you were looking at trends in the data that are pooling all of the different intervention studies, looking at the same construct and looking at the same outcome. When we are looking at the odds ratio, this is a binary variable. There's going to be a 95% confidence interval. And the pooled odds ratio that we look at with respect to making decisions is that bolded number at the bottom. Our I-squared statistic gives us an idea of the spread of the data and the results that we see. When we are looking at continuous variables, you're going to see either a mean difference or a standardized mean difference. The mean difference is reported in the measurement of the outcome measure that we're talking about. So it could be seconds, it could be points. A standardized mean difference is an effect size where we are transforming multiple different outcome measures into one output that's pooling these things together, but we have to do it in a standardized metric that looks at the magnitude of the effect of that outcome. So how do we think about this clinically? Well, the first thing is that we need to understand where these effect sizes are and if they are significant. And then we have to put it through the filter of, is this clinically relevant? When we have something that isn't statistically significant, the next thing to do is go into the methods and say, you know, was this dose appropriate? Was this done in the way that I would do this? And can I be confident that the interaction between what I would do in the clinic and what was done in these studies is significant enough for me to drive changes in my practice? All right, I hope you found that helpful. I'm at 18 minutes, I knew I would. But if you have any other questions about statistics and how to interpret them, please let me know. It's really important that we know how to understand the data that we're being presented with because that's how we're gonna change our clinical decisions based on what we are seeing. All right, have a wonderful afternoon, everyone. I promise hopefully I didn't stress your brain out by talking about math too much and hopefully, this was helpful and we can do it again sometime. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 8, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment. Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum. Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels. She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame. Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we're gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don't need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you're interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you'll see is slightly less because we are making it equivalent to the Canadian dollar. So if you're wondering why that course is at a different price, it's because we're creating an equivalency to the Canadian dollar. And so if you're interested in catching us before the end of 2023, those are your last two opportunities. EXERCISE IN THE PREGNANT & POSTPARTUM SPACE Okay, let's talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don't have an abundance of literature. And I made the argument that it isn't. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who's looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I'm gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn't doing CrossFit at that time so my body was not used to the impact of running and So I didn't feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn't feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn't do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn't get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I'm sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don't have any evidence to say that Riding a horse is bad, but we just don't want to minimize the risk of falling But here's the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones. BECOME A PRO AT PUSHING THE BOUNDARIES As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals' risk tolerance may be different than ours. And I'm talking about kind of pushing the extremes of exercise, but I'm also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You're going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it's the same thing. THE RISKS OF NOT EXERCISING DURING PREGNANCY Our division is adamantly against the six-week blanket statement that we shouldn't be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it's going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it's important for us to be able to make informed decisions, which includes the fact that early movement, and I'm not talking exercise, I'm talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that's something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they're at. REFRAMING RISK TOLERANCE And so why is this reframe around risk tolerance so powerful? we don't have a movement problem, which means that we need to push our recommendations within a person's risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person's risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don't have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients' wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don't know to the yes within these kinds of buoys or navigational obstacles that we're going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we're asking it to do. It doesn't it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there's obviously some big risks or red flags, we are going to educate on that. But most of the time, it's our own discomfort because their risk tolerance doesn't match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client's perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can't believe I'm already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client's, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don't have any justification for that kind of shifting or that moving away from a person's own tolerance zone. And I really challenge individuals to not make individuals feel bad. There's a lot of shame in the perinatal space that is unfounded. And I think it's really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It's a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We've been fielding questions. We just love the interest that we've seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will talk soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 6, 2023

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment. Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum. Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels. She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame. Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we're gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don't need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you're interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you'll see is slightly less because we are making it equivalent to the Canadian dollar. So if you're wondering why that course is at a different price, it's because we're creating an equivalency to the Canadian dollar. And so if you're interested in catching us before the end of 2023, those are your last two opportunities. EXERCISE IN THE PREGNANT & POSTPARTUM SPACE Okay, let's talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don't have an abundance of literature. And I made the argument that it isn't. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who's looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I'm gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn't doing CrossFit at that time so my body was not used to the impact of running and So I didn't feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn't feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn't do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn't get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I'm sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don't have any evidence to say that Riding a horse is bad, but we just don't want to minimize the risk of falling But here's the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones. BECOME A PRO AT PUSHING THE BOUNDARIES As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals' risk tolerance may be different than ours. And I'm talking about kind of pushing the extremes of exercise, but I'm also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You're going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it's the same thing. THE RISKS OF NOT EXERCISING DURING PREGNANCY Our division is adamantly against the six-week blanket statement that we shouldn't be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it's going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it's important for us to be able to make informed decisions, which includes the fact that early movement, and I'm not talking exercise, I'm talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that's something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they're at. REFRAMING RISK TOLERANCE And so why is this reframe around risk tolerance so powerful? we don't have a movement problem, which means that we need to push our recommendations within a person's risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person's risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don't have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients' wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don't know to the yes within these kinds of buoys or navigational obstacles that we're going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we're asking it to do. It doesn't it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there's obviously some big risks or red flags, we are going to educate on that. But most of the time, it's our own discomfort because their risk tolerance doesn't match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client's perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can't believe I'm already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client's, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don't have any justification for that kind of shifting or that moving away from a person's own tolerance zone. And I really challenge individuals to not make individuals feel bad. There's a lot of shame in the perinatal space that is unfounded. And I think it's really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It's a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We've been fielding questions. We just love the interest that we've seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will talk soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 3, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ALAN FREDENDALL All right. Good morning, folks. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. We're here a little bit early in the garage. We're going to be talking about some double unders today. Welcome to Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at the company, as well as the Division Leader in our Fitness Athlete Division. We love Fitness Athlete Friday. We would argue it's the best day of the week. On Fitness Athlete Friday, we talk all things relevant to the CrossFit athlete, Olympic weightlifting, powerlifting, bodybuilding, anybody that's recreationally active in the gym. We also talk about our endurance athletes, whether you're running, rowing, biking, swimming, triathletes, If you have a person that's getting after on a regular basis, Fitness Athlete Friday has a topic for you. Some courses coming your way from the Fitness Athlete Division. We have a couple live courses before the end of the year as we get ready to close out 2023. This weekend, as in tomorrow and Sunday, November 4th and 5th, both Mitch Babcock and Zach Long will be on the road teaching. Mitch will be down in San Antonio, Texas, and Zach will be in Hoover, Alabama. Even though it's last minute, both of those courses still have some seats. And then your final chance to catch Fitness Athlete Live will be the weekend of December 9th and 10th. That's gonna be out in Colorado Springs, Colorado, and that will be with Mitch as well. Online from the Fitness Athlete Division, our entry-level course, Clinical Management Fitness Athlete Level 1 Online, previously called Essential Foundations. The next cohort of that class begins November 6th. We love that class. That is a great entry-level experience into all of this stuff if you have not taken it yet. We take you through the very basics, back squats, front squats, deadlifts, presses. We get into some basic gymnastics with the pull-up and introduce you to Olympic weightlifting with the overhead squat. Along the way, we have case studies relevant to athletes with those particular issues that we discuss with those movements. We talk a lot about loading and we get you introduced to basic programming, both for injured athletes and also how to recognize CrossFit style programming, strength style programming to better prepare you for those folks who want to continue on to our level two online course, previously called Advanced Concepts, who really want to drill down into programming, advanced gymnastics, advanced Olympic weightlifting, and truly become the provider of choice for athletes in their region through the clinical management fitness athlete certification. So that's what's coming your way course-wise from us in the CMFA division. WHAT ARE WE DOING WITH THE DOUBLE UNDER? Today we're going to talk about double-unders. This is personally an issue I've struggled with for a long time and probably maybe aside from pull-ups and handstand push-ups, one of the more basic movements we see in the gym that still a lot of your membership base will struggle with, maybe you personally struggle with, and I want to talk about what are we actually trying to do with the Double Wonder, some tips and tricks and cues to think inside your mind as you're going through them. I want to spend some time talking about the equipment involved in jumping rope because I think there's two sides of the equation, people with very basic equipment and people with maybe equipment that they don't need that's maybe too expensive, too advanced, And then I also just want to talk about how to begin to better practice double unders so that you can work towards achieving them and being able to complete them during a workout, in large sets, when the CrossFit Open comes up, or just in your regular workouts at the gym. So first things first, with double-unders. When I ask a lot of athletes in the gym when I'm coaching, when they say, oh my gosh, I just did five double-unders in a row, I say, great, great, what were you thinking about? And overwhelmingly, the majority of the people say, I don't know. I couldn't tell you what I was thinking about. And that strikes me as very different from a lot of stuff that we do in the gym. People usually have maybe one cue or maybe even a couple cues in their mind when they're setting up for a heavy deadlift, when they're setting up for a clean and jerk or a snatch or a handstand pushup. They often don't kick up upside down or go to max out their snatch and tell you that they had nothing going on in your brain. But something about the double under, people think it's just magic, how you learn these and how you get better at them. And unfortunately, it's not magic. Fortunately, it's just physics. So I want to talk about really at a base level, at a nerdy physics mathematical level, what are we doing with the double under? We are translating linear force. We are creating force across the lever that then transforms into rotational force where your jump rope handle meets the bearing. FIX THE SET-UP If your jump rope is nice enough to have a bearing. So a lot of times the setup, even with just the handles is wrong of looking at a jump rope. Again, it's quite a basic piece of equipment. It's got some handles. you to hang on to in a rope. Even a cheap moderate jump rope of $20 should have some sort of bearing set up so that it spins a little bit. We are trying to create force at the end of the handle that as we flip that jump rope it turns into rotation through the rope and that by doing it both hands at a time with that flicking motion we spin the jump rope. What we're not trying to do is physically spin the rope ourselves with our shoulders, right? We're trying to create rotational force through a flick. So the first thing is making sure that you are even handling your jump rope appropriately. If you are cinched down with a full grip, right where the handles meet the bearing, first of all, you can physically block the bearing if you're not careful. If you hold right here with a depth grip, that bearing cannot spin anymore, right? It's going to be extraordinarily difficult to easily create rotational force here and you're going to naturally be that person who has to spin your arms to spin the jump rope. That's exhausting. It's not a great way to do single unders and it's an even worse way to do double unders. So first things first, where are you grabbing the handle? You should be grabbing further down the handle, ideally with a loose grip, as low on the handle as you can get, right? The longer the lever, the more force amplification we have, right? The more force is going to be transferred and transformed into rotation down here versus the higher we grab up towards that bearing. So a nice loose grip, thinking about flicking, creating linear force at the bottom of the handle that creates a spinning force for me up at the bearing. So that's number one of making sure that you're even using the jump rope correctly. The next thing is making sure it's sized correctly. I always laugh when I see people in the gym who I know are taller than me, which is not very useful because most human beings are taller than me, but I know someone is a couple inches taller than me and I see them using a rope shorter than a rope I would use and I think What the heck, why are they using such a short rope? It makes sense why trying to do double unders, they're bringing their knees up to their chest and bending their knee to try to clear the rope because the rope is so short. How do we sign the jump rope? We take the jump rope, we hold both handles, we step one foot, we try to even it out as much as possible, bring it towards our body, and the length of that rope should be at our nipple or maybe a little bit higher. If it's down at our stomach, it's too short. You're gonna have to do some really unnatural jumping things, like piking your hip, or kicking your legs back, or both, just to be able to clear that short rope. Likewise, being a little bit longer is okay, but this thing up to my chin or above my head, I have a lot of slack behind me now. I'm moving a lot of extra weight I don't need to, and that's all the more drag factor on the rope that's gonna mess up my timing as I try to learn double unders. So making sure we're holding the handles in the appropriate place and making sure that we understand how to measure our jump rope. A really nice jump rope will have maybe a nut or a screw here to adjust. This is a typical, what we call a class rope. This is just a $20 rope from Rogue. You'll often see these in the wall at a gym for everybody in class to use. These can't be adjusted. They go based on your height. There should be a table or a chart or the coach should know what color you should be using based on your height, assuming that you know what your own height is, to make sure that you're using a jump rope that is long enough with maybe a little bit of extra slack, but is not extraordinarily short or long. So that's first things first, using linear force to create rotational force, making sure the rope is sized to us correctly, and making sure we're holding the handles in the right spot so that we're not hampering ourselves from creating that rotational force. SOMETIMES IT'S THE WRENCH We have a saying, with jump rope, with most things in life, it's usually not the wrench, right? It's not the equipment, it's the mechanic. But sometimes it is the wrench. A lot of folks start trying double-unders with maybe the class rope they have, and I think that's a great place to start. Now the issue is a lot of folks will start trying double-unders, they'll look at people in the gym who are really great at double-unders, and not recognize that that person probably started with the class rope, and they'll immediately go out and buy a $200 competitive CrossFit game speed rope. There's a couple issues with the wrench itself of making sure you have the right wrench. We've already talked about length. A really nice jump rope, again, will have a way to adjust the length that you can undo a screw or a nut and make it longer or shorter and get it really dialed in. These ropes, again, are a fixed length but making sure the length is exactly correct. The next thing that most people don't consider is that this jump rope has some weight. Yes, the handles have weight, but that's going to be relatively fixed based on the brand that you have. So not considering the weight of the handles, what is the weight of this rope? This is a class rope. This is about 2.5 ounces or so, which I would call a medium weight rope. When we are doing jump rope, In learning double-unders, the best thing you can do is use a rope that's a little bit heavier. null: Why? Two reasons. SPEAKER_01: When you spin a heavier rope, you can hear it slapping on the ground in the gym, even over the loud music. That helps your brain learn the timing. A heavier rope also forces you to develop wrist speed. When we're doing double-unders, it's not about how fast you jump, it's about wrists. And a really light rope doesn't force you to learn that speed because it costs you almost no energy to go through that movement pattern. So for a lot of folks, they're trying to purchase the most lightweight rope ever, and I'm going to show you some different ropes here in a second, when in reality they should probably be working with a heavier rope. Again, this is a class rope. This is maybe two and a half to three and a half ounces, somewhere in the middle. What's going to help a lot of folks Smartgear brand rope. You can buy this from Rogue or from RX Smartgear directly. You can see just by looking at these two ropes, significantly thicker, right? This is a 4.1 ounce rope. The handles are different. Yes, they spin a little bit better. They have a little bit better hand grips. You can see here different spots to put your thumb along the handle. But most importantly, the cable is heavier. This is going to teach hand speed, this is going to build up endurance with the double under, and it's also both the sound and the feeling of this rope is going to help learn timing a lot better for our jump rope. So making sure that we have the right rope. Again, almost everyone trying to get good at double unders immediately goes and buys the $200 speed rope, when in reality they should probably buy this. Now the nice thing about these ropes, as you can see, I'll bring it up really close, is this is just a keychain type carabiner. When I'm ready for a lighter rope, the most expensive part of a jump rope are the handles. The cable is usually cheap or sometimes even free if it gets frayed. If you fray your actual rope, you can email Rogue, you can email RxSmart here, they'll send you a new cable that you can reattach to your handles and you can use the same handles forever. So as you get better, you can detach, put a lighter cable on, make it easier and more energy efficient as you actually start to string together double-unders. But early on, you're going to want a heavier rope, something around four ounces. That's the biggest recommendation I can make to folks who are trying to learn double-unders, and especially to those folks who have 19 different speed ropes at home. They've got a second mortgage on their house full of jump ropes just to pay for them all. and they're going lighter, lighter, lighter, thinking they need a lighter rope, a faster rope, lighter handles, diamond grip handles, when in reality they just need a heavier cable. So when in doubt, go heavier. Again, four ounce rope compared to maybe a two and a half or three ounce rope. Once you can start to turn over bigger sets of double unders, 25, 30, 50, you're able to start doing them in workouts, your efficiency, your endurance with them improves, now you're ready for a cable itself is basically non-existent. This is aircraft grade aluminum. This is about eight tenths of an ounce. So almost 500% lighter than that heavy rope I just showed you. This weighs almost nothing. It is very hard to feel when you jump rope with this cable and it's very hard to hear as well, especially if you're in a CrossFit style gym in the middle of workout with loud music playing. What's different about this besides the cable weight? The handles are so much nicer. They are diamond grip. My thumbs can lock on. I can hold very low on the rope. Again, I want to have as much time for that force to build up and transfer along the length of the handle as I can. I can hold just my index finger and my thumb and really develop that flicking motion. What's also very nice is look at the spin on this handle. right? That thing spins forever. Very, very, very efficient for large sets of double-unders, but only once you can actually do them. So this is kind of the in-stage progression of somebody who looks at a workout that has a couple rounds of 30 or 50 or maybe even 100 double-unders and says, no problem, I got These ropes are about $200. And again, the most expensive part arguably is the handle. If the cable frays, you can replace it. But a very, very, very high quality jump rope intended for folks who have already learned how to do big sets of double unders, ideally using a heavier, cheaper rope. So that is what we would call a speed rope. So that's the wrench. BUT IT'S USUALLY THE MECHANIC Now let's talk about the mechanics. because there are a lot of things we can do, a lot of cues we can give that can very quickly make double unders a lot better. The first thing is understanding, again, in a double under, what changes is my hand speed. Jump, spin, spin, jump, spin, spin. It is a double spin of the rope. It is not an increase in my jump rate. A lot of folks, off the ball of their foot. Because in a single-under, we're only clearing the rope once, we can get away with a very small jump and just clear that rope once. We see a lot of boxers do this. You see a lot of people in the gym who have jumped rope a lot in the past do this with single-unders. They can crank out 150 single-unders in one minute with that very fast, low jump. That's not gonna cut it for a double-under. Why? The rope has to pass twice. A lot of athletes in the gym will ask me, I have no problem getting it over the first time, but it gets caught the second time. The answer is yes. The rope has to come back around again twice and you have to be in the air the whole time. That's why it's called a double under. You're trapping the rope on the second time through, which is why you're not getting your double under. How and why are we trapping the rope? Most commonly, is we do not increase our jump height, we just now try to jump even faster. All we're gonna do there is trap the second pass of the rope that much more quickly. We're just getting more efficient at bad double-unders. We need to consider a smaller, taller, slower jump. We should practice single-unders on the ball of our foot, and we should practice a little bit taller jump, but not try to pick up our legs not jump speed. If you correspondingly increase your jump speed, you're going to trip because you're now trying to basically get in rhythm and jump twice for two rope swings. That doesn't make sense. Keep your jump speed the same. Stay tall, vertical on the ball of your foot, and jump a little bit higher. Practice single-unders that way. When you can begin to turn over 50 or 100 single-unders like that, now you know you have the jump height, the jump speed, to be able to begin to turn over double unders. Remember, wrist speed, not jump speed, and stay on the ball of your foot. A lot of folks will do some really dramatic stuff to get that rope over twice, and they will land on their heel. Again, the rope has to pass twice. If you land on your heel, there is no physical way that rope can pass under your foot for its second time through. You're going to track the rope underneath your foot. So small, short, sorry, tall, vertical jump. PRACTICING & DRILLING DOUBLE-UNDERS Make sure we're practicing wrist speed. A penguin drill is a great drill to give people, to have them practice maybe what's a new jump height and cadence for them. And at the top of their jump, have them slap their thighs twice to imitate the double flick of the jump rope. You'll find a lot of athletes who think they should be able to do double-unders, struggle a lot with that drill. They're used to that short, very fast jump cadence for single-unders. Asking them to slow down and jump a little bit higher wrecks them. It also messes them up mentally when now they have to focus on actually doing something with their hands. You'll find they're probably not as ready for double-unders as they thought they were. So double-unders, not magic, just physics. We are creating force across a lever, the handle of the jump rope. We're holding it as low as possible. We're trying to create rotational force where the rope meets the handle at the bearing. We're holding it as low with as loose of a grip as we can. We're thinking about flicking the wrist, not spinning the shoulders. Sometimes it is the wrench. Make sure the rope is the correct length. Make sure newer athletes who are beginning to experiment with double unders use a heavier rope, something three, four, maybe five ounces, and that we reserve those speed ropes for once we're actually able to string together bigger sets of double unders with a heavier rope. PROGRESSIVELY OVERLOADING DOUBLE UNDERS The final thing is how to progress these. A lot of folks want to be able to do more unbroken sets, Can you just practice more sets of double unders? Yes. The key thing though is that we practice that. We don't try to do it in the middle of the workout under an extreme amount of cardiovascular fatigue and that we consider double unders no different than a back squat or a clean and jerk or a deadlift. That we take principles of progressive overload and we carry it over to our body weight, cardiovascular stuff, especially higher scale, like double unders. How do we do that? Things like a Zeus Rope. or a drag rope are great. A drag rope is literally climbing rope with handles. It has, you can see the same handles as some of the other jump ropes I've shown you. The only difference now, there is no handle spin. The only way I'm going to rotate this rope is by being really aggressive and really fast with my hands. This is a nine ounce, I guess you'd call it cable. Again, it's technically just a length of climbing rope. This is nine ounces. So this is 900% heavier than the speed rope. So if I want to get better at double unders where I can look at a workout that has a couple rounds of maybe a hundred double unders and it has some other stuff in there too that's also going to make me tired from a cardiovascular perspective, how do I know when that workout shows up that I can blast through those with my speed rope? Well, when I go back and take class workouts that maybe have small sets of double unders 20 or 30 at a time, I bring my drag rope to class. And I do smaller sets with a heavier, slower rope that continues to progressively overload my double-unders so that when big sets do show up in different workouts, I can handle those no problem with my speed rope. So it takes practice, intentional practice. Folks are always disappointed that they don't magically learn double-unders 18 minutes into a 20-minute AMRAP. That's not how it works. Sometimes it does, but it usually doesn't. Practicing this stuff at home with a cheap jump rope from Rogue that's 20 bucks, practicing 10 minutes a couple times a week is really going to go a long way. I always tell folks when they're practicing double-unders the same way I tell them when they're practicing things like pull-ups. When you're learning to kip, when you're learning that motion, forget about getting your head over the bar. Just learn the rhythm. That's the most important thing you can do. I say the same thing to folks who are going to be going home and practicing double-unders. Don't focus on actually getting the double under. Focus on doing the mechanics correctly. Use a timer so that you're not just in your garage for an hour and you're breaking stuff because you're so frustrated or the neighbors are worried because you threw your jump rope into the street. Set a timer, do as many as you can, and then take a break for two minutes and do a couple sets of that. Make sure that you aren't treating it as a workout, but that you're treating it as practice and that you use different methods once you actually can do double unders. to continue to progressively overload your double unders. So double unders, not magic, physics, make sure your wrench is set up, but make sure your mechanics are dialed in as well. And make sure if you want to get better at these, that you actually spend diligent time to practice and make sure that it's actually practiced and it doesn't turn into a second workout that day. I hope this was helpful. I hope you have a fantastic Friday. If you're going to be at a live course this weekend, we have 10 of them going on, I believe. So I hope you have a fantastic weekend. We'll see you all next time. Bye everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 2, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea that moving into a leadership role requires a shift in mindset from focusing on individual accomplishments and deliverables to prioritizing the building of culture and guiding the team. Jeff emphasizes that one of the hardest things about transitioning into a leadership role is separating your sense of worth from the tangible outcomes of projects. Instead, leaders need to concentrate on steering the team in the right direction and creating an environment that fosters productivity and engagement. Jeff describes that a true leader's job is not to solve every problem or complete every project themselves. Instead, their role is to provide guidance and support to the team, ensuring that they stay on track and between the "buoys." This means constantly having touch points to build culture and considering where the team should go, as well as where they should not go. Jeff also highlights the importance of reframing what being productive looks like in a leadership role. It suggests that leaders should focus their energy on three main areas: culture building, organizing and strategizing, and problem-solving. Culture building is described as the leader's top priority, as they need to create an environment that people want to be a part of. Organizing and strategizing involves evaluating when to intervene and when to let capable team members come to their own conclusions. And problem-solving requires knowing when to provide guidance, but not getting caught up in completing the task oneself. Overall, Jeff suggests that moving into a leadership role requires a shift in mindset from individual achievement to team success. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JEFF MOORE All right team, what's up? Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Moore, currently serving as a CEO of ICE, and always thrilled to be here on Leadership Thursday, which is always Gut Check Thursday. Let's get right to brass tacks. What's the workout this week? It is ascending squats, but of decreasing challenge, and then the reverse for our gymnastics. So it's gonna look like this, kind of an interesting workout. So it is for time, You're gonna open up with nine overhead squats. That barbell prescribed weight's gonna be 135, 95, so scale accordingly. Paired with 21 pull-ups. Then you're gonna increase your squat number 15, but moving to front squat, same barbell weight. gymnastics going to 15 chest-to-bars and then 21 back squats and then 9 muscle-ups. So you got kind of this 9, 15, 21 climbing a number of a decreasing complexity on the squats and then the opposite 21, 15, 9 as your gymnastics get more challenging. So should be a very interesting workout. Just one time through that for time. All right, regarding upcoming courses, it is all about the certifications this week. So if you have not heard, we launched our entire brand new suite of new and renovated certifications over on ice. So we've got our brand new pelvic certification. We've got our dry needling certification now. The group has launched that advanced course. We have our brand new ortho certification, the endurance athlete certification. on top of a tremendous amount of renovation and facelift on all the other ones. So if you have not browsed our new certification offerings, go to PTOnIce.com. That certification tab is right on the top. Jump in there and look at all those different search. Remember, One thing that separates ice certs from everybody else is live testing is involved in every single one of them. So regardless of which one of those you jump into, there is live testing. We believe that is really what holds the standard. So just know that you will be examined in person to make sure you indeed have the goods before we throw that stamp of approval on your work. So that is what's basically, involving all of our worlds this week is getting all the certifications launched. Hope those really improve not only your skill set next year, but your ability to market effectively that you're a specialist in these areas and really take over your geography and serve your community. So enjoy those certifications, check them out. All right, it is Leadership Thursday. BREAKING UP WITH DELIVERABLES We are talking about breaking up with deliverables. A challenging but necessary conversation. Challenging because… There's very few things, especially for really high performers, that is more satisfying than completing a really big project, right? Something you've been working on and chipping away on, very few things feel better than putting a bow on something like that, crossing that off that to-do list that you've been looking at for months as you kind of worked your way through the project, not to mention just delivering a beautiful deliverable. Nothing feels better. The bigger leader you become, the better leader you become, the less you will get to experience this. If your leadership trajectory really takes off, you will literally never, again, get to experience that wonderful feeling of wrapping up a project. The reason for this is it almost never makes sense For you to finish anything, right? Once your job is getting the train on the tracks, your job is approving the project. Your job is saying, you know what? That makes sense to put resources towards that. Considering all the other options available, your job. is figuring out the right combination of people that will maximally effectively take over that job and really bring it to completion as fast as possible and be able to scale it. So is it the right gig? Who are the right people to do it? What resources do they need? How can I collect those in the most cost and time effective manner? Those are your jobs. But once that train is on the tracks, proper delegation should always bring it to the finish line. It would be very rare, very rare, that a task needs your personal involvement end to end. Just because you want it to, doesn't mean it does. In almost every case, your job is going to be saying, yep, that's the right thing that we should do with our resources. These are the right people to make that happen. And here are all the resources they need to be freed up and made available so they can execute properly. Those are all of your jobs. The actual doing of it, the execution, the part you want to do, right? Cause it just, again, feel so wonderful to be a part of creating and finishing something like that is something you should almost always hold yourself back from. Now, I know what you're saying. You're saying, but that's what makes it feel like I've accomplished something. Like getting something to the finish line is what feels rewarding. You have got to reframe if you're truly moving into a leadership role. Like you're going to be organizing and strategizing a number of people that are in your circle and your job is kind of commander in chief. If you're heading in that space in whatever your division might be, you've got to reframe what being productive looks and feels like. You gotta reframe this, and you gotta think about three big buckets where your energy is gonna be going, and none of them are gonna be about bringing a project to execution. CULTURE BUILDING The first one is culture building. Your number one job, right, is that glue that keeps everything together, that makes the energy of the organization feel like something that people who are a part of it want to be a part of. Number one is culture building. In every single touchpoint, with another individual in the group is culture building. It doesn't need to accomplish anything, right? These touch points, these little moments of interaction don't need to finish anything. They don't need to accomplish anything. What they accomplish is you understanding each other just a little bit better. What they accomplish is you seeing where the other person's coming from, is a little bit of trust building because you had that moment of connection. They accomplish that. No, it's not finishing anything. This is an infinite game. Culture never has an end point. You never win culture, right? You nurture culture. And it's with every single touch point that you do so. So one of your biggest buckets as a leader is gonna be culture building. And culture building has no conclusion. So you'll never get that feeling of finishing. INNOVATING Number two, energy bucket number two is innovation. Time spent pondering solutions is one of your most important jobs. And here's the rub, here's the really uncomfortable part. 90% of your time will be considering solutions that you don't move forward with. You certainly can't finish anything you never start. And 90% of your time is going to be exploring options that don't wind up being the right call. But that is a critical part of your job. There's no way that you can rule down where your resources should go if you don't consider all the options and say no to most of them. So because so much of your time is going to be spent evaluating possibilities that literally never get off the ground because you decide they shouldn't, obviously you won't have any sense of completion there. But yet, if you're not in that role, you will never allocate your resources properly in a way that allows the company to move forward efficiently. Innovation, and namely deciding what shouldn't get off the ground, is a huge spend of your time and has no completion. PROBLEM SOLVING And finally, number three is problem solving. One of your key roles as a leader is evaluating when should you intervene. Oftentimes, my number one recommendation there is to restrain yourself, right? To let very capable, high-performing people come to their own conclusions, but be evaluating it from a 30,000 foot view. But you do need to sometimes say, you know what? I'm gonna jump in here. A little bit of restraint is always a good thing, right? But knowing when to jump in is very important. Now, here's the key. When you jump in, you jump in with a couple pieces of information or a little bit of guidance, again, to get the train back on the tracks. What you don't do is follow the train. Right, that's falling right back into that temptation of wanting to get something to completion. That's not your job anymore. Your job is, ooh, this isn't going in the right direction. Watch it, study it, think about it, find your moment, and then jump in and say, team, can I ask that we look at one thing a little bit differently? What are your thoughts here? Okay, now you jump in, you change the energy of that environment, of that project, you get people chiming in as a group, you decide, Oh, this is the one change we've got to make. And then very importantly, you get back out because you've got to go do that somewhere else. If you stay on that ride, you're not getting back over and solving that same problem in seven other spots. The people can handle it. Your job is just to steer, just to get them back in between the buoys and then get out of there. One of the hardest things about truly moving into a leadership role is you've got to divorce your sense of perceived worth from deliverables that you're a part of. Your energy needs to be in constantly having touch points to build culture. Your energy needs to be spent thinking about where should we go and maybe more importantly, where should we not go? Your energy needs to be in and out of different projects when you see an area that your experience or wisdom can nudge people in the right direction and get their momentum built back up before you remove your energy from the scenario. These things never feel done because they never are done. None of those buckets even move closer to a perceived finish line. You just keep nurturing and spinning those plates at all times and never ride any of them to the end. DIVORCE YOURSELF FROM DELIVERABLES TO IMPROVE THE EFFICIENCY OF YOUR BUSINESS You have to divorce yourself from deliverables, otherwise you're never going to take the true position of an effective leader. Give that some thought. I know you're high performers. I know you love finishing projects. I know for many, many, many years that has filled your cup, but it's killing your team. Try to reframe it. Let me know if you have any thoughts. PTOnIce.com. Thanks for being your team. We'll see you next week. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Nov 1, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the difference between sarcopenia (the loss of muscle mass) and potentiapenia (the loss of muscular power). Dustin reminds listeners that performing functional outcome measures & then creating a treatment plan based on functional deficits uncovered during assessment is the most important thing in ensuring patients receive the individualized care they need: "Assess, don't assume." Dustin also discusses the utility of using functional outcomes to assess & track progress so that insurers like Medicare will continue to pay for treatment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - DUSTIN JONES All right, welcome y'all. This is the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division as we call MMOA. We're going to talk today about a really interesting topic. We're going to name the enemy and that is potentiopenia. We're going to name the enemy particularly when we're working with older adults and that is potentiopenia. This is brought to you by a listener question, a commentary that they wrote and I want to dive into the topic of power, strength, Sarcopenia as well. What should we really be focusing on? How can we screen? Before we get into the goods, I want to mention about some upcoming MMOA live courses. MMOA live is a part of the cert MMOA curriculum. Part of that curriculum is a live course. Also our MMOA level one online course, which was formerly called MMOA essential foundations. And then MMOA Level 2, which was formerly called Advanced Concepts. You complete all three, you get your cert MMOA. We have three upcoming weekends where you can go to that live course. We're gonna have Annapolis, Maryland and Central South Carolina. This upcoming weekend, November 11th, we're gonna be in Wappinger's Falls, New York. And then right before Thanksgiving, November 18th, that weekend, we're gonna be in Westmont, Illinois. So if you are looking to get some Con Ed before the end of the year, be sure to check us out. PTOnIce.com is where you can find all that. POTENTIAPENIA All right, so naming the enemy, potentiopenia. So this is a term you probably have never heard about because it's not been coined, it's not been researched, it's not been agreed upon in literature. This is a word that was made up by Dr. Ronald Michalak. So Dr. Michalak is an orthopedic surgeon that's been practicing for roughly 20 plus years that has quitting his surgical practice to go back and pursue his PhD in Rehabilitation Science. Dr. Michalak is an avid listener to the PT on ICE Daily Show, so I want to take the time to shout out to him, but also for all of y'all that listen to this show that aren't our typical physical therapy crowd, right? The OTs, the speech-language pathologists, the other healthcare providers. I know we have some PAs, some NPs in here, but we're really grateful for y'all tuning in because we're starting to see we have a fitness-forward army clinicians that are trying to solve the same problems. This is one example. So Dr. Mitchell like you know 20 plus years doing orthopedic surgery you start to see some patterns right? You start to see the issues with focusing on the tissue, right? Of focusing on, oh, that bone-on-bone, we should probably just go ahead and replace that whole joint, and that will solve all your problems, right? There's some issues to that, that when we focus so much on the anatomy, the structure, that we apply surgical interventions to non-surgical problems, that creates issues, right? And so over his career, he started to see, man, the biggest issue is not the quote-unquote bone-on-bone, it's the fact that these folks are deconditioned, they're weak, they're not able to do the things that they want to do and it leaves them susceptible to some of these medical situations that I'm often performing surgery on. What can I do to prevent them from even having surgery? And so we started to dig into the research and science and what he has come to the conclusion of is we are really missing the boat to where we're focusing on the wrong things and what we need to focus on particularly with this population is their lack of power. hence the term potentiopenia, the lack of muscular power. So, I want to give some context for this discussion because I think it's really interesting of how much progress has been made in this area, particularly in geriatrics and geriatric rehabilitation. SARCOPENIA So, sarcopenia, you've heard us talk about this so many times on the PT on ICE Daily Show. If you've taken any of the MMOA courses, you've heard this term. Sarcopenia was first coined in 1989 by Dr. Rosenberg, and at the time, the definition, the accepted definition of sarcopenia was age-related loss of muscle mass. That we thought, oh man, these folks are losing muscle mass, therefore, they are losing their strength, they are losing their ability to do what they need to do. This is a big issue. It's age-related, but we may be able to do something about it. As this was studied more and more, and just this whole concept, was being critically you know thought about that the term of sarcopenia or the definition of sarcopenia was missing a little bit right because you can have someone that is losing muscle mass but may still be really strong or you may have someone that does have a good bit of muscle mass that is rather weak or they're not able to produce their force quickly aka they have low power So, in 2008, Dr. Clark really started to push against this definition of sarcopenia and say, hey, this isn't the issue. The issue is the lack of strength, the age-related loss of muscular strength. And he coined the term dynopenia. That was a back and forth, back and forth. And now in terms of the term of sarcopenia, what we're seeing is that it's starting to incorporate some of the things that Dr. Clark really was pushing for. And now you're often going to see sarcopenia defined as the age-related loss of muscle mass and strength. That's what we speak to in the MMA course. And so a lot of the screens that you're seeing of being able to identify folks that have sarcopenia are mass related screens of actually measuring muscle mass and having cutoffs based on certain age groups and so on and so forth. But then there's also functional measures, right? Gait speed is one, grip strength is another one, the SPPB, the short physical performance battery test can indicate that someone is at risk of sarcopenia. Sarcopenia has changed a ton over the past few decades. Now, what's interesting is that the amount of research, which is so massive in this particular topic, that we have really good evidence to show, man, if this person scores below one meter per second, for example, on the gait speed, that this individual is at risk of sarcopenia, also a host of negative health outcomes. It's very predictive. We have a lot of data to show that poor performance on some of these outcome measures is a big issue and very predictive and warrants medical treatment or physical therapy, if you will, or occupational therapy, some of these rehabilitation-based services. Now, here's the issue. Here's what I think Dr. Michalak is going towards, is a lot of these screens that have been used to say, hey, this person has sarcopenia, age-related muscle mass and strength, that these screens may not actually be measuring what we think, right? If you think about gait speed, normal gait speed, for example, is that a measure of strength? Not really, right? Is it a measure of, let's say, power, the ability to produce that strength quickly? Potentially, right? Definitely, if it's a fast gait speed, or if we're looking at gait speed reserve, the difference between max gait speed and normal gait speed. Think about the 30 second sit to stand test, where we're standing up and sitting down 30 times. Is that a measure of strength? You can make a strong argument that, no, not necessarily, but it's more of a measure of how people can use that strength quickly to perform that transfer. Same thing could be said for the five times sit to stand. And so these outcome measures that are often tied to quote-unquote sarcopenia, the age-related loss of muscle mass and strength, isn't really measuring that. We can say that those tests are very predictive of some of these negative health outcomes. That's not what we're talking about. What we're talking about is do these tests actually measure, indicate what they're saying that they measure, right? Now, here's the, I think the important part about this is that if I am performing a five-time sit-to-stand test or a 30-second sit-to-stand test and think that, oh, this indicates that this person has impaired lower extremity strength and I focus on strength-based interventions, right, I'm just worried about getting them stronger, not necessarily trying to help them get stronger, produce force quicker, aka power. THE NEGLECT OF POWER-BASED TRAINING And so what Dr. Michalak is really proposing is that our focus on age-related loss of muscle mass and strength, the focus on strength has resulted in the neglect of power-based training. We need to really think differently about these terms and ultimately what they result in. I think we should have a new term, potentiapenia. That was his argument. This is all in a beautiful commentary that I loved reading that I'm going to link in the notes. So here's our take on this. I agree that… we have really dropped the ball on power-based training, right? That we often neglect that in this population for many reasons. One is just we haven't named the enemy as one. Two is that we often have ageist assumptions about what people can handle, right? That, oh, that's too intense for them or they will get hurt. It's not as well studied as strength-based training. There's a lot of reasons that go into that, but I do agree that we have really dropped the ball there. A new term, creating a new term, and everything that's associated with that, I don't know if that's the answer, but I do think we need to continue to be critical of the term sarcopenia and what that actually represents. It's already changed to age-related loss of muscle mass and strength, which is lovely, and I would love to see that conversation continue to include power as well. Clinically, here's what I think is really important for us when we think about some of these deficits that folks are undergoing and we're throwing around some of these terms. STRENGTH VS. POWER TRAINING I think the big thing that needs to be focused is we're diving into the weeds of strength versus power and you know reps and sets and volume and all that type of stuff that when first one is when we're working with individuals that are relatively sedentary or inactive and Movement is king. I don't care what they do. The fact that they are moving is ultimately important, right? We got to get people moving first and we need to be less picky of what that looks like, especially with sedentary and active individuals. That's the first thing. The second thing is we need to really think about our assessments and challenge our assumptions with this. This is why in our courses we always say assessments over assumptions. It's very easy for us as clinicians, when you're doing an assessment, you're doing the five-time sit-to-stand test, 30-second sit-to-stand test, to assume, oh, this person needs to do more lower extremity-based strength training, right? That's a very common thing for us to correlate. Now, that test may not be and probably isn't testing pure strength, right? There's other ways to do that. One rep max testing, estimated one rep max testing. We can use dynamometry as well. There's other methods to test strength. These functional and very practical outcome measures may be more a testament to someone's power ability. So when we use these tests, particularly the 30 seconds sit to stand, five times sit to stand, I think is a great example. that we need to be thinking probably about strength training, but we also need to be thinking about power training. Can they produce that force quickly? Because it ultimately is an indicator of power, the ability to produce that force quickly and do that transfer. So what your outcome measures tell you, we need to be very careful of how that informs the intervention, right? And ultimately what we're often going to find, I think this is not an or conversation, strength training or power training, in the realm of ice, you will hear this so often, it is and not or, right? Probably both, strength and power, we can do both. In reality, when we do get people stronger, you often see, especially in folks that are untrained, you are gonna see an improvement in power production. You could do specific power training, where you're doing force movements quickly, you're probably using lighter loads, and you're probably gonna see an improvement in strength, right? That's gonna happen with a lot of untrained individuals. But I think in the context of rehab, in the context especially of One Rep Max Living, that we probably want to do both. Heavy loads are really good. Heavy loads provide an amazing stimulus to promote muscle mass, our strength, but also the strength of our bones, also our soft tissue remodeling. It makes us more resilient individuals. But fast loads are really good too, right? They give us that type 2 muscle fiber stimulation to prevent some of that preferential decline. in those fibers. That quick speed is so practical for so many things that we do in the real world and also in high-risk situations. It's an and conversation. We want to do both. Now, Dr. Mitchell, I had two specific questions that I also wanted to hit on. Could referrals be written or phrased better from the physician end to encourage PTs to try to help get these individuals moving toward fitness? Now, I want everyone to listen here, and by and large, the PT on ICE Daily shows largely physical therapists, physical therapy assistants. Think about what this physician just asked. This physician is basically saying, where are my fitness forward clinicians, right? Where are my fitness forward clinicians? Where are the people that I can trust with my patients? I love this question. I think from our angle, from kind of the rehab fitness side of things, Let it be known. What are you about? Lock arms, lock shields with us, the ICE tribe, the ones that are really pushing this fitness forward message because there are healthcare providers looking for you. Now, Dr. Mitchell, from the physician's standpoint, I do think it is helpful to make it clear as a physician that you have that fitness forward approach. And oftentimes, we don't see that on referrals, right? It's the diagnosis and treat, which you love as a PT, to be honest, but if you do run a 30 second sit to stand and acknowledge that it is under or below a particular cutoff let it be known and let it be known what you are thinking about that it is a potential loss of power production potential right and let the PT do the job of assessing to determine is this a bigger power issue or a bigger issue of just producing force of strength. FUNCTION-FORWARD HEALTHCARE PROVIDERS But let it be known, I love it whenever I see another healthcare provider perform some type of screen, like a 30 second sit to stand, a timed up and go is another one, that tells me that this is a function focused healthcare provider. And we're speaking the same language, especially when we're coming from the MLA tribe. We speak function, we speak that fitness forward mindset, include some of that information and that's really going to get the point across particularly to the fitness for clinicians. I would also say Dr. Michalak is go to PTOnIce.com, look at the find an ice clinician map and build relationships with that person that is local. The second question that he asked was, are there any insights into Medicare billing or reimbursement that would allow them to do so and actually get paid for their expertise? So the question here is mainly looking at, he's interacted with some PTs where he sent the referral that was not pain based, where these clinicians said, I can't get this covered, right? I treat pain, I get paid to treat pain. That is not correct, right? So you can definitely get reimbursed to have the fitness forward approach when you use appropriate outcome measures. When you can demonstrate medical necessity through the performance of these validated outcome measures that we cover extensively in our MMOA level one online course, and a little bit as well in our MOA live course, when we're using those outcome measures to demonstrate, hey, this person has a score, which based on the literature is showing that they are at a higher risk of whatever, negative health outcome, usually it's a fall, that that warrants your services. It is medically necessary. So we can have fitness-forward physical therapy. This is what we often see in the context of home health. We treat more function than pain in the context of home health. Outpatient, not so much. It's more of a pain driver, but you can still have a fitness-forward approach in the context of outpatient. These outcome measures are absolutely key because they demonstrate medical necessity. Multiple outcome measures I should say great conversation. So what I want y'all to do if you like this topic I want you to come to Instagram and I'm gonna drop a couple links. You could also send me a direct message At Dustin Jones dot DPT and I'll send you the links as well because it's a really great conversation. I think by and large Yes, we need to get people stronger We're already really pushing forward with that and I love that but we may need to take it to the next level of power based training In terms of a new name, potentiopenia, I don't know. I'll let the really smart people debate that and discuss that, but I'm going to keep pushing the message that we need to build people's resilience. We need to end one rep max living and really show that people may be quote unquote old, but not weak. Also that they may be quote unquote old and not slow. Y'all have a good rest of your Wednesday. I'll talk to you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 31, 2023

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry as he discusses the reverse hyperextension exercise as the go-to exercise for the low back. The reverse hyperextension provides a decompressive effect on the spine, often reducing symptoms, while simultaneously allowing for strengthening & mobility through the full range of motion of spinal extension & flexion. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION JORDAN BERRY Good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management Courses. Coming at you on Clinical Tuesday, we are chatting today about why the reverse hyper is king. We love the reverse hyper when we're either building strength in the back, trying to modify symptoms and pain in the back, but we're gonna talk about today about all the different exercises and machines, equipment that we have in the clinic when we're talking about the lumbar spine, why the reverse hyper is king. Before we get into that, just a couple upcoming courses. We've got a few spine courses left before the end of the year. So if you're trying to catch cervical spine management, you've got two options left this year. You've got November 11 and 12 is going to be in Bridgewater, Massachusetts right outside of Boston. And then we also have December 2nd and 3rd out in Hendersonville, Tennessee. So two options left for cervical spine. If you're trying to catch lumbar before the end of the year, you've got three options. You've got Fort Worth, Texas coming up November 4th and 5th. And then two options, December 2nd and 3rd. We've got Charlotte, North Carolina, and then Helena, Montana. So a few options left before the end of the year. We've got a ton of dates on the books already for 2024. So hoping to see you at one of those live courses either before the end of the year or maybe sometime in 2024. So let's dive into the content today. THE REVERSE HYPEREXTENSION So again, chatting about the reverse hyper and why the reverse hyper is king. So let's define king to start with. So when I think about an exercise, ideally it would do three things. So it would do a combination of reducing someone's pain, improving the mobility in the lumbar spine, and then building strength and endurance in their back as well. Like if I had one exercise that could do those three things, that's what I would consider king. So reducing pain, improving mobility and building strength and endurance all at the same time. And so yes, there are multiple techniques and exercises that we have that are incredible for reducing low back pain. but they don't do an awesome job at improving someone's mobility or strength. And then we've got exercises that are awesome for range of motion. However, they don't do a good job at reducing pain. And then of course we have some awesome exercises for building capacity and building strength in the lumbar spine, but maybe they don't do a lot for improving range of motion. What I'm saying is the reverse hyper is the king of all three of those if you package that up into one exercise. And so to start with, If you're not familiar with the Reverse Hyper, I would say YouTube it or look it up or try to find one even better and test it out in person. But if you're not familiar with that machine, there's a, essentially you're laying on a platform. So it's elevated a few feet in the air, almost looks like a GHD machine, but you're laying across it and you're holding it with handles in the front. So your torso's laid out on the area. and then your legs are essentially hanging off the side of it. So the pad that you're laying on hits right around the hip crease, legs are laying off the machine, and then it's plate loaded. So you have this pendulum underneath that you can load with weight, load with plates, and then the strap goes around the lower leg. And the exercise is essentially just contracting the posterior chain. So you're lifting the legs up and down, And then it's taking your lumbar spine through full flexion and full extension. And again, hard to explain verbally, um, on the podcast, but look it up on YouTube, um, get out to a gym that has one and test it out. But I want to talk about the three reasons why I think this exercise is king. STRENGTHENING THROUGH THE FULL RANGE OF MOTION So the first one is it's strengthening through full range of motion. Now, if we're just talking about building capacity and strength in the lumbar spine, no argument, the deadlift is king. The deadlift is an incredible exercise for building strength and capacity in the posterior chain. However, the deadlift doesn't utilize a lot of range of motion in the lumbar spine. Like, when we coach the deadlift, what we want to see is essentially straight lines. Straight lines or strong lines. So, we coach it to have a neutral spine position throughout, so the lift is more efficient, right? But, we're not actually utilizing a lot of range of motion for the lumbar spine. And we would never treat another joint like this. So, you know, if you're only utilizing hip hinge type of movements, then you're missing a ton of range of motion. And think about treating an Achilles tendon or rotator cuff. We would never utilize just a very small amount of the range of motion. We always talk about strengthening through the full range of motion. So why is the spine any different? So the reverse hyper, as you kick those legs up and down, right, you're taking the lumbar spine through full flexion and full extension. and you know an exercise similar to the Jefferson Curl in a way where we're utilizing a lot of range of motion of the spine but Jefferson Curl is much easier to cheat on because if you have really good posterior chain mobility then you can essentially do one massive hip hinge on the way down. And it looks like you're really utilizing lumbar flexion, but you're not. The reverse hyper, because you're locked in laying on the pad, it's much harder to cheat. And so we love this exercise for strengthening through the entirety of the range of motion. DECOMPRESSIVE EFFECT Now, second, there's what we call a decompressive effect. So on the actual reverse hyper machine, not a variation on the actual machine, you have this pendulum weight underneath that is plate loaded. And as you lift the legs up and down, that plate swings pretty far under. And so as you're flexing the low back, because the weight is underneath and has some momentum to it, you almost get this decompressive traction like effect. Now, why this is so awesome is this exercise can work for someone who has almost any levels of irritability. So, for high levels of irritability, like when someone's back is really jacked up and they have a lot of pain, it can sometimes be challenging to find an exercise that relieves symptoms and feels really nice. And you'll be surprised to find that for those individuals that can't tolerate other forms of exercise, they will really like the Reverse Hyper. And even the heavier you go on it, the better it feels sometimes because it's more weight underneath that is almost tractioning the spine. And in my mind, what I think is happening here is we're essentially creating a pump. So when we have that pressure gradient that we're creating, when you contract and relax and contract and relax, And that pressure gradient is going to essentially pump fluid and water into the lumbar spine. And I think about the couple of research articles that we referenced in lumbar management, they're both from Paul Beatty, 2010 and 2014. And he's looking at diffusion weighted MRI. And in the first study, we're looking at interventions like prone press-ups and lumbar PA mobilization. Second study four years later, lumbar spine thrust manipulation. But what they found in both studies is the individuals that had a significant symptom reduction, so a massive pain reduction, following the intervention, we saw an increase in hydration, the diffusion coefficient, in the discs in the lumbar spine. So essentially the discs brought in fluid, brought in water content, and that matched up to who had a significant reduction in pain. What do I think is a massive, massive pump that we could utilize in the clinic? It is the reverse hyper. So I can't prove that there's no research for that, but I would love to see something like that in the future. But I really believe that's what's happening is one of the ways that we're reducing symptoms is the diffusion coefficients. We're creating that pressure gradient is drawing in fluid to the lumbar spine and helping to reduce pain. I think that's why some individuals they have pretty high levels of pain, pretty high severity, are able to tolerate that type of exercise. SCALING THE REVERSE HYPEREXTENSION And then lastly, the third reason why the reverse hyper is king is it's easily scalable. So yes, the actual reverse hyper machine, the official true reverse hyper machine is a bit harder to find in commercial gyms, but there's a scalable option for pretty much anyone. You know, you could regress it anything from a GHD machine where you're on the backside of it. So you're holding with your hands where the feet would go and lifting the legs up and down. You could throw a band around the bottom of it and have some banded resistance. We could utilize just a bench. We could either lie on the bench and so the end of the bench would hit the hip crease and have our legs hanging off. Or we could go on top of a physio ball on the bench to get more of the curve in the lumbar spine that mimics the true machine. Or something as simple as just holding something at home. Like sometimes in the clinic for my clients that don't have a lot of equipment at home, I'll have them just lay across our coffee table or a bed or some sort of table that they have where the edge of the table hits the hip crease and they can just lift their legs up and down in its simplest form. It's an awesome exercise for, again, not only increasing range of motion, reducing pain, but also building strength and endurance in the lumbar spine. So there's pretty much a variation for anyone where you can mimic this type of movement. CONS OF THE REVERSE HYPEREXTENSION The pushback with the reverse hyper over the last few years has really been two things. Number one is the cost. The traditional reverse hyper machines were a couple thousand dollars and they took up a significant amount of space. So if real estate is an issue in the clinic, a lot of the old reverse hyper machines took up the space of about a squat rack. And so because of that, not a lot of gyms and not a lot of physical therapy clinics utilize that. But thankfully, a lot of companies are solving that issue. A couple companies like Rogue and Titan and a couple smaller ones are now making reverse hypers that are not only significantly cheaper, but are more compact as well. Some of them even fold up. So they take up pretty much no real estate in the clinic. So because of that, That is why we think the Reverse Hyper is the king of exercises for the lumbar spine. So again, there are exercises that yes, might be best for pain, might be best for building range of motion, might be best for building strength for any N equals one. But I'm arguing if you gave me one exercise that could do all three, I'm taking the Reverse Hyper all day. That's what I've got team. Thanks so much for taking a few minutes to listen. I would love to hear some thoughts on this. So if you're utilizing the reverse hyper, either in your personal training, um, just from a performance standpoint, or if you're utilizing it, um, in the rehab setting, I would love to hear comments, how you're using it, what you think about it. Um, drop those in the comments and, uh, and we'll chat about it. But other than that team have an awesome Tuesday in the clinic. Um, if you're coming to a cervical or lumbar course in the future, I will see you soon. Thanks team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 30, 2023

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses simple, but often overlooked interventions for treating patients with symptoms of pelvic prolapse including the Kegel, unilateral hip strengthening, and proper breathing & bracing. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 - JESSICA GINGERICH Welcome to PT on Ice Daily Show. My name is Dr. Jessica Gingerich and I am on faculty here at Ice with the Pelvic Division, which means that it is Monday again. We are getting super close to Halloween. I'm really excited. I'm definitely a Halloween girly. Today we are going to talk about what may be missing during the plan of care when it comes to prolapse. So this is another hot and relatively scary topic for a lot of mamas, but also for a lot of clinicians in this space. So we're going to talk about a few housekeeping items before we get started. We are currently in our last cohort of the year for the online course. This is something we are gonna put the pedal down come January. We've got a lot of exciting things coming up. So if you have not signed up for this course, head over to ptonice.com, just sign up. We also have a few more courses, live courses, to round out the year. So, if you're looking to dial in your internal assessment with that kind of higher level population, that athletic population, head over to PTOnIce to sign up there as well. My hope after this podcast is that you guys want that. You want to sign up for that live course. You want to dial in your internal assessment, dial in your interventions, and just guns a-blazin' out in this population. For those of you in the ICE Students Facebook group, you will hear more about the revamped certifications from Jeff tonight. Otherwise, stay tuned to Hump Day Hustlin' emails for details. So if you haven't signed up for Hump Day Hustlin' emails, again, that's all on the website. It's free. We just want to get out as much information to you guys as we possibly can. So we have some really fun new certifications coming up that Jeff is gonna dive into later tonight. So as we begin our PT careers, a lot of us prefer a specific population, right? We want to treat the older adult, the pregnant person, et cetera. We want to dial in our skills. And we love to see that, right? Like that, I love that. I want to get really good at that one thing. I want to go to the provider that is that provider. I am the person that you want to see if you are experiencing X, Y, and Z. We hear that a lot as faculty, especially in the pelvic space is, you know, well, I only want to kind of treat this type, this, the urinary incontinence or, you know, low back pain. And as a faculty, we've all kind of experienced those same thoughts and feelings. Again, it's intimidating when you get into this space. Well, we quickly learned that you can't just pick and choose. If you have someone that's experiencing urinary incontinence, they also are likely experiencing something else as well. If you are in the pelvic space, you're going to see all things. PELVIC PROLAPSE The ones that are at the top of the list, at least that we hear about as faculty, are the ones that are scary are pelvic pain and prolapse. So today we're going to focus on treating prolapse and specifically what we may be missing in our plan of care. It is going to be outside of the scope of this podcast to talk about the assessment of, um, like the subjective or objective assessment of prolapse. So if you are unfamiliar or you feel like you're just kind of shaky on this, again, that live course is waiting for you. Once we know the pelvic floor is strong or weak, or that it's a timing issue, or that they may or may not be tender to palpation internally or externally. And when I say externally, I mean hips as well. And that they may or may not have objective signs of prolapse. we then get to develop our plan of care. Now notice that I said may or may not because these clinical patterns are not identical. You will see so many different clinical patterns when it comes to symptoms of prolapse. So let's just say your patient comes in with feelings of heaviness, pressure, or dragging, and it feels like they may be sitting on something. That's something how they're describing it. When they're in the shower, they feel, as they're bathing, they may feel something physically. The heaviness gets worse after they have a bowel movement, void, go to the gym, or have been on their feet all day. So what's your next plan of action? Well, first and foremost, we wanna encourage you guys to stop focusing on the biomechanical components of a prolapse. Of course, there is that person or that type of prolapse. We're maybe talking about surgery. That does happen, but it doesn't happen without needing that pre-physical therapy, the stuff that they're doing beforehand, getting stronger, learning how to poop and pee. learning how to brace. So all of this stuff is still happening, even if surgery is part of the discussion. So first and foremost, let's stop focusing on the biomechanical components. Let's start focusing on the symptoms. So understanding what makes the pressure heaviness better, what makes it worse. Can we, part of their plan of care, ramp up the things that make it feel better and ramp down the things that make it feel worse? That has to be followed with this is not gonna be your forever. This is not gonna be you never doing that thing because it ramps up your symptoms and always having to like sit and be immobile because it ramps down your symptoms. We have to think about this on an irritability scale just like we do with pain. We have to be able to bring down their irritability, so then we can make them better by loading them. So now that we know that, I'm gonna give you four points to go home with today that are great points to start with. When you have that person come in with a script that says pelvic organ prolapse, or doesn't say that, it says pelvic pain, but then you start asking them questions and you're like, hmm, they may have symptoms of pelvic organ prolapse. REMEMBER THE KEGEL We have to remember the Kegel. This is number one, the Kegel. It has gotten so much hate over the past few years, especially on social media. I don't think that was anyone's intent to just say never do Kegels, but it matters. Teach your client how to do a Kegel. Lift and squeeze, shut off the holes, come to the attic. But we have to remember the relaxation component to the Kegel. Teach them how. to relax. Have them focus on this. A lot of times people feel like they can multitask a cubicle. If they are new to this and they don't know and they didn't even know they had a pelvic floor, they need to go in a room where it's quiet with no kiddos running around and focus on the up and the down component of a cubicle. Something that I love to say in the clinic is the relaxation component of a Kegel is sometimes more important than the contraction. Everyone always thinks we need to go up, up, up, up, up. And when I say everyone, I mean typically our clients. And they forget that this actually has to happen as well. Or, not that they didn't forget, but they think that they may be in that relaxed position and they're not. and that's where that internal palpation can be golden. Again, people tend to focus on the contraction, so being constantly contracted can also lead to symptoms of heaviness. So maybe their symptoms of heaviness are coming from this versus actually symptoms of prolapse. UNILATERAL HIP STRENGTHENING Number two, single-sided hip strengthening. get their hips stronger, always, but even here, get their hips stronger. And I don't mean with a TheraBand. Throw it out. If you want to warm them up with it, great. But we've got so many options. Step downs, step ups, we've got single leg RDLs, we've got variations of that. We have Core stuff that we can do, like the options are endless. We can do side planks, we can do hip thrusters. Don't forget about strengthening their hips. INSTRUCTING THE BRACE Number three, teach them how to brace. Symptoms of heaviness can happen due to faulty bracing strategies. Bracing is not only for lifting heavy either. We need to prepare mom for the demand of life. And mom is holding Johnny who has a runny nose and she's trying to wipe his nose and he's flinging his head back. She's going to be bracing her core and she's not even gonna think about it. So let's prepare her for that. Number four is find and encourage frequent rest positions that ease or make their symptoms go away. This could be lying on their back. This could be seated, this could be laying on their stomach, it could be leaning over the counter, anything that makes their symptoms ease. Again, follow this up with this is not forever, this is a for now, we wanna get those symptoms, the symptom irritability down. And once we get those symptoms down, what can we do? Everything that we just talked about in one through three. So to recap, find the symptom aggravators, find the things that make their symptoms go away or ease. There may be multiple clinical patterns to prolapse-related symptoms. Prolapse can be scary to a lot of women. It is, if they've Googled it, they are gonna come in wide-eyed, or if the doctors told them that, there might be tears. But it can also be really scary to clinicians if we don't know how to treat this. You have four places to start. The Kegel. Gets a lot of hate, but we need to start using it. Don't forget about the hip. The hip muscles are gonna be supporting structures to the pelvic floor. Bracing is not only used for heavy lifting, and using positions that ease symptoms to lower irritability, which will increase our loading capacity. That is it. Start there. So team, I hope this helps. I hope you have a great week and enjoy your Halloween and we'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 27, 2023

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock discusses how to approach setting up at a competitive event, including looking the part, preparing to capture leads, and knowing what is possible in the context of a short session with a potential patient. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - MITCH BABCOCK All right, here we are. Good morning, everyone. Welcome to the PT on ICE Daily Show. I'm your host on Fitness Athlete Friday. I'm Mitch Babcock, lead faculty in the online Essential Foundations Level 1, Level 2 courses and our live Fitness Athlete course on the road where we do all things barbell in your hands all weekend long. I'm pleased to be joining you guys this beautiful Friday before Halloween here, October 27th. And my apologies for nine minutes behind the clock as our CrossFit hour this morning was jamming and ran a little bit long. Today's topic is something that we derived off the ICE Students page. So shout out to all of you that are active on the ICE Students Facebook page. We always appreciate the engagement, the questions, the comments, the thought. It spurs topics like these. You don't even know what kind of good info may come from a question that you pose on the ICE Students Facebook page. So thanks for being a part of that to everyone. 01:18 - THE ART OF THE 10 MINUTE EXPOSURE The topic today is the art of the 10 minute exposure. We're talking about, hey, someone posted a question of, I have an opportunity to set up at a local CrossFit gym or a CrossFit competition that's going on. And I want to know what should I do? Should I treat for free? What should I be doing? How long should I be doing it? And so we want to talk around that concept today of like, let's say you have 10 minutes with a free prospective client and you're trying to win them over in that fitness athlete space. What are some things that you need to be doing and doing well? And so that's going to be our topic of discussion today. And just before I dive into that, I do want to let you know that next weekend November 4th and 5th. Both Zach and myself are gonna be out on the road. Zach's gonna be in Hoover, Alabama, and I'm gonna be in San Antonio, Texas. Team, we are running out of dates to catch the live course at the end of 2023, so if you were hoping to wrap up that cert, or you wanted to hit that course and get dialed in on all your barbell dosage, treatment, refinement, everything, there's like a total of three weekends left at the end of the year. Anna Marie Island just sold out, so that one's off the map now in Florida. Shout out to everyone that's gonna be in Florida. We got Colorado Springs, we got Hoover, Alabama, and we got San Antonio, Texas. So if you want to catch us next weekend, we've got two dates. Check the PT Online's website and we will see you there at those courses. Okay, let's paint the picture. You are a newly minted business owner of your own. You've started your own practice, maybe in a CrossFit gym or near one. And you're looking to do this fitness athlete thing on the out of network side of things. And you want to anchor your ship tight to a CrossFit community in your town, which is smart. And you have an opportunity now to go to a CrossFit competition, market yourself, get your name out there, your business exposure, all of that. What should you focus on? I wanna start with looking the part. 05:07 - PHYSICALLY LOOKING THE PART Aesthetically, physically, from a business perspective, from a clothing perspective, all of the above. That if you're gonna go into this environment, that you need to pull up on the right horse. I don't want you showing up to a biker rally on a scooter and thinking like, I don't know why I didn't blend in with this culture, this community, right? Humans still operate on that first impression basis. That is still a key component. Those first three seconds that someone looks at you, sees you, makes all these internal assessments on what your business is like, what kind of information they can gather from you, what kind of expert you are. We have to respect that first impression and we have to bring our best foot forward. So let's start with your setup. your nice pop-up table, right? Whatever that is, they're cheap on Amazon, you can get a nice brand new table for 100 bucks, it's black top, looks good. Go on Vistaprint or Banner Buzz or one of these websites that will print out a nice custom fit tablecloth that will stretch over an eight foot pop-up table that has your business logo branded across the front of it. So you've got your treatment table and you've got a nice table up front that's going to hold all your brochures or anything else that you have on it. Marketing materials wise, that's a very nice printed stretch fit cover. You're going to invest a couple hundred dollars into having those things ready at any event you go to and market. 5k races, CrossFit events, whatever, right? Tent or not, really doesn't matter. Indoor comp, outdoor comp, you may wanna invest in a little pop-up tent, but let's just assume you're set up inside and you don't need to worry about that. You've got your treatment table, you've got a table up front. You need to personally look the part as well. And I don't just mean the clothes you wear, and yes, I do mean the clothes you wear, but I also mean physically. You need to physically look the part. If you're going in here and working with fitness-forward athletes, you should look the part like you train from a fitness-forward approach yourself. If you're not there yet, and you're trying to inject yourself into that community, anticipate a hard ramp up, right? You need to look like you work out, you train, you've exercised, you do CrossFit, you have some calluses on your hands, that you can speak to the expertise that these athletes are expecting you to have. That is just a cold truth that no one really wants to admit and talk about. If you can't tell the person in front of you how many burpees you do in seven minutes, you're probably not ready to set up at a CrossFit comp yet. Your personal expertise probably has some developmental work to be done on the back end prior to you setting up and going out there and being like, yeah, I can solve all your problems for you. I know exactly what you're going through. So get yourself dialed in from a physical perspective. Two, get your wardrobe updated, right? Do not roll into a CrossFit comp rocking that same polo that worked in the in-network setting and the khaki pants that you wore Monday through Friday. We're not in that setting anymore, right? So invest a few hundred bucks into a nice clinic wardrobe that looks good. Some nice athletic pants, joggers, whatever. Black always goes well. And get yourself a nice top and take it to your local screen printing place and have your business logo screened on the top of it. everyone's wearing the cotton freaking t-shirts with their low company logo on it but not everybody's wearing that that next level nice t-shirt whether that's lulu or whatever you go and you buy your stuff from you get that nice t-shirt you get your company logo on it it just stands out it just looks a little bit better a little bit more professional and a leg up on the competition you're going to business suspense that stuff anyways you might as well get a shirt you like you feel good you look good in and go get your company branded on the front of it So step one, looking the part. Both your setup, your table, your banner, your clothing, right? And physically looking like you train and you exercise and you know what you're talking about when it comes to this stuff. Two, Treat for free. Everyone's talking about should I charge people at these comps. I say that you're there to gain exposure. You're there to convert people back to your clinic. You want them to come to your operation. So you need to funnel everything through that filter. Everything needs to be geared around how do I get in front of people, show them I know what I'm talking about, and then get them to schedule an eval and come see me at my clinic. It's not about a transactional thing here. It's about giving things to the consumer in that environment where you're in front of hundreds of them, over delivering for free, and then converting on that at the end of the sale. 09:49 - CONVERTING LEADS And that's a key part. You need some way to capture leads and convert leads. The best way to do this is having some sort of QR code available. Everybody's scanning QR codes these days. Having a flyer printed out on a little plastic flyer holder that when they walk up and it says right there, free 10 minute session with Dr. So-and-so. Scan here. Boom, that's easy. Boom, pull out my phone, scan it. It takes them to something, a lead generation on your website. That could be sign up for my newsletter, name, email, phone number, city, whatever. That could be put in your contact information. We're going to reach out after today and kind of be in touch with you. Whatever that is, whatever lead funnel that you want people to go to, that's where that QR code directs them to on your website. So they scan the QR code. Boom. That holds their place in line. And then you're calling the next person up 10 minutes at a time. Hey, I got 10 minutes. What's going on here? In that 10 minutes, your goal is to address the areas that most need addressing, to over deliver the best you can, and then to convert that individual after the sale. Give, give, give, and then ask. Give, give, give in that 10 minutes. Here's what I think is going on. This is common. These get blown up. This gets overworked. This is out of position. This is stiff. We need to mobilize this. Here's some things that I like to do. Let's get some needles in that area. Let's do some cupping. And at the end of it, say, hey, I would love to earn your business. If you would, please take my card. I'd love to have you call and set up an appointment. I can actually get you scheduled right now. This looks like something that needs some work. Would you like to schedule right now while I got a few minutes? Don't be afraid of the ask. You're giving free content, you're giving free knowledge, you're giving free experience, and you're giving your time and service to that individual. Do not be afraid for the ask at the end of it, right? Can I earn your business? I'd love the opportunity to work with you, get you in the clinic. My e-mail rate is this. Can I get you scheduled for next week? Convert those leads. We stink at this as a profession and something we definitely have a lot of work to do on getting better when that conversion, that sales conversion process kicks in, right? 10:43 - TRIAGE & TREAT And then the last thing I have, if we're looking the part, if we are converting our leads is to know what works and deliver on that. Team, if they're at a CrossFit comp, they don't need pain science information right now. Okay? I'm not saying there's not a time and a place for that. What they need is something to help them recover. Their back is likely blown up. It feels like there's a hundred gallons of blood shoved right in their erectors right now. They want their back to loosen up and feel better. Their legs are probably imploded. They want their legs to feel better. Their shoulders are probably imploded. They want them to feel better. Right? Understand what these comps and these things are going to ask people to do. Lots of pull-ups, lots of squats, lots of deadlifts. Know what works for those things so that you're efficient in your clinical approach in those 10 minutes you have with someone. We're not trying to solve all their pain and all their problems in 10 minutes. We want to show them that we have tools that can help them. And if you give me more time, if you give me an eval, if you give me a couple sessions, I can get to the root of your problem. So you're having things at the disposal, ready to go for shoulder, like high-volume pull-ups, what am I gonna do to address the lats and the biceps? High-volume squats, what am I gonna do to address the legs and the quads? High-volume deadlifts, what am I gonna do to address the low back? Are you gonna bring needles and stim and hook people up and get them stimming? Cool, maybe get two treatment tables so you can get one person started on that and you get the other person on the table right after that. Are you gonna do some cupping on there, try to increase some blood flow? Great, get it set up, get it rocking, take a bunch of pictures. Another good thing to ask someone for is to have them take a picture and post about your company on social media. Remember, they're getting this for free. They're willing to do something in exchange. Scan your QR code? Sure. Post a picture? Sure, I can do that. Tag my business? I would really appreciate the exposure. We're just getting started. I love working in this community. I love working out in CrossFit. I'd love to be able to help athletes like you down the road. If you could post about my business, that would help me a ton. Thank you so much. They're thankful for your time, your service, and your free delivery of something to them, and they're willing to exchange that in terms of something else for your business. So there's some things for you guys to think about. The art of the 10-minute exposure. You've got 10 minutes in front of somebody. Treat them for free. Have some way of funneling and converting those leads. And don't forget to ask for the sale. Can I get your schedule? Can I get your book? Can I get your e-mail? Look the part. clothing, wardrobe, physically, and then your environment that you're set up, your tables, and your banners, and your marketing materials. And don't forget to ask for something on the tail end. Let's take a picture. Let's post about it on social media. Convert those leads, team. Get those people that you're there, you're giving your time for, for free. Convert those people into prospective clients that are on your books for the next week's following. I hope this was helpful. I hope you took something from it. that you know what works and that you're going to deliver on what works in that 10 minutes for that patient. Team, thank you so much. Shout out to anyone that's going to be at our courses to the end of the year. We're looking forward to wrapping up 2023 with a bang. Next weekend, we're in Hoover, Alabama and San Antonio, Texas. And still some spots for you to join us if you want to. And have a happy Halloween. I know we're rolling into it this weekend. Our gym has a Halloween WOD planned for tomorrow. So a costume WOD for tomorrow and then Halloween on Tuesday. So let me be the first to wish you a happy Halloween weekend, team. Thanks so much. Go kill it in clinic today. Have a great one, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 26, 2023

Alan Fredendall // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses different ways to use band tension to make bench pressing easier for those dealing with pain, weakness, or stiffness, as well as techniques to add accommodating band resistance to improve bench press performance. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show here on Instagram, here on YouTube. My name is Alan, happy to be your host today. Welcome to Technique Thursday. You may have seen this the last couple weeks. We had Paul on here and Ellie on here last week talking about some dry needling techniques. We're happy to bring techniques back. They used to be on Tuesdays, but now they're on Thursdays. So the goal of Technique Thursday is to show you some sort of manual therapy technique maybe a variation you've never seen before and likewise to maybe show you some tips and tricks with a certain exercise. The goal being something hands-on that maybe you could use in the clinic later today in front of your patients. So if you're joining us on the podcast and you're just listening to my voice, you're not going to get a lot out of this episode. So go on over to the Ice YouTube channel and find this episode so that you can watch the video. Before we get started today, it's Technique Thursday, which means it is Gut Check Thursday. This week's Gut Check Thursday, five rounds for time, a 400 meter run, 50 double unders, and 15 burpees. Much more cardio focused, body weight focused than last week. So last week we had an EMOM of calories on the bike and some bench press. So if strength and power is not really your thing, then maybe some lighter, long-duration cardio this week is your thing. You're thinking maybe 3-5 minutes around there, a relatively fast 400, ideally an unbroken set of double-unders or single-unders, and then a relatively fast pace on those burpees, trying to get that workout done, maybe somewhere between 15 and 25 minutes. Courses coming your way today, I wanna highlight our Extremity Management Division. The last three courses coming your way this year are coming up in November and December. So the weekend of November 11th and 12th, we're gonna have Mark Gallant, aka Mark Gallant, aka Mark Lanz. He'll be down in Woodstock, Georgia, the weekend of November 11th and 12th. And then the weekend of December 2nd and 3rd, you can catch Extremity's newest Lee faculty member, Cody Gingrich. He'll be out in Newark, California. That's gonna be in the San Francisco Bay Area. And then Lindsey Huey, the very next weekend, the weekend of December 9th and 10th, she will be out in Fort Collins, Colorado for the very last extremity management course of the year. So if you're looking to catch that course, check one of those three courses coming your way in November and December. 02:29 - BANDED BENCH PRESS TECHNIQUES Today's topic, we're going to talk about some banded bench press tips. So you might be thinking, Alan, this seems like a topic for Fitness Athlete Friday, and you could be correct. But I hope by the end of today's episode that I get you some buy in that bench press is really appropriate for almost all of our patients. And today we hope to explain why and show you how you can introduce this movement to everybody. So when we think about bench press, we mainly think people who are already active, who are in the gym, either bench pressing, recreationally because they like it, they like to have a big puffed up chest, maybe they're doing it competitively, maybe they're a powerlifter or a strongman type athlete, and bench press is one of their events. And bench press does show up occasionally in CrossFit, so we do, not as often as powerlifters or strongmen, we do bench press in CrossFit as well. What's really cool about bench press is it's one of the four primary movement patterns of our upper body. If we think about our shoulder and chest complex, our upper body in general, what movement patterns can it fundamentally do? It can move things vertically. We can vertically pull, right? That's our pull-ups, our muscle-ups, our toes-to-bar, that's getting out of the pool functionally, jumping over a fence or something like that, some sort of vertical pulling pattern. We can press things overhead as well. the turnover of a snatch, things like that, moving weight overhead in a vertical pressing pattern. But then probably the more neglected patterns across fitness, recreational or competitive, is horizontal movements. We have our horizontal pulling, things like bent over rows. And finally, we have our horizontal pressing, things like bench press, but also more functional movements like pushups and burpees, right? Getting off the ground. So we like to use bench press here a lot with our older adults. It's a great way to load the shoulder complex, especially somebody with a painful or stiff shoulder that maybe can't even begin to initiate vertical pressing, maybe not even prone with body weight on the table, maybe not even in a landmine press, they have a really hard time due to stiffness, due to pain, whatever, even lifting any sort of weight vertically overhead. We know there's some carryover from horizontal pressing to vertical pressing. We're working primarily the pecs with the bench press, but we are getting some delt as well, and we're able to lift in a horizontal press pattern to maybe 115 degrees. So this is a great way to reintroduce load to the shoulder complex, even if we can't vertically press. Now today, I want to show you some ways to make the bench press easier for folks, whether strength is limiting them, range of motion is limiting them, or pain is limiting them. 04:57 - MAKING THE BENCH PRESS EASIER So we're going to show you two techniques to make the bench press easier, and then we're going to show you a technique to make the bench press harder. So the easiest way to offload a bench press is a banded bench press like I have set up here in the rig. So I have two bands, half-hitched over the pull-up bar, the upright of the squat rack. onto the bench press in the center of the barbell so that I can still grab whatever grip width I want and now the bands are offloading that barbell for me. if I have pain maybe above a certain percentage I'm already bench pressing in the gym this can make bench press feel a little bit lighter so that it's more comfortable and tolerable and I can still get into the gym and maybe I can't bench at 75 or 80 or 90 percent of my max like my training has me doing but I can go in the gym at 60 percent with some bands on the bar and maybe I can move some weight at 60 percent so at the very least I'm maintaining or maybe a little bit incrementally increasing my strength as we calm pain down and build tissue resiliency back up. So pretty simple, half hitch the bands, put them over the barbell, lay back down in your normal bench press pattern, and then what you're going to feel is with no plates on the bar, you're going to feel almost like you have to pull the bench press down, and then the bands, if you have no weight on the bar, are really going to pull the bench back up for you. So you're able to really move through the movement pattern efficiently. So this can be great to train the bench press as well. And now we can put plates on there. What's great about this is we can get plates on the bar for maybe somebody who just the empty bar is challenging. By being able to put maybe even 10 pound plates on the bar, it helps them feel really successful, like they moved some weight around the gym. even if all they can normally lift without the bands is the empty barbell. So they get to go home and tell their spouse or their kids that they lifted a bench press today with the greens on or the yellows on, right? So it can help build success with that novice athlete. Folks who have pain or stiffness, we're now able to load at least in a partial range of motion of the shoulder, begin to strengthen within that range of motion that will hopefully now also allow us to transition to a vertical pressing pattern. If you don't have a way to set this up, another great tool is the slingshot. So this is from Mark Bell and colleagues. Anytime you've used a hip halo, maybe to do some monster walks, if you've used one of the official hip halos, that's also a Mark Bell product. If you have one of those, you probably recognize this looks very similar. So there's really no difference here and what I'm about to show you from what you get with the banded unloaded bench press, except now I don't need a squat rack with uprights to hang bands, but this is going to come up on my upper arm. I'm going to put both sides in. and now this is the slingshot. So now, as I sit down on this bench, there's going to be a tension that's created at the bottom of my bench press that's going to push me back out of the bench. So I'll lay back and show that to you all. If I were to pull a barbell back down, that band would stretch and help me out of the bottom. Now, what's great about the slingshot that you can't do with the barbell and the rig is I can translate this now and I can do push-ups or burpees with this on as well. What's really, really, really cool in the literature is how correlated maximal bench press strength is to push-up and burpee capacity. That is to say that the stronger your bench, it tends to track that you can do more push-ups. The reverse is also true. The more push-ups you can do, the likelihood is that you have a stronger bench press, and you can train one or the other to improve the other one. you can just do push-ups for a year and as long as you're progressing, how many push-ups you do, you're progressively overloading your push-ups, you will see an increase on your bench press and vice versa. So same thing, maybe somebody's not bench pressing at all but they come in and they have pain with push-ups or burpees, we can use the slingshot to offload that bottom position and make them feel more comfortable so they can continue to doing push-ups or burpees in their training program that we know that will translate down the road to bench press strength and vice versa. So two different ways to make the bench press a little bit easier, whether somebody's new, whether somebody needs to learn the range of motion, whether they have stiffness that prevents vertical pressing, or they just have a painful bench press and they currently can't lift as heavy as they would like. 07:53 - USING BANDS TO IMPROVE BENCH PRESS PERFORMANCE Now we can also transition, we can use bands to make lifts a little bit harder. So now, instead of these bands over the barbell offloading, We're going to put these down on the floor to this pair of dumbbells you see down on the ground. Key here, really heavy dumbbells. I've got 50s here. If you try to do a banded bench press with like 25s, the resistance of the bands is going to pull the dumbbells off the ground. So keep that in mind that you need some heavy dumbbells to anchor for you. Setting these up, don't overthink it. Loop it halfway through, underneath the handle of the dumbbell, and then loop it up and over the barbell, right? You can see this is even challenging the 50-pound dumbbell. If I had even 45s or 40s, it would be lifting this dumbbell off the ground. Same thing on this side. Half loop on each side. up and over the inside. There we go. So now, the resistance is going to be coming out of the bottom. Because it's an elastic band, it's going to give us the least tension in the bottom, and it's going to give us increasing tension as we drive out of that bench press. Now, there's some criticism of this, of the weakest point of the bench press is the bottom, so why am I doing a training method that makes the weakest part, the easiest part to train with a banded bench press. The answer is that when I have accommodating resistance out of that bench press, I need to activate more and more and more and more and more muscle fibers to drive out of that bottom. So yes, It will never improve the dead stop where the bar is touching my chest at the bottom. The only way to train that is to go through full range motion bench press more often. But the benefit I'm going to get is I'm going to activate more muscle fibers, which in the future is going to translate to being able to recruit those more easily when I bench press in the future. And also I have to continually increase my velocity out of the bottom of the bench press to overcome the steadily increasing resistance from the band. That band is going to get tighter, tighter, tighter, tighter as I get out of the bottom. I'm going to have to continually increase my velocity out of the bottom or I'm not going to be able to go anywhere. That's really helpful for anybody that's maybe stuck at a certain weight at their bench press. They can go to the bottom and they can drive out, but it's really slow and grindy and maybe they're stuck at a weight like 315 and they said, hey, I haven't added weight to my bench press in a year. This can be a great way to break some plateaus. It can also just be a way to overload the bench press. If my max bench press is 315, I can put 275 on here. Yes, the bottom is going to feel easier, but as I drive out, it's going to feel as hard as 315 maybe coming up. And now I can get more volume in, in a way that my speed is maintained, that's going to translate into having an overall stronger bench press down the road. So pretty simple, bands on the barbell, on racket. A lot of tension at the top, right? This is super tough even with no weight. As I come down, easier, easier, easier, and now I really have to focus on increasing speed continually to get out of the bottom of the bench press. With an empty barbell, that would be pretty difficult for maybe even a set of five. So don't knock it till you try it. There's a lot of criticism about bands and chains. Obviously the most important thing is the weight on the barbell over time, but this can be a great way to just change up variance in your bench press, to break through a plateau, and even to overload your bench press, to be able to lift a weight Maybe you use a bench block, you come down to maybe 80% of the range of motion and drive out, and now you're working at a weight that's maybe heavier than your one rep max bench press. Again, the goal, recruit more muscle fibers and kind of overload that bench press pattern. So banded bench press, why? Folks who maybe have a lack of range of motion or lack of strength overall in the chest and shoulder complex, who maybe not right now are able to show you any sort of vertical pressing pattern. It is a great way to offload a bench press for somebody that maybe is already training the bench press that has pain, and then we can flip the resistance. Now we can give resistance as we drive out of the bench press. Why? Accommodating resistance, help improve our barbell velocity, help break through plateaus, recruit more muscle fibers. So play around with banded bench presses. I hope this was helpful. Have a fantastic Thursday. If you're going to be on a live course this weekend, I hope you have a wonderful weekend. Thanks for listening. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 25, 2023

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses that the fountain of function is muscle mass and estrogen in the aging female. Christina breaks down these two areas for function, and what we have physical therapist can do to help encourage both muscle mass and estrogen preservation. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the team within our Modern Management of the Older Adult Division. In our division, we have three courses in our geriatric curriculum. We have our eight-week online Essential Foundations course. We have our eight-week online Advanced Concepts course. And we have our two-day live course. We have a couple of courses that are left in the remainder of the year. We have a course coming up in November in Chandler, North Carolina. We have another course coming up in South Carolina. And we have a course coming up in Texas in December. So if you are near those courses or you are looking to get in some content before the end of the year, I encourage you to check those courses out. and you'll be able to get in with some of our faculty before, you know, we ring in 2024. 01:18 - THE FOUNTAIN OF FUNCTION Today I'm going to talk about the fountain of function. And so this is a reframe that I think is really important. And we're going to talk about what those fountains of function are. You'll notice that I did not say fountain of youth. We have this idea in our society that youth is the goal, to not feel like we're getting older in any way, to not show signs of age on our faces. And don't get me wrong, I see my aging face, I was like, oh, my face doesn't look like I am 21 anymore, and I look at the wrinkles on my face, and I have those emotions. But the idea for my life is not to try and get younger. It's to try and optimize my reserve and try and live the way that I want to live with the most amount of function possible into my 30s and 40s and 50s and 60s and hopefully all the way up to 100. Because at MMA and within ice in general, Aging is a privilege. It is something that I am very thankful for because the alternative is not that great. We're not gonna be able to reverse back time, but we can have a really successful aging process, especially when we put in the steps to live the way that we want to live, whatever that filter means for us. So I'm not looking for the fountain of youth. I am looking for the fountain of function. And so the two types, the two areas that are the fountain of function in aging women, so I'm going to talk about female anatomy, is muscle mass and estrogen. And these two things, especially when taken together and optimized to the best of our capacity, is going to allow us to have more function towards the end of our life. So let's talk about muscle mass. You have not been following the Institute of Clinical Excellence in any ways if you don't know that LODE is our love language across all of our division, across all of our faculty, and that is absolutely true in the geriatric curriculum as well. And I love it so much that I did an entire PhD on the influence of resistance training in an aging body. When we look at resistance training, we are accumulating a growth and a continuation, a plethora of education and research that looks at the impact of resistance training on health outcomes. And I just posted a paper that was a narrative review from Stu Phillips, who is one of my committee members on my PhD. 04:18 - THE COMING OF AGE OF RESISTANCE TRAINING And he talked about the coming of age of resistance training and how we are starting to see some accumulation of evidence that is mirroring and is just as strong as literature that we're seeing in aerobic training to prevent stave off different chronic diseases, including some cardiovascular diseases. And so there means that there, as of course, we're going to target the aerobic system. This is not to say to not do cardio in stead, just do resistance training, but it's showing that there is a continual and persistent growth of literature talking about the impact of resistance training on health outcomes. So what we see is that those who have more muscle mass tend to have lower all-cause mortality. They are less likely to develop cardiovascular conditions. They are better able to manage diabetes. They're less likely to get diabetes. We know that muscle mass is protective around things like osteoporosis, right? Tensile strength of the bone is important and we need impact, body weight movements, resistance training across the lifespan in order to optimize that. We see that individuals who are stronger or less likely to have sarcopenia, right? Sarcopenia is clinically relevant amounts of muscular weakness that are preventing a person from completing their day-to-day tasks. It's a totally important output of frailty. Fried's physical phenotype of frailty talks about physical reserve and physical capacity as an output of individuals seeing these constellations and signs and symptoms that lead to vulnerability to external stress. That external stress includes things like hospitalizations and being able to withstand different stressors with respect to immune system insults, including things like COVID-19, pneumonia, and the flu that allows individuals, while they are sick, to have that reserve and resiliency to lean back on in order for individuals to be able to get back to baseline or improve past baseline, post-hospitalization, or acute insult. All this to say, we know that individuals need to be trying optimize their muscle mass in their earlier life and then hold on to it for as long as possible. If you are in a setting where you are not working with individuals who have optimized their muscular mass, we also know that muscular mass can be developed and we can see improvements in physical function with resistance training at any age when we start including in our 90s. The mechanism at which strength develops is a little bit different. We're looking a lot more at neuromuscular efficiency. However, we can absolutely see that it can improve function. And so whether you are 30 or you are 85, muscle mass is a fountain of function and it allows us to withstand stress. 12:24 - ESTROGEN FUNCTION & MENOPAUSE Now let's kind of talk about this second piece, which is estrogen. I've done several podcasts on menopause, but I want to talk about the influence of estrogen around female physiology, because I think this is really important. So when we are going through the menopausal transition, on average, individuals will start menopause between 50 and 51. Definition of menopause is when you've gone a full calendar year, 12 months without a menstrual period. That is your menopausal transition. But individuals can be experiencing perimenopausal symptoms that are indicators of dwindling or are coming down of estrogen status for up to 10 years prior to the transition into menopause. And so individuals who are in their early 40s can start to see the influences of loss of estrogen on their body. And then that influence is persistent as individuals get older. When we're talking about menopause, we often are putting this into two camps. So we have vasomotor symptoms, which are these symptoms that occur because of an acute withdrawal of estrogen. These are things like night sweats and hot flashes. As individuals transition through menopause and we get into our later life, into our 60s, 70s, 80s, and beyond, those symptoms tend to decline. So those vasomotor symptoms that occur as our body transitions to reductions in estrogen status they tend to go down as our body gets used to this new state of equilibrium that occurs without estrogen. In the opposite direction, the second kind of camp that we speak about when individuals are going through menopause is genitourinary syndrome of menopause or GSM. And that is signs and symptoms across the female physiology that are responding to losses in estrogen. and anywhere where there is an estrogen receptor within our body, they are going to experience changes when individuals transition through menopause. And we oftentimes will, in the pelvic health space, talk about changes to our reproductive anatomy, which are unbelievably relevant, but we have to also extrapolate that out and talk about different areas where estrogen is influencing female physiology and how, if you are working with an aging female, they are experiencing changes because of that change in estrogen status. And so within the reproductive track, we see that there is changes in ligamentous stability around the pelvis. And I hate that word stability, but it's a change in the turnover of the way that our ligaments are restructuring. So we have a little bit more ligamentous breakdown than buildup, right? That turnover rate is different. And so we have this shift between static support in the pelvis to the requirements or dynamic support around the pelvic floor. We see that individuals start to have vaginal atrophy. We see that the vaginal microbiome starts to change. We don't have the same cervical mucus secretion. And so things like chafing and redness can be more prevalent in a person who is postmenopausal. We can see fusing of the labia minora and majora. and this can lead to increased risks for pelvic floor dysfunction. So when we are in estrogen low states, rates for pelvic floor dysfunction go up. This includes anal incontinence, urinary incontinence, pelvic organ prolapse, dyspnea, or painful punitive intercourse, and other aspects of the reproductive tract. We also see, because of this change in the vulvar anatomy, that we have an increased risk for things like urinary tract infections, that increased risk for urinary tract infection also influences individual's physical function. We know that recurrent UTIs can be a cause of changes in cognitive status for our aging females. And so something that is extremely relevant for our aging women. Other things that we see is that as individuals go into an estrogen depleted state, increased risk of cardiovascular disease goes up. Individuals as they transition through menopause, we see that in general, men tend to be more impacted by cardiovascular disease. That is shifting for a lot of different reasons, but that risk profile increases when individuals are in an estrogen depleted state. We see a change in central adiposity where weight starts to increase. Adiposity accumulation can increase, especially visceral fat accumulation, which has a risk profile in and of itself for different chronic diseases. And then we see, for example, in our bone microarchitecture that the influence of estrogen allows for continual bone regeneration and that profile again starts to switch and there's an increased risk for things like osteoporosis in an estrogen deficient state. So there's a lot of things that get impacted, right? Our skin gets impacted, our breast tissue gets impacted, our urinary tract, all of our mucosal membranes, not just in our vulva, but across our entire body, and this has impacts. And so when we are thinking about working with these individuals, one of the things that is starting to become really recommended is topical estrogens. And there's a lot of debate about this because of a study that had been done a little while ago that looked at increased risk for sex-related cancers, breast cancer, endometrial cancer, cervical cancer, et cetera, with systemic estrogen. However, what we are starting to see now and many of our menopausal experts like Dr. Mary Claire and Dr. Rachel Rubin are really trying to have this public health approach to medicine saying that we are not doing our females a service when we are saying that there is a risk profile when subsequent studies have not been able to substantiate or replicate those findings. And so there's been a big shift in the last five years to the need for or the desire for many women who are really suffering with genital urinary syndrome of menopause to be able to take things like topical estrogens in order to really significantly reduce their symptom burden. And I'm not just talking about their pelvic floor, which is an extremely important part of their sexual health, also a vital sign of aging, but also, you know, all of these other physiological signs of estrogen deficiency that are impacting our outcomes, right? We see that individuals with that combination of muscular mass, we are seeing individuals with negative consequences of osteoporotic fracture. if we were able to be preventative in this approach where we are talking about estrogen supplementation when these symptoms start to arise, especially when they hit a threshold of bother, where there's going to be this spectrum, some individuals are very bothered and very impacted by the signs of vasomotor symptoms and genital urinary syndrome of menopause, and then some individuals are not, but for those individuals with bother, is this something that should be taken? Is this something that they can talk to their physician about? Is there this literature to support these topical estrogens? And we are starting to see this mounting of evidence that is starting to come up to help individuals in the aging process. So many of our aging adults are being told that this is just what they should be living with. This is because they're going through menopause. Deal. We saw this in the peripartum space where there's a lot of advocacy still happening with respect to not having this thought process that as soon as you have a baby that pelvic floor dysfunction is just something that you should live with. We're starting to see this rise up in our perimenopausal and postmenopausal population, where they are not accepting that this is what they should be doing. They're not being dismissed anymore for these symptoms, and it's super important. When we take this lifespan approach, this education becomes extremely relevant. Talking about the peripartum space, I truly believe that that is where we start to tell females that they are not resilient, that they are somehow fragile, that they need to be concerned for their organs falling out and all these different pelvic floor dysfunctions. And then they are not encouraged to be as resilient as they could be by taking part in heavy resistance training or impact activities or things at higher intensities. We start bringing that intensity down and the idea of, ooh, be careful or, oh, monitor this or, oh, if you have these symptoms, it's time for you to stop participating in those activities. We are seeing this shift and what this shift is going to do earlier in life is it's going to set up are aging individuals with this mindset that pelvic floor dysfunction one is not inevitable two that reserve is protective when it comes to muscular reserve and three they're going to be advocates for their own health and that includes their hormonal health and that includes not accepting that some of these symptoms of menopause are things that they just need to live with, but things that can be medically managed. Genital urinary syndrome of menopause is a syndrome condition. It is a medical diagnosis, and therefore it is something that we can be treating. As physical therapists, us being educators and conduits of that knowledge translation is extremely important. And then we are going to optimize function for these individuals. Last point that I'm going to make, because I ended up being a lot more long-winded than I thought I was going to be, is that we are now seeing this interaction between menopause, genital urinary syndromes, and long-term health outcomes. We are seeing that individuals with higher physical activity, combination, aerobic resistance, or both, are having a much lower GSM burden than those who are not. And so again, it comes back full circle, whether this health promotion is extremely important, that not only are we gonna optimize a person's muscular reserve, we're gonna make that fountain of function be extremely relevant, but we're also going to make the quality of that function a lot better because their quality of life is better because we are not allowing them to just live with these symptoms and be dismissed by our medical system, us included, that just expects this to be the way that it is. And so this advocacy piece is extremely important and it's something that we are going to be screaming from the rooftops. All right, everyone, I hope you have a wonderful week. I'm going to be diving a lot more onto my page and I'm going to be collaborating it with ICE and MMOA around hormone therapies for individuals with GSM. I am not a medical physician, so I encourage you to reach out to your urogynecologist and urologist in your area. Get that relationship with them so that you can start having these conversations and we can start talking about risk profiles. All right, have a wonderful week. If you are not on our MMOA digest, I encourage you to sign up for those newsletters. Otherwise, have a wonderful week and I will talk to you all again soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 24, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant emphasizes the importance of having a well-coached and appropriately dosed set of exercises for patients. He stresses that these exercises should be ones that the therapist is extremely familiar with and knows exactly how to prescribe. By having a clear understanding of these exercises, the therapist can confidently explain to the patient the objective criteria and expectations for progression. Mark acknowledges that sometimes our egos can hinder us, leading us to believe that we can come up with a better plan for each individual patient based on the information we have at that moment. However, he argues that research has shown that the human brain is a sensitive instrument that responds quickly to changes. Therefore, having a preset plan of exercises allows for consistency and efficiency in treatment. Additionally, Marj suggests that having a set of exercises that can be progressed by increasing work volume, range of motion, load, or speed, while keeping the exercises relatively similar, can be beneficial. This approach allows the patient to become more efficient with the exercises and increases their buy-in. It also reduces stress for the physical therapist and ensures that enough time is given for each intervention to make a meaningful impact. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - MARK GALLANT What's up PT on ice crew we got Instagram here YouTube over here. I'm Dr. Mark Lantz coming at you here on Clinical Tuesday, lead faculty in the ice extremity management division, alongside Lindsey Hughey, Eric Chaconas, and Cody Gingerich. Happy to be here this Tuesday. Before we get rolling, a couple of housekeeping things. We've got a few more courses for the extremity division coming up here for 2023. I'll be in Woodstock, Georgia, second weekend of November. and then Cody and Lindsey each have opportunities early December, so check that out on the ICE website. More importantly, if you've been looking to get a certification through ICE and the overall ICE cert seemed like a bit much to chew off right now at this stage of your career, we are happy to announce that we've launched the Ortho cert. If you take the two spine management courses, cervical management, lumbar management, the extremity management course and total spine thrust manipulation, take a short test at the end of whichever the last of those four that you take, you can become ortho certified. So that is officially launched and on the website. So definitely head over there and check that out and we hope to see you on the road soon. 01:39 - INDIVIDUALIZED CARE So today what I want to talk about is individualized care. your ego is killing our profession. And what I mean by that, or what we mean by that, is that when we go around the country and we mentor folks, or we help out and talk through cases with individuals, watch people treat, one thing that we're starting to see as a trend is that folks are jumping around quite a bit in their plan of care. So that patient comes in for one visit, they're given a certain set of manual therapy techniques, a certain grouping of exercises at a specific dosage, and then each subsequent visit that person comes in, the plan dramatically changes. They're given a new set of exercises, there's different manual therapy techniques done. They are getting a completely unique plan of care each visit. And what we're recommending is that there needs to be a plan, that for any given pathology, you have a plan of what this is typically gonna go like. With that individualized care of jumping around from place to place, visit to visit, what we believe is that it is a reaction to old school physical therapy, what we like to call physical therapy 1.0, where a person would walk into a clinic, they would be put on a new step or a bike for five to 10 minutes, the physical therapist would wave the ultrasound wand on wherever their area of pain is, and then they would be given an exercise sheet. And it would be very specific to, here is the foot and ankle exercise sheet. Doesn't matter what you have going on, here is your foot and ankle exercise sheet. Here's our shoulder sheet. And if you were lucky, you would have a tech that would take you through that. If you were not one of the lucky few, you would either be given that to go run through in the clinic on your own, or even worse, just sent home with this exercise sheet. 04:17 - INDIVIDUALIZED PLANS OF CARE So we swung the pendulum hard to everyone gets an individualized plan depending on what they show up with the clinic that day. So if their pain has changed, if what the exercise is looking has changed, then we ditch the entire plan and then we're going to go to this very individualized thing each visit. The problem with this is it's hard for the patient to buy in if everything changes each visit. They're not sure what the plan is. Humans love to have a target in a bullseye. So if that person knows like, ooh, here's the plan that we laid out during the first couple visits. And here's where I am along that plan. It allows them to be more bought in. They're going to comply with the plan more. They're going to be more adherent to the plan because they can see the target they're shooting for. And they can very clearly see where they currently sit on that plan. In addition to that, if we're jumping from thing to thing all the time, we're actually likely not giving any one intervention enough time to do its thing. So we know with exercise, the research is fairly clear now that exercise for musculoskeletal pain is the most bang for your buck intervention from a cost perspective and from a getting the job done perspective. It takes time. If we're jumping from thing to thing every visit, then we're likely not giving those interventions enough time to actually make changes. And in addition, it takes people time to get used to doing an exercise. So if we switch to exercise each visit, we're not allowing that person to become efficient with that exercise. And then finally for us, if we're seeing anywhere, depending on what type of setting you're in, between six and 20 individuals a day, creating six to 20 unique plans of care. Every single visit for every single person becomes wildly exhausting. I've lived it. Everything that I'm saying here, I have personally done for many years. That type of physical therapy becomes exhausting. And it's likely part of the reason why we have such a high burnout rate in our profession. If the expectation is a unique individualized plan of care for every individual, every day. That becomes a lot for any one given physical therapist. Whereas if you know, for X pathology, for my rotator cuff related shoulder pain folks, I know that I can modulate their pain, decrease their symptoms with these three to four manual therapy techniques. I know that my bread and butter early on exercises are gonna be these four to five exercises that I can coach extremely well, that I know exactly how I want to dose, and that I have an expectation of when the person can do these, what the next group of exercises that I'm gonna move on to, and I can clearly explain the objective criteria to the patient of what that's gonna be. Now, our egos often get in the way of this, because many of us, myself included, I'm speaking to myself more than anyone, believe that for any given person that comes in, that we're going to be able to give them a better plan based on the information that's coming that day than the preset plan before that may seem more cookie cutter that we're afraid of. What we know about the human brain, now having a lot of research over the years, it is a very sensitive instrument and it's going to respond quickly and rapidly to what's changing in the moment. So therefore your plan or what that person is coming in can be highly deviated by anything that's happened to you that morning or that day. If you had a stressful interaction with your boss, if the kids were having a hard time getting ready for school, if someone called you right before the patient came in and gave you some bad news, that is all going to very dramatically sway what happens in that session and how you go about what you're going to do in that session. Even more dramatically, our patients are in pain. which means that their nervous systems are gonna be all over the place. And so their drama and their brains are gonna be very sensitive and that is also gonna shape those interactions. So we're leaving a lot of interpretation to that interaction. Whereas if we have a plan that we know if this is looking like this, I'm gonna go this way, if this is looking like this, this is how I go based on the plan for this pathology, we are far less likely to succumb to the sways of any given day. When we look at other professions, professions that have higher stakes than physical therapy typically, we see that they use systems and plans to deviate from those in the moment sways. Pilots are the easiest example to talk about. When you have a pilot, it doesn't matter if that pilot is on his second day of the job or if they have 36 years of experience. That pilot has a checklist for almost everything that could possibly happen on a plane. If the weather looks like this, this is our checklist of what we're going to do. If the wind changes this way before we land, this is what we're going to do. And that pilot follows the checklist, not what they're feeling in the moment based on their experience. So much so to the point where there's a second person there, the co-pilot. whose primary job is literally to say, hey, why aren't you following the checklist? We got to go back to the checklist. We know this works. 99.9% of the time go to the checklist. 09:30 - RECIPE REPETITION For those of you who have been following ICE for a long time, our CEO, Jeff Moore, spent a lot of time working in restaurants and kitchens. And if you were lucky enough to take a class with Jeff or got to spend some time with Jeff, we used to always get all these stories about his time in the kitchen. And a lot of those things I still think about to this day, the stories he told as far as patient care. And one of the main ones that stuck with me was a chef that he worked with, who now has a Michelin star, by the way, told Jeff that for any given recipe, you need to cook this 1,000 times before you start to deviate from the plan. Doesn't matter if you're the greatest chef in the world, you don't add salt, you don't add fat, you don't add any flavor profiles until you have cooked that recipe 1,000 times. Because that 1,000 times is going to allow you to see how this thing really responds, what could possibly go wrong, what could happen, how you really get the full breath by committing that much. That's the same with our plan of care. There is no way that we can confidently say to the human in front of us, for most people what we see, if you follow this plan, this is where we get to. If we're changing the plan all the time, we never get to experience that to show the patient and to say confidently. So we want to have the plan for any given pathology that we're going to give most people. Another example, is the 12-step plan in recovery. I am not in recovery myself, so if I'm butchering this, I apologize to anyone who is in recovery. But with the 12-step program, it's 12 steps. You run the steps, and people who have addictions all over the country have been using this 12-step program to help deal with their said addiction. And when you look at that plan, it's a simple, not easy plan, and you follow those steps to a T. Again, same as the co-pilot, they have a mentor or a sponsor who helps them work those steps. If that person is struggling or deviating, what that mentor's job is to do is say, hey, make sure you go back and are following these steps and are not deviating. So lots of examples of really solid professions and organizations that use a plan to get the job done. 12:07 - STICK WITH THE PLAN: MODULATE PAIN, INTRODUCE MOVEMENT, PROGRESS MOVEMENT So what should the plan look like for us, for any given patient? When you have a pathology, rotator cuff related shoulder pain, plantar fasciitis, things that you need to know. Early on, what are the manual therapy techniques or exercises that you know can modulate pain and decrease symptoms for most people? Have a few of these that you know you can do effectively and work for most folks as part of your plan. Then have your bread and butter exercises. What are the exercises that are gonna be the main, let me back up for a second. Before you have your bread and butter exercises, what are the few exercises that you're gonna have that are for that irritable patient that you know before they can tolerate a lot of load that we're gonna give them? So your pain modulation techniques, your lower level exercises that are not gonna overstress the tissue while we're trying to calm this down. Part two, what are your bread and butter exercises? What are the handful of exercises that you know tend to work best for any given pathology that you can coach really well, that you can dose really well, that you can manage workload really well? And then finally, what is the criteria that that person needs to demonstrate to move on to their more advanced exercises? And then a final piece to have in your mind is what does this look like If the person does have a flare up or relapse, how do we coach them? What point in the program do they go back to if they are indeed not ready to progress? So again, what are the things that can modulate pain and that can calm symptoms down or exercises that are not going to require a lot of stress to the tissue while things are calming down? What are your bread and butter exercises for any given pathology? What are the most common things that you're going to give in most people's plans? And then finally, what are you going to have as your criteria to progress these people on and having a game plan if they do flare up or regress? What this is going to allow, it's going to allow the person to go, ooh, I know exactly where I am on Mark's plan of care at this time and where I need to go to take the steps to move forward. It's also going to allow you to not have to switch exercises so much. You're not going to have to get overly creative with your exercise prescription. And by doing this, what you're typically going to be changing is same exercises, but you're going to be increasing the work volume. You're going to be increasing the range of motion. You're going to increase the load on the exercise and you're going to increase the speed on the exercise while keeping the exercises relatively similar or the same so that the person can become more efficient with that exercise. It's going to allow the patient to buy in way more. It's going to take our stress way down as a physical therapist. And if there is that small percentage of folks who do indeed need a more nuanced program because they are actually not responding over time, or they're having a lot of trouble adhering to the plan, it's only a small percentage of the folks, which takes a lot off of the mental stress for us as physical therapists. Love to hear what you all think about this in the chat. Definitely hit us up. Love to see you on the road in Woodstock, Georgia next month. Cody and Lindsey have courses early December. Check out the ortho cert on the website. Have a great day in clinic today. Hope you all crush it. See you soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 23, 2023

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic lead faculty Alexis Morgan discusses the research & practical approach to helping runners return to running beginning at 4 weeks postpartum. She references research that about 50% of postpartum patients begin reintroducing running at approximately 4 weeks postpartum, with varying degrees of symptoms. Alexis emphasizes utilizing the symptom behavior model to monitor symptoms, educating & encouraging patients that about 85% of all individuals have some sort of symptom(s) with running, and that volume is an important variable to have a successful return to running. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 - ALEXIS MORGAN Good morning, Instagram. Good morning, fellow ice people. Welcome to the PT on Ice Daily Show. Welcome to Monday. It is the start of another week. And we are so excited to be here. Really as we're wrapping up the end of this year, we still have a lot going on at the end of the year that I want to tell you all about this morning. And then we are really getting already very excited about 2024. And just want to talk to you all about some of the things that are going on. If you are in the ICE Students Facebook group, you've been to an ICE course or you were just recently added in because you just finished a course this weekend, welcome. You've seen some announcements in there as well a while back. And I just want to highlight a couple of things. So let's get started on that before we discuss four weeks returning to running, four weeks postpartum. So number one, we've still got three more chances for a live course, or you've got three more chances to hit us in the pelvic division at a live course. So this, not this weekend, but next weekend, if you're listening live, November 4th and 5th, we will be in Bozeman, Montana, and then a few weeks after that in Bexar, Delaware. And a few weeks after that in Halifax, Nova Scotia, Canada. That is the first weekend in December, December 2nd and 3rd. So those are your three chances to get into seeing this Pelvic Live course, experiencing it, having fun with us, learning so much about pelvic floor health. not just for pregnancy and postpartum, but in general, across the lifespan, men and women, pregnancy, yes, but also all things pelvic health. So those are your three chances, Bozeman, Bexar, Delaware, and Halifax, Nova Scotia, Canada. So if you're on the fence, go ahead and pop onto those. Second, thing that we i want to share with you all is about the pelvic level one course so our name is changing as you all have heard us talking about and we're actually going to be taking a little break through the next few months and our new level one cohort is going to start in january so Be sure, we've already got people signed up for that, gearing up, ready to experience the new content. Very regularly, we are always reading the research on a weekly basis. And once enough of it stacks up, we've got to reframe the way that we're teaching, particularly in the space, because it changes so incredibly rapidly. And so with that, we are updating that material. So that is coming up on, that will be on the website soon. Actually, that is actually already on the website. So that is on there. So a lot of things coming up at the end of this year, the beginning of next year. We've got even more announcements, so stay tuned. And we're gonna be announcing a couple more exciting things in our ice pelvic newsletter. So if you're not already signed up for the pelvic newsletter, go ahead and sign up for that because we've got even more things to discuss and share with you all. 04:31 - RETURNING TO RUNNING 4 WEEKS POSTPARTUM So all of that aside, let's go ahead and discuss this four week return to running. This is a topic that a handful of years ago really was not discussed. No way are we going to be facilitating someone running one month after giving birth. That's what we thought a handful of years ago. But fast forward, we've got several examples of elite level athletes which then trickles down to our recreational level athletes, we've got several examples of people returning to running. And it's actually even showing up in our literature. And when we are starting to see this, it's kind of interesting in the pelvic world, like we have all of these thoughts and beliefs and oftentimes you're you're gonna run into some strong opinions surrounding those, and a deep connection here. We've gotta have that connection with our beliefs, but also be willing to let that go once the evidence and once the, even the anecdotal evidence that your clients show up to you with, once that narrative begins, and it's maybe opposite of yours, we need to be able to let that go and to explore and ask questions and be curious about, well, what are some other possibilities? And that's exactly what we're seeing in this four-week return to running. So what we've seen is people aren't running. Runners will run, as we always say, in pregnancy and then early postpartum. And what we know is that the longer someone runs in their pregnancy, the sooner they're going to run in that postpartum phase. And in Shefali Christopher's study looking at returning to running and risk factors associated with musculoskeletal pain, she actually saw that it was close to half of those individuals, 46%, reported returning to running at four weeks. And so we've got some information to kind of digest, right, as therapists. And what we know, and again, in her research, what we know is that when runners return to running, we're seeing that musculoskeletal injuries or musculoskeletal pain does occur. And so that's the number one thing that we want to be educating our runners on and we want to be looking out for. But rather than waiting until they've hit certain guidelines, what we are proposing and what we are doing, what I am doing clinically, what a lot of our faculty is doing clinically is we're educating our patients. And we urge you to educate your patients as well. Based on this evidence, this is what we're seeing. We're seeing that when we're returning to running, we're actually, many people are experiencing musculoskeletal pain, about 85% of people. Not just those that are returning at four weeks. The median time returning at 12 weeks. So that's significantly before and significantly afterwards. We educate them. So we can, Educate them. They know that okay. There's a risk of injury. There's a risk of musculoskeletal pain Of course, just like with everything and what we tell them is when you feel something You need to let me know That visit is so much easier to discuss that if it's already been planned. So you schedule your person a couple weeks out. Go ahead and return to running and see how that feels. We're gonna control for the volume. We're not gonna go out and run five miles for the first time in eight weeks. We're gonna control that volume. Build up slowly and see how they feel. If you're experiencing some mild knee pain or some hip pain, we are gonna address that. All the while, absolutely, we're doing our basic hip strengthening, right? I say basic, not just talking about a basic squat, but also your accessory movements like clamshells to work on that rotation. Or better yet, some single leg standing you know, the standing variation of the clamshell or the hip abduction with your foot on the wall. That way you're working both sides. We love that accessory work to decrease the risk of pain. But even while they're working on that strength, they're still, everyone is still at a risk. And so the best thing they can do is talk to you about it as soon as they experience that. And tell them, okay, let's back down on that volume right when they're when they experience that let's say they bumped it up to a two mile total volume of running maybe they were doing one minute of running 30 seconds of walking and they had just bumped all of that volume and those intervals up experience that bit of lateral knee pain let's bump that back down. What were they doing last week? Let's repeat last week's volume. Let's repeat last week's running workouts and let's calm that system down. That's how we'll address it from that pain aspect. And then of course, we're going to be continuing to build that accessory strength training and coaching their running, looking at their running form. We're not afraid of them experiencing that pain. In fact, we know more than likely they're going to experience that. Again, 85% of runners are experiencing some level of pain, typically in the lower extremities, not necessarily their pelvis or pelvic floor. So we know we're gonna bump into that. So we educate them on the factors, and then we schedule a visit to where we're gonna follow back up on that. That's already in their calendar, they already know. That way we can discuss those itty bitty issues that they have, and we can address them before they get bigger. That's exactly the same thing that we want to do with pelvic heaviness, symptoms of heaviness, really fatigue, we've talked a lot about that on the podcast here and of course in our courses, but pelvic floor heaviness or fatigue is another symptom that we're going to address in the exact same way. We're gonna decrease their volume. We're gonna educate them about it first and talk with them when they experience it, but they are going to decrease their volume when that occurs. We're gonna continue to be building that hip accessory work. All the while we're working pelvic floor strength, but pelvic floor and hip accessory movement, that's what builds up strength and endurance for the run. Just like how we expect them to experience pain, what we're realizing is that we expect them to bump into some symptoms of heaviness as well. We, as the rehab providers, are not scared of that. Just like we're not scared of them experiencing pain. We know they bump into that and we get them to back off immediately. We know they're not gonna have an issue there. We know they're gonna meet all of their goals and continue to run. We know this with the symptoms of pelvic floor heaviness as well. Heaviness, in most cases, many cases can come on with a lot of emotional concern. And honestly, in some cases, pain can do that as well. You've all experienced that with your patients. Very similar with pelvic floor heaviness. I see it very, we all see it very heightened in that emotional response. But if we can educate them on this first, if we can tell them, Hey, You're gonna bump into this. This is a symptom of fatigue. What you're gonna do when you bump into it is you're gonna back down. You're gonna back down in that volume. You're gonna wait to return to your next running workout until those symptoms have died down, because your body is telling you that that's too much. But you're gonna return, and we're gonna talk about it on our next visit, and you are absolutely gonna run that 5K at Thanksgiving. or you're absolutely gonna run that New Year's Day 5K, whatever that may be for them. So, educating them about symptoms, whether it's pain, whether it's heaviness, of course, leaking. I feel like we as pelvic floor PTs have educated people so, so much on leaking, but similar conversation here. you're probably going to have leaking with some point of return to running. Again, it's muscle fatigue that often precedes that return or that leaking. So we're going to probably experience it. If that athlete is running to a fatigue level, that's okay. We've gotta understand where their capacity is and where that lies and where that threshold is for leaking or for heaviness or for pain. We figure out where that threshold is, we go down from that. We build capacity and we bump that threshold up. That's the name of the game in all things that we do. That is the name of the game in pelvic floor health, in returning to running, even when they're returning early, like at four weeks. Realize runners are gonna run. Many of them are already going to run at four weeks. So go ahead and have that conversation at your two-week follow-up. Better yet, go ahead and have that conversation in their late pregnancy. Prepare them for what they're going to experience in that return to run. Prepare them for it to decrease fear and to improve education and awareness. Education goes such a long way in this area, but we've also gotta have that follow-up. We've gotta have that action item, okay? When they experience the pain or the heaviness, what you're going to do is X, Y, Z. Decrease that volume, right? Maybe return to some, diaphragmatic breathing and regulate your nervous system if it's someone who's has a heightened level of concern, right? We're going to repeat last week's workouts after symptoms have resolved. Give them several action items that way they feel empowered to make those decisions for themselves. All of that and then have that follow-up appointment with them already scheduled a couple weeks out. And that way, you can address all of these issues that are small, and we ensure that it does not continue to grow. So that's a very different way of guiding someone in this return to running, where someone is starting to run early, we don't have the time to go through all these strength and all of these assessments, but we just say, hey, let's use our symptoms as our guide. Let's start small, 15 seconds of running, 30 seconds of walking. Let's start small and add that in and let's see how you do. That is an example of us coming alongside someone who's already going to be running. This is how we stay in their corner as opposed to, Hey, you're not ready to run. Person's like, I know I'm ready to run. I mentally am so ready to run. I'm not gonna go back to that person. I'm gonna go run. We lose people when we have this black and white yes and no and I am the boss. We gain people, we gain people's trust and confidence and their willingness to work with us if we come alongside them. So that's what we're advocating for this return to run. Absolutely, you're gonna work on strength, overall building capacity, calf. We're gonna work on coaching them and how do they look with running and running form and their cadence. And we're going to be addressing all of these factors. Let's do it by letting them run and coming alongside them. That's a bit different than what you might be doing. That's different than what we used to do several years ago. What do you think? Do you want to try it? Have you recently tried it? Or are you concerned? Think we might be missing something? I'd love to hear your thoughts on this. Have a wonderful Monday. Hope to see you on the road at one of our three courses at the end of this year. And we will talk soon. Thanks for being here, y'all. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 20, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com https://journals.lww.com/nsca-jscr/fulltext/2019/12000/validity_and_reliability_of_the_rear_foot_elevated.9.aspx https://journals.lww.com/nsca-jscr/pages/articleviewer.aspx?year=9900&issue=00000&article=00300&type=Fulltext In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad". Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday, the best darn day of the week. I currently have the pleasure of serving as our Chief Operating Officer at Ice and a lead faculty member here in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things CrossFit, power limping, Olympic weight lifting. recreational bodybuilding, running, rowing, biking, swimming, triathletes, marathoners, anybody who's out there getting after it on a regular basis, we address all things relevant to that population. Some courses coming your way really quick from the Fitness Athlete Division. Your last chance to catch us online for our eight-week online entry-level course, Clinical Management Fitness Athlete Level 1 Online will begin November 6th. So that's just two weeks away. That'll be our last cohort of the year. That class will take us right through the holidays. and then we'll take a little break. The next cohort after that will be available sometime in the spring. So if you've been hoping to join us for that class, November 6th is your last chance for the next couple months. Live courses coming your way between now and the end of the year as we get into the back half here of quarter four. You can catch Zach Long down in Birmingham, Alabama. That'll be the weekend of November 4th and 5th. That same weekend, Mitch Babcock will be in San Antonio, Texas. The weekend of November 18th and 19th, Mitch will be in Holmes Beach, Florida. Beautiful place, just actually took a vacation there a couple weeks ago. Wonderful place to get to, especially in mid-November if you're from the Northeast or the Midwest, Florida's a great spot that time of year. That class just has one seat left, so if you've been looking to get baby both to Florida and to fitness athlete, that is your chance. And then our very last live course of the year from the fitness athlete division will be December 9th and 10th. That will be out in Colorado Springs, Colorado. That course will also be with Mitch Babcock. So check us out online, check us out live. We'd love to have you here at the end of the year before we get into the holidays. 02:16 - DOES FORM MATTER? Today's topic, we're going to take a deep dive into form and mechanics. Does form matter? How much does it matter? We hear this question a lot in our courses as we're introducing movements, instructing the basics of how to perform some of the most basic movements, your squats, your deadlifts, your presses. This may be a question that you get from athletes or patients in the clinic and for a long time and even right now this is kind of a very dogmatic campy approach to this topic of yes form is the most important thing or no form has no application at all we've even heard things like Sheer force is an artificial construct created by physical therapists to scare people away from moving. Physics doesn't matter as much as we thought it did. That movement, however it happens, is normal, natural, and that's how the human chooses to move, and there is no right or wrong way to move. So, where's the magic lie? Where's the evidence lie? What actually works in practice in the gym with real human beings? And what are some pearls to take away from the discussion on form? So often we get questions of does it really matter if the low back rounds during a squat or a deadlift? Does it really matter if the back hyper extends with overhead lifting? Who cares if someone catches a snatch with a bent elbow or they never reach full extension of the elbow at the bottom of maybe a pull-up? If someone presses their jerks or snatches out, is it really that big of a deal? So today I want to approach this topic from a couple different directions. I want you to go back and watch last Thursday's episode or listen to it on evidence-based medicine about making sure we're addressing all of the facets of evidence-based medicine when we approach a really hot topic like this that also has a room for a lot of interpretation one way or the other. We need to look at what does the evidence say, we need to look at what does our friend physics say, what does our clinical experience say as far as What is our anecdotal experience with clinical pattern recognition with actual patients and athletes? And then what does the patient say? What matters to the patient? Patient expectation and input matters. So let's start from the top. 04:42 - WHAT DOES THE EVIDENCE SAY? What does the evidence say? As much as we don't want to hear this, we don't have a lot of strong evidence either way in this discussion about form. When we talk about what does the evidence say, we have nothing concrete or strong for or against poor mechanics and lifting. We have a ton of research out of the functional movement screen space that looks at movement quality and its association to injury. And time and time again, I have to declare my bias. I hate that test. I think that test is total garbage. I think the research supports that that test is total garbage. And when we look at does particularly unweighted movement transfer to predicting injury, we have stacks and stacks and stacks of research across a wide variety of populations, recreational athletes, tactical athletes, first responders, professional athletes, that shows the association between quality and injury prediction or injury risk reduction is simply not there. We do have some research that looks at the effects of lifting, and I'll put lifting in air quotes here for those of you listening on the podcast, that lifting with a rounded back does not seem to cause low back pain or make current low back pain worse with the caveat of when we look at that systematic review and meta-analysis from O'Sullivan and colleagues a couple years ago, that the papers they included did not have any patient lifting more than 25 reps across the span of a day at a weight heavier than 25 pounds. It's really hard to take research like that and extrapolate it to our population who might be deadlifting two or three times their body weight, cleaning or snatching their body weight, doing dozens or hundreds of things like pull-ups and handstand push-ups and double-unders, really getting a lot of load through their body, running, crossfit, lifting, whatever. That research really has no application. It's really hard to even call that lifting, right? Those are just kind of activities of daily living. We can't take research like that and extrapolate it to somebody dead lifting with a low back and say these are the same. They are just simply not. We also need to be mindful of the research that we do have. When you look at papers on deadlifts with low back pain, on the effects of lumbar reversal with lifting, what you'll find in those studies is that one of the variables that the research authors always control for is the lifting mechanics themselves. You'll often see, if you actually read the full paper, not to harp on that, but when you read the full paper, when you read the methodology, what you will find is that very often those folks are instructed how we would instruct a movement in the gym, which is to try to maintain a brace-neutral spine, modifying the load or modifying the range of motion to maintain that, to therefore reduce that as a variable in the research study. That if we cannot control mechanics, that's one more variable that maybe takes a little bit away from our conclusion when we look at the data. Of trying to standardize the mechanics as much as possible is how we can narrow down the focus of that research study on whatever the intervention is and whatever the outcome and feel really confident that the association there is direct and that other variables aren't at play. If we can't say deadlifts are safe, deadlifts increase low back strength, deadlifts improve low back pain, if we look at a study and there was no control on how the deadlift was performed or how the mechanics were performed through those deadlifts. One study does sumo deadlifts, another does conventional, one does trap bar, one allows back rounding, one does not. You'll see when you read those studies that controlling for those variables, controlling for those mechanics, is one of the ways that variables are reduced. And so it's hard to look at those studies as well and extrapolate to altered mechanics, what we might call a movement fault, and translate that to the population that we're working with. It's hard to take research and say, you know what? I'm gonna do everything this study did except change everything about it, right? That doesn't mean you're implementing that research and practice. You're taking the general idea and you're kind of going your own way with it. You no longer have that evidence base to stand on. From the research, we do know that symmetry can be objectively quantified, we can assess it, and we can intervene on it. Very often, physical therapists are very comfortable at calling out and identifying qualitative faults without really understanding what might be going on, how to assess it, how to measure it, how to track it, or how to change it. But if we look at some really nice research papers, a great one came out this year, I'm gonna butcher this name, I'm so sorry, Yuja Kovic and Sarah Bond came out this year, looking specifically at asymmetries and change of direction in basketball athletes and finding that there are ways that we can objectively quantify things like asymmetries, strength, speed, motion, quality, asymmetries, that we can also intervene on them. This study in particular sought to reduce the change of direction asymmetry by overloading the slower slash weaker limb with three times as much training volume compared to the stronger or faster side. That looking at an 11% or so difference in change of direction speed, able to reduce that down to just 4% simply by overloading the volume on the weaker, slower, basically problem area. In this case, it was the lower extremity. A very simple study, just using some lower extremity strengthening, three times as much volume as the contralateral limb. We know we don't need a biodex or some other form of fancy isokinetic testing or force plates in our clinic to have ways to objectively identify and assess maybe quality that is associated with asymmetry that is maybe the cause of pain, aggravating current pain, aggravating past pain and or limiting performance. Great study by Helm and colleagues 2019. wanted to validate the five rep max rear foot elevated split squat. Maybe you have heard of this as the Bulgarian split squat, but essentially kicking up that back leg, doing a five rep max on each leg. In this study, they used a barbell. In the clinic, you can use dumbbells as well, trying to find a five rep max per side, and then quantifying and objectifying the asymmetry side to side. Finding it's a very reliable, very valid way as compared to things like Biodex, and force plates to develop an idea of asymmetry from side to side. I would argue a paper like that we can extrapolate to the upper extremity, we can do something like a landmine press, we can do something with our lats or back with something like a bent over row and really start to think if we're seeing movement faults that we think are the cause of symptoms or some sort of performance issue to start getting more objective in how we assess, reassess, and intervene on these things. So that's what the evidence says. It doesn't say a lot. Besides that, we need to help people get stronger and we need to quantify where their strength is at as they're starting their rehab program and then reassess it as they're finishing in order to be sure that person actually got stronger and actually closed the gap on any sort of perceived or actual asymmetries that we found. 11:38 - WHAT DOES PHYSICS SAY? What does physics say? This is something that we tend to ignore a lot, that we exist as human beings on a planet with things like gravity, and that we are subject to certain physical characteristics that we can't avoid. Physics would say that the shortest route between two points is a straight line, and anything else, any other extraneous movement is a force leak. Any amount of force leak doesn't matter what your sport is. If you're an Olympic weightlifter, a powerlifter, a crossfitter, a gymnast, a swimmer, a runner, The more inefficient your mechanics, the more extraneous movement, the more your leg kicks out into circumduction in your run, the more your lower back rounds and extends back and forth as you go through deadlift reps, the more you bend your knees or bend your elbow in your pull-ups, it doesn't matter. The more extraneous movement you have, the more you're leaking force out of your system, the more you're limiting your top end performance. I have yet to this day see anybody break the deadlift world record by doing a Jefferson Curl. Yes, under extreme loads we might see a little bit of low back rounding, but we don't see people intentionally initiating a 1500-pound deadlift with a Jefferson curl mechanic. They tend to approach the barbell over and over again in a similar fashion, either setting up in a conventional or sumo deadlift and really doing everything they can, again, to minimize extraneous movement, put the maximum amount of weight through the ground to lift the highest load up in the air. That is performance, that is physics. We have to remember, unless we can invent some sort of technology or better understand physics, we can't get around that. So that's the evidence, that's the math. What does our personal experience say? Our clinical experience, maybe some of you would say this is anecdotal, but remember, part of evidence-based medicine is our clinical experience. 13:59 - WHAT DOES CLINICAL EXPERIENCE SAY? Our clinical experience would say that those folks in the gym that we see performing pull-ups, overhead movements with things like a constantly bent elbow, tend to be the people that we most often see over in the PT clinic for stuff like elbow pain. That the folks who rock up on their toes, catching their cleans, their snatches, because they lack ankle dorsiflexion, are the folks that we tend to see coming into the clinic with things like knee pain. That those folks who always quarter squats, no matter how much we try to help them get to a deeper range of motion, a greater range of motion, whether it's working on their mobility, elevating their heels, giving them a squat to target, whatever our coaching cues corrections are, those tend to be the folks in the clinic with things like knee pain and hip pain. And those folks who show up with lumbar rounding in the bottom of their deadlifts, as they're pulling the deadlift off the floor, the bottom of their squat, catching a clean, catching a snatch, those tend to be the people who come to see us for low back pain and hip pain in the clinic. 18:01 - WHAT DOES THE PATIENT SAY? And that connects really well to the third part of evidence based medicine of what matters to the patient. We have to understand these folks are often aware of their faults, especially the more they've been training, the less faults they tend to have, and they're more acutely aware of the ones they have left, and they also know the association between the faults they have and maybe aggravation of symptoms, re-aggravation of symptoms with maybe a previous injury. Understanding as well that we don't just always work with the lead athletes, that our goal is to introduce movement to everybody who comes into our clinic. How hard is it to introduce movements, even basic movements like the squat or deadlift, to patients who maybe never done this in their life before? Not even with a barbell. Maybe we just hand Doris a kettlebell for a goblet squat, or we have Frank just deadlifting a kettlebell off the ground. How tough is it for that person who is a complete novice to this If our instruction is, hey, Frank, you know what? Mechanics don't matter. Points of performance are arbitrary constructs created by rehab providers and fitness professionals to scare people like you into purchasing more care than you need. How helpful is that to teach movement to somebody new? What are they going to say? Uh, okay. So like, is there a way I should do this? Is there a best way? Well, Frank, it doesn't matter. All human movement is good and natural movement. Just do whatever feels good. That's not very helpful, right? And you would never do that in the clinic with a patient. You would never do that in the gym with an athlete. If you do actually do that, I challenge you to film that and send it to me because my gut tells me that nobody actually does that because you know how stupid you would sound and how likely it is for the patient to be successful if that's your approach to instructing movement. Likewise, if we do have that more experienced athlete, what good does it do to tell that person who has extreme low back pain, when their spine rounds in the bottom of the squat, there may be somebody who's filming their lifts to try to figure out why do my squats bother me? And our answer is, hey, there's no evidence to support that your spine flexing is a source of your pain. Same issue, right? Same outcome, entirely different patient population, but same outcome. Okay, that's not very helpful. I can see my tail tucking here, and I notice that when that happens, that's when I feel my extreme low back pain. That person has already associated that in their mind. What good does it do to tell them that there's no evidence to support that that's what's happening? They're experiencing it firsthand, right? We need to be mindful of the way that we instruct this, both with new and experienced athletes, patients in the gym and the clinic, that mechanics do seem to matter. People seem to have a natural awareness that at least some sort of standardization of performing a movement seems natural and that some sort of association exists between maybe symptoms and faults. We always acknowledge the resiliency of the human body, that yes, it can develop tolerance in different positions, such as lifting with a rounded back, but we can also still do stuff at the same time to limit pain with lifting. We can modify the range of motion. We can modify the load, the volume, whatever, to a more tolerable level. We need to get a lot more comfortable living in the gray area. Yes, we can recognize injuries multifactorial. Yes, the body's capacity can be temporarily reduced by things like sleep, stress, illness, nutrition, but we can also still manipulate movement to be more comfortable and enjoyable and also help that person work on strengthening in a manner that we know is very evidence supported that's going to reduce the likelihood of future injury. I have an athlete on my caseload right now, very, very impressive athlete, been doing CrossFit a long time. every time she's under an extreme amount of cardiovascular fatigue, or she's doing something like a 10 rep max with a back squat or a three rep max clean or something like that. Usually under a high amount of fatigue, she demonstrates some lumbar reversal associated with that lumbar reversal is always extreme low back pain. She is aware of that. She's somebody that films her lifts. She knows every time she rounds her low back in the bottom of her squat, that is what usually will kick up an episode of low back pain that could last short term, a couple of days, or could really set her back weeks or maybe months. So she's very aware of her spine rounding, the association of form with the development of symptoms, and aware of how bad those symptoms can get. So what are solutions with that in regards to does form matter or not? Well, the first thing we can always do is help reduce that pain acutely, right? Of that person is an extraordinary pain in our clinic, regardless of what we're going to do with them in the gym, regardless of how we're going to address their form, we have ways to reduce their acute pain. We can modify those squats, we can do things like belt squats, we can do lightweight, high tempo squats, tempo squats at maybe 30 or 40% of her max where she's maybe taking three, five, seven seconds to sit down to that squat to maintain or continue to build strength in a way that doesn't aggravate her symptoms. We can do alternate movements if a squat pattern is not tolerable at all, hip thrusts, deadlifts, et cetera, to train lower extremity general strengthening. Yes, we can build up general strength and endurance of the low back, the legs, the posterior chain as we're getting more comfortable, but we can also spend some time working with that athlete on their mechanics of what's going to probably help you the most is that under extreme fatigue, you know how to breathe embrace, you know when to call it for the day when you know you're extremely fatigued, so you don't find yourself in this position again and again. And yes, the final step there is probably to layer in some intentional lifting in that what we would say poor mechanical position, right? Let's also add in some rounded back lifting so that we expose ourselves to the movement so the only time we encounter it is not under a 10 rep max on the 10th rep where we tend to encounter our symptoms. So let's do things like sandbag cleans and sandbag squats and yes, Jefferson curls and other things like reverse hyper extensions. Let's do all the things. We don't have to focus just on form but also form matters. We need to train in that position so that when we get into that compromised form position, it is going to have a less likelihood to be symptomatic and set that athlete back. 21:09 - MECHANICS & PERFORMANCE And finally, we need to go beyond pain into performance. What does the evidence say? What does physics say? What do we say? What does the patient say? What does performance say? What can you possibly help an athlete with who comes into your clinic, who wants to pay you $150 an hour to improve their snatch, and you say there are no optimal mechanics to complete the snatch. We know that's not true, right? People who win gold medals in clean and jerks and snatches tend to lift a certain way. They tend to all show relatively the same mechanics. That tells us that mechanics seems to matter a lot in regards to high level performance. There's a reason those Olympic weightlifters tend to initiate their pull off the floor in the same fashion, going through their first pull, their second pull, their receiving position, the jerk overhead or the catching of the snatch. There's a reason that it looks pretty much textbook no matter who the athlete is, how tall or short or big or small they are or what their race or gender is. They all tend to show the same mechanics time and time again. It seems like it's physics at the end of the day. We don't see anybody breaking the snatch world record with a rounded back deadlift to a muscle snatch, do we? And I think that tells us a lot of now beginning to shift towards using mechanics to push performance. And again, as long as we can be objective about it, I think that is the way to go. 24:41 - SUMMARY So what does the evidence say? We have nothing strongly for or against poor mechanics and lifting. is it relates to people actually performing resistance training not just picking up pins off the floor with a rounded back. We need to be mindful that research studies tend to standardize points performance for lifts such that everyone is performing the same thing the same way every time. What does physics tell us? It will always tell us unless something miracle happens with a change in physics that the shortest route between two points is a straight line Mechanics matter in performance. Straight lines are strong lines. What does our clinical experience tell us? That people who tend to move like crap, especially under increasing amounts of load and or volume, whether it's due to poor mobility, going too heavy, going too fast, those tend to also be the people who need a lot of healthcare treatment, right? Those folks who tend to move quite well tend to have maybe one particular fault, that they're usually aware of, and that they're usually also aware of being associated with their symptoms, and we need to be mindful of that. And what do those patients say? People who are already active are usually aware of that fault, they're usually aware of when and how they demonstrate it, and they are usually aware of that it's associated with some sort of symptom, development of a new symptom, re-aggravation of a previous injury, that sort of thing. We know the group of people we probably need to help the most are inactive patients. The other 90% of the population, right? The majority of the people in our caseload. Inactive patients, people who are complete novices to movement, can't learn things in a structured manner that they're going to be able to repeat them on their own in the gym or at home in the garage or whatever. if our approach is that physics, points of performance, faults, are just artificial constructs that we create to scare them and somehow fleece the general public out of their money. And then also finally, something to remember is that you'll be stuck on a hamster wheel in your clinic forever just treating people in pain if you're not able to transition people to the lifelong fitness and performance side of what we can offer them. At a certain point, mechanics do matter as it relates to top end performance, as it relates to goal setting. And you're crazy if you think, quote unquote, normal people don't want to increase the amount of weight they can snatch, or how fast they can run their mile. We need to be mindful that with top end performance, when people want to see their 5K time come down, or their one rep max back squat go up, that mechanics really, really, really do matter. So mechanics, do they matter? It depends, but there's probably more to be said for mechanics mattering for a performance aspect, for instruction aspect, and for overall higher quality and the ability to perform more movement more often, which is the goal. If we are aware of mechanics, but also being mindful that sometimes they don't matter, especially if we're not being objective about assessing them, reassessing them, and what we're doing to intervene on maybe trying to improve mechanics. Tough discussion, but I think it's worth one having. I hope you all have a fantastic Friday. If you're gonna be at a live course this weekend, I hope you have a great time. We'll see you all next week. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 19, 2023

Dr. Ellison Melrose // #TechniqueThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses an alternate technique to dry needle the lumbar multifidus. Take a listen to the podcast episode , watch the video , or read the full transcription below. If you're looking to learn more about dry needling, especially dry needling with e-stim using the ITO ES-160 stim unit, take a look at our Upper Body Dry Needling course , our Lower Body Dry Needling course , or check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ELLISON MELROSE Good morning YouTube and good morning Instagram. This is PT on ice daily show. I am Dr. Ellison Melrose and I am currently lead faculty with the dry needling division of ICE. So we are going to go over a alternative approach for dry needling the lumbar multifidus today. Um, before we get into that, I want to go over our upcoming courses. So this, the remainder of 2023, we have, um, a handful of courses. This weekend, Paul's going to be out in Anchorage, Alaska, and I believe that is capped. After that, he will be down in Seattle, Washington on November 3rd through the 5th for the upper quarter. I will be out in Rochester, Minnesota for upper quarter dry needling on November 18th through the 19th. We will both be teaching the first weekend in December. So December 1st through the 3rd, Paul will be in Bellingham, Washington, and he will be hitting upper quarter then, and I will be out in Clearwater, Florida, so opposite sides of the states, doing lower quarter. So if you guys have a chance to find us out on the road, or want to join us for the remainder of 2023, those are the courses. We have one other one also in Fayetteville, Arkansas, the second weekend in December, where we'll be doing lower quarter. out there. So if you guys have any questions about those courses coming up, feel free to message us here or yeah, stay tuned for those courses. And then 2024 we'll be starting out pretty hot with some more courses and our advanced course as well. It will be, will be coming, um, in 2024. 02:10 - COMMON APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS So what I wanted to do today was to go over an alternative approach for, uh, dry needling the lumbar multifidus. So there, We are not gonna go over clinical reasons for needling the lumbar multifidus, but for those who have been taught how to needle the multifidus, there is one technique that is used fairly widespread across all educators, and that is the wrap-over technique. For demonstration purposes, I am going to be using my knuckle as the spinous process, and then we will be demonstrating it on a human body as well. For that wrap-over technique, so we have our spinous process here, Wrap over technique, we use two fingers to compress within a one centimeter gutter, just lateral to the spinous process. And we create a target window with our fingers and treating within that zone. In order to treat bilaterally, so both sides, you have to walk around the table to treat the contralateral side, which is fine, But when we're talking about clinical efficiency, it may be conducive to be able to treat or to needle staying on the same side of the patient. So we have an alternative approach for needling the multifidus where you are able to stay on the same side of the patient, and that will be your dominant side. So I am right-handed, so I'm going to be treating from the right side of the table treating the lumbar multifidus. I'll demonstrate first the wrap over technique and the alternative technique. 04:02 - ALTERNATIVE APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS For that alternative technique, so instead of using that spinous process, our palpation hand, two finger, stepping over that spinous process and compressing into the gutter, what we are going to be doing is we are going to be using our palpation hand, index and middle finger to orient us to where that lateral border of the spinous process is. In the lumbar spine, we have about a one centimeter gutter where we can feel fairly confident that we're going to be directing our needle towards the lamina with a directly posterior to anterior approach. From there, if we go outside that one centimeter gutter, we need to angle the needle medially to ensure that we have contact with the lamina as we need that laminal contact to ensure that we are at the depth of the multifidus. We are going to stay within that one centimeter gutter for today's demonstration, but we will start with that wrap over technique and then the alternative approach. The alternative approach, instead of using that two finger digital compression, we are going to be using the spinous process and either our middle or index finger to find that lateral border. So, first we want to find the spinous process and take the mid pad of our palpation finger and palpate that lateral border of the spinous process. From there, we're going to take our middle finger or our index finger, depending on which side we are treating, and compress tissue down within that one centimeter guide. From there, we're going to create a treatment window between our two fingers and treating directly posterior to anterior. towards laminal contact. 07:19 - ALTERNATIVE TECHNIQUE DEMONSTRATED So it'll make more sense when we're demonstrating it on the patient. So let's go ahead and do that. I'm just going to angle this camera down towards my patient. So here we have an exposed lumbar spine. I'm going to just orient myself to where we are. I am standing on my dominant hand side. From there, We'll just go over palpation. So spine is processed, we can palpate the lateral borders with our thumbs here. For that wrap over technique, we're going to take our pads of our palpation hand, stepping off, compressing tissue down, treating within that one centimeter gutter, okay? So let's start with that technique and then I'll show you the alternative approach after. So, palpating that lateral border of the spinous process, two fingers stepping off, compressing down into that gutter, keeping that needle angle directly posterior to anterior, so vertically, tapping, advancing the needle towards laminal contact. So in order to treat the ipsilateral side now, I would have to walk around the table and straddle that needle to do the same compression and same technique that we did on this side. So what I will demonstrate is the alternative approach and then we'll do another segment down below of the alternative approach just to show you how efficient this tool can be. So, instead of using those two fingers to hug the lateral border, I'm going to be using my middle finger on my palpation hand to palpate the posterior aspect of that spinous process. From there, I'm going to take the middle aspect of my pad and hug that lateral border of the spinous process. My index finger is then compressing into that gutter creating a nice treatment window. Again, we want to be aware of where that one centimeter gutter is and treating within that zone, directly posterior to anterior. So vertical, vertical needle approach here. So compressing down towards laminal contact. So there we have the alternative approach on that ipsilateral side. From there, thinking clinical efficiency, if we were going to set up multiple different segments in the lumbar spine, if we started proximally or superiorly and worked inferiorly, kind of like you're reading a book, that is going to be the easiest way to avoid some awkward hand positions with the needles. So we will needle the segment just distal to the ones that have needles in. So from there, Instead of using my middle finger to contact that lateral border, I'm gonna be using my index finger. We are treating the contralateral side from where I am standing. So again, we can appreciate the lateral borders of the spinous process. Take the pad of our index finger and hug that lateral border of the spinous process. Compress my middle finger now and create a treatment zone between my two fingers. Again, appreciate that we have a one centimeter gutter. Now we want to be treating directly posterior anterior to contact lamina. From there, I'm going to do a firm guide to compression, firm tap, advance the needle to laminal contact. And then we can do the same thing on the ipsilateral side. so middle finger palpating the posterior aspect of the spinous process wrapping to that lateral kind of hugging that lateral where it starts to curve creating a one centimeter gutter with my index and middle finger treating within that zone directly posterior to anterior towards laminal contact. So there we have, we went over the wrap-over technique and the alternative approach and just looking at the clinical efficiency that being able to stay on that ipsilateral side of the patient can do. I have a very small treatment room, so it allows me to not have to kind of wiggle my treatment table back and forth, and allows us to get a handful of segments within a couple minutes, which I think when we're thinking about using dry needling in the clinic, we want to save as much time as we have for using our electrical stimulation, as the new research is showing how beneficial that can be for treating pain, neuromuscular priming, also, um, recovery or hemodynamics, improving hemodynamics. So we want to get the needles in as efficient as possible as to allow for some optimal treatment time with the Eastern. So we, again, just to review with this technique, we are going to be using our index and middle finger. And instead of hugging the lateral border of that spinous process, we are going to be treating, um, with those fingers just off the lateral border, creating a one centimeter gutter between those two fingers, treating directly posterior to anterior and maintaining laminal contact to ensure we are at the depth of the multifidus. Thank you guys so much for joining me this morning, going over the alternative approach for dry needling the multifidus. And I hope to see you out on the road sometime this year or next year. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Oct 18, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the significant issue regarding the lack of individualization and care for older adults with cognitive impairments. Jeff points out that many older adults on their caseloads are at different stages of cognitive impairment, but this often goes unnoticed until it progresses to advanced dementia. The problem lies in the one-size-fits-all approach to treating cognitive impairments, where individuals with mild impairments are grouped together with those with severe impairments, or they are treated the same as the general population without screening for cognitive impairments. This lack of individualization and care for older adults with cognitive impairments is also evident in nursing homes. Jeff mentions a study from Germany that examined a population of nursing home residents. The residents were grouped based on their cognitive and physical impairments. However, the study found that there was a lack of personalized care, as a more diverse group was randomly assembled with varying levels of cognitive and physical function, and they all received the same basic intervention. Jeff emphasizes the need to tailor care to the individual's cognitive capacity, just as their physical capacity is considered. He uses the analogy of coaching a peewee football league, where practice would not be taken to the local NFL team if the capacity is not appropriate. Similarly, individuals with cognitive impairments should not receive interventions that are beyond their cognitive abilities. However, in the current state of rehabilitation for those with cognitive impairments, interventions are often not matched to their cognitive abilities. This lack of individualization and care for older adults with cognitive impairments is a significant problem that needs to be addressed. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - JEFF MUSGRAVE Welcome to the PT on Ice Daily Show. Good morning, my name is Dr. Jeff Musgrave. Super excited to be with you this morning, talking about a topic that's really important to me, but also reviewing a research article eight days off the press, a new technique called clustering to give better care to those with dementia on our caseloads. But before we get into that, if you're looking to up your Geri game, we are available. We've got some extra seats in our New Jersey course in Matawan, New Jersey this weekend. If you want to hop on that train, we'd love to have you. We've got space for just a few more. Next weekend, if you want to join us for live, we'll be in Annapolis, Maryland or in Central South Carolina. Last cohort of Essential Foundations just kicked off. We've got our first live meetup, so sorry if you missed it. We will be up in full force in January 2024. There is still time to catch advanced concepts if you want to sign up for that. The last cohort is about to begin, so grab those seats. 02:42 - JEFF MUSGRAVE So team, man, I'm so excited to get to talk to you about this topic. There are so many older adults on our caseloads in various stages of cognitive impairment. And this oftentimes goes unrecognized until it becomes advanced dementia. when things are a bit harder to turn the tide, but also there's a severe lack of individualization and care for those that have cognitive impairments. A big problem in general practice is this one size fits all. In geriatrics in general, whether we're talking about physical impairments, but unfortunately we see the same problem when it comes to cognitive impairments. We see those with cognitive impairments get treated the same regardless of how advanced those symptoms are. So we see one of two big problems here. We either see those with very mild cognitive impairments grouped with those with very severe impairments, Or we just see them treated the same because no one's screened or picked up on the fact that there's a cognitive impairment on board and they're treated just like the general population which is also not appropriate. So neither of those are a good look. So this study out of Germany was looking at a population of residents in nursing homes and what they did is they clustered them based on their cognitive as well as their physical impairment. So they used a clustering approach to try to get homogeneous groups of people based on not only their physical function but their cognitive function. So all these residents were 65 and up. They had mild to moderate dementia and were living in a skilled nursing facility. The physical measures that they used were the six minute walk test, the timed up and go, 30 seconds sit to stand. But the biggest place where they saw variation that dictated their function was on their mini mental state exam. So their cognitive impairment did a lot to dictate their function. So what they found at the end of this was that those that had more advanced cognitive impairments were not able, even if they had the physical function, to participate in as high level balance training as those that had more severe cognitive impairments. So those with more mild cognitive impairment were not able to participate at the same level, in particular when it came to balance challenges. 04:56 - COGNITIVE IMPAIRMENTS & TRAINING The interventions for this study unfortunately the link did not go through that I could see all the details but what they what they were doing was some form of strength training either seated if there was lower physical function versus standing or dynamic movement in standing if they had higher physical function. So lower to higher physical function and then they gave also a cognitive layer to their interventions while they were doing balance or strength training. So that allowed them to scale the intervention to those who, to make it more appropriate. So they had a higher and lower physical function, higher and lower cognitive function group, and they scaled the cognitive load as well as the instructions So one big thing that's missing is the environment and the type of cues that we give typically in clinical practice for those with cognitive impairments also need to be scaled. They can't be as complex of cues with multiple sentences in the same duration of time. We've got to really scale that to the person in front of us and individualize that care based on their cognitive capacity, just like we would their physical capacity. The way I kind of think about this is if you were coaching a peewee football league and practice is going really well, you would not march them over to the local NFL team for practice. Their capacity is not appropriate. But we do the same thing with cognitive impairments where we've got someone who has more advanced cognitive impairments, getting a much higher level of training than what they should be and it's no surprise when the results aren't as good and that's also what was found in this study was the experimental group had the matched physical and cognitive and then there was a more heterogeneous group that was just kind of randomly put together with higher and lower cognitive and physical function, and they all got this lowest common denominator intervention, which we commonly see, especially because this was looking at group training in skilled nursing facilities. What typically happens is we've got this big group of people, and we find the person with the lowest cognitive and physical function, and we give everyone that. So the person that has the lowest physical and cognitive function gets an appropriate challenge. Everyone else has lots more ability that is not tapped into and is not being challenged. So it's no surprise once you hear that's what's happening, which unfortunately is the state of rehab for those that have cognitive impairments in general, is it's not being matched to their cognitive ability. So those that were not matched based on their cognitive and physical function showed decline in their mental function by the time the study was complete. So those with matched physical and cognitive challenge to their actual, their functional level, They did great. They were able to maintain their cognitive level in this skilled setting. And those that were not matched showed cognitive decline in even a short period of time. This is pretty wild. 08:09 - SCREENING FOR COGNITIVE IMPAIRMENTS So some big takeaways here. Are we screening? Are we screening cognition in our older adults? The research says that the sooner we can screen people, the better chance we have to change their life and help them maintain their cognitive function and sometimes actually improve their cognitive function. There is a mountain of research that shows exercise is beneficial for cognition, especially if we're pushing into the fitness realm. and we're pushing people at high intensity and we're asking them to lift heavy things, we're asking them to learn new novel tasks. So we want to make sure we're doing that with older adults, not only for their physical function, but for their cognitive function. But we need to get a baseline of where they are to make sure that we're scaling these things appropriately. The tool that was used in this study was a mini mental state exam, which unfortunately is not great at screening for mild cognitive impairment, which is kind of that first phase before there is problems with activities of daily living, like once we get into more advanced forms of dementia. Tools like the MOCA, the Montreal Cognitive assessment may be more appropriate for catching signs of mild cognitive impairment. Also the SLUMS, the St. Louis University Mental State Exam. However, with that one, it's good to be aware that that can trigger automatically a local referral once it is complete. So you want to make sure that your patient, if there's any family members involved with care, that they're all aware that that will happen. And if this is like, man, I am not comfortable with this cognition stuff, this feels like way out of my depth, that's fine. You don't have to be the expert on everything, but you do need to be accountable to having resources in your area. Who is the SLPs, maybe outpatient, Or on your team if you are in a skilled environment that you can send for a cog referral. Or OTs, we have lots of OTs that are great at screening and intervening cognition and giving you an idea how many step commands, what type of environment, what type of cues are appropriate for this patient. but we have got to meet them where they are for cognition, just like we do for our physical interventions. So if you're not screening, start there. We've got to do more than alert and oriented times three. We've got to be getting these screening tools in use, or we've got to start making those referrals to people that are able to help get a baseline and make sure that our interventions are appropriate. So if you are screening, awesome, you are ahead of the curve. So now your job is to make sure that these interventions are appropriate, just like we're outlined in this study. 14:09 - SCALING UP OR DOWN BASED ON COGNITIVE PROCESSING DELAYS So what we want to make sure that we're doing is we want to know that there are things like cognitive processing delays, where it may take someone with more advanced dementia symptoms two minutes to process our commands. That was just five seconds of silence from me. If you can imagine two minutes of silence after your cues made this mistake so many times with this population. In two minutes, we've said a thousand things. and they're still processing the first thing that we said. So want to be mindful as we pick up on these symptoms. Cognitive processing delays can be up to two minutes. More mild forms, it could be five, 10, 15 seconds. It may feel a little more natural. Likely your skin's going to crawl, but it may be a very appropriate communication. It's going to look way different in this population. We want to make sure that the more advanced the cognitive impairment is, the more familiar the tools and the exercise interventions that we're using. We can't give a 40 point intervention and biomechanical explanation on a beautiful trap bar deadlift with an older adult. who has advanced dementia, we may be better off to use their purse and add some stuff to it, or add just grocery bags with food in it, and just ask them, pick this up. Once they do that, let's walk, walk 20 feet, or walk over to this area of the gym. No more cues, no more instruction, set it down. That may be a very skilled, very appropriate set of cues for an older adult with advanced dementia. So we want to keep in mind the tools. We also want to keep in mind the scenario. Can we control the environment? That is a skilled scaling tool. How loud is it? How busy is the environment? Is there lots of interaction? Are we at prime time in the clinic, out in a busy clinic where there's people throwing balls on a rebounder or the music's blaring? There's lots of laughter and fun. That may be a completely overstimulating environment for someone who has more advanced dementia. So the complexity… of the environment, the amount of noise, background noise, all those things are scaling options. So if we start in that quiet environment, we may eventually scale in to more advanced and complex environments where there are more distractions, where it is more like real life. But that's gotta be an intentional choice. That doesn't need to be an accident. We need to be very skilled with our interventions and that is part of it. How we choose to practice is also very important. Are we going to do random practice where we're jumping between tasks to task? That's going to be way less on the ability for someone with more advanced cognitive impairments. We may need to do block practice where we spend a big chunk of time, maybe 15 minutes, working just on a sit to stand. We may never get to a squat with a bar. That's fine. But if we can make it practical, we can meet people where we are, that may be where we need to stay. 15 minutes here, 15 minutes on the next thing, that may be our whole session. Or maybe it's something like a simple obstacle course. Pick this up, carry this, and follow me. That could be it. So I wanna keep these things in mind. If we are screening, we are getting a sense of what the cognitive ability level is of our clients, then our job is to scale it appropriately, and then you guessed it, then progress it as we're able. So we wanna use all those leveraging tools. So my advice to you, we're gonna switch gears, so that should be relevant to everyone. Now, if you are training in a group setting, kind of like this study outlines, where you're in a skilled facility, and you're doing group training, you can start with this lowest common denominator approach, but what you have to add in are easy scaling options. You've got to think about, we've kept everyone safe, but then for those that have the cognitive ability to do more advanced balance, or they're safe to do more advanced strength training, What can we do to scale it up for those individuals? So we've got everyone moving, everyone's safe. Now, how do we scale it up? Go heavier. Have heavier weight options available. Maybe instead of sitting, those people that have more advanced functional and cognitive impairments, they're going to be standing. Or maybe they're doing a dynamic movement. Maybe we're going to add some type of vestibular component where we're going to ask them to fixate and move their head side to side or up and down with the fixation point or maybe without a fixation point. Maybe we're having them close their eyes and head turn side to side or up and down. We can add that vestibular layer. We can add a cognitive component as well where we can ask preference questions like everyone, someone shout out, you can think to yourself or shout out loud some of your favorite foods. or name as many states as you can, or name things that are green. We can go very simple up to more complex counting tasks where maybe we're subtracting by 7 from 300 for someone that has a very mild cognitive impairment. Those things may still be on the docket. Those still may be very appropriate. But if we're doing group training, we can start with that lowest common denominator and then just offer scale up options. Another easy one that was even outlined in this study that they found to be beneficial was even just having a little piece of compliant foam for those that were already doing standing. Everyone in the group was mostly doing standing. They added the compliant foam in and that was a great option to scale up balance training. Everyone's getting instruction on the same movement, but there's not really a whole lot of extra instruction to change the surface. All right team, I got super fired up about this. Treated lots of people with cognitive impairments. If you're treating this population, I would love to hear any tips and tricks. Drop those in the comments. Thoughts? I will be dropping the article citation for you. The study was a new approach to individualized physical activity interventions for individuals with dementia. Cluster analysis based on physical and cognitive performance. I hope you enjoyed it. I hope you have a wonderful rest of your day and we will catch you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Oct 17, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses the importance of working with patients to dispel negatives beliefs & fear concerning movement aggravating symptoms. Zac describes different strategies to discuss with patients how not moving after surgery or while in pain is probably the riskiest decision. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ZAC MORGAN Good morning PT on Ice Daily Show crew. I'm Zac Morgan, so I'm lead faculty with the spine division. I teach lumbar and cervical spine management, so you can find me on the road doing those things. Shout out to that crew in Hartford, Connecticut or Waterford, Connecticut this last week. We had a good time learning about cervical spine over there in Waterford. Few more courses on that note coming up this year that if you're trying to jump into either cervical or lumbar, just wanted to point you in the direction of. So November 11th and 12th, we'll be back in that Northeast region up in Bridgewater, Massachusetts for cervical spine. December 2nd and 3rd, Hendersonville, Tennessee for cervical spine. And then if neither one of those work for you, the next chance will be at the turn of the year on February 3rd and 4th over in Wichita, Kansas. If you're looking for lumbar spine management, we've got three different courses this year that are all still have tickets available. Frederick, Maryland, that's next week or this upcoming weekend, October 21st and 22nd. Then we've got November 4th and 5th. That'll be over in Fort Worth, Texas. And then lastly, Charlotte, North Carolina on December 2nd and 3rd. So still several Good offerings if you're looking for cervical or lumbar spine management. We've already got quite a few booked for next year as well, so if this year the calendar doesn't work out or if the Con Ed budget resets at the beginning of the year, Take a look at the 2024 course offerings as well and more to book there. 01:36 - CATASTROPHIZING REST So team, this morning I wanted to talk to you all a little bit about rest and why I think we need to catastrophize rest. I think we need to make a bigger deal out of it when our clients come in and we find out that they've been resting. So let me talk a little bit about this. I've been chewing on this idea for a while and I think it's important for us to sort of understand that when someone's in pain, their risk meter is broken. Like they don't have the ability to conceptualize what's actually risky for them often when they're in pain. And so let me unpack what I mean with maybe a clinical scenario that we're all really familiar with. Let's think about something like a knee replacement. I think most of us in our career will interact with patients who have had a knee replacement. Usually we have interacted with those people on the days right after they have had a knee replacement or maybe you're the one that's getting them out of the bed in the hospital and you're the first person that's getting that person moving. I think we understand the risks to this person pretty well, and as a profession, we respond to them pretty well. We understand what this person's actual risk is when it comes to the knee replacement, and their risk would be being too sedentary or resting too much. And what would come alongside of that risk would be a lot of problems that we'll cover in a bit. You think about what that person's concerned about when you talk to that person in the subjective exam on day one, or maybe you just went into their hospital room and you're talking to them. That person's usually concerned about things that are unwarranted. They're worried that their knee is gonna pop out when you start to flex it. The first time you have that person do active range of motion, that person's like, oh my gosh, is my knee gonna fly out? Is the implement actually gonna pop out? They're worried about things like that, but we as PTs, we know that's not very common. We tend to mobilize knees really early and get them moving really, really rapidly and get as much range of motion as possible as quickly as possible in something like a knee replacement because we know that it's crucial that that happens at short term. So a large part of our job early on in managing this person who has just had a knee replacement is convincing them that their risk meter is off. Again, they're afraid to move. They walked through the door that day with a lot of blood in their amygdala. They were very concerned. They were worried, what if something's going wrong? I didn't know it was going to hurt this bad. I didn't think it was going to be quite like this. And they have typically not been moving as a response to all that pain. 03:22 - CONVINCING PATIENTS TO MOVE And our job is to help them understand that, hey, if you don't move, that's where the risk lives. The risk lives in being sedentary after a knee replacement. Like what's actually risky is if we don't move, the blood will pool, right? And we will wind up with things like a blood clot. Very risky. If a blood clot ends up dislodging and we end up with a pulmonary embolism, that's life-threatening. So that's real risk. That's something that we have to help those people understand is like, hey, if you're too still, we could wind up with something like a blood clot. And maybe we don't fear-monger that to patients, but we do help them understand that risk. You think about some of the other risks that that person has if they don't get moving. What about long-term mobility? If a knee replacement patient does not get their knee moving, you think about what that person's long-term mobility is gonna look like, and it's gonna be quite poor. That first 12 weeks after knee replacement is the most important time for us to restore full extension and get as close to full flexion as we can. We're really trying hard to push range of motion early because we know that person's long-term risk is having a stiff knee. and then not being able to participate in some of their ADLs because of the immobility in their knee. We get the risk so we help unfold that to the people in front of us. I mean the last big ones that happen if someone rests are things like atrophy or loss of cardiovascular endurance and we know this happens very very rapidly. when someone's on bed rest, when someone's immobilized, when somebody's truly sedentary or even sedated, things like that. We know the body responds and we see wasting of all those systems. The same thing's happening if someone doesn't move when they've had knee replacement. maybe not as rapidly as true rest, but we know that they're losing muscle mass, we know their muscle girth is going down, we know their endurance is getting worse. All of these things are truly risky for that person. And for that reason, I think we as PTs do a really good job of helping that person understand, hey, I know it hurts, but the risk of you moving through pain is much less than the risk of you not moving through pain. So I need you to move. And I think we do a really good job with patients like knee replacement patients or patients with a knee replacement. I think we do a really good job with those folks, getting them moving, even though it hurts, getting them back to their ADLs, getting them progressively loaded back to where they're out of sort of disability. I want to shift gears now. And I want to talk a little bit more about my expertise area, which is cervical spine and lumbar spine. So patients with neck pain and patients with back pain. That's typically who I'm seeing the most of in the clinic these days. And I think our response to these folks is a bit different than it is with the knee replacement patients, which is sort of understandable, because with a knee replacement, you understand exactly what happened to that person, where with back pain and neck pain, we never know what the tissue driving their symptom is. 06:57 - FEAR & OUTCOMES WITH BACK PAIN But I think we often respond with fear, and I think that influences the person's outcome. So let me unpack what I mean. So when someone acutely strains their back, they do something, they were lifting their kid and something happens and now their back is really strained and they're in high, high levels of pain and usually high levels of disability as well. Like a lot of patients will tell me, Zach, I can't even tie my shoes. I have to have my wife help me tie my shoes. I can't get my pants on. I can't get on and off the toilet. The activities of daily living are really influenced by these high pain levels. And a lot of these people, when you start to talk to them, they're terrified to move. Especially a forward bending, but really just to A lot of people in general with acute back pain, they're so scared to move their back around. And they're afraid that what will happen if they move their back around, is that they'll worsen their scenario. They're concerned that if they move too much, and maybe some of this is valid, but if they move too much, they'll worsen whatever's wrong with their back, and then they'll have long-term problems. But team, as you're hearing that unfold, you and I both know that's not the case, right? Like it's actually the people who choose not to move who usually wind up with worse recurrence of their back pain. It's why, I mean, you look at the Olivera study in 2018, where they compared all the lumbar clinical practice guidelines around the globe that they could get their hands on. And there's really only two things, all CPGs, not profession specific, um, not region specific, just all the CPGs that they looked at in that study, they agreed on two things. One of them, don't image. The second one, get moving, right? Don't rest, some sort of exercise. We know people with back pain need to get moving. It is clear, no one argues about that anymore. There's no studies, no big studies that have looked into, hey, rest is actually the successful recipe for back pain. It's not that. We gotta get them moving. But I think sometimes we let our fear of allowing that person to move hold them back. But we need to conceptualize those risk factors. Like you think about what it was like for your knee replacement patient. Maybe we don't have the same concern of like a blood clot or an infection, but think about this person's other risks. 06:57 - THE IMPORTANCE OF MOVEMENT Like, what about long-term mobility? If someone doesn't restore their ability to forward bend, they often end up with a loss of long-term lumbar flexion. And how does that usually wind up? Maybe sometimes they're fine and they're asymptomatic throughout the rest of their life, but often when I see recurrent back pain patients, They have had episodes throughout life and they've chosen to avoid a certain range of motion and part of our job is to do some graded exposure back to that to help them conceptualize the risk. To help them realize actually being still is where the risk is. We've got to get moving. You think about atrophy. You think about what happens to that person's muscular system. If they have severe back pain and they're not doing the things that they normally do, perhaps they're laying in bed a little bit more, sometimes they're laying on the couch a bit more, a lot of times their spouse is helping them out, their partner is helping them out with a lot of their ADLs. Team, when people have acute back pain, they often get very still because their fear level is really high, and part of our job is to help them understand that where their head is at, what they're concerned about, is actually much less risky than being still right now. Being still is where the risk lies. If we don't get back to movement, you're going to lose that long-term mobility. You're going to lose a lot of your muscular system. You're going to end up losing quite a bit of your cardiovascular endurance. That's where the risk lies. Because what do we all know about people who tend to lose muscle mass, who tend to lose cardiovascular endurance? Most of those people will struggle to get that back. And I think the longer they live, the more challenging that climb back to fitness is going to be. So our older adult clients are definitely in this boat. We've got to keep these people moving. We've got to get them afraid of resting. That's where the fear should be because what happens when you rest is the long-term stuff. That's what causes recurrent back pain. If a person hurts their back and they're now afraid to move in that range of motion and they don't restore capacity, whether that's cardiovascular capacity or the actual strength of the tissues because of fear, now that area is more fragile. It's more susceptible to injury. They're usually careful with that area and being careful with that area often is not a solution for getting rid of a recurrent back pain. As a matter of fact, we want to move more towards things like graded exposure, graded exercise, building that engine, building the tissues, how robust that underlying tissue is. That comes with movement. It doesn't come with rest. So team, I think just putting this whole thing into perspective, what I want to get across this morning is that when someone comes in to see you in pain, their brain is not in the right decision making area to understand risk. Their amygdala has all the blood in it. They're really concerned. they don't know if they're going to be okay. It is our job to use our prefrontal cortex because we can use that in that state because we're not anxious because we see this all the time. We use our prefrontal cortex to say, you know what, actually we need to develop a plan that gets you back to X, Y, and Z. And that's what we do with rehab. And that's how we try to bring down that recurrence, is we avoid all these catastrophes that happen when people sort of follow their natural instinct, which is to rest. So that's all I've got for you this morning. I want us all catastrophizing rest a lot more on our patients, helping them understand that that is not necessarily the safe choice. A lot of times people's risk meter is broken there and it's actually the unsafe choice. So let's catastrophize rest, get out there this Tuesday team, meet us on the road if you're looking for anything. Please feel free if you want to have a big conversation here, jot it into the thread and I'll be on here all day answering any questions. Thanks team. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 16, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 - RACHEL MOORE Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I'm on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don't really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We're talking about the internal assessment and actually going over and practicing it on your back and in standing. We're talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we're diving into the actual fitness side of things where we're doing squats and we're learning how to brace and we're using weightlifting belts and we're getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I'm hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we've got a course in Corvallis, Oregon. November 4th, we've got one coming up in Bozeman, Montana. November 18th, we've got one coming up in Bear, Delaware. And then December 2nd, we've got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you're interested in joining us in the ice pelvic division, that's what we got coming up. 02:08 - THE HISTORY OF VALSALVA This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it's described so many different ways in the literature. So what we're going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we're looking at research, but when we're talking to patients about what this term even means and what we're actually looking for in our strength training fitness world when we say the word Valsalva. So let's kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn't even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we're looking in the ENT world, autolaryngological world, we're thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we're looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that's where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we've got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is. 06:04 - VALSALVA IN STRENGTH TRAINING In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you're a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we're again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we're not a competing athlete, if we're talking about just getting stronger and we're pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we're thinking about straining and bearing down, we're pushing down with our abdominal wall muscles, we're pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn't put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that's not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don't want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that's placed on that system. So if we're thinking about somebody who's lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we're not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we're taking that concept and applying it to lifting, it is the opposite of advantageous. So when we're looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don't ever do a Valsalva, in their mind, they're saying, don't ever strain and push your pelvic floor down when you're lifting. Totally. We agree. 100%. Don't do that. It's not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we're with our patients, that looks like breaking down the definition for them. 09:01 - VALSALVA MANUVEUR IN THE LITERATURE But if we're looking in the research world and we're trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we're, looking at this article and it's actually meaning the bearing down, then we're not getting, we're not able to extrapolate that to the strength and conditioning side. So really with this term, it's one word named after a man who the original maneuver isn't even what we're talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we're talking about. So rather than just telling your patients, do a Valsalva, maybe we don't use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we're gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it's all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they're literally the opposite. It starts to click with patients, why it's okay that my physician told me not to do this Valsalva, but you're telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We'll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 13, 2023

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses hip shifting in the squat. Zach emphasizes the need to ensure first and foremost, pain is in the hip or elsewhere in the body is not the cause of the shift. Second, Zach urges listeners to determine if the shift occurs under increasing loads or not. Finally, Zach discusses that if the squat is pain-free and that the movement pattern does not change under load, hip or ankle mobility is the final culprit. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - ZACH LONG Hey everybody, welcome to the PT on Ice daily show. It is the best day of the week here on the podcast, and that is Fitness Athlete Friday. I am your host today, Dr. Zach Long. I'm lead faculty inside of the clinical management of the fitness athlete curriculum, teaching in our live weekend seminar, as well as our advanced concepts course. And today we're going to be chatting about assessing the individual that has a hip shift when they squat. what are the questions you should be asking, and what are the things that you should be looking at and programming for them to help address that hip shift in the squat before we dive into that topic. Upcoming courses that we have in the Fitness Athlete Live arena here. November 4th and 5th, I'll be in Hoover, Alabama, and Mitch will be in San Antonio, Texas. November 18th and 19th, we'll be in Holmes Beach, Florida, and in December, Colorado Springs, Colorado. If you can't make it to any of those courses, we are already filling up the 2024 calendar as well. And we have Portland, Charlotte, North Carolina, Boise, Idaho, Renton, Washington, Raleigh, North Carolina, and Fenton, Michigan on the map. So check out all of those courses, as always, at PTOnIce.com. If you want to get registered, learn how to better assess, treat, and help fitness athletes do the movements that they love, as well as how do we get those people that are not already getting their daily dose of physical activity, how do we start to get them involved in that sort of stuff as part of their plan of care when they come to see us for pain? So PTONICE.com there. 02:32 - ASSESSING THE HIP SHIFT All right, today's topic, the hip shift in the squat. What I mean by that is you watch somebody squat, and instead of their weight staying even side to side, you see them shift some of their weight more towards one side than the other. Why does that happen? What are the questions you need to be asking? And then what are the things that you need to be doing as part of their treatment? So I think there are two big questions to ask subjectively when somebody comes to see you for a hip shift or you notice that when you're watching videos or watching somebody actually lift in the clinic. Question number one is, does that individual currently have pain in regions of the body that are impacted by the squat? Question number two is, does that change under load? When you ask and answer those two questions, you'll have a much better idea of what interventions you need to do to help improve that squat pattern. 3 Different Pieces to That 1. If someone is having pain, That's kind of the end of the discussion on the hip shift in the squat. So if somebody comes in and they're dealing with really nasty patellar tendinopathy or they're dealing with an ankle that was just sprained and is very, very sensitive as we dorsiflex the ankle. or someone has really irritable hip impingement. As they squat down and those tissues start to get loaded more as we go through range of motion, if those tissues are really sensitive, the body is understandably going to want to unload those tissues and try to avoid further aggravating them. So, when pain is on board and I notice a hip shift, I don't really worry too much about the hip shift right now in terms of trying to correct that. Instead, my main focus is on doing everything I can to calm down that irritability, because until we calm down that pain, we're probably not gonna make a whole lot of progress on the hip shift. So if pain's on board, take care of the pain. Now, there are definitely things that you can do that might assist this a little bit, but to me, those are secondary to the pain portion of this. So you could have somebody do box squats where they limit their depth to where they don't hip shift. or some other variations of lifts that maybe load that tissue a little bit less so that they demonstrate less of that hip shift. I think that's a fine intervention to do so that maybe that hip shift doesn't become, you know, as much of an ingrained movement pattern to them. But overall, when pain's on board, just take care of the pain and don't worry quite as much about the hip shift. 04:29 - HIP SHIFTING UNDER LOAD The second component to that, the second question was, does this change under load? And this is the big one that I see missed quite a bit. So I've had a couple of these show up in the last few months in the clinic, which is why I decided to do this podcast. And of those that I've seen lately, most of them, I was a second opinion. So they'd already seen another physical therapist or a chiropractor. And they had already had a lot of mobility drills that they were working on to try to improve the hip shift but they weren't noticing a change with the mobility drills. And what was missed by that previous practitioner was the fact that the hip shift worsened with load. And if we think about like the mobility demands of a squat, those demands don't change drastically when they go from an air squat to a 45-pound barbell squat up to a 400-pound squat. What does change is the demands that we're putting on the muscles. And actually, it's a little different than that. It's a little opposite. When you put load on a bar, if you're a little stiff, that load will often help you move a little bit better. It'll help push you through a little bit of that stiffness. So the key thing here is that if you notice the hip shift gets worse under fatigue or under load, then it is probably not a mobility issue. It is much more likely to be a tissue capacity issue, a strength issue. That's the big turning point here. So two examples of this that I've seen lately. Number one, super high level power lifter. He started noticing when he looked at videos of his squat that his bar would get uneven, but that wouldn't happen until he got to weight over 400 pounds. Prior to that, it didn't happen. And if you watch a set of him squatting over 400 pounds for say a set of five, what you notice is rep one was a little bad, rep two a little worse, rep three worse, rep five was really, really bad in terms of that bar being uneven. And what I noticed when I started analyzing that was that as he came out of the bottom of the hole, you would see his one side of his leg, if you're watching that Instagram, I have no idea why fireworks just popped up on my background, but You saw one of his legs really extend rapidly and the other one slowly extend. And what that's called is a good morning squat fault. If you've taken the Fitness Athlete Live course, you've heard us discuss that squat fault, but he was doing it only on one leg. And that leg had previously had an ACL reconstruction. And when we went and measured his limb circumference on that leg, he had a significant quad muscle mass difference on that side compared to the other side. So it was a strength deficit. And what we ended up doing with him was we loaded up his quads, doing a lot of unilateral work. We'll talk about a few drills for that in just a second. And what we noticed is the more we built up that unilateral quad strength, the less that hip shift was present. Another example I saw was recently in a… very high level CrossFit athlete, like top 200 in the world. When he deadlifted, he lost a major competition because his deadlift was relatively weak compared to his level of fitness. And when we watched his deadlift, he kind of did the same thing. So he starts pressing off the ground and the side that he had previously had an ACL reconstruction on about a year and a half prior to this, he hyper extended that knee as soon as he started pressing off the ground because he was still had a little bit of top end quad weakness relative to the other side. So he locked that knee out and he tried to, on that surgical side, make it almost a straight leg deadlift and rely on his posterior chain rather than his quads. So if it changes under load, it is a strength issue, not a mobility issue. 09:26 - ANKLE & HIP MOBILITY If it doesn't change under load, then you're gonna shift your thinking towards it possibly being more likely to be a mobility issue. And so from a mobility perspective, a few things that we like to look at, Number one, I'd say the most common are ankle and foot limitations. So lack of ankle dorsiflexion, lateral tibial glide, or the ability of the midfoot to move as somebody drops down into a squat. In our Fitness Athlete Live course, we talk you through a couple different tests that we think really help you screen out the foot and ankle, and if that's the impacting factor on somebody's squat technique. The second one to that is going to be somebody's hip mobility. And then the third to that is sometimes you'll see knee flexion limitations, but typically you don't see knee flexion limitations unless somebody's had some really significant trauma to that knee or a recent surgery. Outside of that, it's typically the ankle or the hip from a mobility perspective that will be impacting somebody's squat, causing them to have a hip shift in the squat. So once you answer that, you kind of know what to do. If it's pain, take care of the pain. If it's mobility, work on mobility. If it's strength, then let's do some unilateral strength loading of whatever tissue it is that you identified was a little weaker on one side versus the other. Take care of that. But I also think that it's worthwhile to spend a little bit of time working on some drills that might help reinforce a better movement pattern. So that as you build up maybe that unilateral strength or as you open up that ankle mobility, now you start teaching them a little bit more of where they want to go. And there are two drills that I really frequently use for that. My favorite to use is what's called a sit squat. So what I do there is I get an individual sitting on a box, a bench, a chair, a medicine ball, whatever the lowest surface they can perform this drill on, and they're sitting on it. We pull their feet back underneath them. We lean over. I get them positioned exactly how I think they should look in the bottom of the squat. And then they're sitting there, and I've got everything lined up so that it's symmetrical or as close to symmetrical as I feel like we're gonna get or we need to get. And then what I do is I tell them, imagine that there's a scale underneath your butt. Right now it says 100% of your weight. I want you to make it say 50% of your weight. So they just unload that medicine ball a little bit. Now I say, I want you to lift up one inch and only one inch. So they barely lift off the medicine ball or chair. They go back down to 50% weight and they just cycle up and down. And if you do a set of five to 10 reps of that, it is gonna actually burn really, really good because most people don't spend a whole lot of time under tension down the bottom of the squat. because there's no load on it. It's not going to be very fatiguing or really eating to their recovery a lot. So I use this a ton as a warmup drill, but that is deceptively hard and is really good for getting people to evenly drive and press into the ground and get an even lift off. And then when they sit back down, what they should feel if they're on something like a medicine ball is that they have the same amount of butt cheek touching the ball. Like if they sit down and it's only left butt on the medicine ball and right butt is floating off the side, then they're not squatting evenly. They're demonstrating that hip shift so they also get some tactile feedback in terms of their positioning. The other thing that I really like to do at times with individuals is get them to do some tempo box squats. So we squat down to a medicine ball, a bench, a low box, whatever it is, and we're basically doing the same thing there. We're going down nice and slow and we're making sure when we touch that surface that we're squatting to that we feel an even amount of weight on both butts. so that we, again, know if we're hip shifting or not. Those can be two good drills to drill in moving a little bit away from that hip shift. So, again, your two questions to ask when you see a hip shift. Are they having pain? Does it change under load? When you answer those two questions, you'll have a much better idea of what to go to to get rid of the squat hip shift a little bit faster. So, hope that helps. Look forward to being back on here again in a few weeks with you all. Hope you all have a great Friday and a great weekend, and we'll see you on the road. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 12, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the three pillars of evidence-based medicine: clinical expertise, current best peer-reviewed evidence, and patient input. He gives suggestions on how clinicians can better incorporate all 3 pillars to improve practice. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 – ALAN FREDENDALL Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. We're here on YouTube, Instagram, the podcast on Thursday. It's Leadership Thursday, that also means it is Gut Check Thursday. Gut Check Thursday this week, four rounds for time, some interval work. Four rounds, 10 handstand pushups. Those can be strict or kipping. Read the caption on Instagram for some help with modifications if you're still working on those. 10 handstand pushups right into a 50 foot double kettlebell front rack walking lunge. Kettlebells in front of the body, working the thoracic spine, working the legs, 50 feet of a front rack lunge, and then out the door for a 200 meter run on the treadmill, whatever. The goal there is one to one work to rest. That means we're looking to finish that round in about two minutes. Work two minutes, rest two minutes, complete for four rounds. you'll be done in ideally about 16 minutes. So read the caption, check for modifications, scaling is needed to try to get your round time as close to two minutes as possible, modify the handstand pushups as needed, reduce the load on the lunge as needed, and then sub out the run for a row or bike as needed. So hope you have fun with that one. That's a great one that really facilitates intensity. You've got some upper body with the handstand pushups, some lower body with the running and some monostructural, with the lunging, sorry, and then some monostructural with the running. So a great workout to really drop the hammer, rest, repeat a couple times, really working on that anaerobic glycolysis system. Before we get started, just some quick courses coming your way. Today I want to highlight our cervical and lumbar spine courses. A couple chances left towards the end of the year as we get near the holidays to catch cervical spine management. This weekend you can join Zach Morgan up in Waterford, Connecticut. The weekend of November 11th and 12th, you can join Jordan Berry up in Bridgewater, Massachusetts. That's kind of the greater Boston area. And then December 2nd and 3rd, you can join Zach Morgan at his home base at Onward Tennessee in Hendersonville, Tennessee. Lumbar management, also a couple chances left before the end of the year. Next weekend, October 21st and 22nd, Jordan will be in Frederick, Maryland. That's kind of west of the Baltimore area. He will also be in Fort Worth, Texas the weekend of November 4th and 5th. And then you have two chances the weekend of December 2nd and 3rd. You can catch our newest spine faculty member, Brian Melrose. He'll be up in Helena, Montana. And then you can catch Jordan Berry at his home base in Onward, Charlotte, also the weekend of December 2nd and 3rd. 02:55 – EVIDENCE-BASED MEDICINE Today's topic, evidence-based medicine. A couple different ways to frame this. Are you doing it right? Are you doing it wrong? Or it takes a village of really drilling down and better understanding what comprises evidence-based practice. For many folks, they think it's the research. For others, they think it's many, many, many years of clinical expertise, pattern recognition, and others believe none of that matters. What matters the most is actually what the patient believes is happening, what they believe will help them, and matching our treatments, our interventions, our education as best as possible to essentially the patient input side of the equation. And if you're on the podcast, I'm gonna show a Venn diagram. You're not missing much, if I'm being honest. I've got it right here on the whiteboard. What we know with evidence-based medicine is that it's actually all of that stuff, right? It is three different spheres, three stools, whatever analogy or metaphor you've heard to refer to these before is correct. When we look at evidence-based medicine, is it an overlapping of, yes, scholarly evidence, peer-reviewed research, Yes, clinician experience, practice and pattern recognition. And yes, also patient expectations and beliefs, and that the point at which these three areas overlap is the middle where we have evidence-based medicine, evidence-based practice. But what you'll find is because of this overlap, none of these areas can be evidence-based on their own. So our goal today is not to show you this Venn diagram, but to show you when evidence-based medicine goes wrong, how it goes wrong, and how we can all get a little bit sharper at evidence-based practice in our clinic with our patients. So, let's tackle these points one by one. The first, the one we're all most comfortable with as clinicians is our own clinical expertise. Probably more important than anything else with expertise and experience is the pattern recognition, the dose response relationship that begins to form in our brain The more patience we see, the longer we've been seeing patience. This is, you could call this the 10,000 hour rule, whatever you want to call it, but the belief that the more work, the more time you put in, the more you will maybe, theoretically, begin to master your craft. And there's some truth to that and there's some non-truth to that as well. 05:06 – AVOIDING DOGMA IN PRACTICE The biggest issue, as I have it written out here on the whiteboard, is that just focusing on this area in your practice, the bias here is that you become really prone to dogmas, becoming a dogmatic person, becoming almost a guru. We see this, of course, and we're going to mention it a lot on social media, of the approach on one side of the continuum or other. It doesn't really matter if manual therapy sucks. physical therapy doesn't do anything to the far end of that same continuum of, I believe that I'm putting people's bones back into place with things like spinal mobilization manipulation. So it doesn't really matter where people fall in the continuum, they fall somewhere on some sort of dogmatic continuum line, which is not great because it tends to the further they get into their own dogma and guru like behavior, the less they tend to incorporate research evidence from peer-reviewed sources and also the patient input. These people over time you may have heard phrases of I use what works with most people and the key there is that it works with most people not all people of the true person practicing evidence-based medicine the true clinical expert is the person that gets all almost every single person better. It's not enough to get 50% of your patients better, or 60, or 70. You should, or we hope you would be pursuing excellence in such a manner that you're thinking, how can I help 99.99% of people? And again, just focusing so much on one of the three aspects of evidence-based medicine with your clinical expertise is not gonna cut it. I often think of how much pattern recognition informs practice, but that doesn't mean that that's what we do with every person. I often think of when people come into the clinic, they present with anterior shoulder pain, what we might call instability, the feeling of looseness in the joint or otherwise just pain or maybe even stiffness on the front of the shoulder. I look at it as something wrong with the relationship between the deltoid and the lat. I understand the need to treat the rotator cuff, load the rotator cuff, but I also understand that the rotator cuff is ultimately paying the price for what the deltoid and the lat are not doing for the shoulder complex itself. That when these folks present with limited range of motion overhead, that getting in and treating, particularly the internal rotators, subscapularis can have a lot of value in restoring that range of motion and increasing tolerance to load long-term. However, that pattern recognition in my head is yes, where I'm going to go to first, but again, I can't get caught up too much in thinking this is what works with most people, this is what I'm gonna do no matter what. I have to be aware, I have to be humble that if it's not working for that patient in front of me, I need to go back and say what does the evidence say, what other treatments could I pursue, and also what input does the patient have into the equation of Are we maybe, yes, identifying the right cause, using the right treatment, but the patient expectation is that they can continue to do three to five hours a day of elite level CrossFit training on top of trying to move through the rehab of their shoulder. Those two things are always going to be at odds, and until I can start to incorporate more of the other arms of evidence-based medicine, I'm going to have a limited effect of how many people I can potentially help rather than most, I'm thinking again, how can I help that 99% of people? 10:40 – CURRENT BEST EVIDENCE That moves really nice into making sure that we understand that yes, evidence-based medicine does include evidence. It includes what we would call and what's labeled as current best evidence. That's the second aspect of evidence-based medicine. I think we can be really hard on ourselves and social media here can make you feel like you're not doing a good job at keeping up with the research. Because the truth here, if we're being really intellectually honest, is no one can keep up with the research. There are 1.8 million scientific journal articles published every year. There are 35,000 articles being published every single week. It is impossible for any individual practitioner to read all of those. Ever. It doesn't matter if that was your full-time job. You would not be able to keep up with it. So what we tend to see is that we tend to focus on specialty areas in practice. And I think that's okay. I think that helps narrow our lens. And as long as we are finding a source bias here is I think we do a good job with hump day hustling. There are other great sources as well that do a good job of taking a bunch of research and condensing it in a way that can be absorbed, especially that is then kind of classified by specialty area. But understanding, it's really impossible here to always be up to date on the current best evidence. And just being up to date and reading new articles doesn't mean that that evidence necessarily has any value. We need to be mindful of that fact as well, that just because something new has been published doesn't mean it has value. This is a great example. This is an article. You may have seen this make the rounds on social media. The title is, One and Done, The Effectiveness of a Single Session of Physiotherapy Compared to Multiple Sessions to Reduce Pain and Improve Function in Patients with Musculoskeletal Disorders, a Systematic Review and Med Analysis. This paper was published just a couple days ago, so brand new off the press, right? We tend to associate newer with better in research, which is not always the case. And we tend to try to immediately incorporate articles like this into practice and make giant conclusions that often the paper does not support. Already there are people on social media posting this article and saying, look, physical therapy doesn't work. You should not go to physical therapy. There are folks posting this and saying, see, I told you manual therapy does suck. In some of these studies, in a systematic review, they did manual therapy. I told you it was worthless. Dry dealing does nothing. Spinal manipulation does nothing. Cupping does nothing. People who practice that are committing malpractice. They should be fined or lose their license or be in prison for doing dry needling. And all of those giant conclusions are being made from just this one article. They're being made in such a manner too that tells a lot of us who read a lot of research that they probably haven't actually read the full paper, right? They probably have just read the abstract. Because if we read the full paper, what this paper is really saying is that more physical therapy doesn't seem to help as long as all we care about measuring is pain. No information was given about any other outcome measure, strength, changes in vital signs, did people's blood pressure get better, did stuff like depression, anxiety get better, kinesiophobia, all these other different things that we can measure about a patient that we would expect to change with physical therapy intervention were not measured in any of these studies. And probably the most important thing that's missing from this study all the studies that it analyzes and pretty much every piece of physical therapy research is there's absolutely no information on what was actually done to these people in a way not only that the study could be replicated in the future and possibly validated, or that we have any idea of what was done. It's entirely possible that folks in some of these studies only got manual therapy, that some folks maybe, yes, got exercise, but how was it dosed? Did they test the sub-max lift? Did they train at or above 60% of that sub-max number to ensure that strength was actually happening? And the answer to all those questions usually is no. So it's really important we don't get deep down the evidence-based hole, knowing that for the most part, a lot of the research that comes out, even though there's a high volume of it, it's all quite weak and doesn't necessarily get incorporated into practice because it doesn't really help change and inform practice pretty significantly. Also from this study, Most of these patients had a spinal fracture, they had diagnosed osteoarthritis of the knee, or they had some sort of whiplash disorder of the neck. So kind of specialty populations that can't just really be extrapolated to the general population to say that physical therapy doesn't work. Nonetheless, people grab this article and they cite it. That kind of shows us an overlap between the sphere of clinical expertise and pattern recognition and evidence. I've written it right here on the whiteboard. That person, we would call that person a cherry picker. That person has a very shallow knowledge of the research and they're basically using the research to better inform their own dogma, right? That is not evidence-based medicine. That is just cherry picking research that supports your bias and ignoring the rest and not really taking a deep dive in the research. We have to remember as well that it is evidence based not evidence only that we have to act in the absence of evidence we actually have to do something with people and that we don't always have the best research to inform what we're currently doing in the practice that if we are treating a patient we're doing certain interventions they are making progress both according to their own input, their own goals, their subjective input, and also what we're measuring objectively, then by every way we can measure it to both us and to the patient, the patient is making satisfactory progress. And sometimes we don't always have research to support that. And that's okay. We need to also be intellectually honest, that some of the research we would like to see happen can't happen. A lot of research is either done on folks who are already healthy or it's done in a manner that whatever intervention is given can't potentially make that person either less healthy or more injured. We often see people in low back pain get some sort of treatment and then another group gets some sort of what we call usual care. Either way, somebody is getting some sort of intervention that is designed to improve their symptoms, not maybe theoretically worsen their symptoms. I would love to see research of folks lifting near or at their maximal one rep max potential with a deadlift, and I would love to see the outcomes of what happens with a group of people who lift with a focus on a brace neutral spine, what happens to people who intentionally flex their spine throughout the deadlift, what happens to people who intentionally extend their spine without a deadlift. Is that research ever likely to happen? No. Why? Because it would be really unethical to take a group of people who have nothing wrong with them and potentially cause them maybe a lifetime of debilitating injury just to try to prove a point from the research, and that is not the point of research. We have to be mindful that we're conducting research on human beings who have lives, who have families, who have jobs, and as much as we would like to see some specific lines of research come to fruition, we'll probably never see some of that because of the interventions the risk is simply too high, it probably won't pass review from something like an institutional review board at a university. So we need to be mindful as well of, yes, we're always trying to keep up with the current best evidence, but that doesn't mean it's actually the best, even if it is current, and it doesn't actually mean that it's research we would actually like to see happen, because it can be limited, again, by the ethical nature of actually conducting that research on living human beings. The bias here is being prone to being so far in this camp, and I've written here on the Venn diagram of being up in the ivory tower, of only doing things that has a lot of evidence to support it. Again, in the absence of evidence, we still need to do something with that patient. We still need to understand their condition. We still need to at least try some other evidence-based interventions to help that patient out. What many of you can't do is have a patient come in for evaluation and say, I don't have the current best evidence way to treat you, you'll need to leave now. That usually doesn't go very well. And we need to recognize as well, that patient is probably just gonna go see another provider anyways. Even if you were being very, very intellectually honest with them, that there was no evidence on treatment for their current condition, they're probably just gonna go somewhere else and get less evidence informed care there anyways. So for the best, it's probably that they stick with you for the long term. 19:14 – MATCHING PATIENT EXPECTATIONS & BELIEFS Our final aspect is including patient expectations, values, input. I think this is the weakest area for all of us, of the thing we probably consider last, when maybe it should be what we consider first. This is forgotten far too often that the patient, again, is a living human being with thoughts, feelings, beliefs in front of us, and doing our best to match our interventions to their expectations, beliefs, values, is really, really important, and kind of tying in to the current best evidence, we have really good evidence to show that as well. If that patient comes in and says, hey, you know what, you may not remember, but you saw my husband about six months ago for some really bad low back pain. he was in so much pain, he was off work, and you did something with some needles and electricity or something, and anyways, he felt so much better, he was able to go back to work, he's back, he has no issues anymore, that's fantastic, and I was hoping, with my back pain, that we could try something like that. Now, of course, what that patient did not get from their husband is all the other stuff you probably, hopefully, did with that patient. But what they took away from it was that dry needling appeared to cure that person. And so, it's really helpful, I think, if you can match that expectation as much as possible. Yes, you could give that patient a 45 minute lecture on how dry needling for low back pain doesn't have as much evidence to support it as strengthening the spine and increasing cardiorespiratory fitness and reducing inflammatory diet and getting more sleep and managing your stress and you can go all the way down that pain neuroscience rabbit hole to the point at which maybe that patient doesn't come back to see you anymore Or if your long-term goal is to help that person and you know what is the most evidence-based way to help that person is to have their back get stronger, to help them with their current lifestyle habits, then probably the shortest point there, the shortest line between two points is a straight line between points A and B. It means that if you can just offer the dry needling, that's probably going to be the most beneficial thing, right? You're matching that patient expectation, belief, and value. Does it take time? Yes. It doesn't take a lot of time. Does it take a lot of resources? No, it doesn't. It costs a couple cents for the needles, right? And it lets us get to what we ultimately want to get to that person which is addressing their lifestyle, getting them loading, getting them moving if they're not currently moving, and overall changing their life for the better from both a physical fitness but also overall health and lifestyle perspective. And I think far too often We have an agenda, we have a bias with certain treatments where it doesn't matter who comes in the door. We can be on either side of the dogmatic perspective of everybody gets spinal manipulation, everybody gets dry needling without actually consulting the patient, do they want this or not? Are they open to another treatment? And what will ultimately get us to what we know works the best for most people, which is to get them moving more, get them stronger, get their heart rate up, address their lifestyle. So you can have many sessions of education only. You would think you're practicing in the most current evidence-based way, but we know we can't talk patients better. We actually need to do some stuff. And at the end of the day, I would challenge you that it's probably better if they do that stuff with you versus leaving your care and going to see another healthcare provider. That's another thing that articles like this do not address, of how much follow-up care did patients receive after they leave the study. Overwhelmingly, that is something that is not addressed. of if you do not provide the treatments that the patient wants, whether they want manual therapy, whether they want strengthening and you don't have the time or equipment to provide that, whatever they want, if you do not match those expectations and values, they're probably gonna go somewhere else. They're gonna spend healthcare dollars somewhere else. And that might be with a healthcare provider that's not as evidence-based as you are. So challenge yourself. Are you actually practicing within all of these three different spheres? Are you trying your best to keep up on the scholarly research, at least as it relates to the areas of practice that you're passionate about? Are you honest with yourself that you do have clinical pattern recognition that has value, but knowing that it does have its limitations and you're willing to adjust your treatment when things don't work? And are you combining your practice expertise and the current best evidence with patient expectations and values to ensure that the treatment you're offering is actually the treatment that the patient wants. So check yourself. Evidence-based medicine, are you actually doing it? I hope this was helpful. I hope you all have a fantastic weekend. Have fun with Gut Check Thursday. If you're gonna be at a live course, I hope you have a fantastic time. We'll see you next week. Bye, everybody. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 10, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant delves into the various phases of rehabilitation for shoulder instability, providing valuable insights and recommendations. One key phase highlighted is centered around core stability, with Mark emphasizing the significance of incorporating core-related exercises into the rehabilitation program. Specifically, exercises like plank and plank rotations are mentioned as effective ways to engage the core muscles. Furthermore, Mark discusses the importance of tailoring functional exercises to the individual's capabilities. He explains that if certain exercises, such as overhead press or full bench press, are too challenging, alternative exercises can be introduced. Examples provided include the landmine press, bottoms-up press, and push-up variations. The goal is to find a level of functional activity that the person can comfortably perform and then scale it accordingly. This approach not only helps to keep the individual motivated, but also allows them to track their progress towards their goals. In addition to core stability, Mark discusses the significance of incorporating speed work into the rehabilitation program. As the patient progresses through the program, Mark suggests gradually introducing speed training. This involves training the tissues to tolerate different velocities of force through a full range of motion. Specific speed work exercises, such as concentric-eccentrics at different beats per minute (30, 50, 70, 90, 120), are mentioned. Additionally, activities like Turkish Get-Ups are highlighted for their ability to improve core resilience while working on shoulder stability. Overall, Mark underscores the importance of integrating core stability exercises and speed work into the rehabilitation program for shoulder instability. These phases of rehabilitation play a crucial role in enhancing overall function and resilience of the shoulder joint. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - MARK GALLANT Alright, what is up PT on ICE crew? Dr. Mark Gallant here, lead faculty for the Ice Extremity Management Division. alongside Eric Chaconas and Lindsey Hughey. Coming at you, sorry, Lindsey, messing up that last name. Happened to me for years, now it's happening to you. Lindsey Huey, the other extremity management lead faculty. Coming at you here on Clinical Tuesday, wanna talk about atraumatic shoulder instability and traumatic shoulder instability, and what a good plan is if we're gonna treat these folks non-operatively. Before we get into that, I want to update on a few courses coming up. So I'll be in Woodstock, Georgia, November 11th. Cody Gingrich will be in Newark, California, December 2nd. And Lindsey Huey will be in Windsor, Colorado on December 9th. So a lot of opportunities, different regions of the country to check out ice extremity management. over the next couple months if you need to get in those CEUs for the year. So again, that's November 11th, Woodstock, Georgia. December 2nd will be in Newark, California, and December 9th will be in Windsor, Colorado. So definitely come meet us out on the road. 02:58 - CONSERVATIVE CARE FOR SHOULDER INSTABILITY So when we're looking at shoulder instability, it used to be that if someone had a traumatic shoulder instability, it was an automatic do not pass go, you're required to have surgery. And then the folks that had atraumatic shoulder instability, the people who were either born loose or worn loose, those folks, it was a maybe depending on how many dislocations, what was going on. But oftentimes a lot of these folks were getting filtered into surgical procedures. What we've now seen over the last couple of years, now that we're getting better with our rehab programs, is that conservative care and physical therapy can do quite well with both the traumatic shoulder instability and the atraumatic shoulder instability. So Anju Jaggi, who's been researching shoulder instability for years, came out with a trial this past year that recently released that showed in folks who had atraumatic shoulder instability, if they had conservative care versus if they had an inferior capsular shift, if they had an inferior capsular shift or an inferior capsular shift placebo procedure where they actually did nothing, that the folks who had the placebo treatment did just as well with physical therapy. So placebo surgery versus actual surgery, the placebo surgery with physical therapy did wonderful. We also have Ellen Shanley in 2019 who looked at what happens if people do have a traumatic shoulder instability event and they go through a full course of physical therapy and found that a majority of those folks were able to return to their sport the next year. So 85% of the individuals who had an instability event had good physical therapy and they were able to return to their sport. We do want to have some humility as physical therapists and allied health professionals that These folks were all individuals who did not have bony damage, so no bony bank hearts and no Hill Sachs lesions in these studies. If those things are not present, we can do quite well. So what is this actually going to look like? Margie Olds, who's another researcher who does a lot with shoulder instability, recently came out with a clinical commentary of how do we best do how do we best work with these folks? And we've been using it in clinic and seeing some really nice results. What the overall theme is, is we really want to get some of the local rotator cuff muscles really functioning well so that the lats, the pecs, the big movers don't have to take over. 04:13 - MUSCLE FIRING PATTERNS & PRIME MOVERS What we used to see is everyone would try to disinhibit the prime movers, the pecs, the lats. We saw this a lot in FAI treatment where we would try to disinhibit the TFL. What we realize now is this is very challenging, and what we actually wanna do is get the muscles that aren't firing as well to be more robust, more resilient, and fire well, and that will calm down the prime movers. So what we see is if we get the posterior cuff functioning well, if we get the subscapularis functioning well, that we will see the tone of the pecs and the lats calm down. The issue traditionally in physical therapy has been once we get to that stage, we don't move them on to more functional fitness, to more global resilience, to more general preparedness of the system. So what is this gonna look like in clinic? It's actually gonna look quite a bit like our tendinopathy progressions for rehabbing folks. So we're gonna start folks out with more isometric contractions, really getting the cortex and those muscles firing, progressing them more into a rehab dose with concentric eccentrics, then we're gonna focus on speed training, getting those tissues to tolerate speed and different velocities of force through a full range of motion, and then getting them back to their overall functional fitness. So what we specifically like to do in clinic is early on, first phase, they're first coming in to see you, they may or may not have been in a sling for a few weeks, Recommendation for slings and these folks now, if it's first time instability event, or if they've had that atraumatic shoulder instability and they had an instability event, is you can put them in a sling short term. There's no research that says it benefits them. There's no research that says it harms them. Put them in the sling. We don't want them in a sling for more than three weeks. If they feel like they need that to calm down, it is okay for a short period of time. We're going to get them in clinic and we're going to start with our isometrics. Two things that we specifically want to hit with our isometrics, if they can get into a 90-90 external rotation position, we want to hold that three sets, 30 seconds. If that person's willing to perform more, five sets of 45 seconds is even better. Whatever range of that external rotation they can get in, without pain going over a mild and whatever range they have access to, that's where we're going to perform that exercise. The other exercise we're going to perform to go after that subscapularis is a prone liftoff. So they're going to be on their stomach, they're going to put their hand behind their back as far as they can, and they're going to rotate into internal rotation to lift the wrist and hand off the back. If they can only get to the glute day one or just barely to their side, that's totally fine. When you're looking at this one, we want to be really careful that that person is actually internally rotating the shoulder. So this is not the time to turn around and type your notes. We want to be focused that they're getting true shoulder internal rotation. what a lot of people are going to do is they're going to wind up trying to extend their shoulder more or really dump through that scapula. So making sure that when they're doing that isometric, they're getting a pure shoulder internal rotation. We also want to start working on co-contraction of the shoulder. So where the delts, all the muscles are going. Oftentimes these people, although weight-bearing, closed-chain exercise is beneficial, early on it may be too much for the system. We're gonna start them out with a side-lying arm bar. So our big three exercises that we've found to be very beneficial are 90-90 ER, three sets to 30 seconds, if they can tolerate five for 45, that's even better, that prone lift-off isometric, and then a side-lying arm bar for that same period of time. Once they're able to demonstrate that they can do these exercises well, then we're going to, that they can do them well with pain less than a, than a three out of 10 or keeping it in that mild symptoms, they can tolerate the entire timeline. Then we're going to move them into a more of our rehab dose program where we're going to start getting some, some resistance through the system and getting, getting into some actual concentric eccentric repetitions. we really like to do the same motions. So we're going to stand them up, have a, have either a meter band, or if you have a cable pulley system, their hand is going to be behind their back. The cable will be to the opposite side, and they're going to have to do that lift off with resistance. We want them to hit somewhere in the 15 to 20 rep, keeping those symptoms mild for three sets. that will get their subscap, their internal rotation, again, making sure they're not solely substituting extension in that motion. Then we're gonna get them back, either on the table or in quadruped, hitting their 90-90 ER. This time we're gonna hit a light weight, two and a half to five pounds, and then we're gonna do, again, 15 to 20 reps. Can they tolerate that high volume, 15 to 20 reps? keeping their symptoms mild, that would be good for that motion. Then we're going to progress them now instead of doing their open chain arm bar, we're going to see how they can tolerate planks. So getting them into that plank position and having them do plank taps. We can modify this depending on the person by either widening their feet to get a better base of support or putting them onto a box. So for phase two, again, we want to hit that lift off, this time with either a band or a cable resistance, 15 to 20 reps, three sets. We're going to hit our 90-90 ER, two and a half to five pounds, if they can tolerate that, keeping symptoms mild. Again, higher on those repetitions. And then we're going to start working towards our plank taps. As they progress through this phase, then we're gonna start working on speed. 10:30 - SPEED & METRONOME TRAINING What we wanna look at with the speed is how much can that person tolerate velocity? The metronome is one of the best tools we can use to get this going. We've seen this a lot in the tendinopathy research. Margie Old is the first person that we're aware of that really laid out in a peer-edited journal article, clinical commentary, how exactly they're doing this with shoulder instability patients in clinic and what they're doing is they're starting them out 30 beats per minute on the metronome and they're going to do neutral internal rotation with a band or a cable column at that 30 beats per minute then as they can tolerate that well they're going to progress to 50 beats per minute then to 70 beats per minute, 90 into 120, which is moving pretty fast. If they're doing internal rotation at 120 beats per minute, it's pretty rapid. As they can tolerate that better, they're going to go out, put a towel under their arm, 45 degree angle of abduction, hitting those same 30, 50, 70, 90, 120 beats per minute, and then progressing to a 90-90 position, hitting that 30, 50, 70, 90, 120 beats per minute. Same with external rotation for that posterior cuff, 30 beats per minute in the neutral, progressing to 50, to 70, to 90, to 120. Then looking at can they do it at 90 degrees of external rotation or 90 degrees of front plane external rotation, 30, 50, 70, 90, 120. and then progressing up to 135 similar to that face pull type of motion. Again, 30, 50, 70, 90, 120. So really systematically progressing the speed training the same way you would with your loaded resistance exercise. Now, the other thing that we're gonna do during that phase three, we're gonna start progressing the plank taps. Can they now do a plank with a rotation going on to their side. So they've got to get a little bit movement through that closed chain exercise. And we love to add Turkish get up variations. So one thing that we see with a lot of, especially atraumatic shoulder instability folks, is that they're going to have a, their core is not going to be as resilient as it could be. So we often see a lot of that anterior and posterior trunk dysfunction leading to maybe the lats and the pecs having more myofascial tone and if we can work on that while we're getting the shoulder more resilient that can be a nice beneficial step. So what we'd like to do is do the first part of the Turkish get up or doing a whole Turkish get up so that we're getting some shoulder stability and we're getting a big massive core engagement. And then the final phase, phase four, where historically A lot of PTs have stopped. Oftentimes these folks are out of pain now, so compliance becomes more challenging. Really encouraging these folks that we want to get them fully back to everything that we're doing and build as much resilience to their shoulder. This is where you're going to really work on your vertical pulls, your horizontal pulls, so your pull-ups, your rows, your vertical presses, your overhead press, your horizontal press, your bench press, and then really getting into dynamic speed work or sports training. So snatches, push jerks, push press, burpees, things that are going to be more functional and have some velocity to them are really good here. Your kipping pull-ups. What we want to encourage is we're not going to only start the functional phase after they've gone through phase one, phase two, phase three. So phase one, again, being more of your isometrics, phase two being your slow concentric eccentrics, oftentimes starting at a higher volume, those 15 to 20 reps and progressing to more load. Phase three, working on your speed work, 30 beats per minute, 50 beats per minute, 70, 90, 120 beats per minute. Working on your core related exercises, with shoulder stability. We're not going to only do functional exercise after that's all done. We're going to find what is the level of that functional exercise that they can do. So if they can't overhead press, can they landmine press? If they can't do a full bench press with the barbell, can they do a bottoms-up press? Can they do a push-up variation? What is the level of functional activity that they can do? We're gonna scale it down to that level so that the person is, they've got that goal in mind. They are always aware of what they're getting back to. They're doing something that's getting all of the tissues moving. Oftentimes it's a little more fun for them. So we're keeping that as part of the program. as early as irritability allows us. So again, overall for shoulder instability, what we now know is for both traumatic and atraumatic, as long as there's not a Hill Sachs or a bony bank heart or severe trauma related changes that we do quite well in conservative care and physical therapy, we want to have a systematic program starting out with your isometric exercises that give both the posterior cuff and the anterior cuff really going. 16:01 - PROGRESSING TO CONCENTRIC-ECCENTRICS Progressing those to our concentric eccentrics, typically starting out with a higher volume. When they can do that, then we're going to progress to our speed work with our concentric eccentrics, 30 beats per minute, 50 beats per minute, 70, 90, 120, making sure we've got some activities that also engage the core, like our Turkish get ups, our closed chain exercises with those plank and plank rotations, and then getting into our more functional fitness or whatever their sport related activity is. Hope this helped overall. Love to hear anything in the comments. We would love to chat and engage about this. Hope you all have a great Tuesday in clinic and hope to see you on the road soon. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 9, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick continues with part 2 of her series on postpartum depression. In this episode, she discusses how rehab providers can screen for postpartum depression. She also offers tips for communicating with clients who we suspect have postpartum depression with scripted suggestions and responses to support a client in the moment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 - APRIL DOMINICK What's up PT on Ice Daily Show fam? My name is Dr. April Dominick, and today I'll discuss how to screen for postpartum depression and share tips and scripted phrases that you can practice saying to get comfortable supporting someone you suspect has postpartum depression. In the ice pelvic division, updates and course offerings are going to be that we are on the road October 13th and 14th in Milwaukee, Wisconsin. And your next opportunity after that will be with myself and Dr. Christina Previtt. We will be tackling all things pelvic health in the Pacific Northwest in Corvallis, Oregon, and that's gonna be October 21st and 22nd. So head over to PTOnIce.com and grab your seat. Our final courses for the fall are still listed, and you still have a few chances to catch us live. So in episode 1553, that was the last episode I did of this postpartum series, depression series, we talked about prevalence rates, we defined postpartum depression, and we talked about risk factors for postpartum depression. Since then, I ran across another systematic review from 2017 that cited worldwide greater than 10% of pregnant and immediate postpartum women are having depressive episodes, greater than 10%. That number is still astounding to me. While screening for PPD or postpartum depression is one thing, if someone is sharing that they're struggling and you sense they have some signs and symptoms of postpartum depression, we as providers may feel empathy for the person in front of us, but we may be at a loss of words for how to communicate that with another individual. So in the second half of today's episode, I'll go through a few key phrases that you can build off of in response to someone you suspect having postpartum depression, with the ultimate goal, of course, being referring them to the appropriate mental health provider and or medical provider. 00:00 - SCREENING FOR POSTPARTUM DEPRESSION But first, let's chat about how we can screen for postpartum depression. Just a quick definition of postpartum depression, it is going to be someone with moderate to severe depressive symptoms. That can arise around post childbirth whenever that occurs, all the way up to four weeks post childbirth. And then that can also last for up to a year or more postpartum. Postpartum depression, it affects daily functions. So someone has some struggles with chores or daily childcare tasks compared to the baby blues, which is a more mild form of depression. Postpartum depression does require medical intervention as well. So pregnancy and postpartum, as we all know, is a time of psychological vulnerability, especially in those first few weeks when there's so much transition happening after delivery, which is why early identification and screening for treatment is key. So we want to ask the questions, whether that's verbally or in a paper or outcome measure form. So ACOG recommends that patients be screened for postpartum depression at a few certain timeframes. At the first OB visit, at 24 to 28 weeks gestation, and there was a study in 2013 by Wisner et al that suggested for a majority, depression begins prior to delivery. So this is why we have those checkpoints during pregnancy. And then the other times that they suggest that we screen for postpartum depression is at the comprehensive postpartum visit, whether that's at six weeks, four weeks, eight weeks. And then also I loved this at pediatric visits well into the first postpartum year, because pretty much after that six week visit, um, most women are not seen by their OB until the next year for their annual. So those are some timeframes that we as PTs are likely seeing these individuals maybe during pregnancy, postpartum, so we can also help with this screening process. In terms of outcome measures, there are a number of outcome measures out there that are used to screen for postpartum depression. We are going to go over two of the most common evidence-based tools. The first is the Edinburgh Postpartum or Postnatal Depression Scale, and then the Patient Health Questionnaire. They're both two scales that are recommended by ACOG and by the Postpartum Support International Group, which is a really cool resource, and we'll talk about it more in my next episode, but it's going to be a resource available for those in that perinatal mental health space period kind of combines those two things. So the two outcome measures, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire, we love them because they are available in many languages and they are quick to administer and they're free. Who doesn't love free stuff? They are validated also for the perinatal population. which I think is something important that while we can give someone a major outcome measure that's for general depression, it's even really more helpful to have someone go through an outcome measure that is specific to the time and space that they're in. And then scoring, the lower the score for both of the outcome measures is going to indicate lower or more mild depressive symptoms. The cutoff value of 11 or higher out of 30 for the Edinburgh scale is going to maximize the combined sensitivity and specificity. 07:21 - THE EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS) Let's go through a couple of differences, though, between what we'll call the EPDS for the Edinburgh Postnatal Depression Scale. So for the EPDS, it's got 10 questions. And not only does it address the depressive symptoms and suicidal thoughts, but it also has an anxiety component of perinatal mood disorders. And that anxiety piece is likely what contributes to it being the most widely used screening tool. The other interesting thing I came across is that the EPDS is actually reliable and a valid measure of mood in the supporting partner, whether it is a male or a female, which I think is great. Example of items from the EPDS. are as follows. The person is going to be answering whether or not they have been so unhappy that they have been crying, the thought of harming myself has occurred to me, or I have felt scared or panicky for no good reason. Moving to the patient health questionnaire, that's going to be nine questions that assess for the depression component. It does include an item about suicidal ideation, but it doesn't have an anxiety component that the EPDS does. Instead, it includes some of the somatic symptoms of major depressive disorders, such as fatigue, sleep disturbance, changes in weight, and these reflect what is also on the DSM categories. Here's an aside for all these outcome measures. So in my research, I ran across a study from 2017 by Ukatu et al, reviewing about 36 articles that used PPD screening tools, and they investigated the outcome measures and their ability to detect maternal depression. So two of the conclusions from this review that looked at a bunch of articles that use PPD were, one, is that they found no recommendation could be made about the most effective tool for detecting PPD, which is, I guess the good side of that is you can use, there are a lot of tools out there and they will likely be capturing the depression component. 10:28 - WHEN IS THE ONSET OF POSTPARTUM DEPRESSION? The other thing that they mentioned was there's no recommended time duration in which to screen patients, again, from all of those reviews that they studied. So one of the reasons they suggest that the timing can be difficult to recommend is that For certain outcome measures that are administered at the two-week mark, the outcome measure may not be able to differentiate symptoms of baby blues, which commonly ends after about two weeks post-birth, versus postpartum depression that can have a much later onset. And that can be anywhere from post-birth up to three to four weeks for onset. So I just thought that was an interesting find from the screening side of things. But the two that we talked about are the EPDS and the patient health questionnaire. So outside of administering those two outcome measures, when it comes to screening, you'll want to also use the power of your ears and your voice to catch anything that may have been missed in those outcome measures. Remember, some people won't necessarily be honest on the outcome measures. They may be less likely to share that they're struggling due to the feelings of shame, abandonment, maybe they have a lot of guilt about not being enough for their baby, or they may not even realize their current emotional state, even when asked right on the outcome measure. So be an active listener. Ask the person How are you doing? But don't stop there. If you get a general response that's like, I'm good or I'm okay, I think you should ask it again. Say, I'm going to ask you again, how are you doing? Then you should also be on the lookout for words or phrases that the person may use in their conversation, like dark, heavy, blue. And then we certainly also want to have screening out postpartum psychosis in the back of our minds. So hearing voices that tell me to drop my baby, if you hear that, that is very serious. It is a medical emergency. This postpartum psychosis is going to affect about one to 3% of moms. So that's how to screen postpartum depression. How do we have the difficult conversation? How do we navigate the intricacies? when we suspect the person in front of us may be suffering from some postpartum depression. A few general tips. You'll want to listen with compassion and empathy, particularly to the non-physical symptoms. As neuroscientist, Dr. Andrew Huberman said, says, use your body to shift the mind. An individual that's not functioning at their usual physical capacity, or is in pain, or I don't know, recovering from a human body coming out of their body, or they're lacking sleep, right? This does not only affect the physical body, but it's also going to affect the brain and the soul. So it is within our scope to chat about this as their mental status is linked to their physical healing and recovery and management of their condition. As a provider, ignoring their mental status is not an option. You'll also want to avoid being dismissive. So someone may have been very vulnerable with you and they shared that, you know, they're just struggling. They're struggling to find the energy. They're struggling to feed themselves. And then you as a provider, like, okay, moving on to range of motion of your leg, like absolutely not. That is not acceptable. So avoid being dismissive, hear them out. Then remind them that addressing their mental health now will be so much more beneficial than months or a year down the line. And then mentioning that you'd like to take an integrative approach and refer them to a medication provider or their OB or a PCP or a psychiatrist, right? We'll talk in the upcoming podcast, but medications like antidepressants are also a good treatment option for them. So what are some specific responses that you can practice or just have in the back of your head when you suspect someone may be experiencing postpartum depression? I don't know about you, but especially in the public health space, I tend to get, you know, we talk about intimate subjects and there are some times that someone will share something with me. And I mean, I am feeling so much for them, but I have a hard time putting into words the quote right thing to say. And I'm not saying that these things, these scripting phrases that I'm going to give you are the right thing, but it's something to go off of if you're just struggling in that way. 16:43 - HIGHLIGHT & CELEBRATE So the first phrase, and I think it's probably one of the most impactful, your feelings are validated. I'm in a group text with a few moms and one of them, they've all been recently pregnant and recently postpartum. Some of them have been going through some tough times when it comes to emotions. And one of them said, my OB put her hand on my arm and told me how brave I am for asking for help and really realizing that I need to be my best self for my family. And she told me I could call her office anytime to talk to her. And that meant so much. So just letting the person in front of you know your feelings are validated. Number two, early identification. So if you've got someone who is pregnant and you suspect that they're going through some tough times from an emotional standpoint, you can say, you don't have to feel this way for the next eight months of your pregnancy. There are resources available. Number three, highlight and celebrate the person's abilities. Say, look at what you're doing. All of this is very impressive given the circumstances and all the stress that you've been under. Bring it back to a potential or current bond with the baby. And you know, if the baby's in the room with you, even better, have a little side conversation before the appointment starts with the baby. When I point to you, look at your mother with loving eyes. I'm just kidding. But definitely show the person or show the mother, look at how you're learning what your baby needs, right? For comfort, for snuggles, for food, for diaper changes. So remind her of the role she's playing. And then number four, remind her your health is a priority just as much as the baby's is. So often, as soon as labor and delivery is over, maybe we have that six week, postpartum visit, the rest of the visits are not for the mother, they're for the child. So just reminding her that her health is definitely linked and just as important to her baby's health. And then number five, say this happens. There's a fine line though between normalizing that this happens a lot, but also it's not so normal that you don't need to address, that we can't have you not address it. So there was a resource that is, was in the deep dive realms of the ACOG website and the title, the title just gives me chills. It says, how do you talk about mental health conditions in a strength-based way? Love that. Here were their suggestions. Say mental health conditions are common. Mental health conditions are like medical conditions or like diabetes. They need to be treated. Medical conditions are, or mental health conditions are treatable. And that reminding the client that the aim is that every woman who is pregnant or postpartum or every person who's pregnant and postpartum is screened for mood disorders. They also recommended that their clinical support office staff needs to be skilled in talking to patients in a strength-based way, as they may be the first to encounter a postpartum person. And I wholeheartedly believe that because the face of the first person you encounter can really and truly change the trajectory of your care. So let's sum things up. If you're a healthcare provider, interacting with someone In the pregnant and postpartum period, you are in a unique position to be screening for postpartum depression. We covered using two outcome measures such as the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire. If we suspect PPD, we as rehab providers can be confident in having these early conversations early on and during the client's pregnancy and then again in the early postpartum period. Using tips and verbal responses, the scripting phrases that I mentioned, can help support and validate the client's concerns in a strength-based way. Reminding them that their health is equally as important as their baby's. Reminding them of what they've accomplished under these incredible circumstances. And telling them, hey, this condition is treatable, just like we would treat a shoulder injury. This awareness can decrease stigma, it can normalize screening and detection, and encourage women to discuss any mental health concerns with you. Join us next time for specific treatments, resources, and ways to support a person with postpartum depression. Cheers, y'all. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 5, 2023

Dr. Paul Killoren // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren emphasizes the importance of using e-stim in conjunction with dry needling. This combination provides validation and helps the practitioner determine if the needle is in the muscle. Furthermore, using e-stim with needles can reduce post-treatment soreness, making it more approachable for patients. Paul also highlights research supporting the use of e-stim in various treatment goals, such as pain modulation, neuromuscular changes, tissue nourishment, nervous system accommodation, and somatosensory reorganization. Paul always recommends using e-stim after inserting the needle, as it offers multiple benefits for both the practitioner and the patient. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 PAUL KILLOREN Good morning. PT on Ice daily show streaming worldwide on Instagram and YouTube. I'm your host for the day, Paul Killoren, of the dry needling division for ice, and I'm hijacking the mic. Normally on Thursday for the PT on ICE Daily Show, we have practice management, we have leadership stuff, really inspiring messages from Jeff Moore, from Alan himself. I'm hijacking the mic and calling this Technique Thursday. We're talking needles on a Thursday. dry needling division. Before I dive in, some pretty exciting updates. Our very first advanced dry needling course is going down January 12th to 14th. And we actually have a registration page up and live that has a little work to do. But the course is going to be ready and the very first advanced dry needling course for ice will be in Washington in Bellingham in January. And then having the upper, lower, and advanced course that will form the ICE dry needling certification. So again, our division's not even a year old. We have had our upper and lower dry needling courses running across the country for almost 12 months. And this will be that final piece. So really exciting stuff coming out of the dry needling division. But I'm going to dive in, dive right in today. 01:58 - THE NEEDLE IS IN, NOW WHAT? And the title of today's episode is my needle is in, now what? And honestly, when I framed this topic, when I started to prep and form this discussion, in my mind, I pictured that novice clinician, I mean, you're on your first dry needling course, you're doing vastus medialis, vastus lateralis, glute medius multifidus, you learn the technique, the palpation, the anatomy, you're looking for a bony contact, you get super excited, just like, oh, sweet. There's the bone. That's what I was looking for. Now what? So really, this is a question I've answered consistently on level one or kind of first dry needling courses for the last decade. But again, when I started to prep for this episode, there's layers to this. And really, whether you're a novice, an intermediate, or even an experienced dry needler, Sometimes it's worth having this discussion of, our needle is in. Like first we learn how to do it safely, how to do it specifically, but our needle is in, now what? And to fully acknowledge, depending on who you listen to, how you were trained, the answer of, now what, will be very different. Because first of all, there's that technical spectrum of, well, now we piston the needle, or now we twist the needle. Now we use e-stim. But even there, let's say there's a dosage spectrum of, okay, if I piston how many times? If I twist it for how long? If I just leave it there, what duration? If I use e-stim, what parameters? So again, I thought this would be a pretty easy, a pretty short, quick-hitting topic, but there's layers to it. And first of all, let's say that there is significant value to my needle is in a very specific target. Again, safety always comes first when you learn dry needling, but I think we also can acknowledge one of the benefits, one of the advantages of the needle as a clinical tool is we can be sniper precise. We can put a needle in semi-membranosis, in multifidus. You know, this is not necessarily a technique of broad stroking manual therapy of like, we're doing the lateral hip, we're doing the low back, we're doing the SI region. To some degree, even a manipulation, we're saying, you know, we're not joint specific necessarily. We're kind of giving input neurophysiologically to joint receptors and there's more of a regional and global response to that. With a needle, I think we can just say, first of all, I have a needle in semimembranosus. 04:46 - THE BLESSING & THE CURSE OF NEEDLING I mean, The blessing and the curse of needling is it keeps us honest, especially if we use e-stim. When you get that motor response, the needle's telling you, it's like, you know what, Paul? You're not in semi-membranosis. You missed. You're either like, you drifted subcutaneously or you missed superficially in tendinosis, you missed deep in adductor magnus. So first of all, I don't wanna just like completely glaze over the fact that your needle is in a very specific target is a big part of the equation. I mean, for ice, for our dry needling, we teach safety for sure, but you as like highly educated, skilled clinicians, teaching you all how to be safe with a needle happens pretty quick. So our, our goals, our mantra with dry needling are be safe, be specific. Again, that's, that's a big part of using this needle as a tool and then be strategic. And that's what I want to go to today, because again, the topic here is, my needle is in, now what? And again, let's acknowledge that it depends, not just on how you're trained, it depends on that patient on the table, on what is your goal for that session, what is the acuteness or the chronicity of the condition. So by no means do I want to make this sound easy, but I am going to give a very specific answer to this question. And again, I have previous training, I know the narratives out there of the needle is in, now we twist it for two minutes. Or the needle is in, now we just let it sit there. Or we pissed in it. And again, there are narratives, there is research, and there is benefit to each of those approaches. But I'm telling you that those aren't the answers. Again, I have a pretty specific answer that I'm going to get to But I think I'll torture you just a little bit longer by setting the stage. And really, I'm going to flashback, not even talking needling, I'm going to flashback to my DPT education. I went to Regis University, graduated in 2010. So what attracted me to Regist was Dr. Tim Flynn, Julie Whitman, Jim Elliott. I mean, big manual therapy specialists, but researchers of our day. So we finally, you know, you're year one, year two, you finally get to that musculoskeletal management, you finally get to learn some manipulations from Tim Flynn and Julie Whitman. And you know, if you don't remember how you started with manipulations, it wasn't good. The hands were not skilled, like it wasn't crispy right out of the gate. So you spend a half day, you practice on your classmates at home, and finally you're like, man, I'm starting to feel like my hands have some skill. So imagine you are there, you're learning manipulations, your hands are feeling more skilled. Imagine how disheartening it was for me, and I remember this day, when Dr. Tim Flynn stands up and says, you know what, you can teach a monkey how to manip. And I mean, He's overgeneralizing, but the point is still true. He's like, you can teach a monkey how to manipulate. It's really how, like when to manipulate. Um, I guess how to apply it. There is skill there. We'll acknowledge that. But then it's what you do afterwards. So, I mean, that, that hit for me. And first of all, it's like, Oh man, there are manipulating chimps out there that are doing this better than I am. And again, that wasn't his point, but. But the point remains knowing when to use it, how to use it to some degree, but then the dosage and the follow through, the aftermath is really the true magic. That applies for dry needling as well. Again, can we teach a monkey how to put a needle randomly into tissue? For sure. Like there is not much needle skill to getting a needle interstitially, into muscle tissue. There is a skill to being more specific, and there is a skill to answering the dosage question, now what? And I'll tell you now, without further ado, we have our needle or needles in. The answer to now what is e-stim. And you know, I don't, you know, I kind of do the, you know, I was trained previously, I know the research, the narrative and the benefit to all the other approaches, but the answer today is eSTEM. And honestly, what makes me so confident in that is first of all, I have my own empirical anecdotal, like I was not using eSTEM, now I am. I have that sample size to make me confident. But what makes me more confident And it's not even just the research, I'll touch on that in a minute. But what makes me more confident is knowing or hearing that some of the other dry needling educators or other dry needling institutions in the US and worldwide that previously were saying there's no additional value to e-stim with dry needling, or we're essentially just doing tens through a needle, they're now starting to use e-stim. And whether they use it the same way we do with ice, whether they explain it the same way, what they're saying is there's value to e-stim. And here's what the research says, is our needles are in, now what? E-stim is the answer for almost any treatment intent. First of all, I mean, if you haven't taken one of our upper or lower courses, we teach e-stim right out of the gate. I mean, day one, we learn how to use the unit, we get muscles to pump, Again, there's high value when you first learn dry needling to using e-stim because it keeps you honest. Are you in that muscle? Are you not? But that immediately gives you some, I guess some validation, like I'm saying, but some grace. Because first of all, what we know is that if we use e-stim with our needles versus not, any sort of post-treatment, post-needle soreness will be much less. So there's a very, um, a very real like patient approachability aspect to using e-stim. And there's research to support that. 12:33 - E-STIM DOES IT BETTER But beyond that, what if our treatment goal is not pain modulation? What if it's neuromuscular changes? E-stim does it better. What if our goal is, tissue nourishment, blood flow, maybe venous return, lymphatic activation, edema evacuation. What if our goal is that? ESTIM does it better. What if our goal is nervous system accommodation? Or what if it's getting the biggest, baddest neuropeptide or enkephalin, endorphin, but our pain modulating up top cortical response. What if that's our goal? eSTIM does it better. What if we're talking pain science and there's some somatosensory reorganization, there's some homuncular smudging that we would like to remap. We'd like to give a very profound and precise input to that homunculus, to that somatosensory cortex. eSTIM does it better. So again, these are, these are research based answers. Very real research that says group A just got needles, whether that was pistoning or placing or what have you, and then group B got e-stim. What was the difference? At this point, e-stim does it better. And really, that is the long and short of this episode. And again, I think to not minimize the impact of you have to learn how to put a needle in safely, There is significant value, especially with the needle, to say, my needle is in, very precisely, fill in the blank. My needle is in peroneus brevis. My needle is in extensor hallucis longus. My needle's in glute minimus. There is significant value to the precision of that tool. But that's only half the battle. My needle is in, excellent. That took some training, that took some some skill honestly that took some three years of doctorate level like anatomical training and education and awareness that took a lot to say my needle just contacted I guess the external ileum like we are at the depth and the location of glute minimus that's awesome that you checked the box that is step one but if we don't fill in the then what you're leaving a lot on the table clinically And if you just logged on, the answer is eSTEM. So again, I know I see some of the names jumping on. Thanks for joining. I'm preaching to the choir, to some of you, because you've taken our upper or lower courses. We immediately talk about how to use eSTEM, the research behind eSTEM, and then we use it all weekend on the course. And it's a different experience. I think eSTEM makes dry needling a little bit classier. We can be a little bit more classy with our needles when we use E-Stim. We can also be a little bit more dialed, a little more tactical with our treatment intent. Again, is your goal pain modulation? Is it neuromuscular changes? Is it blood flow? Is it just fluid dynamics of moving fluid? Excuse me. So that's the answer for today. Again, jumping on on a Thursday for a Technique Thursday. We're talking dry needling. And the question was, needle is in, now what? And the answer was Easton. Excuse me. So if that prompts any questions, again, this is a big piece of our curriculum. Drop some comments in the thread. Hit us up on Instagram. This is on YouTube as well, so you can throw some comments there. Again, my name is Paul Killoren of the dry kneeling division for ice. If you hopped on late, We are launching our advanced dry needling course in January. That'll be the final piece of our upper dry needling, lower dry needling, and then advanced for the certification. If you're in Washington State, that'll be the third course of the series to allow us to dry needle as far as getting 75 hours. But if there's anyone out there who is trained in needling, who is uncertain about using eStim or the benefit of eStim, first of all, I'll just encourage you to try it. Like, there's value there to hearing your patients explain the difference of using eStim or not. Otherwise, we have an online course if you already have the needle skills, you know how to put your needle in, but then what? If you don't know how to use the eStim, there is an online course through ICE as well, eStim plus needles. That's all I've got for today. Thanks for logging on. I'm incredibly proud of myself. This is my most concise, my most brief podcast topic, but it's an easy one for me. So if you're out there saying, what do we do after we put the needle in? I'm not saying there's not value in twisting or pistoning or just static needling. There's blood flow changes. There's neuromuscular changes. There's tissue disruptive like inflammatory cascade responses to all of that but the answer is e-stim and With that I'm logging off folks. Thanks for joining PT on ice daily show. See you next time OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Oct 4, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Julie Brauer emphasizes the importance of executing obstacle courses in a specific, dynamic, objective, and progressive manner. The purpose of these obstacle courses is to prepare patients for the chaos of their daily lives and help them confidently overcome these challenges. To make obstacle courses specific, Julie suggests replicating the functional demands of the patient's specific goals. This means creating exercises and challenges that directly mimic the movements and tasks the patient needs to perform in their daily life. By doing so, the patient can develop the skills and confidence necessary to navigate these challenges effectively. In addition to being specific, obstacle courses should also be dynamic. This involves incorporating a combination of exercises and layering dynamic challenges. By introducing variability and unpredictability into the obstacle course, patients can improve their ability to adapt and respond to different situations. This dynamic nature of the obstacle course helps simulate real-life scenarios and prepares patients for the unexpected. Objectivity is another crucial aspect of executing obstacle courses effectively. Julie suggests leveraging subjective and objective outcome measures to make the obstacle course objective. This means using measurable criteria to assess the patient's progress and performance. By having clear and measurable goals, both the therapist and the patient can track improvement and make necessary adjustments to the obstacle course. Lastly, obstacle courses should be progressive. This involves gradually increasing the difficulty and complexity of the challenges as the patient improves. Progression ensures that patients are continually challenged and can continue to develop their skills and abilities. It also helps to keep the obstacle course engaging and motivating for the patient. Overall, executing obstacle courses in a specific, dynamic, objective, and progressive way is essential for helping patients develop the confidence and competence to effectively navigate the challenges in their daily lives. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 - JULIE BRAUER Welcome to the Geri on Ice segment of the PT on Ice daily show. My name is Julie Brauer. I am a member of the Older Adult Division, and we are going to be talking this morning about obstacle courses and leveling up our dynamic gait training. So I've been really passionate about creating meaningful obstacle courses for a really long time, and I've become even more excited about this topic since our live course has gotten this massive revamp where we spend an entire lab focusing on dynamic gait challenges and how to layer. So I'm so excited to dive into this today because obstacle courses can be a really challenging, fun, creative way to implement dynamic gait training into our plans of care. With the purpose of preparing our patients for the chaos that is their daily lives, right? We want them to be able to move confidently through the chaos of their lives. And if we really think about it, What better exercise could we give our patients than a combination of exercises, a combination and layering of dynamic challenges that exactly replicate the functional demands of their specific goal, right? However, I think we many times really missed the mark here on executing this in an effective way. And when I say executing in an effective way, I mean in a way that is specific and dynamic, objective and progressive. So when I reflect back on the past eight years of my practice, 02:37 OBSTACLE COURSE LIMITATIONS When I think about all the obstacle courses that I have seen throughout various settings, most of them are variations of stepping over cones, or stepping over hurdles, or many times it's stepping over canes. Many times it's one rep, the patient goes through that obstacle course forwards, and then the next time they go through it sideways. Many times it's weaving around cones as well as stepping over them or maybe stepping in and out of an agility ladder. And when we think about that, we have to realize it's pretty unidimensional, right? It doesn't exactly look like real life. Most of these patients are not on a clock. We aren't often capturing our PE while the patient is going through the obstacle course, right? Like I could go on and on about a list of things that are wrong with our typical obstacle courses that we see in our clinics, in our profession. And while stepping over cones and navigating around them is a really solid place to start, we really have to start thinking about moving beyond that, right? I consider stepping over cones and navigating around cones very similarly to our other underdosed exercise. I will go as far as to say that I think that cone stepping is the ankle pump of dynamic gait training. Stepping over cones is the ankle pump of dynamic gait training. And so why? So let's unpack that. Because many of you would probably say, like, what do you mean stepping over cones is challenging for my patients? And I'm going to respond with, well, yeah, I mean, tandem standing is challenging for a lot of my patients, but I'm sure as hell not going to waste multiple weeks of a plan of care with my patient in tandem stance, right? The question becomes, is it the right challenge? Is it the right challenge? Similarly to tandem stance, Do the demands of stepping over cones match the entirety of the chaos and the dynamic demands that comprise our patients' lives? We have to realize that stepping over cones only hits one aspect of dynamic gait and balance, right? It only hits on anticipatory balance. And we know that balance can break down in multiple different areas. And there's so many other components of balance and dynamic gait that we want to pay attention to. we have to realize that stepping over cones is not super specific, right? It doesn't look like real life. Our older adults are not moving around in an environment where these very bright orange cones are sticking out to alert them they need to step over that thing, right? And then also, you know, just thinking about If I am able to get my patient really competent and confident in stepping over cones or weaving around cones, does that actually translate to our patients feeling incredibly confident to take on the adventures in their world? 06:08 ROOM TO GROW WITH OBSTACLE COURSES So we have to first reflect on why there's just a lot of room to grow when it comes to our typical obstacle courses, all right? So now that we've set that framework, let's talk about how to level up our dynamic gait training from assessment to implementation and creating in dialed in workouts, focusing on how to make these obstacle courses specific, objective, dynamic, and progressive. All right. And we're going to put this in the framework of focusing on two different types of goals. And these were goals and dynamic eight challenges that students who were part of our MMOA live course a couple weeks ago in Oklahoma came up with. absolutely stellar students who came up with really awesome dynamic challenges. So I'm going to share some of these with you. So these two goals that we'll be talking about back and forth, um, that many of you can relate to with your patients are the goals of one, being able to independently navigate through the airport and board an airplane independently to be able to go on vacation. And then two, to be able to independently tend to a garden. All right. So two goals that are very common among older adults. And we'll talk about how to make it specific, dynamic, objective and progressive. All right. 10:21 SPECIFIC OUTCOME MEASURES So starting out with making our obstacle courses really specific. This is where we need to dig deep. So if you're part of our MMA crew, you hear us talk about our formula, make it meaningful, load it, dose it all the time. So this is that make it meaningful part, right? So we need to dig deep into what that goal actually looks like. I want to peel back all the onion layers. So if my patient is telling me, well, I want to be able to go on vacation. I am having my patient take me through from start to finish. I want to know exactly what that looks like for her or for him to go from getting out of that car into the airport through the airport onto the plane into into their seats right so I am asking question after question after question because I want to visualize what that goal looks like, right? If it's gardening, I want to know exactly what the functional movements are that comprise that goal because there is where I'm starting to create my obstacle course. I am in my head taking mental notes about what are all the pieces and parts that are going to comprise this obstacle course to make it very specific for the patient. Now, sometimes going seven layers deep with our patients is really, really difficult, right? They just, they have a hard time answering these questions or having that conversation with us. This is where we can leverage our outcome measures such as the PSFS or the FES and the ABC, right? Those are going to give us some insight into some components of their daily lives that are really scary or they feel like they're going to lose their balance or fall or components that they're actually really confident in. So you can use those outcome measures when perhaps the conversational part and you're asking a million questions and digging deep, is a little bit difficult for your patient. And then we want to really leverage our objective outcome measures, right? So our mini-best and our DGI, because that's going to give us very, very, very specific information. If our patient is telling us that, yeah, I'm having a difficult time because I'm afraid people are going to knock into me at the airport, well, I'm sure as heck gonna want to look at their reactive balance with their mini best, right? So we wanna use both digging deep, asking the questions, using those subjective outcome measures, and then definitely using those specific objective outcome measures to see where perhaps the balance is breaking down, right? So to give a couple of specific examples, If our patient, maybe in their PSFS, are saying that lifting that suitcase over their head is really the part that is limiting them from feeling confident and being able to go on that trip, maybe it's a strength component that we really want to focus on. So maybe I'm going to look at a press or a push press and see what that looks like in isolation and maybe coach that up, right? But then I know that I'm going to add a push press or a press into my obstacle course, because maybe it's not that the strength component of that push press is the big issue, but more that they are so fatigued after going through the entire airport that they just don't have the energy to get that suitcase up into that overhead bin, right? And so, again, to bring it back to the balance component, if they're telling us, I am so scared of getting bumped by someone at the airport, because I'm afraid it might fall, I want to know, hmm, what does their reactive balance look like? I want to look at forward. I want to look at backwards. I want to look at lateral. And then to put that into the obstacle course, maybe I can do something like our stellar students did a couple of weeks ago, where they use TRX straps. And as the patient's walking, they swing those TRX straps at spontaneous times, to see how the patient reacts to that, right? Or you could do something like as your patient is walking, you offer an external perturbation and see what their stepping strategy is. All right, so that's how to make your obstacle course as you're figuring out what the pieces and parts are very, very specific to what they're telling you and what you're finding throughout your assessments. Next, we have to talk about how to make it dynamic. And what I mean by dynamic is not just the patient is moving, right? Like, you know, I can see a lot of you being like, well, yeah, well, you know, stepping over cones or hurdles like that is dynamic. But we have to think more about just the patient moving, right? Yes, that is dynamic, but we have to remember that we need to mimic a dynamic environment, not just our patient being dynamic and our patient moving, right? And in addition to that, what I mean by dynamic is layering. 14:21 MIMICKING REAL LIFE CHALLENGES We want to combine anticipatory balance, reactive balance, vestibular fitness, strength, power. We want to combine all of those things together in our obstacle course, because that's real life. And that's when balance breaks down, when we were trying to navigate through all these different components. Remember that older adults are not waking up in the morning. And for the first two hours of their day, they're only doing a single task. And then the next two hours of their day, they're doing a dual task in reactive balance, right? Like they are constantly moving in and out of forward gate, sideways gate, making 360 degree turns, reactive balance, anticipatory balance, cognitive tasks, motor dual tasking. All that stuff is happening constantly. So we want to mimic that type of chaotic environment. We want to layer all of those challenges on. So what would that look like? Let's think about our gardening example. So if we're thinking, and our patient is telling us, okay, so I have to pull the hose, right? And I have to pull the hose and walk along the grass. And so you're thinking about this, hmm, how can I mimic that? Could I have my patient pull a rope? Could I also then have them do head turns where they're looking behind their shoulder to make sure that their hose isn't totally annihilating all of their flowers, right? You're making it that specific, but you're layering on challenges. What about for the individual who wants to go on vacation, they're really scared about stepping onto the escalator with their suitcase, right? So how do I replicate that? Can I step onto a variable terrain, like stepping onto a BOSU ball, while I'm lifting a weight or doing a suitcase deadlift, right? So now we have that sensory orientation, we're adding in that vestibular fitness, we're adding in the strength to step on and get stability on a moving object while also having the strength to lift an object. If we think about our gardening example, think about the act of pulling weeds. Maybe we're getting our patient down into a half kneel and we're doing a rowing exercise for strength. Or maybe it's more of the balance component our patient is worried about when they go to pull those weeds. So we do something like utilize squigs or we get a really heavy dumbbell and we tie a TheraBand around it and we have them pull the TheraBand and release. or we put a resistance band around them in half kneeling, and we go ahead and give them perturbations. So we layer on all different types of challenges, anticipatory, reactive, vestibular fitness, strength, power. That is how we layer. And we want to layer and layer and layer because that is what real life is like. Next, we have to find a way to make this objective, right? We have to dose it appropriately. We have to find a way to progress our obstacle courses. So we got to think about our goal, right? If we think about gardening or the airport example, if the goal is to be able to continuously move through, let's say 20 minutes, because let's say it takes 20 minutes to get through the airport. Gardening usually takes 20 minutes of time to do all those tasks. Okay, that's our long-term goal. So maybe we start out by, we want to see how many rounds you can get through when you continuously move for six minutes. That's more of the short-term goal. And we're recording how many rounds did they get through? How many breaks were required? Or if you have someone who, for example, gets to the airport really, really, really last minute, which just, like, my anxiety goes up even thinking about it, and you know they're going to be racing through the airport, maybe you want to design the workout so that that intensity is really, really high. And maybe you're doing something like three rounds of that obstacle course for time. We also want to be tracking our PE and using that to progress our goal. So if our patients, you know, capacity is really struggling, for example, you know, within three minutes of the obstacle course, it feels like an RPE of seven or eight, then maybe one of our goals is that it takes eight minutes of doing that obstacle course until that RPE of seven to eight come up. If we're focusing on balance capacity, are we using something like the balance stability scale to ensure that the variable terrain that you have mimicked, right, by perhaps having them walk on foam is enough? Or do we need to progress that by maybe underneath the foam, putting in some ankle weights or some other objects or having stepping stones to increase that balance challenge. So it actually elicits a step reaction, which maybe we saw in our mini best that we want to improve. If our patient more has a strength deficit, right? So that push press to get that suitcase in the overhead bin or the deadlift, maybe to get that mulch up from the ground or like a clean up from the ground to the shoulder and up overhead. Are we looking at our patient's estimated one rep max and making sure that we're working them at least 60% of that so that we can elicit positive strength adaptations? We have to make sure that we are dosing appropriately and that we have ways to progress this. Putting a patient on a clock is the easiest, easiest way to do it. Getting that RPE, really making what you're measuring be specific to what their goal is. And then the last part here is we can really utilize part practice of this big obstacle course to even more specifically dial in where our patient is having trouble, right? And it allows us to be very efficient because to create a big obstacle course can take a lot of space and a lot of time. So what we can do is as we're assessing and looking at this patient going through an obstacle course, we can see the pieces and parts that they have the most difficulty with. We can be asking them again from our questions and our subjective measures, like where are they having the most difficulty or where do they feel the most confident? And then we can pick out those pieces that we see and that they tell us and create like an EMOM or an AMRA. right? Making it very, very, very dialed in. So this is where I would take like three to four functional movements that comprise the goal, that comprise that entire obstacle course. So if we look at our gardening example, minute one, we, for an EMOM, we could do a sled push, or that could be a walker or resistance band, right? And we could be trying to mimic pulling that hose. Minute two, we could have our patient do some quadruped rows. So thinking about being down on the ground and doing some weed pulling or picking up different gardening tools. Minute three, we could be doing some external perturbations while they are in half kneeling. That could be mimicking pulling that weed and having to really catch themselves as they move backwards. Minute four, we could do something like a clean and press that could mimic trying to get that heavy bag of mulch from the ground up to the shoulder or up overhead. So that's how you can take your entire big obstacle course, pick out the important parts and create a workout that is much more succinct and easier to set up and doesn't require a whole bunch of space. Okay. That is what I got for you all today to come back around and wrap that up. When it comes to our dynamic gait training and creating obstacle courses, think about how you have to dig really, really deep. Leverage your subjective and objective outcome measures to focus on making your obstacle course specific, objective, dynamic, progressive, and then utilize EMOMs and AMRAPs to dial in the components that they are specifically having difficulty with. Now, talking about all this obstacle course stuff, I know it's getting some of you excited to think about dynamic gait training and all the different things you can do. You've got to come see us on the road to one of our live courses and check out our new revamp where, like I said, we spend an entire lab just on dynamic gait training and showing you all how to add in a lot of these layers. So on the road, there are tons of opportunities in October. My gosh, yes, it's October already. We will be in Virginia, California, and New Jersey. And then in November, we are in Maryland, South Carolina, New York, and Illinois. Plenty of options across the country to catch us out on the road and check out that super cool fun lab. On the flip side, our online courses, both Essential Foundations and Advanced Concepts are starting, gosh, next week. So October 11th and October 12th. Head to ptinice.com, message any of us. We'll be happy to answer any questions for you. We hope to see you on the road or online next week. Have a good day, guys. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Oct 3, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey explains that patients with frozen shoulder often struggle to manage their condition and experience fear of the unknown, which can significantly impact their cognitive and emotional well-being. Lindsey emphasizes the importance of understanding the patient perspective and their emotional stories. She highlights that patients may fear the future and the unfamiliar territory of living with a frozen shoulder, which can have a profound effect on their psychological well-being. Lindsey also emphasizes the need for healthcare professionals to appreciate the expectations and experiences of patients with frozen shoulder, acknowledging that their pain is not an exaggeration. She suggests providing controllable solutions and empowering patients to advocate for themselves in order to receive timely care and diagnosis. Lindsey underscores the challenges faced by patients with frozen shoulder in managing their condition and the significance of addressing their emotional and cognitive well-being. Lindsey reinforces the importance of healthcare professionals assisting patients with frozen shoulder in finding ways to continue engaging in activities they love. This involves helping them adapt their activities or modify their movements so that they can still experience joy and maintain a sense of autonomy and independence. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning PT on Ice Daily Show. How's it going? I am Dr. Lindsay Hughey. I will be your host today on Clinical Tuesday. It's so good to be with you all. It's been a little while. Today I am going to chat with you about frozen shoulder and helping your patients navigate no man's land. But before I unpack this episode, I'd love to tell you a little bit about courses that Mark, Cody, and I have coming up. Cody actually was just promoted to lead faculty. We are so excited. And he will be teaching his first class this weekend solo in Minnesota so Rochester and there are still tickets left if you want to join him he would love that and you're sure to have a blast with him this weekend so October 7th and 8th can you believe we're already in October so wild other courses coming up in November on November 11th 12th we'll be in Woodstock Georgia and then our final courses of the year are in December. So you have two opportunities on December 2nd, 3rd. Cody will be in California, Newark, California. And then December 9th, 10th, I will be at CrossFit Endure again. That's always a blast of a spot. So Fort Collins, Windsor, Colorado area would love you to join. Those are our last of 2023. And then we'll be in 2024, which is super wild. So please join us. Thanks for letting me share courses coming up. 03:37 LIVING WITH FROZEN SHOULDER So last week, if you tuned in to clinical Tuesday, Mark hopped on here and he chatted about frozen shoulder, just the challenges associated with treating folks with frozen shoulder. And he really highlighted not only best treatment as we know it, but the importance of coming alongside the patient. And we need to do that better because this is an area, and if you think about any patient you've ever seen with frozen shoulder, it's always challenging, right? Because they are suffering and there are just so many unknowns. But we do have more knowns in regards to the patient perspective that just came out this past May. William King and Claire Hebron out of the Physiotherapy Theory and Practice Journal published a qualitative review of frozen shoulder. So specifically giving us the vantage point from the patient. So this study involves six folks, two were females, four were males. Their age range between 35 and 66. So a varied mix of sexes and then age ranges. They all were British and there was a mix of right and left and even bilateral frozen shoulders. So these interviews were done with these six folks and the question that was asked of them was can you describe in as much detail as possible what was important and meaningful to you in your experience of living with frozen shoulder? They used hermeneutic feminology methodology for those research nerds that want to know and they found the following five themes And so today I'm going to tell you what those themes are, and then I want to unpack some of the participant details from each theme. And I'm sure you'll be able to relate with some of your patient care experiences. And then kind of end the show with suggesting a rewrite of the title, plus some key takeaways for us going forward in caring for these folks with frozen shoulder. So the five themes illuminated from this article, and again, that's title, and I'll drop the link, is Frozen Shoulder, Living with Uncertainty and Being in No Man's Land. The five themes that were found were, number one, patients felt an incredible pain experience that they described as dropping me to my knees. Two, a struggle for normality in life. Three, an emotional change of self four the challenges of traversing the health care journey and then five coping and adapting and learning how to do that. So I want to unpack each one of these just a couple examples to help you appreciate that patient perspective. So dropping me to my knees that incredible pain experience All of the patients that were interviewed described multiple experiences where if they move their shoulder quickly or hit up against an object unexpectedly or involuntarily kind of reached and forgot about their shoulder for a second, that this pain would literally drop them to their knees. That when they would go to like stretch in the morning, they would scream and writhe out of pain. And this not only affected their body and their discomfort but like their family. Some of the participants described kind of scaring their partner because of like sudden outbursts or yelled. So an experience that's not just personal but affecting those around them. 07:28 EMOTIONAL CHANGE OF SELF Number two, the struggle for normality. So a lot of the folks describe multiple daily activities just being very limited and I'm sure your patients have had the same right just getting dressed, just rolling over in bed, unable to sleep, just that constant ache that's with them always kind of being in their mind and then challenging just normal daily activities. Not just ADLs and IADLs, but starting to lose work function, missing work and or recreational function. So one participant actually had to sell their fishing boat or chose to because they said just transporting the boat became so cumbersome and a reminder of their shoulder limitation. One of the participants described being unable to throw the ball. They're at a family gathering and their kid is watching other people throw the ball with their parent and the parent that has frozen shoulders just sitting there thinking, oh I can't even like throw the ball with my kid so this normalcy doesn't only impact them personally again in their daily life but it's impacting their family relations around them their work right their ability to actually provide for their family and then the recreation like enjoyment in life people that love to fish that was my dad's like favorite pastime if there's an emotional psychological peace here that is huge then that is challenged when someone has frozen shoulder that they can't do that one activity that brings them peace or joy and they can't um help provide for their family because they're suffering Which leads us to that third theme found, an emotional change of self. So all of the participants described overall just low mood from being in constant pain, having low self-esteem and starting to feel less worth in their family unit. Just kind of feelings of uselessness because not being able to reach overhead or being limited in the ability to just help out with daily chores. this was a really challenging thing to read, but one of the patients described that emotional change as if you were an animal, you would be put down because you're miserable. So basically like lack of thriving and like that was heartbreaking to read, but like this is how low emotions get when you're in, when patients have that frozen shoulder state. And a lot of them said not just the emotional drain is challenging, but like you're physically drained because of that emotional taxation. So multiple participants reported poor sleep, which I already mentioned earlier from a normalcy perspective, but they linked that to how this led to fluctuating mood because you never know when you're gonna get a good night's sleep. And so overall mood was very cantankerous and unpredictable. which patients even again mention that they're not able to even sleep in the same bed as their partner because they're so disturbed and uncomfortable in their sleep. And so they're sleeping in a separate room, again, that's that intertwining like emotional change of self being affected. and when this happens right you start seeing sleep being affected it makes you want to prompt for health care help right and so this leads to that fourth theme where patients are traversing the challenge of the health care journey going to a health care professional hoping they can help them sleep better helping they can take away the pain. 09:28 IMPACT OF DELAYED DIAGNOSIS ON TREATMENT But what most of the participants really highlighted is that this delayed diagnosis happened consistently where they saw multiple healthcare professionals prior to actually getting a solid diagnosis that this is in fact frozen shoulder. And so there was this, there's this period of not knowing and switching back and forth, like what's wrong with my shoulder? And then you finally know. And, um, even the treatments they were getting were challenging because patients said they didn't actually see solid results. So they would ask for a pain medication and then some of the healthcare professionals would be afraid of addiction. So they wouldn't give them stronger medications to help. And so there was this balance of figuring out what's that pain medication that's right for the patient. A lot of the patients, said that injections were life-changing. So getting a corticosteroid injection was helpful, but it didn't always happen right away. And some of them had to really advocate for that to occur. And that some, even the patients that were finally recommended to get the injection mentioned they were afraid of the needle. So we have to understand it might be a delay to get to the treatment that's effective, And then they might even have a fear of actually using that treatment that's recommended from the healthcare provider. So they're dealing with a lot of challenges in the healthcare journal. And disappointingly enough, as for most of our audience that are PTs, a lot of the folks said that PT wasn't the greatest. They didn't have initial great experiences because the PT would give them stretches that were super painful and not working. And the patient would have to wait a whole week to tell the therapist that, and then the therapist would give them something new, and then the stretches would hurt and not really work, and they'd come back again. We can do better here, right? If you test, retest in that session, you'll know whether that's working. So some kind of disappointing healthcare journeys for most of these folks. But there was some hope along the journey. So the fifth theme found was coping and adapting. Once patients did finally get to the healthcare provider or the PT that started providing effective care, they did have hope. Once they saw it start working or when they got that injection and the pain started going away, they could move their shoulder a little bit more. So when pain's down and range is better, they were super jazzed about it and finally had some hope. Various participants did say that it requires that coping and adapting, it requires you to shift your mindset, that press on attitude in the face of adversity. So helping our patients get there quicker, I think is something that we have an opportunity for. Another part of that, some coping strategies was people just learning, some of the participants mentioning that learning to work around the disability, right? If they were right-handed, starting to use their left arm, to keep functioning in kind of a pushing through mentality. The final binding theme of all of these, so we've unpacked examples of dropping me to my knees, an incredible pain experience, the struggle for normality, three, an emotional change of self, four, the challenges of the healthcare journey, and then five, coping and adapting. That theme that they found binding them all together was uncertainty. Or as the authors of the study titled No Man's Land. One thing I said that I was going to unpack was a suggestion for a rewrite. So we are dealing with humans, not just men. So I'd love to suggest that we call this No Human's Land. But this does come from a phrase, right, that was used to describe unowned land or unoccupied land or land that's not officially owned or inhabited by someone. but we are dealing with multiple humans, right? Not just males. So that rewrite I think is important here. 13:58 FROZEN SHOULDER & THE FEAR OF THE UNKNOWN But ultimately the main thing I want you to appreciate is with the unknown of how this disease may progress or regress, we have to do better for our patients here. They will not be able to manage their present living with frozen shoulder if they're fearful of the future. They don't read it. Oh, hopefully you're all still there. Give me a wave or like a thumbs up. If you are a little alarm went off. Sorry about that. Um, but patients will not be able, um, to manage living with their frozen shoulder. If they don't know how to manage it in the present, if they're fearful of the future, sorry for the folks that had to hear this twice on YouTube, but That fear of the unknown, right, or no humans land territory, this affects cognitive and emotional well-being. So what can we do with these themes, knowing patient perspective a little bit more deeply here? And I know it was only from six folks, but I'm sure you can relate and think back and reflect on patients you've seen, and they've had similar tough experiences. There are powerful takeaways here. appreciate that expectations from your patient they're always tied to a real human with an emotional story and we have to know that and appreciate that. We have to know that this pain is not an exaggeration. We need to give stabilization to that human story. with some of the facts of the do's and don'ts about frozen shoulders. See Mark's podcast last clinical Tuesday because he dove into best treatment and about what we know, what we thought we knew, and where we are presently. We have to provide controllable solutions. Some solutions. Help your patients advocate for themselves early. and with tenacity with their specialist, right? Help them get to that corticosteroid injection. You don't usually hear us saying that, right? That medicalization, we try to avoid that here at ICE, but here's a condition where we see, especially in the United Kingdom, this being a helpful pathway in combination with physical therapy. So help them get to the proper care and diagnosis faster. Make it so they don't have to see three healthcare professionals before they start feeling better. USPTs test retest the value of your treatment in session. Don't send someone home in writhing pain that worsens their range. Send them home with something that is helpful, right? That's easing and know that before they leave so they don't have a whole week of time of ineffective self-care. Let's not forget the human behind the painful and stiff shoulder. Those with frozen shoulder, let's help them feel direction at a really destabilizing time in their life. Help them figure out a way to do what they love, to keep working, help them be autonomous, to navigate their pain, their setbacks, and then their interactions with the healthcare team. We have a really cool opportunity to make living with frozen shoulder a little bit more endurable and making the patient feel more known. Thank you for being with me this clinical Tuesday and sorry about that little blip in the middle. Happy Tuesday. Cheers. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Oct 2, 2023

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich challenges the notion of associating the word "safe" with breath and movement, particularly during pregnancy. She questions why breath suddenly becomes a determining factor for safety in this context. While she acknowledges that the pelvic floor experiences increased demand as the fetus grows, she also affirms that it is a muscle that can strengthen with appropriate exercise. Jess encourages weightlifting as a means to strengthen the pelvic floor during pregnancy. She explains that stronger muscle fibers are more resilient, sharing this information with her clients in the clinic. She also highlights the fact that individuals are not instructed on how to manipulate their breath when coughing or sneezing, which exerts similar force on the pelvic floor as lifting 35 pounds. Since this natural phenomenon is beyond our control, it is unreasonable to expect individuals to exhale on exertion for every activity. Jess also address the misconception that breath holding is detrimental to the pelvic floor. She explains that breath holding actually increases spinal stiffness, enabling individuals to lift more weight and become stronger. However, She clarifies that breath holding with a bear down to the pelvic floor is not recommended. She differentiates between different positions of the pelvic floor, referring to the basement (during bathroom use or childbirth) and the first floor or attic for other tasks. Overall, the episode aims to alleviate fear and promote understanding of the pelvic floor. Jess emphasizes the importance of educating individuals about their pelvic floor and its functions, highlighting its potential for strength and dispelling myths and misconceptions surrounding breath and pelvic floor function. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 JESSICA GINGERICH Good morning and welcome to PT on Ice daily show. My name is Dr. Jessica Gingerich. And I am on faculty here with the pelvic division here at ICE, which means it's the beginning of the week. So happy Monday. We are going to talk about breathing in the pelvic floor. This is a hot topic in the pelvic space. often referred to specific breathing strategies that are like safe or protective to the pelvic floor. And in reality, it's just not that simple. So let's start with a few housekeeping items. We are currently in our last cohort of the year for the online course. So if this is something that you've been wanting to get on, we're about to put the pedal down starting January 9th. So head over to the website to sign up for that online course. In the month of October, we will be in Brookfield, Wisconsin on the 14th and 15th in Corvallis, Oregon, October 21st and 22nd. So again, those courses are all on the website, so head over there and snag your spot. They are filling up fast. 01:50 BREATHING DURING EXERCISE Okay, let's talk about breathing during exercise and how it stresses the pelvic floor. How many of you, as moms, clinicians, or just someone with a pelvic floor, hint, all of you, have been told to exhale on a lift or exhale on exertion? My bet is behind your phone, you are silently raising your hand because you've heard that. Whether it's for yourself or for your clients, wherever you are in the exercise space, you've probably heard that. When we think about this, so there's a lot of information from fitness professionals or medical professionals in the exercise space saying a lot of different things and boy is it confusing. This is especially true in the pregnant and the postpartum population. These clients typically come in having some kind of, have done some kind of research around breathing and lifting, and they're worried about their pelvic floor. So how do we help them understand how to manipulate their breath with exercise? So firstly, let's take the word safe out of it. If I am a non-pregnant female versus I get pregnant, Why is my breath all of a sudden making something safe or unsafe with a particular movement? There is more demand placed on the pelvic floor, especially as the fetus grows. Sure, yeah, that happens. Is the pelvic floor a muscle? Yes, it is. Do muscles get stronger as we place appropriate demand on them? Also, yes. We need to encourage weightlifting to some capacity during pregnancy so the muscle gets stronger. Stronger muscle fibers are harder to break. I love telling clients this in the clinic. We don't ask someone to manipulate their breath when they cough or they sneeze. which by the way is the equivalent of lifting 35 pounds or putting 35 pounds of force through the pelvic floor because it is a natural phenomenon that we cannot control. We don't tell them how to manipulate their breath there. So having someone exhale on exertion for everything is unreasonable. There are times where that can be helpful, especially early postpartum or if there are symptoms. But have you tried to exhale an exertion with double unders or box jumps or lifting 80% of a one rep max? You can't control your breath, like during movements where your heart rate's up. It's virtually impossible because your heart rate's up, your respiration rate's up. And as for the 80%, your body is just going to do what it's going to do, which is probably gonna include a brief breath hold or maybe even one that's longer so you can get through that movement well. Secondly, breath manipulation should be initiated one of two ways. Are they symptomatic? No. Continue what you're doing. Are they symptomatic? Yes. Let's change a bracing strategy or breath manipulation to see if we can continue that volume and that weight without symptoms. From there, we continue to scale as needed. And lastly, Breath holding during exercise. And what I mean by this is someone is lifting a heavy barbell or let's say both of their wiggly children at once from the ground. And Oh, by the way, one is screaming their head off. They're going to brace their core, hold their breath and lift the weight or their babies. Have they just ruined their pelvic floor or has their body just done what it's going to do naturally? My answer is the latter. We cannot always manipulate the breath, especially in life, especially life as a mom. We need to stop scaring moms and over-medicalizing breathing when in reality, our bodies are going to just do what it needs to do to get through a task. We believe in this so heavily that we teach bracing mechanics in detail, in depth, in our live course. So I mentioned those live courses at the beginning. Get on that. Like you, whether you're treating this population or not, you're going to see it. So to recap, there are no safe and unsafe exercises. It's simply, are we ready for that particular demand, whether that's weight or volume. We modify due to symptoms. We aren't ruining the pelvic floor by holding our breath. Breath holding increases spinal stiffness, which allows us to lift more weight, which also allows us to get stronger. And that's huge. Now, I do wanna be clear. Breath holding with a bear down to the pelvic floor is not what we want to do. When our pelvic floor goes down, and what we like to refer to that as in the basement, that's when we're going to the bathroom, right? That's when we are actually having a baby. any other time our pelvic floor is likely going to be on that first floor or in the attic and somewhere in between depending on the task at hand. So let's start taking the fear out of this. Let's start encouraging moms, really anybody, to do what their body's meant to do, and let's help teach them. It's something that we can do, we can teach them. Your pelvic floor, we can't see it, right? We can see how our shoulders move and how our neck moves and head moves. We can see that. We can't see how our pelvic floor moves unless we're laying down with a mirror between our legs doing an active Kegel, and that's not realistic. Also, knees go over toes when squatting. I hope everyone has a great Monday. 08:13 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 29, 2023

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock takes a deep dive into the jerk, discussing the importance of learning a strong leg drive, improving shoulder mobility, and committing to a strong finish with the movement. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. Good morning, everybody. Welcome to PT on ice Daily Show. I'm your host, Mitch Babcock from the Fitness Athlete Division. That means it's Fitness Athlete Friday, and I'm stoked to be back on the podcast, bringing to you another episode, this time going into some nuanced stuff around the jerk. So stay tuned for some more details around how to make your jerk a little bit better. Today's topic, don't be a jerk with your jerks. Before we get into that team, first of all, I'm wearing my Lions shirt. Did you watch the game last night? Of course you did. Thursday night football. Let's go Lions. It's been a long, hard existence being a Lions fan. So we're out here stoked that we got t 01:27 MITCH BABCOCK hree wins already on the season. Other news, non-football related, is that the fitness athlete team is going to be around the country coming up real fast here next weekend. Joe and myself are going to be out in Linwood, Washington, and we're rocking a big course out there. So if there's still time, if you want to slide in just under the cap of that course out in Linwood, if you're in the Seattle or greater Seattle area, we'd love to have you out at that course. We also have some courses coming up in the southern region. We've got San Antonio, Texas. And we've got Anna Maria Island in Florida. So if you're looking at Florida or a Texas course, we've got two of those in store for you coming up in the month of November. So otherwise, welcoming in the fall season here today. 01:43 MAKING YOUR JERK BETTER And today's topic around don't be a jerk with your jerks. We just finished up a nice May cycle where we did a lot of snatching and clean and jerking for the last eight weeks. and giving my members of the gym as many helpful tools as I can as a coach and an athlete of what's helped me with my shoulder overhead, specifically the push jerk in this cycle, but all of these principles also apply for the split jerk as well. And I see this done wrong or at least thought about wrong a lot. I figured it was helpful to share with you guys, whether that's from a personal standpoint as an athlete, you're out there training in the gym yourself and you're like, hey, This is sweet. I hate jerks. I hate split jerks or push jerks. And I want to get better at those. Or if you want to be able to pass that on to your clients or members, hopefully this will be helpful. So the first thing I want to talk about is what not to do. Don't press your jerks. 03:37 THE JERK HAS LITTLE TO DO WITH ACTUAL PRESSING The push jerk and the split jerk is not about how much you can press vertically. It has little to anything to do with actually pressing the bar vertically over your head. Think about what your one rep max strict press is. Ladies is usually somewhere in the ballpark of 60 to 100 pounds. Men, somewhere in the ballpark of 100 to 200 pounds of a strict press. And yet people are able to do almost twice as much as that when it comes to a jerk movement. It is not about your strength to move the bar off of your shoulder and press. So stop thinking of it like you need to push the bar up. The jerk is about pushing yourself under. That requires a couple things. One, specifically the legs. You need to start thinking about your legs way more than your shoulders on your jerks. It is all about your legs' ability to launch the bar off of your shoulders enough that you can then press your way under the jerk. Again, goes for the push jerk or the split jerk. So when you're in setup position, you've stood up that heavy clean and you're ready to make the jerk. Hopefully make the jerk. You need to be thinking about how much leg drive can I create vertically on this bar right now to launch this thing as far off my shoulders as possible. That means I need strong legs. I need to be better at my front squat. Specifically, when I stand up out of a heavy front squat, I need to be powerful in the finish as I'm standing and finishing that lift. So that's something that you can be training on days that you're not jerking at all, but be thinking about that last little third of the squat. Standing it up with a little power, with a little speed, and learning how to create really rapid short triple extension. Power cleans, same thing. Rapid triple extension at the top, but all we're trying to create here is more powerful legs. You can work on just dip and drives. It's a very common drill for Olympic lifters to work on. Get a bar in the front rack position. You just dip, hold, and just create a slight little bit of triple extension coming out. Dip, hold, create triple extension coming out. The focus point on the jerk needs to be on a strong leg drive. Now, once you get that to occur, then the press is actually you pushing your body under. It's just pushing myself down to a supported arm position. The shoulder is strong if it can meet the load in its locked out position. It's significantly less strong when it has to do any sort of motion to try to press out that kind of weight. So the quicker you are to press yourself down and support, the heavier of a jerk you'll be able to have, because it's just about supporting the load, not about pressing the load. 07:01 SHOULDER MOBILITY & THE JERK That requires shoulder mobility. And this is the big downfall to your split jerk is likely either A, you've been thinking about trying to press it over your head this whole time instead of jumping over your head. And B, your shoulders are too dang tight to really get into that full 180 degrees of flexion lockout arm position. You're trying to press it out in front and that's killing you, right? So you gotta open up that shoulder mobility. And you guys are the experts at doing this. Mitch, what do you like to do to open up your shoulders right before I'm weightlifting. I'm not talking about a PT session. I'm talking about something members can do out in the gym, boom, in real time to open up that double arm overhead position. I want to use a green band, but I don't want to do a single arm. I want to do double arm. And so rather than looping the band and attaching it to the pull-up bar like we normally do, I want to drape the band around the bar in this fashion. This is a poor example, but you get what I'm trying to say. I just, I don't want to half hitch it at all. I want to just loop it over the bar and have the band hanging down. I'm going to put both my hands through the band and I'm going to spin around. If you're watching this, this is a great I hope you're having fun with this because I'm spinning right now. I'm going to do like three circles and what that's going to do is wind up that band. So I've got it looped over the bar and I wound it up by doing three circles in it. My hands are now held in this double overhead position and I'm going to kneel down on the ground from that position. I'm going to start to have the band pulling my shoulders, essentially both arms, right near my ears at this point. When I'm down there kneeling on the ground, hands overhead and hooked to the band, now I can start to add some side bending into this position, which really starts to peel on this lateral seam of my arm, coming down to thoracolumbar fascia, up into the tricep area. I can side bend left, side bend right, and even add in a little upper back T-spine extension to that drill. It is the best opener I have found recently to get my shoulders ready to push jerk. because I'm hanging out in the exact position, an exaggerated version of it, but the exact position I want to finish my jerk in, which is the head through, the T-spine up and extended, and the arms behind my ears. So when you're thinking about pushing yourself under the bar, make sure your shoulder mobility is opened up so that you can do that. Okay, so what do we got so far? Strong leg drive, Don't press your jerks. Instead, push yourself under your jerks and make sure your shoulder mobility is on board for you to do that really well. 10:47 IMPROVING JERK TECHNIQUE And the last thing you need to think about, the only really cue I'm thinking after I think jump is I think head through. I think jump and I think head through. Too many people are scared to put their head through on a heavy jerk. They're committing to failing it and therefore they're committing to self-preservation. And so what they do is they jerk and they leave their head back behind the bar and they're like, if it works, cool, then I'll bring my head through. But if it doesn't, I can bail quickly and easy. That is just committing to failing the rep right from the start. You have to know that if this goes bad and I'm still pushing my head through and I can quickly get out and underneath the bar if I fail it. You're, trust me, you're athletic enough to move out of the way of the bar. I've seen it a number of hundreds and hundreds of times of athletes trying to get the head through, fail the rep and are still getting out from underneath the bar. You've got to commit to that head coming under and through the window. Because if not, the bar is going to be out in front of your center of mass. And it's way too heavy for you to hang on to out there. My max jerk is 350. There's no way if I don't get my head through that, that I can hold that kind of load overhead. I've got to bring the head through and I've got to bring the arms behind my head. And that's when I close my eyes and say a little prayer. Oh, I hope this goes good. But the head is forward. I'm not looking at the bar. The head's got to be forward and through. So the only two cues, if you're thinking about anything, it's jump as hard as I can and push my head through that window and pray for the best. Shoulder mobility needs to be on board. It's all about the legs. It's not about the shoulders. And it's about getting your head through the bar. And if you do those three things, you go out in the gym today, right now, and you start practicing those three things, I promise your jerks are going to feel faster, snappier. You're going to reach lockout a lot quicker, and you'll be able to PR that push jerk or that split jerk, whatever you're doing. And hopefully add 10 pounds on it. Don't forget to tip your caddy when you do. All right. I'll open, I'll share my Venmo below. Don't worry. That's how to not be a jerk with your jerks. I hope that stuff helps you. I hope that gives you some things to think about maybe for your athletes you're working with or cues that can help them and restore that overhead position. I think I should probably film a video of that shoulder mobility opener. I got a feeling I'm going to get some comments or questions about, Hey Mitch, I had no idea what you were trying to explain. Can you drop a video? So I'll walk right out in the gym. I'll film that and I'll do my best to drop a link to that video in the best place possible. Maybe over on my Instagram. Head over to my Instagram, Dr. Mitch TPT, follow that. And then, uh, I'll drop that video there for you guys, man. So glad you guys are here. Happy Friday. Go lions three and one and one and O in the NFC North. It's a good time to be a lion's fan for the first time in about seven years. Team. I hope you have a great weekend. If you're taking a nice course, let us know if you're taking a nice course next weekend, we'll see you out there. And if you want us to head down South, come find us in San Antonio or find us in Florida. and we'll be hanging out down there in the month of November. Have a great weekend, everybody. 01:27 MITCH BABCOCK Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 28, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes emphasizes the importance of trusting a proven process for success, particularly in the later stages of a business or any endeavor when uncertainty arises. He cautions against blindly trusting any process and encourage listeners to thoroughly evaluate its merits before putting their trust in it. Jeff acknowledges the prevalence of outrageous claims and self-proclaimed experts in today's era. He cautions against falling into this trap and emphasizes the need to dig deep and evaluate a process before trusting it. He suggests spending ample time observing and studying someone who has achieved desired outcomes through their process before fully committing to it. This advice applies to various domains, including clinical practice. If someone is considering adopting a specific treatment approach or following a mentor's guidance, they should first spend a substantial amount of time observing the mentor's success with a wide range of patients. Only after extensive evaluation and proof of the process's effectiveness should one trust and implement it. Overall, Jeff emphasizes the importance of trusting a proven process but stresses the need for thorough evaluation and proof. Blindly trusting any process without proper evaluation may not lead to the desired outcomes. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Okay team, what's up? Welcome to Thursday. Welcome to Leadership Thursday. And welcome back to the PT on Ice Daily Show. Thrilled to have you here. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always happy to be here on Leadership Thursday, which, as always, is Gut Check Thursday. Let's start off every Thursday how we always do. Let's talk about the workout of the week. Here's what we've got cooked up for you. We've got 21-15-9. Couldn't be a more classic rep scheme. We've got thrusters and bar-facing burpees. So hopefully the first thing you're thinking is it looks a lot like Fran, right? We've got two movements, we've got that classic rep scheme, but I'm going to argue it's going to be a bit worse. With Fran, we've got push-pull, right? So at least you're pushing that thruster and then you're pulling up on that rig. Now we've kind of got push-push, right? So we're going to go thruster and then hitting that push-up motion during that burpee. It's probably going to be a little more painful. Additionally, you're probably not going to be able to sprint through quite as fast, looking at how long a burpee takes compared to a pull-up. So in Fran, you might be able to out sprint the darkness, right? You might be able to get done with the workout before that darkness really catches up to you. Here, I think you might be living in it for a while. So just let us know how it goes. Make sure you tag us, Ice Physio, hashtag Ice Trained. Let's have some fun with the workout over the next couple of days. As far as upcoming courses, the thing I want to highlight this week, is that virtual ICE is open. So as you all know, our virtual mentorship, we only open it every quarter for a couple days, bring in a new group, add into the crew, and then launch, close those doors and launch for the next quarter. We are trying to hold that price steady. It's been 29 bucks a month forever. It's still 29 bucks a month. Yes, it's CEU eligible, but more importantly, it's a great way as you're going through ICE courses to be able to be in that group, hold you accountable. Every Tuesday we meet, going over case studies, new thoughts that aren't built into our courses. It's a way to deepen your knowledge and really make it more clinically implementable, if you will, by every week revisiting and expanding on some of our concepts. So if you want to jump in, go to Virtual Ice on the website. PTOnIce.com, as always, is where everything lives. 02:37 TRUSTING THE PROCESS Let's talk about trusting the process. So trust the process, absolutely, right? You should totally trust the process. But I wanna unpack a couple things around this conversation that aren't talked about enough. So number one, trust the process. Everyone speaks of this in the early stages. Okay, so kind of a classic conversation around this topic is, hey, when you're just getting started, you might not see gains right away, don't worry, trust the process, it'll show up in time. That's clearly very relevant. And certainly when you think about areas like fitness where we often talk about this, yes, you're not gonna stack on a ton of muscle in the first couple weeks of training. You've gotta trust the process and those gains do show up down the road. There are certain areas where that early phase This concept is the most important, but I'm going to argue today that in the world of business, it's really in the later phases where I think this concept becomes significantly more important. 05:29 LOSING CLARITY ON CAUSE & EFFECT So let me, let me build the argument. So early on in business. The connections are very, very clear, right? You don't need nearly as much trust that what you're doing is reaping a reward simply because cause and effect are much clearer early on. For example, If you're building a practice and you form a new relationship and you see an increase in customers, it's pretty obvious that those increased customers came from that relationship because you don't have a ton of relationships yet. And any increase in customers is really obvious because you don't have a ton of customers yet either. Additionally, it's really easy when you run an ad or something of that nature to see again that swell of business following that ad is quite noticeable and it's very clear where it came from. Following up with your customers is a lot easier. Number one, there aren't as many of them, so it's easier to dive in and figure out, hey, how did you wind up here? Where'd you come from? and there aren't as many people delivering your service. So you don't have to bring everyone together and try to kind of coagulate the data and see, hey, where's everybody coming from? The connections are simply clearer. There's not as much noise, little changes make very obvious results, and it's not as hard to collect or aggregate the data, because there aren't quite as many people delivering the service. Early on, you don't need as much trust. Five years down the road, it's much harder, right? It's much more challenging. You often find yourself saying things like, I have no idea where that person came from, right? There's so many more things going on. There's so much more noise that it's much, much harder to prove. Did this action result in a certain effect? Now we fight this valiantly, right? Everybody, and you should, is trying to track everything, right? Whether it's where a customer landed on your website, or if you're running an ad, you're putting a tag on there so you can see, hey, when that person came to the website, if we track them through to the commerce side, did they actually convert? You're doing your absolute best to track everything. But the larger you get, the more mature the organization, it becomes significantly more challenging to definitively prove that any individual action resulted in any significant outcome. There's simply too many variables. You don't know, did it come from word of mouth? You really can't track that all that well. There's so many things going on that it's tough to have that clarity that you had early on. The reality is growth results in necessarily losing some clarity on cause and effect. The more mature the business, the more true this is. So what's the answer? The answer is to very much embrace and trust the process. In the absence of proof, You're just gonna need to check the boxes of what's known to work. I would argue the earlier that you can do this, the earlier that you can stop wasting your time demanding proof of every single action that you did having a reward or a response, the more efficient you're gonna be and the faster you're gonna succeed. The earlier that you can say, I no longer need to see proof that this thing that I'm doing is reaping a reward, I'm just gonna do all of these things with absolutely ruthless consistency, and I'm going to trust that by doing so, the end result is going to be additional growth and more progress. The earlier you can trust the process, the more efficient and more successful you're gonna be. But there is a catch here. It's got to be a proven process. And this is what I want us to really think about this morning. 07:39 OUTRAGEOUS CLAIMS & TRUST Team, we are living in an era of outrageous claims, right? We are living in an area where A huge amount of people that can't do are claiming to be able to teach, right? They're claiming to be able to get you unbelievable outcomes, even though they themselves don't really have a track record of being able to do so. That is the era in which we live. Heavily marketed, thinly veiled, outrageous claims. That is really where we are. Because of that reality, you need to dig deeper. The passion behind this topic is coming from having seen so many people over the years come to me and say, here's where I'm at. And me thinking, dude, how did you fall for that? Like that person, there was no reason to believe that those claims were being backed up by any significant track record of proof. The person simply did not dig deep enough. And that's what I wanna say to you today. 12:50 SHOULD YOU TRUST THE PROCESS? Should you trust the process? Yes. after you have went through extensive lengths to prove that that process actually results in the real world, in the outcomes that you're seeking. This is across every domain. Clinically, if you're gonna choose a mentor, if you're gonna lock into somebody and say, I am going to treat the way that person treats, I'm gonna ask that person what the big rocks are, and darn it, I am gonna implement those in every patient that I see. If you're gonna do that, You better have spent a solid year around that person, watching them day in and day out succeed with patients. A wide variety of patients, a wide range of complexity of patients, until you get to a point where you're like, look, that person gets it done. Better than everybody else I've seen, almost regardless of who shows up in front of them, the methods that person's utilizing month after month after month after month consistently work. I buy it. That person can actually get it done. I am going to trust their process. In Con Ed, at ICE, I hope you never sign up for a certification until you've taken one of our courses and went back into the clinic and implemented and decided for yourself, do the tools that I learned in that weekend course or that online course when I went back in my clinic, was I demonstrably better? Was I more efficient? Was I having more fun? Did it actually work? Until we prove that to you, I don't want you to sign up for some long series of courses. I want you to test us, and I want you to go and see, does it actually work? That's the kind of level I want you digging in on everything. In business, you don't buy that someone can grow your business until you have talked to a bunch of people who aren't affiliated, who maybe have done some of their mentorship, but are not actively in their program, and you reach out in your private circle and say, hey, has anybody worked with so-and-so? I want to have some conversations. And you dive in and say, is it really as good as they say it is? Were the principles that they taught able to grow you? Anybody can put that on an Instagram ad. Did it actually work for you? Is your business three times bigger now than it was a year and a half ago like they said it would be? Dive deep and ask the hard questions. I love it when people reach out to me. And they're thinking about opening it onward, right? And they say, look, I want to talk to a couple other owners. I love it. They want to hear from the people. Did they actually deliver? I love when people who are getting coached up to become faculty at ICE, I hear them reaching out to other lead faculty. They're not offending division leaders by doing that. They're just going out and saying, hey, here's kind of what I'm being sold. Did it actually shake out like this? In looking for multiple sources. Business leaders, I hope you all are never offended by that. People are not second guessing you. Yeah, they are, but they're not disrespecting you. They're just doing the work. They're saying, look, I heard you, but now I'm gonna go see across multiple sources if what you're saying historically has added up. Are you actually able to get the job done? Have you proven that? Or are you just saying that because you want your business enterprise to grow? Do you have the goods? Team, in fitness, to me, with CrossFit, I had never heard of it before 2013, 14, but as I got into it, I looked around for proof. In the first thing I saw, in the second thing, in the third month, in the second year, is that everybody who just consistently did what was on the whiteboard and showed up five days a week had what I wanted, meaning tremendously well-rounded fitness. I was shocked by where they wound up. They had tremendous cardio engines. They were strong as all get-out. They had tremendous skills in gymnastics and mobility. The people who did the whiteboard, as written, five days a week, as hard as they could, and used that process, wound up exactly where I wanted to be. You can only watch that so many times until you're ready to say, okay, I believe it. I buy it and I'm all in. So yes, right, trust the process. And yes, put your head down and check the boxes. But after you've established certainty. Now I want to finish by saying here's why this is so critical. Here's why doing the legwork to prove to yourself to be fully committed that this person can actually get it done and that it should thus be transferable to your success. The reason it's so important is two things. Number one, once you do put your head down, and I am totally advocating for you to put your head down, right? Head down, stop looking for proof of every single thing, and just check the boxes with absolute rigor. I'm encouraging that. But once you do that, there aren't a lot of checkpoints. So once you've committed and you've said, I'm just gonna keep checking these boxes and I'm gonna trust the process, you're not really looking for proof, right? Because we've just established it gets harder and harder to gain any, so you've just simply gotta trust. The problem is if you're wrong, there aren't a lot of checkpoints to reveal to you that you're wrong. So you're gonna go a long ways down that trail. There is gonna be a tremendous investment until you realize, oh man, that system or that person or whatever didn't actually have the goods. I should have done more front-end homework. The second reason is because if you've done the work to truly prove it to yourself, if you've watched that clinician for a year and become absolutely certain their method works, if you've taken a couple courses and become absolutely certain that when you implement it, you're better for it, if you've done the work to be positive or as close to it as you can be, you're much less likely to quit. Once you put your head down and say, I'm just gonna check these boxes, I know what's gonna work, you are much more likely to go the distance to a point where you actually begin to reap very serious rewards because you won't be second guessing yourself because you've got certainty in your corner. But if you didn't do the work, you're gonna be saying much earlier than you should, am I sure this is the right path? And now you're gonna need proof and validation, which as we've just talked about, is hard to come by. So now you're gonna quit early, and if anything abbreviates success, it's early cessation of effort. Because there are a lot of checkboxes or checkpoints along the way to tell you whether or not you're on the right path, And because going the distance is so critical to success, you have to do the work to increase your certainty that that person's process or that system is gonna work for you. Do that work and then trust the process. Understand it's probably more important late in the game, at least in business, when things get cloudy and murky, than it is early on. I hope that spins the idea of trust the process, maybe a little bit different way in your brain, and certainly encourages you to go one step further on drilling down to be certain the process you're about to trust has actually proven merits historically. Have a wonderful Thursday, team. We'll see you next week. Enjoy that Gut Check Thursday workout. Cheers. 16:16 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 27, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses evidence based recommendations on shoe wear for older adults. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 DUSTIN JONES Welcome folks to the PT on Ice daily show. My name is Dustin Jones and today is Wednesday where we're going to be talking about all things older adults in particular. shoe recommendations for the older adult population. Shoe wrecks, heel drop, doesn't matter, barefoot, minimal, conventional shoe, what the heck's the deal with the toe box, what in the world is a shoe last, we're gonna talk about all these things, what the evidence says, and then what we're kind of seeing out in the real world, right? Many of us are seeing in clinical practice or in the context of fitness. Before we get into the goods, just a few quick announcements. Our online MMOA Modern Management of the Older Adult courses are going to be striking up here within the next couple weeks. So Essential Foundations, that is our foundational online eight-week course, is going to be starting October 11th. And then our Advanced Concepts course is going to be starting on October 12th. That's just for folks that have taken Essential Foundations. We've got a bunch of live courses coming up through the fall across the country. The one that I really want to point your attention to is Falls Church, Virginia. That's going to be the weekend of October 7th. 02:51 SHOE RECOMMENDATIONS All right, shoe recs. This is a topic that I really enjoy digging into. I've got a decent amount of experience around shoes. I used to sell shoes right out the gate of PT school. I was working in outpatient PT clinic and then working in the first kind of barefoot style shoe store in the country. Two of his treads out of Shepherdstown, West Virginia, currently in Charlestown. And just had a lot of, made a lot of mistakes, learned a ton, met a lot of interesting folks that were in this space that were really challenging a lot of conceptions. around shoes and what is good for individuals. And I was very dogmatic at one point and I've kind of come to the middle a little bit in terms of what I perceive to be beneficial and the evidence is starting to show that as well. 03:55 THE OLDER ADULT FOOT So when we talk about recommending shoes for older adults, I think the first thing that we need to acknowledge is that the foot is different in an older adult than when you're younger, right? We see age-related changes typically in the older adult population that warrant us to really question the shoe that they're in, right? The reality with the footwear industry is that many of the shoe lasts, lasts being the shape of the foot where they basically create the shoe from. The shape of that shoe last largely mimics what you may see in a younger individual, not necessarily the common things that we will see in older adults. What do we see in older adults? Typically, you're going to see a larger circumference of their midfoot. larger circumference compared to when they were younger, you typically will see a lowering of that arch in many older adults. We often do see that the angle, the toe angles of that first and fifth toe typically do go in, which we're well aware of all the issues associated with that. And we see these changes yet 99% of the shoes out in the market are looking at a younger foot and creating the shoe around that as opposed to an older adult individual. So we need to acknowledge these changes because that is what's going to influence the current evidence-based recommendations. So what I'm going to go through is kind of what the current evidence says, the most recent systematic review looking at shoe recommendations for older adults, and then I want to dive into the whole minimal barefoot shoe versus conventional shoe debate, particularly for this population. So what do we know to be true in terms of some key characteristics of shoes that are gonna be helpful for older adults. One, and probably the biggest issue, is that it fits. I know it sounds super simple and silly, but if you check the fit of many of your patient's shoes or your client's shoes, you will see some very ill-fitting shoes. Whether it is the shoe is too big, there's a lot of wiggle room, their foot is moving a lot within that shoe, or it's the opposite, right? The shoe is way, way too tight for that individual, and that creates a whole host of issues related to skin breakdown related to performance breakdown as well. And so we want to be very aware that it fits well, all right? So that's the first thing. Next thing is that it has fixation. A shoelace system, for example, we could say Velcro as well, but laces are typically better, is that if that shoe is properly fit and it's fixated to that foot, that is going to allow them to do what they need to do when they need to do it, all right? The second thing, third thing is going to be a firm supportive heel counter. So I've got a shoe here. If you're listening on the podcast, you can come to YouTube or Instagram to see the video. So this is just a Reebok Nano. I can't remember the model of this one, but back here, you know, is a pretty solid heel counter. So it's this back portion of the shoe. And so you want this to be firm and supportive. and snug when people put this on so you don't want a ton of room around the heel with this heel counter you want to be nice and snug and that's why trying shoes on is super super important. Next thing is around a 10 millimeter heel drop and this is where some of y'all are going to say no Dustin it needs to be just a zero drop shoe Current evidence shows that 10 millimeters around that range that older adults do really well there. If you start to go above that, particularly above 15 millimeters, you see an objective change in their balance performance through different outcome measures and their postural stability as well. If you're not familiar with heel drop, it's the difference of the thickness of the heel to the forefoot. This information can be hard to find on most websites when you go to look up shoe specs. That's why you want to look up the reviews of that shoe. Typically, a running world, there's a bunch of running related sites that will do all kinds of shoe reviews and they will give you some of those specific specs. When we worked at Two Rivers Treads, we would literally get a demo product and then we would cut the shoe right down the middle and we would measure the heel drop because a lot of those numbers weren't being published. We found some really interesting things. What the trend in the heel drop realm You know, 20 years ago, it was very, very common to see heel drops north of 10. You know, you'd be going, you know, 14, 17, 18 range in a lot of running shoes in particular. And over the past 20 years, particularly the past 10 years, that that average has gone down and down and down to where it's pretty normal to see a four to five millimeter drop from the heel to the front. That was not the case 20 years ago. So that has changed tremendously in the footwear industry. So around 10, excuse me, around a 10 millimeter heel drop. Next is a firm midfoot. So when we're looking at kind of the sole that it is relatively firm, you will typically see firmness in the midfoot and the forefoot is going to, excuse me. All right now, the forefoot is going to be a little more flexible. That allows for, you know, terminal stance, that we have a lot of extension, big toe extension is a big one, but that midfoot, a kind of firm, medium thickness is a good thing for older adults. In terms of the traction, a slip resistant sole that's multi-directional and tread. There's not a lot of evidence to support, you know, super thick, aggressive tread like you would see in something like a trail shoe. but some tread that is going to allow them that slip resistance in several directions, not just anterior to posterior. The next thing that you are going to want to look at is the beveled heel and then a rocker angle. All right. So this is really important for older adults that you typically want to see around a 10 degree beveled heel. So towards the back of the shoe, when we're going towards the very back of the heel, there's kind of that upward curvature. So it's not completely flat, but there's a little upward tilt around 10 degrees is really great. This allows or decreases the amount of them kind of catching their heel, especially during that swing phase. On the other side of the shoe, the front of the shoe, we have our rocker angle. You also hear this referred to as a toe spring. Now, not the fact that there is a spring in the toe or the front of the shoe, it just references that upward slope that you will see towards the front of the shoe. around a 10 to 15 degree rocker angle or toe spring is really good for older adults. The reason being is that when you're going into that terminal stance, you need a good bit of big toe extension, right? Some more ankle dorsiflexion as well. Usually you need about 45 to 65 degrees of big toe extension. And if you don't have that or it is painful, then having that upward slope basically gives you some artificial big toe extension. It can be really helpful with walking, but particular activities that require a lot of big toe extension, think going uphill, think lunging or getting to and from the ground, that rocker angle is priceless. And then last but certainly not least, we want an anatomically shaped toe box and this has changed dramatically over the past 20 years as well that we typically saw the shoe last kind of curve inwards and now you're starting to see that wider toe box to where the widest part of the shoe is almost towards the very end of the shoe or the front of the shoe. Now don't mistake a wide toe box to be a loose fitting shoe, because you will have a little bit of room to wiggle your toes in a properly fitted toe box. But if you have good fixation, particularly around the waist or the middle of the shoe, it is not a problem to have some wiggle room in the toe box. So we're talking length, but we're also talking width as well. so that is really important so when you look at all these characteristics hopefully you're starting to say oh my gosh that's a lot to think about this is why it is so so important for two things one to have a good relationship with A local, particularly running stores are usually the best around town. If you have an awesome local running shop to where you can send your folks, they have a solid fit system and they have some solid recommendations that can meet some of these characteristics. you're going to refer your folks and they're going to be in good hands, right? But it's also important to encourage folks to not just go to Amazon, to not just go and buy the shoe online, but you need to try this on. These characteristics, but then also that shoe feeling comfortable is very, very important. All right, so those are kind of the current recommendations. That is based on a systematic review that was released in 2019. I'll drop the citation for that in particularly the Instagram post. I'll do that there. 12:39 MINIMALIST SHOES: PROS & CONS All right, now let's shift gears a little bit and let's talk about the whole minimal shoe, barefoot shoe versus conventional shoe debate. Once again, I will say I was so dogmatic about this. I was the guy that ran half of a marathon without any shoes whatsoever. And the first half I wore Vivo barefoot because we were running on gravel, right? Like I was that guy. I drank the Kool-Aid hard, um, and then learn some valuable lessons along the way. And I've changed my stance a little bit. I'd say a lot actually on this, but let's talk about some of the pros and cons of particularly older adults wearing a barefoot style shoe. The first one is, there is evidence that a barefoot style shoe, when I say a barefoot style shoe, some of the key characteristics, typically it is a zero drop shoe. What I'm holding now is a Merrell Vapor Glove. I've bought three pairs a year of these things ever since they came out back in the day. I love these shoes. So it's typically a zero drop, a very flexible sole. So if you're not watching the video, I can roll it up like so. and it typically has a wide toe box. So the widest part of the shoe is going to be towards the front. That's kind of the typical characteristics of kind of a minimal barefoot style shoe. It also has a very low stack height in terms of how high it is off of the ground. So there are a couple studies, particularly with older adults, looking at how that's influenced some different parameters. And what they found is that when they wear a barefoot style shoe compared to a conventional style shoe, is that it does improve their postural sway. How does it do this, right? So think about the somatosensory input. You get a lot more input from that system whenever there's less stuff between your foot and the ground. You also have a lower center of mass, which can be very helpful for balance. And also, without that heel slope or heel drop, it doesn't shift your center of mass anteriorly. And so based on a couple studies, postural sway was improved significantly compared to conventional shoes when wearing those minimal shoes. So less sway, less postural deviation when folks were in static and dynamic situations. 15:07 CHANGES IN WALKING GAIT The next thing is that when folks put on that barefoot style shoe, they adapt their walking gait, running gait as well, right? Like we'll have the endurance crew talk about that all day, but I'm mainly talking about older adults in particular with walking. Their ambulation parameters will typically change. What we typically see is that we see a shortened stride length, we see an increased cadence with their walking, and the big one is that they have a decreased stance time. So they're moving their feet a little bit quicker and their stance time is a little bit shorter. Now, this is really important because let's think of if you have some type of external perturbation, you lose your balance. You try that ankle strategy, that hip strategy, it ain't working. You got to do that step strategy. When you're taking short strides, you have that increased cadence. When you have a relatively lower stance time, you are much more agile and adaptive to be able to take whatever stepping strategy you want to take. That is a big one, so that is a big reason why these barefoot style shoes can be helpful for older adults. What are the cons to wearing these with these individuals? One is that there's hardly any rocker angle. If you look at the video, there's a slight upslope for these shoes, but if you wear Xero shoes, Vivo barefoots, for example, you don't see any upslope or rocker angle towards the toe. and very little support in that area. And if you have limited big toe extension, if you don't have at least 45 degrees, for example, terminal stance of your gait is gonna be pretty tough, especially if you're symptomatic at in-range big toe extension. So these rocker angles can be helpful for individuals, especially if they're on uneven terrain, going uphill, limited big toe extension, they want that rocker angle. It's helpful for them, get them in one, all right? Though also the cons are the zero drop for many individuals, that life requires some ankle dorsiflexion to navigate the world, especially if you are going uphill, stairs as well. If you don't have hardly any ankle dorsiflexion, zero drop shoes are very difficult and what ends up happening is you end up shortening your stride even more. increasing your cadence even more, and ambulation can become less efficient. What that also does, especially when you're going uphill, if you're wearing a zero-drop shoe and you have limited ankle dorsiflexion, when you're going uphill, you max out your dorsiflexion, you don't have anywhere to go, so you start to see different deviations, and you also start to see a lot of pressure on the forefoot and the ball of the foot. If you have skin breakdown issues, neuropathy for example, this could have a whole host of complications. So there's some drawbacks to having a zero drop shoe for particular individuals and we need to be very aware of that. Now with all that being said, I, this is me, Dustin, anecdotally speaking, I am definitely for most individuals to be in some type of minimal barefoot style shoe. I think by and large, for many of the things that we do throughout our lives, it's a really good thing, but there's a lot of times where you want a solid shoe, right? You want some stuff between your foot and the ground. You want some help with that big toe extension. You want some help with that ankle dorsiflexion. So when I'm thinking about recommending barefoot style shoes to older adults, I'm thinking about three main things. And this is kind of a checklist that I want you to think about. 18:28 PROTECTIVE SENSATION One, and maybe the most important one, and this is probably one of the bigger mistakes that I've made in this realm, is that they need to have protective sensation. They need to have protective sensation. You need to get your monofilament out, your Seams 1C monofilament out. Check that protective sensation because if they do not have that, I highly recommend not recommending a barefoot style shoe because you will have lots of bumps, lots of bruises, stepping on gravel, you can create some trauma, if you will, and if they don't have that protective sensation, they may not be aware, and most individuals are not regularly checking the bottom of their foot to see if they're having any issues. I learned this one the hard way. I was treating someone that had type 2 diabetes and recommended, at the time, Altra, A-L-T-R-A, made a lot of barefoot style shoes, and I recommend the Altra Atom. You can look that up. It's one of my favorite shoes and basically gave this person a foot ulcer from some of the trauma that they received over several, several days. So learn from that mistake. Number two, you want at least 45 degrees of big toe extension. That's kind of the minimum for most individuals through ambulation, particularly through that terminal stance. So 45 degrees of big toe extension and also kind of symptom-free big toe extension. A lot of folks will have painful in-range big toe extension. So you need to be aware of that. If they don't have that, then you want a shoe that has some bit of a rocker angle. And I'm not saying you go to some like maximal style shoe, but even a relatively, I wouldn't call it nano, a minimal shoe, but the stack height isn't anything crazy. The heel drops three to four millimeters from the back to the front. And it has somewhat of a rocker angle. Something like that could be helpful for individuals and not putting too much between their foot and the ground. And then last but not least, their ankle dorsiflexion. At least 10 degrees of ankle dorsiflexion. That's kind of the minimum that we're looking through throughout gait. They need more than that when they're navigating uphill, when they're trying to do squatting, for example. But that's kind of the minimum. And I'd be very clear of when they want to wear these. When they're doing activities that don't require a lot of dorsiflexion or big toe extension, rock those barefoot shoes. But if you know you're going to be getting to and from the ground a bunch, if you're going to be guarding and kneeling, if you're going to be doing a bunch of squatting and lunging, then you probably want a solid heel drop. You probably want a nice rocker angle to support some of those deficits. So, I know that's a lot. I'm going to drop all these studies that I'm referencing in the comments of the Instagram post, but I think we need to be clear that we have evidence-based recommendations for older adults. I went through them at the beginning of this. I would say they're rather somewhat outdated, especially as the evidence is starting to evolve of looking at some of these different styles of shoes. But we're starting to see some early evidence supporting a minimal or barefoot style shoe in older adults. But we can't just do a blanket recommendation. Everybody gets Vivo barefoot. Everybody gets Xero shoes. That's not the case. We need to have that checklist, protective sensation, 45 degrees of big toe extension, 10 degrees of ankle dorsiflexion, and you're probably going to put someone in a good position. All right. Thank y'all. Y'all have a lovely Wednesday. I'll talk to you soon. 21:41 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. 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Sep 26, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses common myths related to the diagnosis & treatment of frozen shoulder presentations based on outdated & low powered research. Mark offers a newer, evidence-based approach which includes addressing diet & lifestyle factors, including judicious manual therapy, and load. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:18 MARK GALLANT All right, what is up PT on ice crew we got Instagram over here we're getting YouTube Pulled up over here. Make sure I get everything set All right, we are live on both platforms now. Looking good. I'm Dr. Mark Gallant, lead faculty with the ice extremity management division alongside Lindsey Huey, Eric Chikones. Want to come at you today on clinical Tuesday talking about frozen shoulder. It's another one of those areas similar to IT band that we talked about a few weeks ago where there are a lot of things that based off research from almost 100 years ago, have stuck around for a long time. So we want to dive into where the problems lie and what we can do to solve those issues. Before we dive into that, few course opportunities coming up to catch us on the road. You can catch us. Cody is going to be in Rochester, Minnesota here in two weeks. So if you're if you're up in the Midwest or that North area and you've been looking to catch us, definitely look at Cody there. I'll be in Atlanta early November and then we've also got another course coming up in California. So we're so we're hitting the Midwest, the Southeast in California. If you're looking to catch us in the rest of 2023, if not, definitely look at those courses for 2024. There's a bunch of opportunities to catch us in 24 and those seats are filling up fast. So so jump on it right now. 02:46 DIFFICULTIES OF UNDERSTANDING FROZEN SHOULDER So As far as frozen shoulder goes, it was said that frozen shoulder is difficult to treat, difficult to define, and difficult to explain. That was said by Ernest Codman in 1934. And we would argue that 90 years later, after Ernest Codman said that, it's unsure how much better we are in understanding frozen shoulder It's definitely a challenge to treat. And for any of you who have tried to explain it to patients, it's one of those ones where you feel like you're going around in circles as you're trying to explain it. We don't know really what the true mechanism is. We've got a lot of theories. We're narrowing the buoys, but we really haven't narrowed it all the way down. And we really don't know what the primary tissue areas are that are really creating this pathology. Again, it makes it difficult to treat, difficult to define, and certainly difficult to explain to patients. Who are the people that are going to come into your clinic that are going to have frozen shoulder or meet that presentation? Well, the main thing is oftentimes they're around 50 years old. It tends to be our 50-year-old folks that have this most often. And what you're going to see is active and passive range of motion are both going to be limited in their shoulder range of motion. At least one of those has to be external rotation. glenohumeral external rotation is the the area that we find to be most limited early in a frozen shoulder presentation so we're really looking at about a 50% reduction side to side of that active and passive external rotation early on in this presentation and then oftentimes you'll see other other motion areas start to be limited so 50 limited shoulder range of motion specifically external rotation the other thing that tends to be tied with frozen shoulder is It's often folks who have diabetes in their medical history as a comorbidity and thyroid disease, which matches that unhealthy tissues are oftentimes attached to unhealthy humans. So if they've got some serious significant comorbidities, especially those metabolic comorbidities, this is another group of folks you want to take a look at and think maybe this could be a frozen shoulder presentation. So what are some of the old myths or some of the problems that we've had with frozen shoulder over the years? 07:18 SUPERVISED NEGLECT Well, the first one is going to be supervised neglect. So there was this idea that if you look at someone who had frozen shoulder early, you say to them, you know what? This is a presentation that runs its course in about 18 to 24 months. Here's some exercises. Go home, sit at the edge of a counter, spin your shoulder around a few times, and let us know how you're doing in 18 to 24 months. Unfortunately these were based on very limited studies so if you go back to again the 1930s 40s 50s with Ernest Codman a lot of his studies were based on on 6 to 12 people so a very limited cohort and he was giving wildly aggressive treatments like he would hospitalize these patients and basically pin their shoulder into end range rotation and flexion for up to 20 hours a day. And then he said, oh, almost all of these people get better. Well, certainly maybe with what he was doing with that aggressive treatment, but it would be, you'd be hard pressed to say like with a cohort of less than 10 folks that, that everyone with this presentation is getting better. If we go to the early 2000s, another popular study is Dirks et al that showed that folks who were just sent on their way with some basic exercises versus folks who were given physical therapy, that the folks who were given exercises and told to check back in at two years and four years, that they actually did better. Well, if you really dive into that study, from a quality perspective, it was not the most robust study. Only 77 people, very poor quality control, and it's really not demonstrated anywhere in that study exactly what the physical therapy group was doing. Again, based on limited research, we would be hard pressed to say that it's truly supervised neglect is the best method to just send these folks on. The other challenge that we run into is, like Codman said, 18 to 24 months, all these folks are going to get better. That does not seem to be true as we dive more into the literature. What we're looking at now is more that These folks can oftentimes have their presentation up to 48 months, so four years of dealing with this. And the only reason we say 48 months is because that is the longest that anyone has ever looked at it. That a large percentage of folks, when you look at them four years later, they are still having some pain or some limitation in their shoulder mobility at four years. And again, We say four years because that is the longest it has ever been looked at. And if you're really thinking about a presentation that is as uncomfortable as frozen shoulder is, especially early on, and we don't know how to define it, we don't know how to explain it well, and it can last up to four years, and potentially a lifetime of increased dysfunction of that shoulder, It's really hard to say to someone, hey, this is all we know. Good luck for the next four years. They're in a lot of discomfort. They've got a lot of shoulder limitation. This is another human being in front of you. We want to do our best to come alongside those people. We really want to walk the line with these folks to help them out. No one wants to be told, see you in two years. That's only going to increase fear and anxiety overall. and there's a new clinical practice guideline coming out for frozen shoulder it has not been published yet but hopefully sometime in the next you know six months to a year it'll come out one of the authors on that ellen shanley done a ton of research in the shoulder space and what their group is finding is that if we get them early physical therapist and we give them a good solid treatment during that first year most of those folks have a better overall prognosis and presentation as time goes out. So again, it does not seem that supervised neglect really helps because so many people really have this problem beyond four years. And we are starting to see new research that that if you get in there and you can help them calm symptoms down some, if you can restore whatever range of motion you're able to restore, that those folks are going to have a much better prognosis. So getting them in with you. And again, no human wants to have that vague of a presentation and be on their own. So us acting as a guide is always going to be very important. So that's the big one, supervised neglect based on poor research, we're showing that the outcomes of supervised neglect are not what we may have thought they once were. And we want to be good humans first and foremost, coming alongside those patients and really helping them out and guiding them along. 14:06 STAGING THE FROZEN SHOULDER The second piece is the idea of staging for frozen shoulders. So historically it's been freezing, frozen, thawing. And a lot of times when the research, these were based on a timeline. So you would have a few months of the freezing phase, a long frozen phase and then coming out of it that last sometimes it was written as 18 to 24 months as their thawing phase. What we see now is those phases are very unreliable and it's rare that someone is going to fit into that nice bucket of freezing frozen thawing. what we're seeing more now is that we really to simplify things both for patients and for ourselves is as complex as frozen shoulder appears to be we want to have the simplest buckets possible so what we're going to look at is is this shoulder more pain dominant or is this shoulder more stiffness dominant and if we keep people into those two buckets it will really ease our mental burden and the patient's mental burden on how to treat those out effectively so So oftentimes early on, it's going to be more of a pain dominant presentation. You're going to be doing things that calm that person's symptoms down as much as possible. Sometimes that shoulder is so irritable that you're not actually going to get into the shoulder to do any direct tissue treatment. Things we like in that case are breath work is a wonderful way to calm the nervous system down. Specifically, if you can have the exhale slightly longer than the inhale has really been shown to calm the nervous system down. Can we get them doing some other sort of mindfulness practice other than breathing? Can we get their diet more dialed in? Again, unhealthy tissues are attached to unhealthy humans. Can we lower the sugar? Can we lower the processed foods, the alcohol? Can we get them doing some general fitness that does not involve the shoulders? So getting them on the bike to pump a lot of healthy blood flow to those tissues and doing our lighter exercises to the area so higher dose higher volume with low tensile load in their available range to pump a lot of good healing blood flow and fluid to those tissues and pump out whatever chemical irritants may be and then lower load isometric long hold lows to get some non-threatening stimulus to those tissues are some of our favorite things for that pain dominant presentation. Now the stiffness dominant presentation What we want to do then is now we're saying that their pain is below that 3 to 4 out of 10, their psychological irritability is down. Now we want to get into those end range tissues. We want to hit our end range mobilizations, followed up with eccentric exercise to really start to own that end range tissue. So oftentimes this is where you're going to do your really long hold stretches and mobilizations and follow them up with some decently loaded eccentric load so that they can learn to control that new range of motion and access new range of motion. Again, that would be once symptoms have significantly calmed down. Now, historically, looking at treatment for the frozen shoulder, this is one of those areas where we would often tell patients, well, hey, we're going to have you grit and bear it, Todd. You know, Tom, we're going to set you on the table and I'm going to crank on your shoulder for 45 minutes and we've got to get through this. And what we know now is that that was likely creating more irritability, both from a psychological perspective and a tissue perspective. The tissues were likely not really ready for that in-range, very vigorous stimulus and our patients, Tom, certainly was not ready. for that vigorous stimulus. And what that led to was not only tissue irritability and potentially delaying healing times, it also led to some psychological irritability. That's where folks like Tom would say, physical therapy, man, it's so painful. I needed to take 10 Advil before I went to physical therapy. They're afraid of physical therapy. They become apprehensive of loading. We were creating a lot of fear and apprehension. We want to meet these folks where they're at. We want to meet the tissue where it's at and get where we can out of it. This does not mean that we don't believe in intensity. We believe in intensity as the ultimate. It's intensity matching that patient's tissue tolerance and symptom profile. And once we can match that symptom profile and tolerance, then we want to maximize intensity when it's more that stiffness phase. Early on, we've got to respect that psychological irritability, the tissue irritability, do the things like breath work, light mobilizations, until we can progress them to those more vigorous exercises. In addition to that, the amount of force that it takes to move the shoulder capsule is absolutely ridiculous. It is almost 2000 pounds of pressure. to actually make changes to that capsule. So what we think we're doing with our manual therapy is unlikely true. We were likely often getting tissues like the subscapularis and other shoulder tissues to calm down and relax a bit with our mobilizations, not making true collagen changes, which would require much more vigorous load that could create injury to other tissues or really long sustained hold. So again, much more beneficial for us to lower symptoms, really manage their pain well early, get what we can out of the tissue, and then when symptoms are down, then really dial up the intensity, your long hold stretches, your eccentric loading, and really getting after those tissues overall. Love to discuss this more. Frozen Shoulder is such an interesting conversation. Again, to recap overall, supervise neglect, What we want to focus on more is coming alongside those patients, helping them calm their symptoms down, helping educate them for whatever stage they're at. When we're looking at staging, pain-dominant or is it stiffness-dominant? If it's pain-dominant, breathwork, diet, nutrition, general exercise, lifestyle, light load to create a pump to the shoulder, getting some light isometric load in, getting those tissues as healthy as we can. If it's stiffness-dominant, that's when we want to get more intense, get after those tissues, long and range hold with our mobilizations and eccentric exercises to get after this. Hope it helped. See you all in a couple of weeks. Hope to see you all out on the road. Have a great Tuesday getting after it in clinic. See you soon. 15:23 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 25, 2023

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett Addresses the fear of exercising during pregnancy and how it can hinder the care provided to pregnant individuals. Christina shares that she has received messages from pregnant individuals expressing their concerns and uncertainties about exercising while pregnant. The fear of exercise causing harm is often the primary concern that arises when someone discovers they are pregnant. Christina emphasizes that this fear is not supported by scientific literature and believes that removing this barrier can lead to a significant shift in the way pregnant individuals are cared for. She argues that the medical system has contributed to this fear and stress the importance of reframing the conversation around exercise during pregnancy. Instead of focusing on the potential harm, Christina suggests highlighting the health-promoting aspects of exercise and removing any obstacles that may prevent pregnant individuals from engaging in physical activity. Christina also points out that society does not have a movement problem, but rather a lack of movement problem, which is often observed during pregnancy. She highlights that the fear of harm is one of the factors contributing to the decrease in exercise during pregnancy. Overall, Christina emphasizes the need to address and alleviate the fear of exercise during pregnancy in order to improve the care provided to pregnant individuals. By reframing the conversation and focusing on the health benefits of exercise, pregnant individuals can be empowered to continue exercising during pregnancy and set up for success. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app.com. Use the code icePT1MO at sign up to receive a one month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the faculty within our pelvic health division. If you did not see, we had an absolutely packed house in Arizona for our two-day live course, and we have a couple of live courses coming up through the end of the year. Importantly, we're taking the move up to Canada and we are trying to see if we can take some of these courses up there. So I am going to be in Ontario this next weekend, the 31st first or 30th first. in Hamilton, Ontario, which is close to Toronto. And then in December, I'm going to be in Halifax, Nova Scotia, in the east side of the country. So if you are a Canadian who keeps saying, why aren't we bringing these ice courses up to the north into Canada, we are trying to do that. So I hope that I will see some of you in our Canadian courses towards the end of this year and this weekend. Okay, so this is kind of a little bit of a punchy topic where, and I've been thinking about this a lot. 02:40 ETHICAL RESISTANCE TRAINING RESTRICTIONS So to give context, so today we're going to be talking about, is it ethical to put resistance training restrictions on women that are pregnant? Where this comes from, so we are in this space of exercise, and to this day, very commonly, there is a restriction that can sometimes be placed on people that are pregnant that tell you that you should not lift more than 25 to 30 pounds during your pregnancy. And if you have seen me in the geriatric division, We've done a lot of pushback against putting restrictions on the amount of absolute load that is on an individual because of these preconceived notions that individuals of a certain age are not capable. I've had conversations before where people think that the two divisions that I'm a part of, the geriatric and the pelvic health division, are very different, but they both have one key concept that are kind of overlapping with them. that is under dosage of an under prescription of exercise. And so my PhD in geriatrics looked at high load resistance training for at risk older adults. I have since shifted some of my research into the pelvic health space looking at high load resistance training during pregnancy And that is where this conversation came up. So the motivation behind this episode was a conversation that I had with Margie Davenport, who I'm doing some postdoctoral research with, where we were talking about a systematic review that we are working on with Jess Gingrich, who's part of our pelvic team, on resistance training during pregnancy. And so part of the things that we are reporting on are things like what was the frequency, intensity, time, and type. exercise prescription principles for these randomized control trials or these exercise studies that were done in individuals who are pregnant. And I've talked about how understanding the context where these prescriptions come from, saying don't lift more than 20 or 25 pounds, have come from the fact that we do not have research in this area over a certain prescription, hence some of the cross-sectional data that we're doing, hence some of the follow-up studies that we are doing. So that's where this came from. But the reframe that really came into my mind over the last little bit was when Margie said, is it ethical to put restrictions on pregnant people for lifting? And so let's talk about that. So when it comes to these restrictions or when it comes to our recommendations, they come from the foundation of do no harm, right? no harm. We are trying to make sure that we are keeping our pregnant people safe and we are making our recommendations and they tend to be more conservative because this is a very protected time in a pregnant person's life. And so because we don't have any research in pregnant people, we say don't do it. But when it comes to the research, where we have to go is looking outside of the research, blending it with what we know in our current patient population, and then take the wants and desires of the person that is in front of us. We know that strength is protective at every single point in our life. We know that being stronger makes you more resilient. We know that it prevents chronic disease. that it keeps you with higher amounts of quality of life for longer. It helps protect you and give you reserve if you are sick. There are so many reasons why strength is protective. And it has been shown across almost every single patient population at every age. It is shown that strength is protective. When we have our pregnant population, we use these restrictions because we don't have anything above. But when we come down to the foundation of strength is protective, And we think about the lens of these restrictions, don't lift more than 25 pounds. We have to ask the question, are we going by do no harm? Because it's not that we have evidence that going above 25 pounds is harmful. It's that we don't have evidence at all. And so when we don't have evidence at all, we have to take a look at other areas or other amounts of the lifespan of the woman. And we have to think about, are there any harms that we can think of that are specific to pregnant physiology? And then kind of blend these two things together. 08:16 RESISTANCE TRAINING DURING PREGNANCY And from a pregnant physiology perspective, the theoretical constructs that are driving some of these recommendations are things like the change to fetal heart rate and placental blood flow as a consequence of lifting heavy weight, and the shunting of blood away from the uterus that happens when we resistance train towards the working muscle. And we don't have any evidence from our acute studies that have looked at hemodynamics in the cardiovascular response to resistance training at a variety of loads to show that there is any adverse event that happens to mom or baby hemodynamically that would insinuate that there is some type of harm to fetal inflows and outflows as a consequence of resistance training. When we look at high load resistance training across the lifespan, we also have to think of what happens if we start to make women afraid of resistance training. What happens when we say don't lift more than 25 pounds or don't lift this heavy weight because you're going to prolapse or don't lift this heavy weight because it's going to cause incontinence. We don't have to just think about this snapshot in time where we're trying to maybe circumvent some leakage. We have to think what is the internal dialogue that starts to happen in that woman's life that is going to impact her at 65. where we think that we shouldn't be that resilient or we shouldn't be doing that much resistance training, we shouldn't put that muscle on us anymore because we are going to cause pelvic floor issues or we are going to harm our baby. What does that internal dialogue do to exercise selection in the postpartum period, in the midlife period, in the perimenopausal period, in the older adult period? Is me saying that you shouldn't be resistance training going to impact what I'm working with older adults down the line? and this may seem like a bit of a stretch but when we don't have evidence around fetal hemodynamics we don't have any case reports that have shown that an individual who's lifting heavy weight goes into a hypertensive emergency or that there's any type of pre-eclampsia that happens acutely or that after going to the gym an individual has had a fetal death which would be a case report that would come out in the literature as a special kind of This is something that happened that we should keep our eyes on that's how we start developing levels of evidence to start investigating different phenomena Because we don't have any of those things This reframe I think can be super important of Not what is the what is the harm of resistance training? it's how are we setting our moms back if they don't resistance train during their pregnancies? And you know I've talked to moms who've been placed on activity restriction or bed rest and they say like I had a complication that caused me to have to be in bed and let me tell you being weaker going into that postpartum period was painful for me. It was a lot harder for me. It was not something that I would wish on anyone to have to feel so weak and vulnerable in a time where you already feel weak and vulnerable. So instead of saying what is the risk of us doing resistance training during pregnancy, It's what is the risk if we decondition our moms to be and have them, are we setting them up for success in the postpartum period by purposefully deconditioning them? And you may think that that is a strong statement of purposely deconditioning, but when you are making a recommendation that they are not allowed to lift their toddler up or that it is somehow dangerous to do that, We don't want to acknowledge that while we are removing a stimulus, that we are actually promoting deconditioning. We are promoting deconditioning of the musculoskeletal system. And when we look at return to exercise postpartum and we look at persistent issues in the postpartum period, for example, diastasis recti, we know that those with diastasis recti are weaker across their abdominal musculature than those that aren't. We know that one of the biggest issues to returning to exercise is pelvic floor dysfunction, but it is also lower extremity musculoskeletal pain where our body has not had that type of stimulus or impact. It hasn't remained as strong as it was before pregnancy. And now when we're trying to return to activity. we're having lower extremity pain. 12:22 MOM WRIST & MOM KNEE Why do we have so much mom wrist and mom knee, which we now have evidence are not actually physiological changes that occur within a female's body that are a consequence of the hormones of pregnancy. We see a weakness issue that comes into pregnancy, a certain amount of deconditioning that is expected as a consequence of pregnancy, but we do not promote, uh, blunting of some of that deconditioning by promoting resilience and resistance training. And so I feel like there is a paradigm shift that is happening, and it starts with reframing our questions. Instead of saying, what is the harm of resistance training? If we flip that and say, what is the risk of deconditioning a pregnant person? that changes the game. It changes the way that we frame exercise and what we consider to be bad. We don't have evidence at any levels of intensity in any modality of fitness that high intensity resistance training or aerobic training is bad for a developing fetus. or for a pregnant person. And in fact, it is creating a cardiovascular training effect to strengthen the fetal cardiac system when individuals are participating in aerobic training. And so how do we set moms up for success? Instead of saying, what is the fear? of exercising because that's the first … I literally had somebody message me yesterday saying, I'm four weeks pregnant and now I'm so scared. I have all these questions. I do all this strength training. I do all of this aerobic training and I don't know what I'm allowed to do. We have created that system where you get a positive pregnancy test and the first thing that you question and the first thing that you start to be fearful of is, is the exercise that I am currently doing going to cause harm? Our medical system has created that, and we need to work tirelessly to remove it, and instead say, what are the health-promoting factors, including exercise, that I enjoy, that I want to do, that I want to continue in order for me to feel strong, for me to feel healthy, for me to feel happy, for me to have strong mental health and resiliency, and that is going to trickle into the health of my baby. If we take that reframe, if we say instead of what is the things that are going to cause harm, it's how do we remove barriers to exercise, especially when we look at our society and we do not have a movement problem. We have a lack of movement problem. And dip in exercise occurs during pregnancy. And there is a lot of things that can contribute to that. But one of the things is fear that the exercise that they love to do, that they self-select to do is somehow harmful. And if we can remove that barrier, we are going to shift the way we take care of our pregnant people. And we are going to start to see our pregnant people be able to do all of these wonderful things without the fear that is unfounded in the literature of doing harm. All right, my rant for a Monday. I hope you all start to think about this. I have actually really been thinking about the do no harm piece of exercise and if it is founded and how to change the way that we frame exercise prescription. for our pregnant individuals. So I hope you found this helpful. If you have any thoughts around this, I would love to hear it. I'm definitely gonna be thinking about the way that I'm framing this up and seeing if there's any challenges that I can think of in my mind that would counter some of these arguments. So I would love to have these conversations with you all. If you wanna see some of the research coming out on exercise and pregnancy, I encourage you to sign up for our pelvic newsletter. It goes out every two weeks. We just had a letter go out last week. where any new research that's coming out, we try and stay on top of it. And this is where some of these podcasts come from. So if not, I hope to see you on the road. If you are Canadian, I hope to see you at one of our courses in Ontario or Nova Scotia. Otherwise, have a really wonderful beginning of your week, everyone, and we will talk to you all soon. 16:55 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 22, 2023

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko stresses the need to maximize preparation and recovery for a successful competition. He emphasizes the importance of preparing for the week before the competition, the competition day itself, and even the week after the competition. Joe encourages individuals to focus on their game plan, proper nutrition (including carbs, protein, and electrolytes), fluids, and electrolytes. Additionally, He highlights the importance of keeping the body moving between events to avoid stiffness and stagnation. The ability to warm up, maintain a good heart rate, and perform at a fast 100% effort is crucial for success. On the day of the competition, Joe advises sticking to one's game plan and not letting others dictate it. He mentions that CrossFit is about being able to adapt on the fly, but it's important to trust one's strategy and see where it takes them. Joe also emphasizes the importance of nutrition during competition day, stating that eating is necessary and what one eats matters. He provides the example of an elite athlete who consumed multiple Snickers bars for fast carb and glucose intake to replenish muscles, but notes that this strategy may not be applicable to everyone. After the competition, Joe discusses the importance of the follow-up week. He suggests focusing on recovery during this time and allowing the nervous system to recover and do what it needs to do. He highlights the significance of giving oneself time to recover, as it is an important part of the overall competition process. Overall, the episode emphasizes the importance of preparation, execution, and recovery in the context of a competition. It highlights the need to have a game plan, trust one's strategy, focus on proper nutrition, and prioritize recovery to maximize success. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app.physicaltherapy. Thanks, everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 JOE HANISKO Good morning, everybody. It's PT on Ice, daily show live. It's Friday, I would say September 22nd, getting close to October already. It is Fitness Athlete Friday. I'm Joe Hanisko. I'll be your host today. One of the lead faculty of the clinical management of the Fitness Athlete crew. Today we want to chat about competition. So CrossFit competition prep 101. Just the basics. We get either personally ourselves or some of our clients who are signing up for local or online competitions and we want to make sure that we're preparing them and that they understand what their expectations are for getting into that competition. the week before, the actual date of, and then even that week after, like making sure they maximize their preparation and their recovery for a successful event, especially when really all that we typically have to see in comparison is these elite athletes who are going to be doing things similarly, but also different because of the amount of training they've put in and just the fortitude that they've built up in terms of an athlete and the resilience that they've earned in an athlete. We'll talk about that CrossFit Competition Prep 101. Before we get going, I want to make a couple of call outs to the CMFA Live agenda that's coming up for the rest of the year. Both of our Essentials and Advanced Concepts course took off online in the last week or so. So those are going to be going through until the end of the year and we'll get those going again at the beginning of 2024. But in terms of live courses, we have a handful coming up in the next few months to close out the year. So if you're looking to get into any Con Ed courses, we are going to be in California. Washington, Alabama, the state of Texas, down in Florida, New Orleans, and Colorado, all before Christmas. So from now until Christmas, we have six or seven CMFA Live courses that will be out there. So grab a seat if you're looking for that. Hop on to theptnis.com and you can find all of our courses there. All right, CrossFit Competition Prep 101. 03:45 PREPPING FOR COMPETITION WEEK Let's talk about the week of. So you're going into this weekend of competition. What do we do that week before? I would say that at this point, We're not talking about the prior weeks and months of training. That's a whole other conversation. But at this point, whatever you've done to earn your right to sign up for this competition, you've done it, you've earned it. You can't really gain a whole lot more in one week of training, but you can lose a lot in that one week. So we want to make sure that we take that week leading into competition pretty seriously. If we're assuming maybe competition day is on Saturday, which is most common for a lot of local events, I would say that those first two to three days of that week, Monday, Tuesday, Wednesday, per se, I would focus on training as normal. Keep things consistent. If you guys have specialized programming through your gym and or you're using some sort of online platform like Mayhem, Days one, two, and three can stay pretty consistent. We don't have to change a whole lot about that. It allows us to stay moving, feel good, test some things out, and it's not until day four and day five that we really start to maybe change some things there. Day four, I would say, is a great opportunity to just take a complete rest day, figure out how the body is feeling, let things calm down. Maybe we focus on just a nice walk outside, maybe we do some mobility work and some soft tissue work to kind of prep the body but I'm cool with day four-ish in that time frame being a complete rest day if that works out into your calendar. It gives us time for the body recover for the nervous system to recover and then it gets us to day five the day before competition. I would suggest that the day before competition you don't do absolute rest. I think it's kind of nice to low level prime the body for movement especially when you're about to do something at a pretty high intensity the following day. So this could be super easy, like moderate EMOM style work, where you're doing a lot of body weight or simple movements. This could be just a zone two kind of monostructural day where we hop on the erg, sorry about that light there, hop on the erg, get some of our heart rate into that zone two level and just do a nice 20, 30, 40 minute cruise control type of workout. But I like the idea of the day before competition, moving the body and taking that rest day, maybe a day or two before competition. opposed to resting right up until that point there. So in terms of our basic agenda, days 1, 2, and 3, you can stay pretty consistent. Day 4-ish, probably 3 or 4-ish, we're going to take a complete rest day and let the body completely recover, maybe focus on soft tissue mobility. And then day 5, we want something smooth and easy, get the body feeling good. If you have any you know problem areas we're doing a little bit of accessory work to tune those up but we're not hitting a hardcore CrossFit style event the day before that competition. A couple other things that I would maybe not do in that week before is I would not go above 75 80 percent of your maximum volume in terms of load so if your programming calls for deadlifts, squats, whatever it might be, some heavy loaded exercise, no matter what, keep that in that moderate, upper moderate range there. I feel like being in that 60, 65, 70, maybe 75% range at the most gives you an opportunity to load those tissues, feel like you're getting something out of it, but also not blasting the nervous system. Our nervous system is probably one of the most undervalued parts of our recovery because it's hard to sometimes assess until you go and perform. But when the nervous system is down, our actual performance will be down as well too. And typically what drops the nervous system is high volume training and high loaded training because we only have so much of the tank to give before we need to recover. So I would avoid hitting heavy, heavy weightlifting the week of. Keep those 75-ish percent or lower. That being said, too, another thing I've seen a lot and had a lot of education on is if your event calls for some sort of weightlifting complex, like a hang snatch to overhead squat to hang snatch complex, I'm just making something up, don't go out and test that thing at max capacity over and over and over again. One of the biggest flaws that I see with our novice CrossFit athletes is that it's something new. It's like, oh, I haven't done this exact complex. I don't know exactly what it's going to feel like. Well, go and test it at that 50%, 60%, 70% maybe. but I see so many people the week or two prior doing it three or four times and what they're doing is depleting their nervous system and when it matters on that Saturday when competition is there, you may in fact lose some by having tested that so often before. So I would, I'm not saying don't trial it to see what it feels like, but I'm saying you should have a good understanding now with all the training you've done before to earn your right to be in that competition, roughly what your capabilities are, and then testing that complex at lower to moderate weights will give you a little bit of an insight to where you think you can be, but you are not going to get stronger by practicing that over and over again in a week or two before that event. So get familiar, but don't blast yourself with those complexes. Yeah, and then the other thing I was gonna say is just don't, in terms of testing, going a little farther, don't test all those workouts that you're about to do at max capacity multiple times either. I'm on board for learning, for strategizing with team, if you have a team event, I think that is great, but do those several weeks in advance. Don't go and blast your body the week of testing an event that you're probably gonna do because that's where we'll see decreased performance and potentially injury risk that will increase when we're doing that stuff there so recap of the week of the week of you're going to train as usual for the most part days one two and three Day three and or four, we're going to take a rest day and let that body completely recover. Just focus on mobility, recovery style stuff. Day five, we want to move a little bit. Lightweights, bodyweight style exercises, throw that into an EMOM format. Get yourself on a ERG machine and do some zone two monostructural work. We want to avoid max effort loads throughout the week to keep our nervous system healthy. We don't want to test everything over and over again. Save yourself for Saturday. You will not lose by not training, but you can lose by overtraining in that week before. All right, so now you're in the day of. Day of competition. This looks a little bit different to everybody, but a few little pointers that I have, some of them will be obvious, but just reminders, is that just stick to your game plan. Hopefully you've thought your process through and trust it. You know yourself as an athlete, your team hopefully has connected, or your training partners, and you know each other fairly well. Don't let other people dictate your plan. Stick to your plan. CrossFit's all about being able to adapt on the fly, which you will have to do sometimes, but don't go in constantly thinking that you have to change your strategy. Trust your strategy and see where things take you. 10:37 NUTRITION ON COMPETITION DAY In terms of nutrition during competition day, I feel like we need to be eating. I think that's an obvious thing to say, but what we eat matters. We see people, Matt Frazier was a good example, who would just slam multiple Snickers bars in a day of competition because he was looking for fast carb glucose intake to replenish those muscles. It's actually not a terrible strategy, but we're not Matt Fraser either. There's got to be probably some moderation to that. I do believe having easily digestible carbohydrates, which may include some sugar and that's fine. A couple little gummy worms here or there, some fruit, maybe some of those protein bars or energy bars that have some carb in it, built in it. things that taste good and that are easy for you to digest are probably best. We need carbs to replenish our muscular glycogen system and just our overall metabolic system. I think getting some protein in is fair, but we don't need to heavily douse protein. We don't need to be eating like multiple burgers that will sluggishly kind of slow you down. So lean proteins, beef jerky, a little bit of pulled chicken, something like that can be a fairly easy type of protein to digest. And then I would say a third thing being fluids and electrolytes. So this is where getting salt waters of some kind, like a element for an example, or your own homemade version of that, getting that electrolyte balance into our body is crucial. You're going to be pumping fluids out, And you can get really scientific with this and weigh yourself before and after an event like some of these higher level athletes do. But I don't think that we have to be at that level. But do replenish your fluids. Be drinking water. Get some sort of electrolyte back into that system. And I think these are going to be two really crucial things in terms of adjusting fluids that are important there. Some of these sports drinks, just read the back. Get smart with these guys. Like read the back of some of these labels and you'll realize that you could make yourself a way better balanced electrolyte style drink than the marketed ones that have virtually nothing inside of them. So get online. figure out how you could dose in some table salt with some other electrolytes and just make something that is gonna help you retain fluids, especially if you're doing this in a hot, humid environment where you know you're gonna be sweating a lot. And then I think the other thing in between events is don't just sit and do absolutely nothing. Take some time, five, 10, 15, 20 minutes at the most to recover and chill, but as you're leading up into that hour before your next event, try to move. walk around, hop on a bike if they have one. This is where I will actually, in some circumstances, support things, simple things like massage guns. There is some anecdotal and potentially actual structural evidence that would say that the vibration and impulse is a good way to just kind of prep that nervous system and keep those tissues a little bit more aware of what they're about to be doing. I'm game for it. Whatever you gotta do to stay agile and feeling like you're at your best is what we need to be focusing on there. So day of, stick to your game plan, proper nutrition, including carbs and protein predominantly, and then electrolytes is big as well, fluids and electrolytes, and then find some way to keep that body moving in between events that you're not stiff, stagnant, going in. The ability to warm up, keep your heart rate at a good level, and then hit a fast 100% effort event is crucial to success. We don't wanna be going in cold. Even if you're feeling a little tired, you gotta find a way to keep that heart rate moving. 14:17 TAKING REST AFTER COMPETITION All right, final thing is our final prep, I should say follow-up week, the week after your event. So you've done your week before, you've completed your event, congratulations. Sunday, Monday, Tuesday, leading into the next week, what do we do? Be okay, I'm gonna say this again, be okay taking more than one day of rest. I have an event coming up this weekend that has for sure three main events that all are at least 18 to 20 plus minutes in domain plus five like mini events. And then if you are lucky and fortunate enough to earn your right into the championship event, that would be four main events. So four main events plus five mini events. I don't train for that. Nope, not many novice athletes do. Elite athletes, yes, they are prepping with four to six hours of training on average per day in a week. We don't do that. Not many of us are doing that. So if we are going to go out and sell our soul in this event on a weekend, be okay taking Sunday, Monday, and maybe Tuesday and doing little to no major physical activity. It doesn't mean you have to be a couch potato. Maybe you are again going for hikes, walks, little bike rides, whatever it might be. Find some enjoyable sport that you like, like golf to get out and just stay active. I'm not asking you to be lazy, but I'm asking you to respect the amount of volume that goes into some of these CrossFit events. I see a lot of people who go and smash it on Saturday and then are at the gym on Sunday working out or Monday doing a, you know, high level, uh, online programming that is consisting of two plus hours of training. to each their own at the end of the day, but it's okay, I'm giving you permission to let your body recover. At the end of the day, for me, I'm reminding myself that this is not about today and tomorrow, this is about 20, 30, and 40 years from now. I am building my fitness to be a better, older adult. So be okay taking some time off. Use the next week to just sort of assess the body. Did anything tweak? Are you sore? Are you stiff? Focus on those areas. This is where getting your clients maybe back into your clinic that following week and just prepare for that. Say, hey Johnny, I know you got an event coming up on Saturday. Why don't we make sure that we have a day to meet on that following week just so we can talk about how it went and be sure that we're doing some good recovery things and I can help you better game plan that following week as well if I can see you early on that week. So take time to assess the body. And I would suggest again, similar to the week before, keeping loads in that 75, 80% or lower before we get back on track with your normal training. Just allow again that nervous system to recover and do what it needs to do, so. Hopefully that was helpful, guys. Again, either for yourself or for clients that you're having, but I love the fact that people are dedicating themselves to fitness and that they're willing to put their body, their soul, their personalities, their mentalities, their identities on the line and go sell it on a weekend or online competition. We are training for a purpose. We have short-term goals. We can go test those out. We have long-term goals. All this is leading to that direction. So preparing yourself for that competition is really important. Executing on the day of is really important and making sure you give yourself time to recover afterwards is also important. Hopefully it's helpful. If you have any questions, comment on the videos. Otherwise, take a look online and see if you have any interest in getting into our CMFA live courses coming up across the country. They are filling up. So let's get on those and enjoy the end of our year together. I will talk to you later. Have a great weekend. 17:46 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 21, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall delves into various lease terms, including flat rate leases, triple net leases, and percentage-based leases. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Thanks for being here today on Thursdays. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty over in our fitness athlete division. Today, Thursdays, Leadership Thursdays, we talk all things business management, clinic, and practice leadership. Thursdays means it's Gut Check Thursday, so let's talk about this week's workout. We have a little couplet of power cleans and push jerks with a low to moderate weight barbell and some running. So we have 20, 15, 10, 5 power cleans at 95-65 and push jerks at 95-65. After each round you're going to run 200 meters. 20 power cleans, 20 push jerks, go for a run, 15-15 run, so on and so forth. When I sent this to our CEO, Jeff Moore, last night, he said, wow, that seems like a heavy, high-volume barbell workout. And I don't agree at all. This should feel about a 10-minute workout as usual on Gut Check Thursdays. You should be able to pick a weight on that barbell where you can really cycle big sets of power cleans. Maybe for some of you, even hang on to all of the power cleans and go right into your push jerks and really get a high intensity stimulus out of that workout and hit some quick 200 meter runs in between. So goal time, 10 minutes, scale to do big sets on that barbell. I love workouts like this because they're really easy to modify. This is the type of workout that I'll probably give to a patient in the clinic, right? If we can ditch the barbell entirely, we can do some dumbbell cleans and jerks, we can do some kettlebell swings and some landmine press, we can run, row, bike in between. It's a workout where you can take kind of the stimulus and manipulate it a number of different ways to achieve the same result based on the equipment you have and what your patient or athlete can do in front of you. So have fun with Gut Check Thursday. Course is coming your way. I want to highlight our pregnancy and postpartum division as we're rebranding to Ice Pelvic Health. So we have one live course and one online course with a second online course launching in 2024, a level two course, an advanced course. So you can catch that Level 1 course. The next chance to catch that will be January 9th. And then that Level 2 course, which will require the Level 1 course as a prereq, will be launching in 2024. And then some live courses are coming your way between now and the end of the year. This weekend, this weekend coming up, Alexis and Rachel will be down in Scottsdale, Arizona. The weekend, next weekend, September 30th and October 1st, Christina will be up in Hamilton, Ontario, up in Canada. The weekend of October 14th and 15th, Alexis will be in Milwaukee, Wisconsin at Onward Milwaukee. Out in Bozeman, the weekend of November 4th and 5th, again, Alexis. The weekend of November 18th and 19th, again, Alexis will be on the road, this time in Bear, Delaware. That'll be out at CrossFit Bear. That's actually ICE faculty member Lindsey Huey's gym. And then your last chance to catch the ICE public live course this year will be the weekend of December 2nd and 3rd. Again, I'm in Canada with Christina. That'll be in Halifax, Nova Scotia. So check out that course. Our goal with that course, bringing on the second online course, is to have a three-course series that results in a certification and management of the pregnant and postpartum athletes. So that's what's coming your way from the Ice Pelvic Division. 04:31 IMPORTANCE OF LEASE NEGOTIATION Today on Leadership Thursday, we're going to talk about negotiating your lease. And maybe for some of you, this is a thought you have in your mind as maybe you're thinking about beginning your practice of what does it look like cost-wise, what does it look like in practical application to buy or rent a space such as a clinic space where you can set up your practice. And maybe for some of you who are working for somebody else, or maybe already working for yourself, and you are maybe going through lease renegotiation, you're thinking about moving locations, of what are the essentials to look for in a good lease, what are the different options available to set up a lease, and what are some things that we look out for. So let's talk first about what and why this is so important. Of all the expenses that a business can have, your lease or your mortgage, the money you pay for your physical space, is going to be one of your highest expenses, but it's also probably the one that is the only one of all your fixed expenses that actually has room for manipulation. When we think about paying for internet or paying for maybe a fax service or something. Those are fixed costs, but they're unlikely to budge, right? You can't really call up the cable company. You can't call up Comcast and say, Hey, you know what? I think I paid too much for this. I'd like to pay half as much, right? They're just, they're going to hang up on you, right? They'll probably talk to you about bundling or try to give you a 5% discount for six more months or something, but you're really not going to be able to move the needle on that expense. Likewise, payroll, paying our folks is another big expense that's fixed. And that's also not an area where we can really budge the needle on expenses. If you don't believe me, go ask the folks that work for you if they would work for you for half as much money. Again, you're probably going to be met with maybe some laughter or maybe anger if they think you're serious. but that's an expense that we're unlikely to be able to significantly manipulate. It's very different with something like a lease. Based on the current commercial market for commercial real estate, based on even zip code, it may only be a five minute trip down the road to a new location, but based on zip code, based on a number of different factors, there tends to be more room here to hopefully reduce that expense a little bit. So I want to talk about ways to do that. and ways to set up your lease terms and maybe terms you have not even heard of yet. So let's start with there. Let's start our first point. Let's talk about what are the typical terms of a lease. So the most common, the one we're all probably very familiar with, even if you've never leased commercial real estate, you're familiar with this because you've probably done this with an apartment. It is a flat rate lease. This is paying X amount of dollars per month based on the lease terms. We're very familiar with renting apartments, maybe renting townhomes or condos of hey, it's $900 a month and it's a one year lease, right? And usually at the end of that lease, the price probably goes up a little bit and if you're still gonna live there, you renew that lease and you're kind of in that fixed rate lease cycle. 07:36 GRADUATED LEASES The next is really kind of unheard of and very uncommon and falls on you, the person looking for a space to really inquire about it as if it can be an option for you. And that's a graduated lease, where you're eventually going to arrive at a fixed price per month that does not change, but you're not going to start out there. So an example might be you pay $500 a month for the first three months of your lease, Maybe the second three months of your lease, you pay $750, and maybe the last six months of your lease are built up to maybe $1,000 a month, as a quick example. So we're slowly graduating to the full terms of that lease. Why is this helpful? Obviously, it's less money over the 12 months. That's the number one reason. The other way is this is really helpful when you're first beginning your business. When you first hand your shingle, you probably don't have a full clinical caseload, which means the revenue coming into your business is probably not where you would want it to be to maybe even pay the full amount of that fixed rate lease. So negotiating for a graduation of the understanding of, hey, I'm not making 100% of the revenue I believe I can make currently. Can we kind of step up to that amount over time? This is a great idea, a great model to pitch, especially if you're not renting your own building or space. If you're thinking about starting up a side hustle in the corner of a gym, and you're literally just getting a portable treatment table in the corner, you're not getting a lot for your money, so the idea of spending maybe $1,000 a month to have 20 square feet in a corner is less than ideal, especially when you're first starting, of hey, can we just see where this goes? Can we do $200 a month for the first three months? Can we do 400 for months four to six? can we do 600 months six through nine and then maybe months nine through 12 we're at 800 a month and then we can revisit at the end of the year what changing to a fixed rate amount might look like. So this gives you some breathing room that you don't have to rush out and think about stressing and worrying about maximizing your revenue from day one. It gives you that kind of room and time to go out and market your clinic and not just thinking about maybe I need to be working in home health or something to even pay for this lease and I don't actually even have time. to see patients at my own clinic because my lease is so high. So graduated lease is a really great option that's often not really thought about, not really offered, something you may have to ask about, but something that a lot of business owners, especially if you're subleasing a space, might be very open to because for most of those folks, that space is empty anyways and they'd rather have you paying more and more and more over time than paying nothing at all for that space. 11:01 TRIPLE NET LEASES The next type of lease is something that almost no one is familiar with unless you live in a really big city or you deal with really serious commercial real estate, and that's called a triple net lease. How a triple net lease works is you pay a little bit of money for the actual principal on your lease, but a lot of the cost of your monthly payment is a shared split of usually the insurance for the building, the maintenance costs for the building, and the taxes for the building. So this is very common in bigger cities where you have multiple businesses inside of the same building, where you have a shared entryway. When I think of a triple net lease, I think of the flagship Onward and Onward Charlotte, where there are, I think, 12 businesses in a three story building, a couple businesses per each floor. That is usually where you will see a triple net lease of the taxes, the insurance, the maintenance costs for that building, are all kind of added together and then divided among the number of leases inside of the property. So this can be a great way to get a cheaper lease, especially the bigger the building. Yes, more maintenance costs, more taxes, more insurance, but more people to spread the cost across. So overall, a pro to this approach is we tend to see cheaper rent and overall a cheaper lease payment because those costs are shared. Now there are some downsides here that we need to be aware of. If you're the first tenant in a brand new building, you have no one else to share your costs with, right? So asking if that does happen to be you and the lease is a triple net term of how does that work with the sharing of this cost? Am I expected to pay 100% of it because I'm the only business in this building currently? That's not ideal. Or is the landlord going to assume the majority of that as more and more businesses open up inside of the common building? The other concern there is that overall physical therapy is really low maintenance. When we look at actual property wear and tear, maintenance, that sort of thing, we don't tend to damage a lot of the buildings we're in. We might have some scuff marks on the door frame from maybe folks coming in and out with with walkers and wheelchairs and things like that. But you don't tend to see a lot of big property wear and tear in a physical therapy clinic, which means in a triple net lease, you could make the argument that we're probably paying more than we need to because we use such a small amount of the shared spaces, especially in something like the bathroom as well. physical therapy clinics are not nearly as business busy as a business like a gym or a restaurant where maybe hundreds of people per hour are coming and going and if they're using maybe shared bathroom spaces they're really causing the majority of the maintenance costs for that compared to your clinic. So just being aware of how many tenants are in the building and also what are their business types. Is there a lot of foot traffic? If so, that's going to jack up the overall maintenance cost of the building, which is then gonna be passed on to you as one of the tenants in the building. So be aware of those factors if you're thinking about a triple net lease or you're being offered a triple net lease. The last type of lease type available is something we should never do, which is a percentage-based lease. We should never do this, first of all, because it's illegal for us to do this as healthcare providers. Getting into a negotiation where you pay 10% of your monthly revenue as your lease, what that looks like, how that functions, is essentially kickbacks. We are not allowed to be involved in any sort of kickback system as healthcare providers. Does it happen? Yes, but part of being a business owner is managing risk and one of the biggest things you get in trouble for. is something like that. So knowing that you should not do this, this also just becomes weird of now if your rent is based on a percent of your revenue. First of all, the payment is different every month. It's not going to be exactly the same. It's going to fluctuate up and down. So that's always a little bit awkward. The other awkward part is now you have to sit down. You either have to give complete access to your landlord, to your financials so that they can look and say, I will be the one that calculates how much you owe me. Or you need to sit down monthly and give that information to your landlord. And that just doesn't feel good for one business owner to just be laying open how they do their operations and financials to another business owner. The issue with this, aside from it being illegal, why it's not good for business, is that in general, a physical therapy clinic can expect linear growth. As my caseload gets more full, I see more patients, my revenue increases. When I reach the point at which I have no more time, in my week to see patients, I hire another therapist. And the process just keeps repeating. Their caseload gets full, their revenue increases in a linear fashion, so on and so forth over time. That does not happen in other businesses. For example, with a gym, especially a gym that maybe has an unlimited membership model, they're going to reach the point at which they can have no more members, and there's no more way for them to increase their revenue at all. So as your Revenue at the clinic continues to increase as you hire a second, a third, a fourth, maybe a fifth therapist. Your revenue grows and grows and grows. In a percentage model, your rent is going up, up, up, up, up, up, up in a way that it starts to become unfair for you as the PT clinic owner to be expected to always pay 5%, 10%, 20% of your revenue of your monthly lease payment is going to increase linear alongside your revenue as a clinic. And it's going to become very quickly an out of control expense. So that's never something we want to get involved in. The last thing we never want to do is not a type of lease that is official is any sort of quid pro quo, any sort of this for that arrangement of if you treat me 10 times a month for physical therapy, you can rent the back room of my gym or my spin studio or my yoga studio or whatever. That's just not really good business for a number of reasons. First of all, we have, I would argue, a lot more to offer as physical therapists. At any given time, 87% of the American population has some sort of pain, which means When you give up time on your schedule in exchange for something, you can expect those times to be almost always booked, right? Imagine that same situation with a massage therapist. Hey, you can have this back room if you give me two massages a week. Guess who's never missing those two massages that week, right? The landlord, right? They're always gonna be using those in a manner where, again, very similar to a percentage lease, you're gonna find yourself having the feeling that you're giving more than you're getting. The other main reason to never do this is that if you trade lease payments or really any other sort of expense in exchange for physical therapy treatment or programming or something like that, that is now an expense you cannot show on your taxes. Part of being a business owner is yes, making money, but also being able to justify all the expenses related to running your business that you possibly can to reduce your tax liability so that you pay less taxes over time and overall the clinic has more profit. If you are exchanging your lease and it has a $2,000 value a year, you cannot write off that $24,000 as rent payments on your taxes to reduce the tax liability of the income that the clinic generates. And the more you do quid pro quo stuff, the less expenses you show, and to the government that looks like more revenue with less expenses, it looks like more profit, it looks like more taxable income. We never want to be in a situation where we're paying Anywhere close to the amount of taxes is actual profit that the clinic makes. It doesn't feel good to go to work and run a business and then pay almost all of your money in taxes at the end of the year and not have a lot left to show for it. So that's really why we want to avoid quid pro quo type arrangements, trading expenses in exchange for physical therapy treatment or other physical therapy services that you may offer at your clinic. So I hope this was helpful. We talked about different lease terms, about why leases are maybe the one area of running a business where we have a lot of room, wiggle room. to hopefully reduce the price, or at least keep the price as capped as we can. We talked about different types of lease terms, a typical flat rate lease, a graduated flat rate lease, a triple net lease, quid pro quo, and percentage based leases. So, I hope this was helpful. I hope you have a fantastic Thursday. Have fun with Gut Check Thursday. I'm literally getting ready to go next door and do it right now. If you're gonna be at a live course this weekend, I hope you have a fantastic time with our instructors. Have a great Thursday. Have a great weekend. Bye everybody. 18:37 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 20, 2023

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses masters athletes who challenge negative age paradigms and serve as role models for younger generations. According to the episode, the decline in physiological systems can be attributed to both aging and other factors such as inactivity, sedentary behavior, obesity, and chronic diseases. It can be challenging to distinguish between changes in physiological systems solely due to the natural aging process and those influenced by these other factors. However, Christina suggests that psychosocial factors also play a role in positive aging. Factors like loneliness, connectedness, sense of purpose, and the ability to make healthcare decisions not only for oneself but also for others contribute to positive aging. These psychosocial factors are independent of physical capacity and can help individuals maintain a positive aging experience. Christina emphasizes the importance of building and maintaining relationships, connectedness, and the capacity to learn, grow, and contribute in the context of healthy aging. These aspects are relevant not only for older adults but also for all generations, including Gen X, Gen Z, millennials, boomers, and masters athletes. Loneliness is a significant issue in society, affecting people of all age groups, as highlighted in the episode. Building and maintaining connections and relationships are crucial for sustaining healthy lifestyle factors and combating the loneliness epidemic. This is particularly relevant for older adults, who may struggle to maintain relationships as they age. Christina mentions the challenges of making new friends as an adult, as expressed by her grandmother. The masters athletes discussed in the episode serve as examples of individuals who demonstrate the importance of these aspects in healthy aging. They not only prioritize their physical performance but also value psychosocial considerations. Masters athletes have the opportunity to build relationships with individuals across different age groups who share similar mindsets regarding health promotion. This allows for the exchange of knowledge and the adoption of healthy lifestyle factors. Furthermore, masters athletes have the capacity to learn, grow, and make decisions. They challenge negative age paradigms and combat belief systems around aging through their athleticism. They set goals not only for their own performance but also for serving as role models to younger generations within their family and sport. Masters athletes also contribute positively to their sport by creating mentorship opportunities for younger athletes. They serve as examples of successful aging and contribute to the overall belief in the ideology of successful aging. Overall, this episode emphasizes that building and maintaining relationships, connectedness, and the capacity to learn, grow, and contribute are essential aspects of healthy aging for all generations, including older adults and masters athletes. These aspects not only contribute to physical well-being but also to psychosocial well-being and the overall belief in successful aging. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a wait list, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 CHRISTINA PREVETT Good morning, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division. We have three courses in our geriatric curriculum that encompass CERT MMOA. We have our eight week online essential foundations course with our next course starting October 11th. We have our eight week online advanced concepts course, which if you have taken our essential foundations, you are eligible for advanced concepts that starts October 12th. And then we have our two day live course that we still have quite a few courses for the remainder of 2023 if you were looking to get involved. So we are in Falls Church, Virginia, October 7th and 8th. I am in Fountain Valley, California on the 14th and 15th. And then we are in Mattawa, New Jersey on the 21st and 22nd. And if you did not see that we are currently in what I call revamp season, we just updated our live content for MMA Live. And if you are in advanced concepts coming up in October, you are going to be getting brand new material. And I am so, so excited about that. 00:00 THE MASTERS ATHLETE And what we are going to talk about today is some of that content relating to the master's athlete. When we think about our geriatric curriculum, let's be honest, we are not talking about master's athletes most of the time, right? We often will talk about this sickness, wellness, fitness continuum. And when we talk to our geriatric clinicians who are on our calls or taking our courses, and we say, you know, what percentage of individuals are in the sickness or the completely sedentary side of the spectrum, We're talking about the majority, right? We're talking about the majority. We're getting individuals who are saying 80, 90% of their caseload is completely sedentary or is struggling with the chronic disease burden from multimorbidity. And very few of our clinicians are working with the master's athlete. So why do we care about this group? Well, one, we want to cover the full spectrum of geriatrics. But secondly, there is this really neat kind of underpinning that we are gaining from a research perspective when we are evaluating the master's athlete. When we talk about aging physiology, it can be really tough to tease apart what is what we would call the natural history of getting older, what are things that we can expect to change across our physiological systems as a consequence of getting older, and what are the contributions of other things to that aging process. We talk about how we have accelerators and brakes to the aging process, and we can stack the deck in our favor, and then we're just talking about risks and statistics. And one of those things is that as we get older, we tend to move less. We tend to be more sedentary. Obesity rates can go up. And chronic disease, one of the biggest risk factors across all categories, is age. And so we have this hard time teasing apart what is from the aging process and what is from the inactivity, the compounding effect of sedentary behavior, kind of what are those influences? And so the masters athlete has, especially for our lifelong exercisers, those who are veterans, who have never really stepped away from the sport for very long, we're starting to get some ideas and tease apart, you know, what is an aging process and what is accelerated because of changes related to inactivity, obesity, chronic disease. And so I kind of want to tie this in. So we have this physiological change. 06:05 CARDIOVASCULAR FITNESS IN AGING And when we look at, for example, in the cardiovascular system, our masters endurance athletes maintain their VO2 max by about 57%. And our endurance athletes, when we compare our masters endurance athletes in their 70s, have a lower VO2 max than our endurance athletes in their 20s, but a similar VO2 max to our younger individuals in their 20s who are completely sedentary. And so that is showing that while yes, there is a change to our cardiovascular output, our max heart rate is going to go down, our stroke output, our stroke volume, our cardiac output is going to decrease. Our amount of deconditioning in our VO2 max as a marker of cardiovascular fitness is a slower blunting than maybe we had previously thought. And things like our ejection fraction and our resting heart rate actually do not change with age in a healthy, cardiovascularly conditioned older adult. And to me, that's fascinating. So we're looking at that from the endurance side. When we flip to the strength side, we see that our raw strength in our power lifters is relatively maintained and up until about the fifth decade of life. So an individual squat bench deadlift, as long as they stay injury free and training volume remains pretty consistent, we're going to maintain those numbers for quite some time. 08:50 TYPE 2 FIBER REDISTRIBUTION And then as we go into different age groups over the age of 40, we're going to start to see some blunting down of that strength effect as a consequence of age. We talk about in the musculoskeletal system though, that there is this change in this redistribution of our muscular fibers, where we see a shift from this composition that has a bias towards type two fibers in certain muscle groups. And we see this shift towards more of a type one slow twitch fiber archetype in many of our muscles. And we seem to see that this is true in our strength athletes as well. And the way we're starting to gain insight into this information is by comparing our power lifters and our weight lifters. So our power lifters are slow strength movements. We have the squat, the bench, the deadlift. For our weightlifters, we are working on speed strength. So we are going to get those type two fibers at high percentages of our one rep max, but we're also gonna try and preferentially activate them with some of these fast twitch movements, such as the clean and jerk and the snatch. And we start to see that the open records for weightlifting in age groups decline much steeper. That means that we are still seeing this switch of type 2 fibers. That does not mean that we don't train power and we're going to try and have this use it or lose it principle that holds true for everything. But we know that that type 2 fiber redistribution is part of this aging physiology that we can expect to see in many of our older adults. Taking a step back from that, it's super interesting to see that we are getting this heightened or slower rate of cardiovascular aging in our endurance athletes. And we're getting this relatively slower change in the musculoskeletal system in our strength athletes. And that specificity principle appears to hold true. And it's something that we see very consistently in our rehabilitation efforts, right? We are trying to train the person's body to not experience pain, dysfunction, or loss of physical function in the exercises, in the movements, in the day-to-day tasks that are important to our individuals. And so when I step back and think about myself as a person in my 30s who's going to try to hold on to my physical function for as long as possible, somebody who maybe isn't in the highest level of competition, but would still consider myself to be very much an athlete, this idea of training both systems I think is extremely important and extremely relevant in our messaging for maintaining physical function. We see oftentimes that we focus in strength training for very good reason. Oftentimes our older adults, unless there's a significant amount of cardiovascular compromise, are losing the strength to complete activities of daily living, like getting off the floor or being able to get up from a chair without using their hands before their cardiovascular system. In our kind of community dwelling older adults, not our individuals with pulmonary pathologies like congestive heart failure or COPD, that cardiovascular system isn't being the limiting factor as often. But what we want to be thinking about is how do we optimize the reserve in both of these systems and how do we slow down the slope of the line? In I'm MMOA, we talk about how we do not want to think that successful aging is just related to physical function. Physical function is a really important part of aging frameworks. and successful aging frameworks, but it is not the only thing. And so I kind of want to take this conversation and then take it a step further. So while yes, we see that our masters athletes are able to have a blunting of the changes in physical function that we see with aging, as a consequence of optimizing their physical reserve earlier in life and then maintaining that optimized physical function into later decades. Where we want to also bridge this is towards some of the frameworks that we're seeing with healthy aging. So the World Health Organization put out a healthy aging framework with the idea of having this decade-long initiative that internationally we are going to try to be encouraging healthy aging initiatives because our global population is aging and that is going to put a massive burden on our healthcare system. And there's a lot of things that we need to think about. And so their framework is really brilliant in that they talk about the ability to meet basic needs and the ability to maintain mobility, like their ability to be mobile around their community. And I think our Masters athletes are good examples of what this might look like in order to try and maintain this type of physical function. 14:58 BUILDING RELATIONSHIPS IN AGING But the other three things are important considerations as well and do not relate directly to physical function, but there are some kind of extensions or indirect relationships that we can make. And those are the ability to build and maintain relationships, so that connection, the ability to learn, grow, and make decisions, so autonomy in some ways and purpose, and the ability to contribute, which really kind of ties into that purpose conversation. And if you listen to the MMOA podcast, Ellen and I were just on that platform, if you want to take a look, talking about the blue zones. And this was a series that was done on Netflix that talked about these areas around the world that have a higher percentage of individuals living over 100 compared to global norms. And where they were talking about this was not only related to physical function, where physical function was something that we were considering, but they also talked about some of these biopsychosocial considerations like building and maintaining relationships and that contribution to that other aspect of a person's soul and a person's being. When we look at the Masters athletes and we look at qualitative systematic protocols or systematic studies that are looking at some of the other indirect indicators of what a Masters athlete values outside of their physical performance, they kind of touch on these other aspects of the healthy aging framework. where the ability to maintain relationships, one of the things that can be a big struggle for our older adults, and my grandmother who was in her 90s said this beautifully, she said, everybody I know is dying. And Having, building new friends as a grownup is extremely hard. And so one of the other things that our master's athlete literature is really demonstrating is some of these other bio, or these psychosocial considerations that are just so important when an individual is aging. So what they're showing is that our older adults who are master's athletes continuing to compete have this avenue to build relationships with individuals across different age cohorts that have similar mindsets related to health promotion. And that's so important, right? We see that we tend to take on a lot of the lifestyle factors of the individuals who are closest to us. Our literature shows that if we are around individuals who are in the overweight or obese categories, we are more likely to be overweight or obese. The business sentence is, if you are the smartest person in the room, you are in the wrong room. And that's around this building and maintaining of connections and relationships that also have this trickling effect of helping to sustain healthy lifestyle factors. And this loneliness epidemic is so relevant now for all generations, Gen X, Gen Z, millennials, boomers, and some of our older adults. Like all of this connectedness is such an important part of healthy aging. And we're seeing this in our masters athletes as well. And then finally, this capacity to learn, grow and make decisions and the ability to contribute. Our masters athletes are also demonstrating this because they talk about this capacity with athleticism to combat belief systems around aging, to start tackling some of these negative age paradigms, to be able to have goals related to not only what their performance is, but role modeling their athleticism to younger generations within their family and within their sport. and their capacity to be able to create this mentorship for some of their younger athletes that allows them to contribute very positively to their sport. And so not only are we seeing that physiologically within our systems, our masters athletes are blunting some of the slopes of the line across different organ systems, but we're also seeing some of these indirect psychosocial positive contributions of individuals in the Masters Athlete space that are contributing to this overall belief around Masters Athletes having an ideology around successful aging. 17:23 MASTERS ATHLETES & CHRONIC DISEASE Some of our masters athletes, we kind of consider them to be completely free of chronic disease. And while we do see a lower incidence of chronic disease, like cardiovascular disease and diabetes, for example, in our masters athletes who have continued being active throughout their life, that does not mean that they are immune, but it does mean that when they are diagnosed with things like chronic conditions, that they are better able to manage those disease processes because they have these healthy lifestyle factors that are going to slow down the disease process. So all of these things kind of coming full circle, where we are looking at the master's athlete that while yes, in many of our older adults that we are teaching for clinicians, they are not going to be primarily focused in the master's athlete category. They do give us a lot of insight into the rates of loss in physiological systems and what we can attribute truly to aging versus other confounding variables such as inactivity, sedentary behavior, obesity, chronic disease burden. And then we can also see how some of the influence of these other psychosocial factors, this loneliness epidemic that we are seeing, this connectedness that is needed, this sense of purpose and the capacity to take risk and be a contributing factor to not only their own healthcare decisions, but those of their family and the people around them that are trusting them with their wisdom and knowledge and experience is a way for us to see this positive aging cohort that is also independent of their physical capacity that they are able to maintain. All right, I ended up going a little bit long, but I think this is such an important conversation. And not just for our older adults who are already in these age cohorts, but anybody who is listening, who is thinking about themselves as an athlete. Because we see in the literature that the Masters athlete is defined as anybody who is kind of reasonably beyond the open retirement age, but is continuing to train and compete in sport for the purpose of physical fitness. But in MMA, we think about it as anyone who wants to intentionally move their body towards a goal. And that may be all of you that are listening to this. It's like, how can you put in that master's athlete mindset into your own life to connect with other people with like-minded goals, to be able to optimize your physical function if you are listening and you are 30 or 40 or 50? to maintain that when you are 80? And then how can we do this to help drive purpose in our lives, to allow for that feeling of fulfillment that is just so important to maintain as we get older? All right, if you are looking for more information about research coming out in the geriatric space, I encourage you to go to pti.nice.com slash resources and sign up for MMOA Digest. Otherwise, I hope you have an amazing week and we will talk to you soon. 20:26 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 19, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses a mobilization technique specifically designed for patients with unilateral symptoms. These patients experience tightness primarily on one side of their body and often feel the need to be stretched out, especially in the morning. To address these issues, Zac introduces the concept of mobilization with movement. This technique involves actively moving the affected area while applying a mobilization force, with the goal of improving symptoms and increasing range of motion. Zac then demonstrates a mobilization technique using cups. He explains that the cups will be placed on the region of the patient's back that is most tight or painful. The patient is then instructed to keep the cups on for about a minute, allowing them to acclimate to the sensation. It is important to note that this mobilization technique may not be suitable for all cases of back pain. Back pain can manifest in various ways, and it is crucial to have the right patient in front of you for this technique to be effective. However, if the patient experiences improvement when they forward bend and their symptoms feel better during this movement, the mobilization with movement technique can be beneficial. Zac suggests starting with easy active range of motion exercises and gradually adding more stimulus, such as overpressure or the use of weights. He highlights the versatility of this technique and mention that he frequently uses it in the clinic for patients with similar presentations. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Good morning PT on Ice Daily Show. Zac Morgan here. I'm a division lead with the spine division, so you can find me on the road teaching either the cervical spine management course or the lumbar spine management course alongside of Jordan Berry and now Brian Melrose. Speaking on that spine topic before we jump into this morning's Technique Tuesday, I wanted to just point out the next handful of courses that we have. So we actually have three different lumbar course offerings this weekend. So last minute you want to jump in, we'll be in Richmond, Virginia. Baton Rouge, Louisiana, and then Denver, Colorado. So if you're looking for a last second seat there for lumbar spine, jump into those. If none of those work, we have a few more offerings this year. So in October, the 21st and 22nd will be Frederick, Maryland. So right outside of the DC area there at Onward Frederick. Also have Fort Worth, Texas, the November 4th, 5th weekend, and then December 2nd and 3rd at Onward Charlotte. I have a lumbar course as well. Quickly, just pointing out the cervical ones, and then we'll jump into the content. Greenville, South Carolina, October 14th and 15th. Bridgewater, Massachusetts, that's November 11th and 12th. And then here in Hendersonville, December 2nd and 3rd. So those are the cervical and lumbar offerings left this year. But without further ado, let's kind of jump into the topic this morning. 01:21 TECHNIQUE TUESDAY So this morning I want to kind of bring back Technique Tuesday in the Spine Division. If you've been around forever, like myself, you remember those days way back in the day where Jeff was in his clinic there in Upper Michigan showing some different techniques each Tuesday morning. And those were always really fun to consume because it just gave you some new ideas and things to play with. in the clinic and this morning I wanted to cover a technique that doesn't live in our lumbar course but it is one that I find myself using from time to time. But before we actually jump in and do the technique I'd like to kind of describe who I would do this to because in particular this is a technique that you want to have the right patient selection for. If you've been to the lumbar course, you've heard the stories of derangement and dysfunction. If you're McKenzie trained, you may be really familiar with those terms as well. If you're not familiar, go back a few months to where I did a PT on ice kind of covering these topics about the lumbar spine needs to flex, and that'll kind of refresh you or jump in the live course if it's all completely blank to you. But essentially, technique selection for the right patient is huge here. So what we're looking for is the patient who does have their symptom onset when they flex forward or when they bend forward, they feel their symptoms, but the response to that flexion is the important part. So we're looking for that dysfunction patient or soft tissue extensibility dysfunction, however you like to think of that. McKenzie coined that term dysfunction and essentially the idea being that the soft tissues living on the backside of the spine are not extensible enough and then when the person bends forward and they reach the limit of that extensibility they receive their symptoms. So the real key in diagnosing this person is their response to the flexion. Because if you've been around for a while, if you've seen patients presenting with low back pain, you know that for some folks, when they move into their symptoms, they get tremendously worse. If that is your person in front of you, each time you have them flex, they feel worse, or they lose range of motion, or perhaps even peripheralize symptoms down their limb, that is not who you would do this technique to. Rather, the inverse should be true. So on your active range of motion exam, this patient's gonna come in, and they're gonna present with back pain, Sometimes they might have some leg symptoms, but more commonly back, buttock pain. And you're gonna have them bend forward, and when they bend forward, they'll say, oh Zach, that's my symptoms, I can feel it right there. And often if you observe their lumbar curve while they're forward bending, you'll notice this person does not have that nice reversal of the lumbar lordosis. As a matter of fact, they'll often hold their lumbar spine very rigid as they move forward. So their back will stay completely flat, and they'll just move into hip flexion. Now the key is that you have to have them do that multiple times. So if you have them go ahead and follow up with another rep, what you should see if the patient's a dysfunction patient would be definitely no worsening, but probably more often a bit of improvement. Whereas the derangement patient worsens every time they flex. This person feels a bit better each time you move them into the provocative motion. So for that, we want to treat that with repetitive flexion. So this person needs to restore their lumbar flexion and we're here to help them. So homework often is going to be simple flexion, like just get in a position, flex your back regularly. You can go with a typical McKenzie dosage of 10 reps an hour. You know here at ICE we make those decisions based off of that person's irritability, both psychological and physical. And so dosage is going to play a lot into their irritability. But one technique that I love for this patient is a mobilization with movement into lumbar flexion. Now we see this patient a ton at our clinic because this, you'll see this presentation show up quite a bit with weightlifters. So weightlifters will often have some sort of a flexion injury at some point and then they'll quit flexing their back. So they'll maintain neutral and often they'll even hyperextend a bit to maintain neutral in their back. But one thing's for sure, they will not allow their back to flex. And as with anything in the body, if you don't use it, you lose it. And so over time, this person develops a lot of stiffness and tightness in their back. They have a lot of complaints like that, and they have a really hard time forward bending. The odd part is the solution again is to forward bend. So in homework, I'm going to have them do that in life. Whether that looks like a cannonball position, repetitive standing flexion, it doesn't really matter so much. But one thing I love doing in the clinic is this mobilization with movement. So shout out to Brian Mulligan who kind of conceptualized mobilizations with movements, snags, nags, huge kind of founder in the manual therapy world and really responsible for kind of giving us some of these techniques. But this is one in particular that I find myself using quite a bit. And I actually have a really good patient here in front of you. So I'm gonna have Alexis step in. If you don't know Alexis, she's my wife, better half, and then also faculty in our pregnancy and postpartum course. So Alexis has this problem. She has a really hard time flexing her back. It's typically pretty bad here in the morning, so now is a pretty good time for us to be doing this. 06:06 MOBILIZATION WITH MOVEMENT But essentially what you want to do for this mobilization with movement, confirm it's on the right patient, then have them sit on a table. In general, I would probably bring up the table up a little bit, but this will work. It really doesn't matter if you have a massage table or a high-low. This one's super easy to do. The only item you need is a mobilization belt. and it doesn't really matter so much which one, but I kind of like this blue one for a couple reasons. It's cheap. Um, so this is the Mulligan belt and then it doesn't have that big leather piece that sort of gets in the way for this mobilization and it costs extra that you don't need. So what you're going to do is form a big loop with that mobilization band. So make sure it's in a big loop and it's going to go around you and the patient. So put it around your back first. And then you're going to reach around the patient, clip, make sure that buckle's not contacting them. And then the belt should live right at their ASIS. So you want that belt to be essentially where like the waist part of a seat belt would be on an airplane or in the car, right at the ASIS. Then I'm going to tighten that up to where I've, right now I've got way too much slack in the belt. So I'm going to put, this to where we now have it taut, so it is nice and firm. And essentially what I'm thinking about with the belt is fixing her pelvis to this table. So you can see it's at a little bit of a downward angle. not completely parallel. If I was completely parallel, I'd be pulling Alexis back towards me. I want this downward angle with the belt to kind of fix the pelvis down to the table. From here, the mobilization is super easy and simple. Sometimes I'll start out without even mobilizing, but just fix the pelvis and then have the patient move through some active range of motion and deflection. So what Alexis is doing is she's just reaching her fingertips towards her toe here, trying to allow this part of her low back to really relax. and just move forward. So typically this is how I would start someone out here. Rather than cranking on them immediately, I'll just allow them to access whatever flexion they feel comfortable with and just move forward. And you know at ICE we like to pump. So we're usually going pressure on, pressure off. We're hitting that in range position and then coming out. Let's say 10 or so reps have gone by and she's continuing to improve each time we do this. She likes the feeling of the stretch. That's where I'm going to add my pressure or my mobilization force. Now I've seen this technique taught segmentally specific where you find the exact segment that you feel is reproducing the patient's symptoms and drive on that. But I'll be honest with you all. I'm typically not the guy that's in there with my thumbs on a specific segment. Rather, I use my whole hand to give nice broad force. If the problem's in their thoracolumbar junction, my hands are typically right here around the bottom of the ribcage, pushing forward. But, go ahead and come on up. If the problem's a little bit lower in the lumbar spine, my hands are just gonna live a little bit lower. So I'm not putting any segmental pressure here. What I am doing is just essentially pushing into flexion in the region of the back that I feel is provoking the symptoms. So don't overthink your mobilization force. Just very gently add pressure all the way to in range and then come off. Super, super simple. I find just as much success being very regional as I do being very segmentally specific. So don't overthink this one. This is just repetitive motions with overpressure. Very nice way to loosen up the lumbar spine. typically this patient loves it. 10:08 LOOSENING UP THE LUMBAR SPINE Now a couple little nuances here with this technique before we finish up. Sometimes you're going to have a patient who is more of a unilateral restriction. So they're going to mostly complain of right-sided back pain and it's going to be mostly tight on their right side but not so much on their left side. For that person, you want them to forward bend and reach to the left. You want all of these tissues to open up. So Alexis is now forward bending and grabbing her left ankle, and you can see that that would open up this side, and it gives you the really nice ability to just kind of push and open up kind of that QL, all of the lumbar extensors, everything sort of living on this side of the back. So for those more unilateral restrictions, come on out, She's liking that position, that's why she's hanging out there so long. For that unilateral presentation, sometimes I'll do this mobilization a bit unilaterally as well, but just some nuances that you can play with. 13:33 MOVEMENT WITH CUPPING The last piece that I wanted to show you all is just a way to increase the vigor a little bit, and kind of give the patient that perceived stretch, because often this person is gonna tell you, when they wake up in the morning, I feel really tight, and I feel like I need to be stretched out. And so we want to kind of match that feeling So for that I want to expose their back a little bit and I'm going to add some cupping. So what I'll do with cupping is I'll kind of take my cups, find the region that seems the most tight or painful to the patient, and then I'll fix these cups on them, have them hang out with the cups on. I'm not gonna do that on the video, but for a minute or so, just to sort of acclimate to having these on their back. And then after a minute or so goes by, they're gonna move through those same flexions with the cups on. So I'll show you real briefly just a couple of those. Always use a little cream when you're using cups. It's much friendlier. to your patient. But essentially what we're going to do is fix that cup on her back. That already gives her a bit of a sensation of stretch. These are over the lumbar extensors and they're in the region that's been provoking her symptoms, the region she feels the most tight. Now again, a minute or so would go by. We would make sure she felt relatively comfortable here. with the cups on before we moved, but let's say that minute has passed and I'm ready to go ahead and move through some more range of motion. The cups are still on. Now my belt is in the exact same position and Alexis is doing the very same thing. So she's just forward bending. I can even add some more pressure if I like, or I could slide these cups around and see if I could isolate the exact area that feels the most stiff. appreciate that this is definitely a higher vigor than where we started with. So you want that person to have lower irritability at this point. You want to have seen some good symptom response prior to progressing to this much vigor. But if you're seeing good success and you want to up the vigor here, cups are a really nice way to increase the stretch to that region. So in summary, No one technique is good for all back pain. Back pain presents a bunch of different ways, and you've got to have the right person in front of you if you expect it to work. So for this technique, if the person improves each time they forward bend, their symptoms feel a bit better when they move into them. you want to move into those symptoms with your treatment, and that's where this mobilization with movement is really helpful. You can start out really easy with just active range of motion. You can then add some overpressure. If you want even more stimulus, you could add some cups, or better yet, even have them hold a weight in front of them and have that weight drag them down. Lots of creative options here with this mobilization with movement, and just one that I find myself using quite a bit as we see an awful lot of folks who have this dysfunction presentation. Team, hope to see you on the road at some point. We are out and about a bunch throughout the rest of this year. Jump on ptonice.com and jump into any of the live courses that are in your area or ones that are on your list. Keep your eyes peeled for future announcements with ICE. Lots of cool things on the docket coming out here in October. So I will see you again here soon in a month. Until next time, hit that mobilization with movement. 14:29 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 18, 2023

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan emphasizes emphasizes the significance of comprehending your own body and the process involved in utilizing the pelvic floor. Without this understanding, it can be challenging to educate and support others in this area. To better understand and utilize your pelvic floor, Alexis suggests a five-step process. The first step is to "tell" the actions of the pelvic floor, which involves becoming familiar with its location and functions. Alexis uses the analogy of an A-frame house to explain the contraction and relaxation of the pelvic floor. The second step is to "demo" the actions of the pelvic floor. This can be done through videos or using a pelvic model to visually demonstrate the movements. The purpose of this step is to help individuals visualize and better comprehend what was explained in the first step. The third step is to "practice" contracting and relaxing the pelvic floor. Alexis encourages listeners to pay attention to any sensations they feel when they contract their pelvic floor. During virtual sessions, she advises being mindful of any additional body movements that may occur during the contraction. The fourth step is to "ensure" that the individual is correctly performing the pelvic floor movements. This step involves confirming if the person felt the intended movements and if they understood the instructions. If there is any uncertainty or confusion, Alexis emphasizes the importance of not progressing to the next phases until both the individual and the instructor are confident in their understanding. Lastly, the fifth step is to "progress" in using the pelvic floor. Alexis mentions that this five-step process may not occur in one session and that it may take time before individuals can confidently progress. However, by understanding their own body and going through these steps, individuals can develop the knowledge and skills necessary to effectively assist others in utilizing their pelvic floor. Overall, the episode highlights the significance of understanding one's own body and the steps involved in using the pelvic floor in order to effectively educate and assist others in this area, as well as provide meaningful care virtually. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code IcePT1MO at sign up to receive a one month grace period on your new account. Thanks, everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 ALEXIS MORGAN Good morning, PT on Ice daily show. My name is Dr. Alexis Morgan, and I am here today representing the pelvic division. Happy Monday. I hope you all had a wonderful weekend. Let's discuss a huge topic that is virtual care this morning. Virtual care is something that really grew a lot during COVID. and we all kind of had to pivot, right, and try to figure out, okay, how exactly is this done? One of the areas that I feel like is potentially the most surprising about doing virtual care in is pelvic floor health, pelvic floor assessment, pelvic floor physical therapy. A few weeks ago, I did a PT on ice, about the virtual care and the subjective exam. And did a whole entire podcast on that, did not have time to discuss the objective assessment. So today I'm hopping back on to discuss how we do the virtual objective assessment. If you missed last time's podcast, go ahead and rewind back about a month and look for that. that virtual subjective care, because that's gonna be important and of course it's gonna lay the foundation for this pelvic floor assessment in the objective category. So, let's go ahead and just dive right in to exactly what we teach and what we do for that objective exam. We talked last time, and we talk all the time in pelvic health, that we are educators, that we really teach people how their body works and we teach them the truth about their bodies when in fact they've read unfortunately online and in magazines and on YouTube and in various forms they've heard lies. They've heard myths and they've heard misconceptions. It's very confusing. It's a confusing area of our body. And we get the opportunity to be educators. Part of this objective exam, when we are virtual, is education. So here's how it goes. It's really a five-step process. Number one, tell. Number two, demo. Three, practice, four, ensure, and five is progress. So let's dive into each of those categories. 04:47 ACTIONS OF THE PELVIC FLOOR So with tell, number one, first you're gonna tell them the actions of the pelvic floor. You're gonna essentially get them oriented with where the pelvic floor is and what it does. You're teaching, you're telling. So you're gonna tell them the actions of the pelvic floor, right? So when it contracts, it goes up. We use the analogy attic, first floor, and basement of the A-frame house here at ICE. So tell them that. So when it squeezes, it goes up into the attic. When you're just chilling, you're hanging out at first floor. We're just at rest at that first floor. That's where life is. happens when we're just chilling. Then we go into the basement. And that basement is the downward movement towards the feet. The holes expand, they enlarge. That analogy is helpful for someone to understand, helpful for them to kind of visualize that. But generally, that analogy isn't quite enough. And because in this objective exam, you know you're not gonna get to give them direct feedback, direct visual or tactile feedback, you've gotta go that extra step. So step number two, so step one was tell. Step two is demo. So you're gonna demo with maybe a video or your pelvic model that you have. Help them visualize what it is that you just said with that analogy. So looking at the pelvic floor, when it squeezes, it goes up towards your head. When it relaxes or an effortful relaxation, it opens up and goes away from your body. That's demo. So they can actually see. So tell and demo these two work hand in hand together. Step number three is practice. So you're gonna ask the client, okay, I want you to practice that. Go ahead and contract your pelvic floor. Do you feel anything? When they are contracting, you're looking for on this virtual call, you're looking for any kind of extra little body movements that they may have. If they're holding their breath, if their entire musculoskeletal system rises, they're doing too much. They're putting way too much into that. And so you can cue them and have them, okay, can you, can you do a similar thing? Can you still raise your pelvic floor? But can you do it with your entire body? relaxed. Just move your pelvic floor, even if it's a little bit less of a muscular engagement practice. You also want to have them do the opposite. So you had them go into that attic. Now you want to have them go into that basement. If they had trouble going into the attic, we definitely want to just move on and go to the basement because maybe they'll feel that a little bit better. So we go into the basement and we say, okay, I want you to bear down. I want you to push towards your feet. I want you to open up those holes, whatever language they need, and you wait for them to feel that. So we're talking them through this practice, but that's not really all. We've got to go on to step number four, which is ensure. So, you've got to ensure that they're doing what you both think that they are doing, what you both want them to be doing. You've got to ensure. So you're gonna ask them some questions, like, okay, so we talked about how it contracts, it closes up, and it goes, your pelvic floor, when you squeeze, raises up, like towards your head. Did you feel any of that movement? Are you sure that you felt it go up? Can you feel the difference between up and down, between that attic and that basement? Can you feel a distinct difference? If they can, I'm still reading their answers, and if they're saying, yeah, yeah, I think I felt that, I'm not convinced with that. I'm not convinced with a little question mark sounding. Yeah, I think I felt that. What we want to hear is, yes. Yes, I felt it. It wasn't strong. I didn't feel much, but I definitely felt a difference in that direction. We want to hear that. Because from that, we can then progress them. Number five. progress them to teaching what the pelvic floor should be doing in their problematic movements. Whether that is double unders, squatting heavy, catching a clean, whatever that might be. We want to teach them what their pelvic floor should be doing. That's again beyond the scope of this of this podcast this morning and please come on to our courses where we can really dive into that. But realize that that five-step process does not always occur in one session. So tell, demo, practice, and ensure absolutely will go hand-in-hand together. But it might be a while before you can progress. because if that person who's like, I think so, I think I felt that, or maybe they're saying like, I didn't feel it at all. I really don't know what you're talking about, Alexis. I didn't feel that. If neither one of you are sure that they felt those movements, you can't go on. You can't go on to the next phases because they have no idea. This little area of their pelvis is like a black box. They can't feel it. They can't move it. How are we supposed to rehab it? We've got to give them homework. We've got to give them projects to work on to be able to feel that. Some examples that I use is I'll send them with a mirror. to look at their pelvic floor to see if they see that movement. Or they can use their finger. They can use a finger and insert it vaginally and feel those differences. They can feel that pelvic floor move. Just getting to the point where they can feel that mobility is a really big improvement and can get them to where they can feel that elevation and that depression of the pelvic floor. So a visual tool for them or maybe a tactile tool for them with their finger. That's kind of a double tactile cue, right? They can feel it with their finger. They can also feel it in their pelvic floor. You might go with just a third option, a single tactile cue. So rolling up a washcloth and sitting on top of that. or straddling over the top of a bouncy ball to be able to feel a little bit of the difference. One of my most commonly used ones for the single tactile is actually tell them to sit in a bathtub where it's super, super still and work on feeling those movements. 13:15 USING WATER AS A TACTILE CUE Because of the pressure of the water, and the stillness of the water, they can actually feel any slight movement, particularly if it's still and if it's quiet in there. So that's one of my favorite ways to send them home with Homework, to try to get to where they can feel that movement, they can actually engage their pelvic floor, and they can discern the difference between a contraction and that effortful relaxation, or the attic and the basement. You send them home, you repeat all of this on the next visit in about a week or 10 days. Give them that practice to do and follow up with them soon on this, and you're gonna go through that same thing. tell, demo, practice, ensure, see how their confidence is, and then potentially at that point, then we progress. Then we move on to their positions that challenge them or their movements that challenge them, and we educate accordingly. I hope that was helpful for you all to utilize in your own practice and realize that It is challenging to do this if you don't understand your own body and if you don't understand all of these steps. So if you're listening to me today and you're like, I don't really understand how to use my pelvic floor, then you go through these steps. And I guarantee you that when you flip to the other side and you're talking others through this, you being able to relate to them is really going to be able to help. and you can understand that client so much better. Thank you all so much for joining today. I hope this was helpful. I hope you all have a wonderful week. This weekend, I'm gonna be in Scottsdale, Arizona with a whole lot of you all. We are so excited to join you all for the two-day live course. We're gonna have a blast down in Arizona. We've got several upcoming courses. So be sure to take a look on ptonice.com and be sure to register for our newsletter. Everyone always asks us, how do I find out more information? How do I stay up to date on the research? How, how, how in this fitness forward pelvic health world that is ice pelvic, The way to do it is to register for the newsletter. It comes out every other week, every other Thursday, and we give you all the goods there. So be sure to sign up for that, it's absolutely free. And of course, come on over to our courses, our live courses, and we're rolling out our last online course of the year right now, and we're gonna start fresh in the new year. So we are really looking forward to seeing you all out on the road or online. Thanks for being here. 16:42 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 15, 2023

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance (or not!) of ground reaction force as it relates to running related injuries. Megan discusses research evaluating the association between ground reaction forces & running related injuries, noting that these forces do not seem to be directly linked to the onset of injuries. Furthermore, Megan shares that footwear that decreases ground reaction forces does not also seem to have an effect on the development of running related injuries. Megan cautions listeners to not worry too much about the manipulation of ground reaction forces in training or in rehab as the link to injury prediction seems to be poor. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app/physicaltherapy. Thanks, everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 MEGAN PEACH So what I want to talk about today is ground reaction force and how it relates to running related injuries. And we need to be a little bit cautious, I think, when we're talking about ground reaction force and how it relates to those injuries, because I think the popular opinion is that ground reaction force really is kind of the cause of running related injuries, or we need to address ground reaction forces when we're addressing running related injuries, or we need to reduce it And what the literature actually says is that it's not really the case. And so I'm going to give you a couple of examples from current literature that may tell a different story from popular opinion. So we'll start with a 2016 article. And this was actually a systematic review meta-analysis. So it pooled a lot of different studies. And what it looked at was the association of a ground reaction force with running-related injuries. What they found was that when they pooled all of the injuries together, loading metrics, so loading variables like ground reaction force or loading rate, were not necessarily related to running-related injuries when all of the injuries were pooled together. It was a bit of a different story when they individually looked at separate injuries. where they took out patellofemoral pain, they took out bone source injuries, they took out Achilles tendinopathy, for example. And what they found was that the vertical loading rate was associated with subjects or was related to the injury in subjects with tibial stress fractures. And so different outcomes there when we pool the running related injuries versus when we look at them individually. Another more recent study, so 2020 now. looked at about 125 injured runners, and they compared these runners to healthy controls. And what they found in this study was, contrary to the previous study, was that when they assessed the whole entire group of injured runners as a whole, so all of the injured running injuries together, what they found was that the impact variables, so vertical loading rate, ground reaction force. They were associated with running-related injuries when all of the subjects were pooled together. Different results when then they separated out the running injuries and looked at them individually. 03:59 IMPACT VARIABLES And so when they took groups of running-related injuries, groups of patellofemoral pain, groups of IT band syndrome, groups of Achilles tendinopathy, et cetera, what they found was that some injuries were associated with impact variables and some were not. And so the injuries associated with impact variables were our patellofemoral pain, our plantar fasciitis, And the injuries that were not associated with impact variables were tibial bone stress injuries, Achilles tendinopathy, and iliotibial band syndrome. So when we take a step back out of that space and think about our injured runner on the treadmill looking at their gait mechanics, when we have a injured runner with patellofemoral pain or plantar fasciitis, and they're on the treadmill, what we would expect to see in terms of faulty gait mechanics are faulty gait mechanics in the sagittal plane. So looking at that runner from the side, very typically or commonly we'll see clinical patterns of an overstride, we'll see a lack of knee flexion at initial contact, and we'll see an increased angle of inclination, so increased dorsiflexion at all at initial contact. in the runners with patella femoral pain and plantar fasciitis. So very common, not always. And it's not like that clinical pattern can't be seen in other injuries as well. It's just very common in those two injuries. And that makes a lot of sense because that clinical pattern is very much associated with increased ground reaction forces as well. So it would make sense that within this study, when we separate out all of the injuries and pull them as separate injuries and look at them, that those two specific injuries would be related to ground reaction force. When we also look at the other injuries, so IT band syndrome and Achilles tendinopathy, and we get those runners on the treadmill, we see different clinical patterns. So more likely in those runners, are we going to see movement faults from a different angle? We're likely to see um, faulty movement in more of the frontal plane and, and maybe kind of surrogate transverse plane movement faults as well. So we would likely see, um, increased femoral adduction, maybe internal rotation of the lower extremity, uh, potentially this crossover sign or a narrow, um, foot to center a mass, maybe over pronation. Those are very, very common mechanical faults that we might see with, um, your IT band syndrome and your Achilles tendinopathies. And so when we think about those movement patterns, those are much more associated with range of motion deficits. Maybe they have too much, maybe they have too little. Neuromotor control of that range of motion, maybe strength deficits in that frontal plane, but much less associated with the impact variables like ground reaction force and loading rate. So it makes sense from this study that those specific injuries, the IT band syndrome and the Achilles tendinopathy from like a clinical standpoint would be less related to ground reaction force than the other already previously mentioned injuries. So then when we take tibial bone stress injuries and we look at that, it's kind of in a group all of its own because when we look at bone stress injuries, and I'm talking more specifically to tibial because we just don't have enough information on the other common bone stress injuries like metatarsal or femoral. Most of the research right now is on tibial bone stress injuries in terms of biomechanics. And so when we consider a tibial bone stress injury and whether or not it's related to ground reaction forces. We have to look at the forces on that bone. And so ground reaction force is just one component of the force, the total force on that bone. And it's the external load. When we look at the internal load, it comes from muscles. And so when we're talking about the tibia specifically, we're generally talking about the soleus because it's directly attached to that tibia. And when the soleus contracts, it imparts this internal load directly onto that bone. So it's considered an internal load. When we look at the differences between the external load and the internal load, the external load during running activity or the ground reaction force is generally about two and a half to three times body weight of that runner. But when we look at the internal load, it's upwards of eight times body weight for that specific runner compared to the two and a half times for external load. So you can see how the internal load in a tibial bone stress injury is going to play a much greater role in the development of that bone stress injury than the actual external load coming from that ground reaction force. So again, the results from this study suggest that ground reaction force doesn't really play a big role in, um, tibial bone stress injuries. And that is consistent with the rest of the literature as well. Um, there was a systematic review about a decade ago, looking at ground reaction forces in, um, bone stress injuries, tibial and metatarsal and their conclusions were, um, supportive of this result as well, where they found that ground reaction force is really not related to the development of, um, bone stress injuries in runners, as well as more recent literature has basically corroborated that and their results are very, very similar. Now, a more recent study, so one published just last year actually, looked at 800 runners Um, now that's, that's insane for our running study that those are huge, huge numbers. And so initially I was thinking, okay, this was a survey study. Like they sent out a survey to a bunch of runners and they got it back and they figured out some results from the study, but no. they actually got 800 runners and put them on a treadmill, did their motion capture, and then evaluated it all for ground reaction force and biomechanics. And so that's a tremendous amount of work, a tremendous amount of data, and really interesting results as well. And so really, the big purpose of this more recent study was to look at um, risk factors, uh, for running related injuries in two different shot conditions. And so one shoe was a, uh, like a hard cushions shoe and one shoe was a softer cushion shoe. And so they're looking at the differences in risk factors between those two different shoes and, um, interesting results. So while they did find, uh, different risk factors based on the different shoe condition, what they didn't find was any of the loading variables, so there were numerous in this study, but the big ones are ground reaction force and loading rates. And they did not find any association with the loading variables and in either of the shoe conditions and risk for injury. So basically, what they're saying here is that regardless of the type of shoe that that runner is wearing, or those 800 runners are wearing, 10:41 GROUND REACTION FORCE & RUNNING RELATED INJURIES Ground reaction force did not play a role in the development of that injury, which is super, super interesting because I think often we associate different shoes with different ground reaction forces as well, but that's not necessarily the case. And that's not what the literature is telling us. And so. all of this literature combined. And certainly this is not all the literature. It's not all encompassing. And these are, these are just four different studies. Um, so take that with a grain of salt, but I think there's, there's this popular belief out there that, um, ground reaction force is very closely related to the development of bone stress or not, sorry, not bone stress, but running related injuries, regardless of the type of running related injury. And I think we can look at studies two different ways. And so In one way, we can look at the study as a whole and take all of the running-related injuries and pool them together, and then look at the results from there. But those results tend to be very, very different from when we separate out running-related injuries and say, okay, what do the patellofemoral pain injuries look like, and what are the mechanics for Achilles tendinopathy, and how are they different from IT band syndrome? And when we do that, we actually get very different results, not only for the biomechanics, but for the ground reaction force as well. And so, you know, contrary to popular belief, I don't think impact variables like ground reaction force are a very good predictor for running related injury, nor may they be. And again, this is different per injury. So they may be something to address in injuries that are definitely related to ground reaction forces like patellofemoral pain, plantar fasciitis, plantar fasciosis. But ground reaction force may not be the best thing to try to address with other types of injuries like bone stress injuries or Achilles tendinopathy or IT band syndrome. And I think the main goal here is just to get the point across that it's not the only metric, and quite often we don't actually have access to that information anyways in a clinical setting. It's more in a lab based setting, but we need to look at that whole runner. So we need to not only address if we are addressing ground reaction force, but address the range of motion, address other running biomechanics, address the strength, address the neuromotor control, so that we can basically address that runner as a whole. Okay, that's all I have for you today. I hope that was helpful. I hope you have a wonderful Friday and a wonderful weekend. Don't forget, if you want to sign up for Rehab of the Injured Runner online, our last cohort of 2023, make sure you get in there. Go ahead and sign up today. All right, have a good one. Until next time. 14:39 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 14, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the concept of excessive humility and being overly open-minded, discussing how it can hinder individuals from taking action and being useful. While acknowledging the importance and benefits of open-mindedness in considering different perspectives and possibilities, Jeff also points out that excessive open-mindedness can render one unable to take stances or make decisions, rendering it useless. Jeff emphasizes the need to strike a balance between open-mindedness and the ability to take a stance. He cautions against being so open-minded that one loses their ability to make decisions and take action. Excessive open-mindedness, according to Jeff, can lead to a lack of direction and clarity, making it difficult to make progress or contribute effectively. Similarly, Jeff addresses the issue of excessive humility, particularly in relation to feeling inadequate to take action due to a lack of knowledge. While it is important to acknowledge and respect the limits of one's knowledge, Jeff argues that excessive humility can be detrimental. Constantly waiting for more information or certainty before taking action, they assert, can result in paralysis by analysis and prevent individuals from being useful in their professional careers. Jeff encourages individuals to have a level of humility that allows them to act even in the presence of uncertainty. Jeff highlights the importance of being willing to make choices and decisions, even if they may not always be perfect. By embracing the imperfection of action and remaining focused, individuals can gather data and fill the gaps in their knowledge. This approach allows for continuous improvement and growth while avoiding the pitfall of doing nothing. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Okay, team, what's up? Welcome to Thursday. Welcome back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always thrilled to be here on Leadership Thursday. I cannot wait to jump into this topic about choice and the need to make one. Before we do, it's Gut Check Thursday. Let's not ignore the workout. Let's talk about it. Let's take it on head on. It's a doozy. We've got five rounds for time, okay? We've got 12 handstand pushups, nine toes-to-bar in six squat cleans. Okay, it's gonna be at 155, 105, so a little bit heavier than we usually encounter our cleans in Gut Check Thursday, but the volume's a little bit lower there on that set. Five rounds of that for time, bang that out, you're probably gonna have some rest on the handstand push-ups and the heavier squat cleans. Try to keep moving steady, make sure you tag Ice Physio, hashtag Ice Train, we love tracking those videos. Get it in, it's Thursday, get the work done. All right, upcoming courses, I want to highlight CMFA Live this week. We've got Newark, California coming up. I think there's only two spots left in that course. That's with Zach Long and crew. It's going to be September 30th, October 1st, so in a couple of weeks over in California. We've got Linwood, Washington coming up October 7th, 8th, and then down in Hoover, Alabama, November 4th, 5th. So if you want to get out on the road, learn all things barbell movements, get into some basic gymnastics, talk about programming, demystify a lot of things around resistance training. That is the course you need to be in. It is, of course, part of our CMFA certification, which includes Essential Foundations, Advanced Concepts, also known as Level 1 and Level 2 on the fitness athlete side. And, of course, during that live course, you get testing in person if you want to obtain that certification. So hit that up. PTonICE.com is where all that good stuff lives. 02:16 YOU HAVE TO CHOOSE Let's talk about the topic. You have to choose. Team, it has always driven me nuts. From the very, very first entrance into my professional career, this comment or idea of more research is needed has always driven me crazy. Now, I don't mean from the actual research side. Like, I get the idea of why that statement is made, at the end of papers, like, hey, to get to a certain level of statistical significance or confidence, we have to have more data, right? Totally understand where that comes from in the research world. But the ridiculous incorporation or discussion of that into patient care has always blown my mind, right? So you see so many folks saying that, we don't know, we don't know, we don't know, as though we can't do anything. This is absurd from a patient care perspective. Like, I always imagine these people, like, are you really sitting in front of your 8 a.m. and saying, hey Lynn, I know your shoulder's really bugging you. Problem is, the jury's still a little bit out on the best rehab for this until we know, we're gonna pause here, I'm gonna have you come back. Like, are you really doing this all day, every day, every 30 minutes with a new patient? Of course not, it's absurd. To be of any use, we must decide and act in the presence of uncertainty. This is true literally everywhere in our lives. It is obviously true in patient care, right? We've got to do something for Lynn, right? We know it's not gonna be perfect, but we've gotta act with the knowledge we have and do our best. We have got to decide and act in the presence of uncertainty. And this goes so far beyond patient care. This is true in every aspect of our professional journeys and lives. We've gotta be willing to say, we've gotta be willing to choose to say, From what I've learned and experienced thus far, I currently believe X. I don't care what domain you're talking about. I don't care if you're talking about business, sports, hobbies, patient care, nothing moves forward with waiting. I was thinking about this last weekend. So for those of you who haven't followed my recent journey, I'm getting into enduro motorcycling, right? So I'm signing up for some races next year and I'm terrible at it. So this weekend I'm up in the mountains and I'm flying down this trail, moderately out of control per usual, and having to choose lines in real time, right? So you're coming up on obstacles, going relatively fast, thinking I've got to do something in real time in this moment. I have to choose. Now, knowing full well in that moment that if I was to go back to that same trail two years from now, I have no doubt that I would choose a different and by different I mean better line because I'll be better at the activity. But that does not mean right now I don't have to choose. I just have to choose, thinking with the experience that I have, what is the best way to move forward, knowing full well it isn't going to be perfect. In a couple years when I come back, I'll choose something different. This is the process. Just because you know down the road, you will know more and do better, doesn't mean right now you do nothing. not in patient care, not in business, not in sport. Yet, people are always trying to remain neutral and I want to discuss a few of the reasons why they do this and I want to challenge them a little bit. So, number one, people are often proud of themselves for being open-minded. What I would say is excessively open-minded. Being open-minded is great. Always remaining vigilant that better options are out there and keeping an eye open that you're not missing them because you're so tunnel-visioned, that's great. But being excessively open-minded to the point where You say, yeah, I'm open to that, I'm open to that, I'm open to that, I'm open to that, I'm open to everything. 06:23 "AT SOME POINT, BEING SO OPEN-MINDED IS HAVING NO MIND AT ALL" Well, at some point, being that open-minded is having no mind at all. And having no mind at all isn't useful to anybody. Being open-minded is great. Being excessively open-minded to the point where you can't take any stances is useless. And you've gotta be careful of which side of that line you're on. Number two is excessive humility about what we don't know yet. People love to say, yeah, but we aren't sure yet. We will never be sure. That's the nature of the game. So while, again, some of that humility is useful, so you're not excessively betting on something that you truly don't have the requisite data for yet, understanding that we are never gonna hit a point where we say, we are absolutely certain about this, Knowing that and owning that will allow you to act even in the presence of some level of uncertainty. So this excessive humility of, we never know enough to do anything, again, simply isn't useful. Number three. People don't wanna be seen as falling into a guru camp, and there's some good reasons for that. Looking back historically, and again, speaking to physical therapy, it's the area I know the best, there have certainly been plenty of extremists in guru camps that have led the collective astray, no doubt, but don't be one of those. You don't have to be an extremist in a camp to go in and say, hey, I think most of what's going on here is pretty useful. There's no reason you can't go into it with that frame of mind. But people are so afraid of being labeled, of being in this camp, or that camp, or that camp, that they stay, again, doing nothing. And unfortunately, doing nothing doesn't serve anybody. Number four, they don't want to step on toes. Once you say, hey, I believe this, you are naturally going to rub some people the wrong way because now you've committed a bit. You've said, I kind of looked at everything that I could and I'm going to go this direction. I think this makes the most sense. Well, other people that made other commitments are going to be rubbed the wrong way by that. If that is not happening, you are not doing anything of merit. If you are never rubbing anybody the wrong way, I can promise you, you aren't moving anything forward in a relevant fashion. So reflection point number one of this episode is are you doing that? In the past couple years, have you rubbed some folks the wrong way? I mean, give this some serious thought. Like really think, have your stances, have your actions bothered some folks? If that answer is no, you're not standing for anything. And if you're not standing for anything, you're not being useful. So just give yourself a little pause today and really think, like, am I committing enough that people who have made contrary decisions are a bit bothered by that? That should be a constant in your life. As you're working through decisions and emerging and making choices, some people aren't gonna love those, and if you aren't feeling some of that pushback, I think you're holding yourself back and trusting yourself and making commitments that actually allow you to decide and move things forward. But the number one reason is I look at folks who are forever trying to stay in this kind of neutral ground that I really feel this static posture doesn't get anybody anywhere is because they don't want to be wrong. They don't want to be wrong. They don't want to look back in two years and know the line they took on that motorcycle trail was the worst one they could have chosen. They don't want to be wrong. They're perfectionists. Team action is always imperfect. Action is always imperfect, especially in hindsight. There is not a single action you are ever gonna take that you're gonna look back with five more years of data and say that was perfect across every domain. That's never going to happen. So if you can't embrace that you're gonna be wrong, at least in some percentage, every single time you make a choice, You are forever going to be paralyzed. It will be paralysis by analysis for the rest of your professional, business, patient care career. You've got to get over that. You've got to embrace that every single action will always be looked back as imperfect, and that is a beautiful part of the process. That's what allows you, as you recognize that, to alter it, shape it, and make it better. This is the process. 10:55 "IF YOU CAN'T CHOOSE IMPERFECT ACTION, YOU CAN'T CHOOSE ACTION. PERIOD." But if you can't choose imperfect action, you can't choose action, period. And that's a problem if you're trying to be useful as you're moving forward. Bottom line is this, the people that I've observed who have been the most useful, and of course, the most useful meaning the most successful, because these two things tend to go together. You provide a lot of value, you're useful, success follows, are always those who took really deep dives. They said, I think this makes a bunch of sense, I'm going all in. Like I'm gonna learn as much about this as I can, I'm gonna try to replicate it, I'm gonna try to leverage it, I'm gonna try to use it. But as they're doing that, they're aware and okay with acknowledging the shortcomings of that model. So that they can in real time be seeking out solutions to fill those gaps. They're learning through action, which necessarily followed decisions, choosing. You have to do anything besides nothing. You have to do anything besides nothing, because if you don't get out there and go, you can't evaluate the shortcomings, because you aren't doing anything. The people that I see that act with the most, again, it's not arrogance, it's not even confidence, it's out of necessity to act. They know they have to say, I know this isn't perfect, but I have to go anyways. Those people that are willing to be in that space, first of all, provide the most value, and absolutely learn and refine at the highest rate of speed, simply because the data's now coming back at them because they're out there. And because they're out there, it's a bit vulnerable and emotional, and you tend to learn a ton in those phases. Now, all of that being said, Your decisions should always change. This is a critical part of this conversation, right? Your decisions should always change with emerging data. If they aren't, you're just being arrogant. And now you're falling into the other side of the problem, which is not having one eye open. If your decisions aren't changing consistently, if that's not just a part of your growth and process, where you look back and say, ooh, shoot, should've done, now that I know better, I'm definitely gonna do better because that was imperfect. If you are not regularly doing that, you are also going about this process wrong, but on the other side, right? Remaining blind and over-trusting your actions. So reflection point number two of the episode is have they? In the past couple years, Have you reversed course on a couple of key philosophies, beliefs, decisions, directions? If not, I think you're erring on the other side, where you're not keeping one eye open. You think your action's perfect. You aren't aware of the imperfection and looking for the gaps. You're going in blind. This is every bit as errant, maybe even more dangerously, than the former. In this case, not only are you probably not being as useful as possible, but you're probably leading folks excessively astray by not being aware of what's emerging. So reflection point number two is are you every couple years realizing something you believe strongly had some pretty significant flaws and are you willing to incorporate emerging data to change them? Team. If you aren't willing to embrace that action's always imperfect, you're never gonna choose, decide, and move forward. If you don't do that, you can never get the data that fills the gaps of what we don't know that you're so concerned about, it's holding you back from action to begin with. Trust that your intentions are good. Remain focused. Humble in the face of everything emerging, so you're not totally just tunnel visioned in one direction. Allow that to shape your actions, but make sure that you're actually playing the game. So when you get information, you can modulate in real time, forever become better, but always stay away from the pitfall of doing nothing. 14:49 "PARALYSIS BY ANALYSIS IS THE ONLY WAY TO ENSURE YOU'RE USELESS YOUR ENTIRE PROFESSIONAL CAREER." Paralysis by analysis is the only way to ensure you're useless your entire professional career. Do anything besides nothing, stay humble, be ever evolving, but be willing to choose. You'll be wrong. I guarantee it. Me too. Let's be wrong bravely and let's adapt in real time. You have to choose. I hope it makes sense. Hit me up with questions, comments. Thanks for being here on Leadership Thursday. PTOnIce.com where everything lives. We'll see you next week. Cheers, team. 15:28 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 13, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the book "Radical Candor" by Kim Scott as a valuable resource for improving patient care and leadership skills. Jeff highlights the book's teachings on radical candor, including its definition, common pitfalls, and practical application in patient care. Jeff emphasizes the significance of caring personally for patients and challenging them directly. Caring personally entails demonstrating genuine concern for the patient's life and goals, while challenging directly involves establishing and upholding standards and expectations that contribute to the patient's success. Jeff believes that this book is relevant to patient care and can assist clinicians in becoming better leaders for their patients. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a wait list, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 JEFF MUSGRAVE Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave. I'm one of the faculty with the Institute of Clinical Excellence in the Geriatrics Division. We call modern management of the older adult. Super excited to talk to you about a book that I recently read called Radical Candor, written by Kim Scott. This is a great leadership book, but it has some direct correlation to ways that you can improve your patient care, okay? So super excited to talk about radically candid patient care with you this morning. But before we get into that, just a couple things going on in the MMOA division. If you're looking to continue on to get your MMOA cert, Our next cohort of Essential Foundations is going to be on October 4th. If you've already had Essential Foundations, you're looking to get into Advanced Concepts, you're going to want to hop in the cohort October 10th, and if you want to see us on the road, there's still some spots in Oklahoma City for this weekend. 02:55 RADICAL CANDOR IN PATIENT CARE So, this book, Radical Candor by Kim Scott, what does it have to teach us? The things we're going to cover is what is radical candor. We're going to talk about some of the ways we sometimes miss a mark. This is going to hit home for me because one of these downfalls is something that I have succumbed to time over time and have been working to improve. And then how to apply this well in patient care and some things to consider. So, what is being radically candid? What does that mean? So, Kim Scott defines this in the book as two factors. Two factors to being radically candid. You've got to care personally. You've got to care personally. I think oftentimes, if you're listening to this podcast, you're someone who cares personally, because you're trying to get better. You're trying to level up. The second piece of this, where I think oftentimes we miss a mark as clinicians, is to challenge directly. to challenge directly. And for me personally, this was something really difficult to learn is how to challenge our patients directly to hold the line. We've got to hold the standard. We've got to say, this is what it takes. and we're going to hold the line until we get there. Or we're gonna make referrals to other people, we're gonna bring in whatever parts of the medical team it takes to get you to this standard, because this is what it takes to reach your actual meaningful goal, the thing that you really want to do. So that's what radical candor is. You've got to care personally and challenge directly. Some of the ways we see this go wrong, the first bucket is the one I fell into over and over and over again, and that was ruinous empathy. So ruinous empathy is defined as you care personally, but you don't challenge directly. You care about your patients, they know you care about them, but you don't challenge them directly. They may give you a really bad rep or any effort and you just say, that's so great, that's amazing, that's exactly what I wanted. And you know in your heart of hearts, that wasn't it. You didn't hit the mark. That's not anything like what I told you to do, and we did not coach them up. We want to be really effective coaches, really effective coaches, set people up for success, and we challenge them directly. We give some room for them to struggle. So ruinous empathy is the first bucket if you miss being radically candid. That is, you care personally, but you don't challenge directly. We're congratulating every attempt, whether it's actually a progression or not. Now that being said, I will tell you one of the factors that we use, one of the principles we use when we're working with older adults is we do intentionally underdose. We do make things a little bit easier so we can hit success. So we make the challenge a little bit easier so that we can get some successful reps early on, and that is important. But over time, we ramp up that challenge pretty quickly because we don't have time to waste, particularly with older adults. If we're not getting them strong, we're going to see them decline very quickly. 04:05 RADICAL CANDOR & FEEDBACK So to circumvent that, to make sure that they can be successful and we can be honest when we're giving them that feedback, we make sure the challenge is appropriate. And sometimes we'll make it just a little bit easy at the beginning, but we very quickly ramp up so that we are directly challenging our patients because that is where they're gonna get better. So maybe you're not being ruinously empathetic, Maybe you've fallen into this other category that Kim references as obnoxious aggression. And that could represent the burned out clinician here. I've had periods in my career before I found my passion where I was doing work, too much work, not saying no, and found myself completely overwhelmed with work. where you don't care personally about this patient, you've not connected on a deep level to be empathetic to what their experience has been, but you do challenge directly. So that could look like you being obnoxiously aggressive in your feedback. Like, nope, that's not it. Nope, nope, nope, nope. Instead of just being quiet, letting those improper reps happen, we like to have people start some of these new movements that we're teaching in such a way that they're not gonna get hurt if some ugly reps happen. We can let those ugly reps happen, and then once we see a good one, we'll be like, yes, that's it. that can help you circumvent if you tend to be obnoxiously aggressive in your feedback. So that is when you don't care personally, but you do challenge directly, and there's a mismatch there. And that can do a lot of damage when we're trying to build a relationship with our patients so that they trust us. If they don't think we care about them, then they're probably not going to come very long, they're not going to take our instruction well, probably not going to be very beneficial of a therapeutic relationship with that client. So that's the basics of radical candor and how we can miss a mark by being ruinously empathetic or obnoxiously aggressive. What I want to do now is just lean into what it looks like to truly care personally for our patients. So I truly believe that you cannot give world-class care, you cannot give the best care if you don't care about your patient. If you don't know enough about your patient to know how their problem is impacting their life, you just can't do it. If you don't know how it's impacting their life, you're never gonna dig deep enough to even get a good goal. And if you don't get a good goal, you don't really know what movement to work on. To give you an example of this, say someone is having knee pain. You've got an older adult coming to you for knee pain, and you just take that at surface level. Okay, I'm just gonna figure out why your knee hurts, and I'm gonna give you exercises for your knee. But maybe you've not dug deep enough to find out why the knee hurting, why that even matters. Why does that matter to this patient in their world? What impact is this having? If that knee pain is keeping them from taking care of maybe their favorite pet. We like to talk about Fluffy a lot. A lot of our older adults have pets. And we say, okay, why does it matter that you have to get in the ground, get on the ground to take care of Fluffy? Or maybe they need to kneel down to clean the kitty litter. It's like, well, I live alone. I have no help whatsoever. And Fluffy is my only emotional connection. Fluffy's the only person in my world. I'm completely socially isolated, and if I can't take care of Fluffy, I'm gonna have to get Fluffy away. And my fear is that my only social connection, my only being that I can connect with is going to leave me, just like maybe family members that have passed away. 10:53 CARING PERSONALLY FOR PATIENTS Man, if we have dug that deep into our patient's goals to know why it's important that they get their knee better, First of all, we're going to set a better goal because their knee may feel good and they may have better manual muscle testing. But if we don't ever bridge the gap back to them being able to get in the floor or take care of Fluffy, we've not really done our job. We've not dug deep enough to even get a good goal to care for them. And if they don't know how important this is, they're not going to trust us. like they would if we dig deep enough to know that we really genuinely care. And that trust is going to allow us to do the second part very well, which is to challenge them directly. We've got to challenge them directly. So what we've got to do is set very clear expectations of what success, what it's going to take to get to success. This client may have been dealing with this problem for decades. And if we tell them, oh yeah, I can get you better, in three weeks, even though we know this problem has been coming on for decades and decades and decades. When the reality may be that we are in more of an acute setting, someone just had a fall, they're in an acute or subacute setting, and the reality is to get back to getting into and out of the floor or getting their own groceries, it may be a year-long process. And if we just tell them, oh yeah, you know, I'm gonna give you a few exercises to do and if you do those for a week or two, you're probably gonna be better. That's not it. That's not truly challenging directly. That's being ruinously empathetic. 12:01 SETTING REALISTIC EXPECTATIONS We care, but we're not setting realistic expectations. We're not challenging directly. That patient needs to know this journey is gonna take you a long time, but you can get there. The tools, the resources are out there. I'm gonna get you started on your journey. I'm gonna plant the seeds of the fitness that you actually need. to hit these big goals and I'm going to make a referral to someone who can take care of you. So if you're in a more acute setting your job is going to be planting some seeds and you're going to send them to a fitness forward clinician on the next step down the line so they can hit those big goals after you've uncovered them. So This may take one referral, maybe you're an outpatient, it may take several referrals. Maybe their medications are off, maybe they need different shoe wear, maybe they need to go to a podiatrist or an optometrist. If we dig deep enough, we do a really good job on the front end and get this information, we need to set realistic expectations of all the people that may be involved and how long it's really gonna take. Our older adults know when we're not shooting them straight. They know. When you hear, I've not been active for 40 years, and I've got a goal that requires a lot of activity and strength I've not had for 40 years, they know immediately if the goal is not realistic, and they've already lost trust with you. They may show up and get what they can, but they're not going to open themselves up to the challenge that they're really gonna need to reach their goals. So that's what I've got for you team. I think that this book by Kim Scott was very beneficial. It is a leadership book, but is very relevant in our ability to be leaders to our patients. And the two main goals here is we have got to care personally for our patients. It's got to be clear to them that we actually care about their life, that we've dug deep enough on that first visit to find out what their true meaningful goal is. And then our second job is to challenge them directly. We've got to set and maintain the standard. We've got to set realistic expectations that's actually going to lead to their success. If you've read this book, if you've got questions, comments, concerns about what I outlaid out here, I would love to discuss it. Leave me some comments. Otherwise team, have a wonderful Wednesday. We'll catch you soon. 14:29 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 12, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses treatment progressions for lateral knee pain/"IT band" pain. Mark encouraged beginning with open chain exercises as a starting point for individuals with high irritability. These exercises can help decrease force on tissues while still providing a stimulus for the body to adapt. Additionally, open chain exercises stimulate the release of endorphins, which can have a positive effect on pain and mood. Mark mentions several open chain exercises that are beneficial for individuals with high irritability, including hip abduction, hip extension, and hip rotation. These exercises can be performed in different positions, such as bent over hip extension against a table or in a quadruped position with significant bracing of the anterior trunk. It is important to note that the intensity and volume of open chain exercises should be adjusted based on the individual's irritability level. For individuals with high irritability, the podcast recommends starting with a high volume of open chain exercises, such as two to three sets of 20 repetitions with a low load intensity. The goal is to challenge the individual and provide a stimulus to the nervous system. Overall, open chain exercises can be a beneficial starting point for individuals with high irritability as they help decrease force on tissues while still providing a stimulus for adaptation. It is important to adjust the intensity and volume of these exercises based on the individual's irritability level. As symptoms decrease and heavy, slow resistance training is introduced, closed chain exercises such as the hip thruster and Bulgarian split squat are recommended. These exercises effectively strengthen the hip and quad muscles while improving stability and control in the lower extremities. The hip thruster involves thrusting the hips upward while keeping the feet planted on the ground, targeting the glutes and hamstrings. On the other hand, the Bulgarian split squat is a single-leg exercise that requires the back foot to be elevated on a bench or step, improving balance, stability, and leg strength. In addition to closed chain exercises, proprioceptive training or reactive neuromuscular training can be incorporated. This involves using loop bands around the knees to provide feedback and improve body awareness. Proprioceptive training enhances control and stability during movements, reducing the risk of injury. Once individuals can handle both heavy slow resistance training and reactive neuromuscular training, they can progress to plyometric training. Plyometric exercises involve explosive movements like jumping and hopping to develop power and improve muscular endurance. The recommended goal is three sets of 20 repetitions or three sets lasting a minute for endurance, and 10 sets of three to six repetitions for power. Plyometric training enhances both endurance and power, important for athletic performance and overall functional fitness. Mark finishes this episode by offering a number of different options to reintroduce running, if it's part of that patient's goals. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO All right, what's up PT on Ice daily crew. Dr. Mark Gallant here, lead faculty with the extremity management division alongside Lindsey Hughey and Eric Chaconas. Coming at you here Tuesday morning, Clinical Tuesday. Before we dive in, a few upcoming courses that we want to announce. I'm going to be in Cincinnati, Ohio this weekend with Onward Cincinnati. So if you've all been looking to check the extremity management course and haven't had that opportunity yet, definitely sign up today. Get on the list for Onward Cincinnati. There's still seats left. If that's not available, Cody will be in Rochester, Minnesota first weekend of October. So that'll be your next opportunity to check the extremity management crew out. 1:01 LATERAL KNEE PAIN So I was on here a few weeks ago and we talked about the myths of iliotibial band pain, where we came from, from the research in the 70s, and now how we've adapted with newer research and things we now know. Mainly being that this is no longer believed to be a friction mechanism of the lateral knee because we know the IT band is firmly attached to the lateral femoral condyle, the patella, the tibia, and that this is more of a magnitude or a volume of load with a potential lack of frontal plane control or simply too much volume to the lateral knee. So what are we gonna do if that person comes in? Tim's been running on the treadmill for most of the year, he decides that he wants to get out and do some trail runs, start working some downhill in. Brittany has been relatively unfit for most of her life and decides, you know what, this fall, it's the time that I'm gonna run that half marathon. And then they start to develop some lateral knee pain. Well, how are we gonna treat those folks out? And what we're really gonna look at, that's gonna depend on where their irritability is. So we have four or five steps that we're gonna go through and that individual can jump onto that highway wherever they're at on this progression. So if that person comes in and they're highly irritable, they tell you that they've got eight out of 10 lateral knee pain, it hurts when they're going downstairs, when it's the trail leg that's walking, they begin to have some discomfort, they're certainly having trouble getting out and doing any of their runs, and it's really a quite uncomfortable pain for them. Well, when that person comes in, like we talked about last time, we'll do the dry needling, the myofascial decompression, the soft tissue to help modulate their pain. How do we work the exercises in and how do we specifically dose those exercises? So if the person has that 8 out of 10 or above or even 7 out of 10 irritability, oftentimes a good place to start with our exercises is open chain exercises. they're really going to decrease the amount or magnitude of force going into those tissues while giving them a nice stimulus so that the body knows it has to adapt, we get some good endorphins going. We specifically like open chain abduction of the hip, open chain extension of the hip, and if you want to get some open chain rotation of the hip, that works as well. So we like either a bent over hip extension so that person is leaning against the table so they can really contract their abs so that we know they're not getting any back arching there. Or if they go into a quadruped position, really brace the anterior trunk significantly, and then do their hip extensions. For the open chain abduction, we'd like to get them against a wall, starting them so where their hip is in neutral, so their hip is either, their leg's propped up on a ball or a bench, heels against the wall, slightly internally rotated so we know we're really hitting those glutes and working our hip abduction that way. 04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS For our hip rotation in open chain, the traditional clamshell has come under fire quite a bit in the last handful of years. What we like to do is a pseudo open chain clamshell where their feet, their bare feet are gonna be against the wall. So they have to keep that flat foot against the wall and then go into their clamshell. How are we going to dose this? Well, if you've been to the course, you know, we talk about the rehab dose, eight to 20 repetitions, 30 to 80% of their one rep max basing that that volume and intensity on their irritability. Well, these folks are higher on the irritability, so we're going to go higher volume. We're going to hit two to three sets of 20 repetitions with a really low load intensity. It's hard to get a high intensity load an open chain without volume anyway. So that's really going to lend itself to this to begin with. So our hip extension, our abduction, our pseudo clamshell, we're going to hit those two to three sets of 20 reps where they feel challenged when they approach that 20. It's getting a lot of stimulus to that nervous system. It's letting the tissues know that we want you to be active, but it's not giving them a magnitude of load that's going to be threatening to the tissue. Once the person says, you know what, I went downstairs last night and my pain was only a 3 out of 10 or my symptoms were only a 3 out of 10 or less, or that person comes in and says, you know what, now when I'm walking, when that leg's the trail leg, really doesn't seem to bother me that much. Maybe a 2 out of 10 at best. That's when we really want to make sure we're progressing to a more closed chain activity. What we love for our closed chain exercises, again, working into that hip extension, getting the quad stronger. We like a hip thrust, so a barbell hip thrust that we can really load up a lot of weight. If we see a big side-to-side discrepancy in strength, we can go single leg landmine hip thruster to make sure we can load that up. We also like a Bulgarian split squat. For our IT band folks, we're gonna modify this split squat a bit Instead of having all the weight on the front leg, you're gonna have a majority of your weight on the leg that's slightly elevated so that we can get a big eccentric load into that posterior leg. How do we like to dose this one? Three sets of eight to 12 repetitions at a weight where they feel like they've only got two or three left in the tank by the time they get to that eight out of 12. You'll notice that three sets of 10 fits beautifully into that eight to 12 repetitions. A lot of clinicians out there like to bash the three sets of 10 calling other clinicians lazy. Three sets of 10 is a wonderful stimulus as long as you're dosing it out appropriately, as long as they're approaching failure. We're not saying they have to get to failure, but can they get in the ballpark of that failure? So again, three sets, of eight to 12 reps. We really love three sets of 10. It's easy for us, it's easy for the patient, and making sure they've only got two to three reps left in the tank, specifically with the barbell hip thruster, the Bulgarian split squat with the weight shifted posteriorly. You can also add, if you want to continue to work on those hip abductors, we really like a kettlebell-weighted hip hike to get a closed-chain version of that hip abduction. At the same time you're doing your heavy, slow resistance training with your Bulgarian split squats, your hip thrusters, with your hip hikes, we also want to get that person to start being able to feel where they can control that lower extremity in space. So we really like reactive neuromuscular training, often used the acronym RNT for short, where they're going to have a band around their knees, so a small loop band that's going to pull their knees into valgus. with a flat foot, they're going to drive their knees outward. We're going to do this at a high volume. So either two to three sets of 20 or setting a timer and saying, I'm going to have you rock this three sets for a minute each. Again, we're really trying to get that nervous system to feel where that limb is and is in space to gain more control. So we want that volume to be a bit higher. You can also do this single leg where you have a meter loop band attached to a rig or a door frame. It's going to pull them into that, that valgus force with a flat foot. They have to drive that out again, high volume, three sets, 20 reps, three sets for a minute. You can progress this into having them do step downs, lunges or squats with that band on. So they have to feel their lower extremity limb where it's at in space while going through a movement. So, Just to rehash where we're at right now, high irritability, we're going open chain exercises at a high volume, lower intensity. Once they can tolerate that with mild pain, we're going to go into our closed chain exercises, increasing the intensity, making it really challenging for that three sets of eight to 12. At the same time, doing our closed chain proprioceptive work or our reactive neuromuscular training. 09:28 PLYOMETRIC TRAINING From there, when they say they're starting to tolerate that really well, then we wanna start working into our plyometric training. We talked about last week, we know that iliotibial band has a lot of similar properties to tendons. We wanna make sure that it has the ability to transfer force and absorb force quite well. We need to do this from both an endurance perspective and a power perspective. So can that tendon or that iliotibial band Absorb a lot of force and generate a lot of force and can it absorb and generate a high volume of force? So we like to do Lateral skater hops for a high volume to really get that endurance. So they're gonna be jumping side to side To get that that that volume for the endurance piece of three sets of 20 or three sets of a minute We also like pogo hops, where they're having to hop on one leg. Again, three sets of 20 or three sets of a minute. And then we really want to work on the power component. How high can they jump? How long can they jump? And can they go laterally against resistance? A couple of exercises that we really like for this, box jumps are great. Our long jump, just the traditional long jump. And then again, strapping either a band around the hips or a strap that's attached to an anchor cable column, and then we have them go three sets of three to six repetitions. So we're gonna have them go relatively low. If you've got the time in clinic, what we really prefer is 10 sets of three to six repetitions, because it's really gonna train that power very specific to how like our Olympic lifters would train. So again, if time is short in clinic, get the job done, get it in. What we really like is that 10 sets of three to six repetitions for our power. Another thing you can do for power is your rebound jumping. So they come off of a small step and they immediately have to jump to a higher box. That's going to train that lower extremity to both absorb force and immediately generate force overall. 12:01 RUNNING PROGRESSIONS FOR IT BAND PAIN As they're tolerating those plyometrics better, both from an endurance perspective and from a power output perspective, then we're going to really look at how we're able to get them running more effectively. So what this is going to look like is early on for running to get them out of symptoms, we're often going to have them run on a treadmill with a fairly steep incline. This typically will reduce symptoms for a lot of our iliotibial band folks. Then we're going to lower the treadmill. have them make sure that they can run with relatively low symptoms at a normal treadmill where it's a very controlled environment. Once they can run on a regular treadmill at that very controlled environment, then we're going to have them outdoor run. Once they can outdoor run on something like a track, a blacktop, or a sidewalk where it's relatively controlled, then we'll progress them to their trail running when they can handle a relatively flat trail then we'll progress them back to their downhills and then get them back out there on the circuit, hitting their runs. So again, these folks can enter this anywhere along that progression, depending on their irritability. If they're highly irritable, start them out open chain, high volume exercise. As their symptoms decrease, get them into that heavy, slow resistance with closed chain exercises. We like the hip thruster and the Bulgarian split squat. As you're doing the heavy slow resistance, also getting them into some proprioceptive training or reactive neuromuscular training with loop bands around the knees so that they can feel where those knees are in space. Once they can handle both the heavy slow resistance and the reactive neuromuscular training, we're gonna get them into their plyometric training. We want them to have both endurance and a lot of power. So three sets of 20 or three sets of a minute for the endurance piece. 10 sets of three to six reps for their power piece. And then, of course, whatever their functional activity is that was initially their aggravator, the thing that they love to do that they wanna get back to, making sure we're incorporating that. Starting out incline treadmill, go to a neutral treadmill, get them on the outdoor, on a blacktop, pavement, or a track, then progress them to a trail, and then progress them to the downhill running. Hope this helped as far as the plan for IT band pain goes. Hope to see you all out on the road next week in Cincinnati. If not, catch Cody in Rochester. Hope you all have a great Tuesday in clinic. Thanks for your time. Have a great day. 14:14 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 12, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick kicks off part 1 of a series on postpartum depression. In this episode, she discusses the differences between postpartum depression and other PP mood disorders. She then highlights the prevalence of and risk factors for developing postpartum depression. In her next episode, she will focus on screening for and how to communicate with folks who may have postpartum depression. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app.com. Use the code icePT1MO at sign up to receive a one month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on Ice daily show. 01:26 APRIL DOMINICK Good morning, everyone. Dr. April Dominick here from the Ice Pelvic Division, and today we're gonna talk about postpartum depression. This is a series, so in part one, we will define it, we'll talk about its prevalence, and we'll go through some risk factors for developing this condition. But before we dive in, we have some exciting updates from our division. Drum roll, please, or Harp glissando. So if you didn't catch our big news that dropped on Thursday of last week in our pelvic newsletter, we now have an eight week online level two course that will drop in spring 2024. We are so excited for this course. It is loaded with fun material. So we'll talk about pelvic pain syndromes. We'll go through post-op rehab for the pelvic and abdominal surgery that someone may get. We'll go through some birth prep and talk about all things fertility and infertility. So hop into that course when it becomes available. If the virtual option is not for you or your cup of tea, then I invite you to join us on the road live where we teach all things pelvic health rehab, bridging the gap between the fitness athlete and pelvic health. We're doing internal exams, external exams. We are talking about core rehab, going through labs that go over diastasis recti, return to the barbell, hopping on the rig, endurance, impact. It is so much fun as well. So when can you catch us live? We have some courses coming up September 23rd and 24th in Scottsdale, Arizona, and October 13th and 14th in Milwaukee, Wisconsin. Those classes will be with Dr. Alexis Morgan and Dr. Rachel Moore. Or you can find Dr. Christina Previtt. That's right, I said doctor. She just earned her PhD and we couldn't be more proud of her. So Christina and I will be out in the Pacific Northwest in Corvallis, Oregon on October 21st and 22nd. Tons of opportunities for you all to learn with us head over to PTOnIce.com and check out more. 06:34 POSTPARTUM DEPRESSION All right, postpartum depression, the topic of the day. Let's just cut to the chase. We'll call a spade a spade, pregnancy and parenthood. That is a transformative time. It's filled to the brim with new challenges when it comes to emotional, physical, mental, and lifestyle changes. We'll talk about pregnancy, I mean, that's approximately nine months of physical body alterations that support and nurture the baby. Then we have labor and delivery. That's an incredible feat. It's remarkable in the mental and physical strength that is required to get the baby to come out into the world. And then we have postpartum. Voila, the baby has arrived. Now what? So even though the baby may be all that the birthing person has ever dreamed of, it's gonna come with a lot of emotions, anticipation, joy, maybe even fear. Not to mention the added responsibility of caring for a baby while the birthing individual is functioning on minimal sleep, who knows what's happening with nutrition, and then there's an emotional rollercoaster going on. What up, hormones? and all the while that person is trying to heal and recover themselves. All of that can put a person at risk for postpartum mood disorders. We'll focus on postpartum depression or PPD, but I am going to share other conditions that may look like PPD. There's a side note here. A lot of the research that I did is on the postpartum parent who identifies as pronouns she, her, hers, or mother. So I'll be using that terminology for this podcast just based off of the research that I found. So here are three different postpartum mood disorders to include in a differential diagnosis if someone is coming to you postpartum. Number one, we have baby blues. This is gonna be the mild, most mild form of a depressive mood disorder. Then we have postpartum depression. And then our third type is postpartum psychosis, and that's gonna be the most severe form of depression for postpartum. So let's unpack baby blues. Due to the hormonal changes that happen immediately postpartum, About 50% of new mothers get the baby blues. That's a lot. By definition, the baby blues are mood changes that are mild, transient, and self-limited. And that means it'll resolve on its own and there is minimal medical retreatment required. Someone experiencing baby blues may exhibit signs of tearfulness, sadness, exhaustion, They may be irritable, they may have decreased concentration, mooniness, and decreased sleep. But all of those changes don't affect the person's ability to care for the baby or their own daily function. So from a time standpoint for baby blues, the onset and conclusion is like a bell curve. The symptoms come on within two to five days after childbirth, they peak, and then they generally resolve within two weeks of onset. One of the most common complications though of baby blues is the development of postpartum depression. So what is postpartum depression defined as? The DSM-5 defines it as a moderate to severe depressive episode that starts around four weeks post delivery. And this is typically going to require medical intervention. Compared to the baby blues, The big difference is that with postpartum depression, or PPD, symptoms persist for a longer period of time, so they aren't transient. 09:06 EFFECTS OF POSTPARTUM DEPRESSION If we zoom out, a person with postpartum depression can have changes in feelings, changes in everyday life, and they may even change how they think about their baby. Common symptoms for someone who is experiencing PPD They may have chronic feelings of guilt, feelings of failure as a mother, loss of interest in activities that used to bring them joy, feelings of despair that do interfere with their ADLs, and self-care. They'll also have unreasonable worries about the child's health and possibly infanticide or suicidal thoughts. So I wanted to talk about the effects of postpartum depression on the members in the family. So it's going to put the mother at greater risk for developing depressive episodes in the future. It can also affect the mother and infant bonding, and this has some potential implications if, say, the person is wanting to breastfeed, that may interrupt the success with that just due to the bonding issue. Beyond that, it's gonna affect the co-parent or the spouse and overall family dynamics. And there is some research showing the effects of postpartum depression and how that may negatively affect the behavioral and emotional development of the child. All right, so we went over baby blues, we went over postpartum depression, I can't leave this conversation without talking about postpartum psychosis. This is a psychiatric medical emergency. It's associated with increased suicide and infanticidal risk. It's rare. The global prevalence of it is about one to two and a half in every 1,000 women. It's going to emerge during the first few days or weeks of childbirth. And folks with postpartum psychosis will demonstrate rapid shifts in mood swings that are similar to bipolar tendencies. They'll have a loss of sense of reality. They may experience hallucinations, lack of sleep for several nights, agitation, delusions, and attempts to hurt themselves or the baby. So when you're meeting with a client, two keys for differentiating between baby blues and postpartum depression is the time since childbirth and severity of symptoms. So with baby blues, symptoms are usually present and gone within the first two weeks. Whereas those symptoms that persist beyond the first few weeks are more in the PPD camp. And then with baby blues, the symptoms are more mild and they don't affect the daily function of the individual. Whereas with PPD, it is more moderate in symptom nature and it will affect their daily life. So what is the prevalence of postpartum depression? It is one of the most common complications for someone after they give birth. PPD occurs in 15% or one in seven postpartum women. One in seven. These numbers are just representative of those who actually report it. So according to a study done in 2006 by Beck and colleagues, as many as half of PPD in new mothers goes undiagnosed because the individual is not wanting to share this with their family members or to share it with a research study. They wanna protect their own privacy. There are some effects of race as well in terms of prevalence, at least in when postpartum depression hits folks. So African-American and Hispanic mothers reported the onset of PPD within two weeks of delivery versus white mothers who tended to report the onset of PPD later. Region also matters. So geographical region. The prevalence of PPD varies by country. And what we know is that folks from developing countries have a higher prevalence of postpartum depression. Okay, what are the risk factors for postpartum depression? Y'all, there are so many. There were so many that I'm only gonna highlight the ones that came up over and over again that had the greatest impact in the research. So a 2022 literature review of risk factors of PPD identified the following as those that had the most powerful impact on development of PPD. Previous history of depression or psychiatric illness, depressive symptoms during pregnancy, and decreased social and spousal support. So there has been some research done that suggests, hey, if someone has healthy and supportive relationships, that is going to act as a protective mechanism during the prenatal period, specifically for the development of depression as well. There were some other factors, risk factors for PPD. Low socioeconomic status, stressful life events, and obstetrical specific factors like gestational diabetes, negative birth experiences, preterm deliveries, and low birth weight infants. All of these have a profound effect on the development of PPD. There was another systematic review from 2021 that they identified six major risk factors, which some of those we've gone over. But there were two in their list that I thought were interesting. One was that a risk factor if you were a pregnant woman who gave birth to boys, and then if you had an epidural anesthesia during childbirth. So I felt like those two were interesting, just side effects or side notes, and they were from a systemic review as well. 15:06 THE ROLE OF THE HPA AXIS Another area of emerging evidence looks at the role of the hypothalamus pituitary adrenal axis, or HPA. So we're about to get a little nerdy, but I love the brain, I love neuroscience, and I'm a psychology major, so let's talk about the brain and the endocrine system. So the HPA, or that hypothalamic pituitary adrenal axis, is a known responder during stress because it regulates physiologic processes such as the immune system and the autonomic nervous system. The HPA releases cortisol in trauma and stress. So if the HPA is not functioning correctly, there's a poor stress response. I think we can all agree that pregnancy itself and labor and delivery are some pretty extreme stressful and sometimes traumatic events. So during pregnancy, there are higher levels of estrogen and progesterone. Then during the delivery of the placenta, there's a dramatic fluctuation and drop of estrogen and progesterone. This rapid drop in hormone levels during that immediate postpartum period is a potential stressor and thought to contribute to the onset of depression. There was a 2017 systematic review that found seven out of 21 studies evaluating postpartum blues, and then 15 out of 28 studies evaluating PPD found abnormalities in the HBA axis. And from previous literature, we know that the dysregulation of the HBA axis is present in those with mental illness. So from all that, this is what I want us to think about. A healthy management of stress during pregnancy and postpartum should be a priority. We as rehab providers and medical professionals can have a tremendous impact in offering solutions for stress management like exercise, nutrition, sleep, proper medications. All right, let's recap. 18:39 IDENTIFYING POSTPARTUM DEPRESSION When working with the postpartum population, one of the most common complications is postpartum depression. It affects 15% of women giving birth. It's imperative that we're aware of the different mood disorders that can happen postpartum and the differences between them. We have postpartum blues, very common, affects about 50% of new mothers. It's mild, it's transient, doesn't usually need medical intervention, but we do need to provide some validation and compassion for those individuals. It's usually resolved by week two from childbirth. Then we have postpartum depression. It's moderate and severe in symptom nature. It can arise around four weeks post childbirth. It is going to affect daily functions and be present for up to a year postpartum. It will usually require medical intervention. Then we have postpartum psychosis. This is going to be a medical emergency. It's rare. but the person will present with rapid shifts in emotions, maybe have hallucinations, and the lives of the birthing person and infant are at risk. We as PTs play a tremendous role in identifying postpartum depression and other mood disorders. We can refer them to their physician, their mental health providers, and this can be helpful for someone if we think it's a medical emergency and we're suspecting postpartum psychosis. Understanding risk factors for PBD can be impactful when it comes to managing and treating it. Some of those major risk factors we can ID during pregnancy as well. So, hey, we're treating someone who is pregnant and we notice, oh, they have a lack of social or spousal support. They've told you they have a previous history or are having some depressive episodes during pregnancy. They have a lower SES or increased stressful life events besides pregnancy and delivery. Or they may say, hey, I was diagnosed with gestational diabetes. What I want to point out, these risk factors are modifiable. So in my upcoming podcast in this postpartum depression series, we'll discuss screening for PPD in the clinic, ways to communicate with a client who may be suffering from PPD, Then our final episode will cover resources, support, and the effects of exercise in treating PPD. Cheers, y'all. 19:53 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 8, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 02:14 ALAN FREDENDALL Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance. 04:18 WHAT IS A CARBOHYDRATE? So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat. 09:13 MUSCLE GLYCOGEN Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour. 11:17 GLYCOGEN DEPLETION DURING EXERCISE Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that. 13:58 CARBOHYDRATE CONSUMPTION And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout. 22:08 CARBOHYDRATE CONSUMPTION & TIMING How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody. 24:46 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 7, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the different avenues to find out if a potential hire is right for your clinic: screening the resume, conducting a series of interviews, and getting to know the person outside of work. In addition, he reinforces to listeners the importance of utilizing employment contracts. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Leadership Thursday. We talk all things practice, management, and ownership. Leadership Thursday also means it is Gut Check Thursday. Gut Check Thursday this week is a workout called Gut Check. Kind of going back to our roots of a really kind of low skill, high work workout. We have four time, 180 calories on the fan bike, a one mile run, and then 100 bar facing burpees. So nothing complex here, just some good old fashioned grunt work. Each of those elements you're thinking is going to take you maybe 8 to 12 minutes and that you're going to get done maybe depending on your run speed, on your biking ability, on your ability to ignore the pain during the burpees. You might get done somewhere between 20 to 25 minutes. So that's a great workout to do in the garage, in the basement. Great workout in the clinic to scale and modify for patients. Very easy to modify the volume there, modify the movement, so on and so forth. So try Gut Check Thursday this week called Gut Check. Course is coming your way. I want to highlight our online courses. We have a bunch beginning related specifically to Leadership Thursday and Practice Management Brick by Brick. Our next cohort starts September 12th. That's next Tuesday with yours truly. All things related to getting your practice off the ground, all of the legal things you need to do to establish and incorporate your business, and then finishing talking a little bit of strategy depending on if you want to open a brick and mortar clinic, a mobile clinic, a dock in the box style clinic, whether you want to deal with insurance, be 100% cash, or maybe meet in the middle with a hybrid practice. Whatever your goals are for starting your practice, that is the course for you. Eight weeks online. That starts September 12th. Other online courses starting next week, Clinical Management Fitness Athlete Essential Foundations begins Monday, September 11th. Myself, Mitch Babcock, Guillermo Contreras, and Kelly Benfey. All things related to helping the recreational fitness athlete, the crossfitter, the boot camper, the orange theorist, the powerlifter, Olympic weightlifter, you name it. That class is for you. Clinical Management Fitness Athlete Advanced Concepts, the level two course of Clinical Management Fitness Athlete. That cohort begins September 17th. You need to have taken Essential Foundations first. That course is taught only twice a year, spring and fall, and it has two seats left. So if you've been thinking about rounding out your Clinical Management Fitness Athlete certification, you'll want to jump in that class this fall. Otherwise, you'll need to wait until the spring. Other online courses, Rehab of the Injured Runner online. That also begins September 12th. Modern Management Older Adult Essential Foundations kicks back off October 11th, and then Persistent Pain Management begins again October 31st. So today we're kind of building on last week's topic. If you were here last week, you know that we talked about really being intelligent and diligent and intentional about growing and scaling your practice, about how to add new practitioners to your practice, about how to do it the right way in a way that facilitates long-term growth, but also quality of the product that you're offering. So go back and listen to last week's episode if you have not yet. We used the example of McDonald's, of how they've grown and scaled to be one of the largest, most successful businesses in the world in all of history, and how they've done that. They've done that by having that shared foundation of training and a common belief system in all of their leadership and ownership to help maintain that company culture as they grow. Today we're going to build on that. As I said, we're going to talk about how to find that person. We talked about how McDonald's has Hamburg University, but how can you, maybe is the individual practitioner right now, solo practitioner, how can you find practitioner number two? How can you find maybe practitioner number one for location number two, so on and so forth. 04:15 FILTERING CANDIDATES So we're going to talk about the different ways that you can really get to know somebody, and then we're going to talk about something that's really undervalued and not really discussed in physical therapy at all. The legalese of bringing somebody on board, of getting everything that you are promising them, everything that maybe if you're on the other side of the table, everything you're looking for in a position that you get that stuff in writing. You get it written down, everything that you are offering, everything that you are wanting to see out of the position, get that stuff in writing. So let's start first about talking, what are the three avenues where we can get to know somebody better? They are the resume, very familiar with resumes, they are the interview, most of us are very familiar with at least participating interviews, maybe not conducting interviews, and some other maybe non-traditional ways to get to know somebody else. So the thing to understand about finding that next practitioner, about maintaining that clinical culture, that standard of quality and excellence that you want to maintain, is that you can teach some of the stuff, but some of the stuff that's really important to be a physical therapist unfortunately cannot be taught. If I can teach anybody a clinical reasoning algorithm to rule in or rule out the lumbar spine if somebody comes in with low back pain, or comes in with maybe what we're suspecting to be, radicular type pain. I can teach the clinical reasoning to help that person find out if it's actually that patient's low back or if it's something else. I can teach somebody manual therapy skills, I can teach somebody spinal manipulation, I can teach somebody dry needling, I can teach somebody exercises, go-to exercises for different conditions, I can teach them about dosing for tendinopathy, I can teach them a lot of different things related to clinical practice, but what I cannot teach anybody is how to be a nice person, an interesting person, or a hard-working person. So we talk about these three different avenues of filtering people in and out of kind of sitting in what we might think of as a potential pool of candidates for a position. How do we find that stuff out? Because that's ultimately some of the most important stuff and it's stuff that you cannot teach somebody to do and you cannot make somebody good at. They have to kind of come on board with it naturally or at least show a passion at getting better in those areas. 08:30 THE RESUME So the first way we're probably familiar with is the resume. If you have not gotten to this point yet in your clinic ownership or business ownership career, you will eventually, where you receive pretty much an endless stream of usually unsolicited resumes, of they come via fax, they come via email, sometimes they come via email and there's no message, it's just an attached resume. Sometimes people give you a long story about why they think they're the perfect fit and why you should hire them and they are a little bit forceful and they say things like, let me know when I can start. Sometimes they come in person and they drop a resume off. So we talk about a resume, you as the person evaluating a resume, what should you be really looking for? And when I look at a resume, I really just think it is a box check to get to the next step, which would be the interview of when someone gives me a resume, if I have an open position and I want to look at it, what am I looking for? I'm really looking to see is this person a licensed physical therapist because sometimes they're not and that's really important to be a physical therapist that you have successfully finished school and passed the board exam and you have a license. And then the only other thing I really care about on the resume is previous work experience besides school. My question in my brain is has this person done anything remarkable other than go to school for 25 to 30 years? Because when you look at a lot of resumes, when you evaluate new graduates who are coming out of school, what you'll find is that not everyone has experience besides going to school. And yes, I don't want to poo poo getting a doctor of physical therapy degree. Yes, work went into that. Yes, it is an advanced education. It is a remarkable achievement for that individual, but across our profession, it is not. Most of us are DPTs or we're working on our DPT or a transitional DPT. It is now the entry level of education for our profession. So just having that doesn't make somebody stand out. I'm saying, okay, this person has their DPT and their license, but what else? When I think about other things in life, hey, if you can run 10 miles in 90 minutes, that's kind of fast. You're faster than people who can't run that far, run that fast, but it's not that impressive to people who can run faster and or further, right? It's a remarkable achievement for you in the moment, but overall not remarkable. And that's how I look at the long list of education that you might see on someone's resume. Of the question in my mind is, does this person have experience outside of just going to school that would translate into being a good physical therapist? And again, those are the elements we're looking for. Is this person a nice person? Is this person interesting and are they hardworking? So when I see resume experience that maybe somebody worked in the restaurant industry or they worked in a retail position, I know, well, this person probably knows how to wake up to an alarm clock and be to work on time. I know they probably have some experience working with human beings, which is a very important part of being a physical therapist. And they're probably used to working relatively hard. So I learned a lot by looking at somebody's job experience on the resume. So that's my first filter of what else has this person done besides go to school to be a physical therapist. And in some cases, the answer is nothing. They have gone to high school, to undergraduate and to graduate school. And that's it. And that's okay. But that's not the person that I want to bring into my business. Again, the idea of having that shared foundation of training, having that common belief system of having things that I can't teach on board already. That's really going to facilitate that person getting into a good position in the business that I'm operating. 10:14 THE INTERVIEW So that resume is just a filter for the next step, which is the interview. In the interview, I'm really trying to figure out where does this person lie with their passions and do those passions and interests line up with a position I currently have or that maybe I'm looking to provide, right? Is this person really passionate about vestibular physical therapy? That's fantastic because we don't have a vestibular physical therapist. That is an entirely new demographic of patients that we could attract and treat here at the clinic. If somebody had experience in it, maybe clinical experience in school, but also had a passion for that area. A lot of people in an interview, interviews tend to be very redundant and basically just a, a live action version of a resume of explaining what has been done. We often hear things like, I'm really passionate about physical therapy, just like a resume. Cool. You've gone to physical therapy school. What else you're passionate about physical therapy. Okay. Tell me more, right? I think many, many years ago, when I came to Jeff Moore, the CEO here at ice, when it was just the Jeff Moore road show, ice was just Jeff Moore and had taken a couple of his courses. I had not received my certificates, which I needed for school to prove I had taken the credits. And I said, Hey, I need those certificates. And he told me how long it takes. And I said, Hey, tell me your process. And his process was, as you can imagine, terrible. If you know, Jeff, not very logistically minded. And what I came to him with was a better process about a passion for logistics, about a passion of creating a system that streamlines things like issuing CU certificates. So that's kind of the same passion we're looking for in that interview. Does this person already have an idea in their mind of what they want to do? Do they want to run older adult, small group fitness classes? Do they want to treat vestibular or concussion type style presentations with their patients? That is something that in your mind, you're thinking, Ooh, that's something we don't offer, but I would love to offer. And finding more about that person's passions kind of again, checks another box of resume. Yes. Got them to an interview, interview, interesting person. It's obviously hard to learn everything you can about a person in a 30 minute or 60 minute job interview, even across maybe multiple interviews. But you're looking to uncover where does that person's passions lie? And is that something that can be put to use here at my clinic? And something that's almost never discussed in an interview is what is that person's longterm plans? I don't need to know where you see yourself in 20 years or 50 years, but I do need to know if you're planning to move out of state in a year, right? Because that's probably going to affect my decision to hire you. I'm looking to bring longterm people on board. I'm looking to train them, help them become a better clinician, but also give them a really stable, a well-paying job that really offers a lot of benefits as far as schedule flexibility and treatment, kind of freedom and how they want to almost run their own practice within a practice. So if somebody says, well, I'm thinking about moving to Colorado in six months, then again, that's in my check, check box in my head as I'm going through it thinking, well, that's probably not going to work out just as we kind of train you and bring you on board, you're going to be leaving. So that doesn't really work out. So don't forget to really kind of dig deeper of what are your longterm plans of if you see yourself settling down and having a bunch of kids and maybe leaving the workforce altogether, that's okay. But when is that again? Is that three months from now? If so, that's probably going to affect my hiring decision versus somebody who says, I do want to have a family, but I'm 24 or I'm 25 and that's maybe five to 10 years away. Okay. We can cross that bridge when we get to it. Again, that's a box check in my head. 14:52 EVALUATING SWEAT EQUITY So the resume builds, get somebody to interview, interview, get some more boxes checked, maybe, or maybe it doesn't. But what else? How do you really start to learn those things about a person? We've talked here before on the podcast of watching that person practice in your clinic. That's great to do. If you're hiring somebody that's maybe currently or previously was a student, you can certainly go watch somebody practice. It's really kind of hard and awkward to have somebody come to your clinic and treat your patients while you watch them to get an idea. But there are other ways we can look at those characteristics of a person and get a good idea of is this person a nice person? Is this person an interesting person? And is this person a hard working person? And that's to get outside of the clinic entirely of, hey, come to my gym. Let's work out a couple of times. I can learn a lot about a person outside of the clinic. I can learn, are they punctual? If I say, hey, come to CrossFit class at 8 a.m. or meet me at 6 a.m. for a run, are they punctual? Are they reliable? Are they showing up late? Are they showing up not at all? Are they snoozing that alarm? How do they handle stress? If CrossFit is brand new to them or running is brand new to them or whatever you're doing is brand new to them, how do they handle that stress? Is that the person that trips on a couple of dumbbells and throws their jump rope out into the parking lot? Or is that a person who goes, hey, they're not in the cards today and just scales to single unders and keeps working out? How does that person handle pressure and stress? And ultimately what we're learning when we kind of use sweat equity as an interview is how is that person with being coachable and open-minded of are they open to feedback on improving their performance in the gym, running, rock climbing, whatever you all decide to go and do together, are they open or do they believe they've already learned everything and they have mastered it and they can't be taught anything? Because that is a red flag for somebody, right? Of somebody who shows up late to the whiteboard because they think they already know how to do CrossFit really well and they think they have nothing to learn from the coach. They don't listen to any sort of coaching. Those are all kind of red flags for you of if this is how this person behaves outside of the clinic, how is this person going to behave at my clinic? Are they going to be late to treat patients? Are they going to be somebody that calls in a lot? Are they somebody who believes they can't get better as far as the clinical practice goes? If their clinical reasoning is already at an expert level and they have nothing to learn? Those are all red flags for you of maybe this is not the right person for my job. This person does not seem to have our shared foundation of training and our common belief system. 18:36 GET IT IN WRITING So moving through those three avenues, resume, interview, sweat equity call it. What if then you fall upon somebody you think this is the person that I want to hire for this position? What should you do? You should always, always, always get everything in writing of you can be the best friends with somebody. You can have known them since you were kids. It can be your brother-in-law or your sister-in-law. It doesn't matter of when we're talking about dealing with professional employment, we should have employment agreements on board. We have these here at ICE with all of the faculty who teach for us. They don't have to be this complex 50 page document. It just needs to lay out what we're offering and what we are expecting for essentially work in return. And all that stuff, no matter how small, should be listed out. Obviously pay should be described of how a person is going to be paid. Things like time off should be described. Things like payment for continued education benefits or health benefits. Anything you can possibly think of that you are giving in exchange for work should be written down. Anything that person is wanting to receive in place for their work should also be written down in that agreement. And these things do not have to be set in stone. You can set a three month, a six month, a one year, a three year expiration agreement on these agreements. You're not forcing somebody into chains, but you should have that stuff in writing. I will tell you as Jeff and I sit at the head of ICE over the years, what we see not daily, but definitely weekly are really unfortunate emails from you all who follow us at ICE, who take our courses of, Hey, I was promised this, but then this happened. I was promised X, but because Y happened, now I'm stuck with Z. And it all comes down to the question we always ask of is that in writing somewhere? And universally the answer is no, it was promised verbally. It was promised in passing. It was promised maybe at a meeting or maybe at my first job interview five years ago, eight years ago, 10 years ago. And I kind of just expected that that person would keep their word. And certainly things change with the economy or whatever excuse we want to use on the employer side, but at the end of the day, it's not in writing, which means it doesn't really count. Right. And so getting stuff in writing, it doesn't matter how you're going to be paid. If you're going to be a W-2 employee, a 1099 contractor, it doesn't matter. Get all that stuff in writing, get time off in writing, get benefits in writing, get scheduled pay increases. If you agree upon those in writing, this is just another friendly reminder that if you don't get a pay raise that matches or beats inflation every year, you have taken a pay cut. And if you don't have that in writing, you probably didn't get it. Right. So having all that stuff in writing, when you're accepting a new position, putting it in writing, when you're bringing somebody on board is later on going to save a lot of time, money, hardship, bad feelings by having that stuff in writing. And if everything related to what's expected at the job, productivity, you clean your own room, somebody cleans your room for you when you're done, whatever, no thing too small can go in that employment agreement. And once you've both read it, reviewed it and agree, sign it. And that's how you bring that person on board. We have all been in that position where maybe we were told, Hey, it's one-on-one for an hour. And maybe it became, Hey, could you see a double book this hour? And one patient per hour became two, two became four. And all of a sudden you find yourself, how am I seeing 20 or 30 patients a day? And you go back and none of that was in writing, right? It was all verbally promised in your initial interview or your onboarding training. And none of it was in writing. And ultimately at the end of the day, there's not much that can be done. So whether you're hiring, whether you're being hired, get all of that in writing. And that should be a red flag to you on either side of the table. If one party to the other does not want to put anything hard and fast into writing, that should be a big red flag in your mind that you push the chair back and you step away from that table. That should already be enough of a red flag that you shouldn't even consider bringing that person on board or being brought on board if you're the person being hired. So get it in writing, find those people, figure out that we have a shared foundation of training, a common belief system, use a filtering system of resume into interview, into maybe sweat equity interview to filter those people out, really ensure that they are the fit of the person that you see working for you at your clinic. And then get as much of that stuff in writing as you can get done. So I hope this little mini-series was helpful. Again, if you have not listened to last week's episode, listen to that one, get some context, and then maybe revisit this one. If you're going to be on a live course this weekend, I hope you have a fantastic time. We hope to see you in our online courses starting next week. Other than that, have a great Thursday, have a great weekend. Bye everybody. 20:35 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Sep 6, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses setting expectations with patients as a home health provider, learning when to "fire" patients in order to "hire" patients who are better able to utilize your time & services. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:33 JULIE BRAUER Hello, everyone. Welcome to the Geri on ICE segment of the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Julie Brauer. I am super excited to be talking to you all this morning all about setting expectations with your patients and I'm going to focus this on the home health setting in particular. Okay, setting expectations with your patients. I think we can all agree that really successful relationships are built upon effective communication of setting expectations. Think of arguments you've had with friends or your partner, relationships you've been in. I know I've been here where when you come out on the other side, you think, man, if I just would have communicated what I wanted or if I just would have set that expectation, maybe things could have been different or you say, man, like if I knew that that's what you wanted, if I knew that that's what you expected of me, maybe things could have been a little bit different. Like I definitely can reflect on a lot of relationships I've had or arguments I've been in and that would have saved a lot of heartache if those expectations were laid out in front, if they were communicated up front. And what I think we should be doing when we are starting a plan of care with our patients is to remember that we are entering a relationship with our patients and ideally they are going to have expectations of us and we are going to have expectations of them. We should level set those expectations and we then can hold each other accountable. When we are introducing a plan of care to quote Jeff Moore from his process lecture, you are coming to a mutually agreed upon plan where you pitch optimal and then you agree on acceptable, right? Like these are ways in which that relationship can really thrive. Unfortunately, and I've been here, we get really burnt out from being in long term shitty relationships with patients. Long term shitty relationships. I know you guys have been there, right? I mean, think about it, especially in a home health situation, you get that patient on your caseload and right away you know, you're like, this patient is going to be an absolute pain. You're already thinking like, oh my God, I have to deal with this patient for eight weeks. You dread seeing them. They dread seeing you. They're not motivated. They don't follow your HEP. They don't want to be there. You don't want to be there. You kind of sandbag your treatments because this person is just sucking all of the life and joy out of you. They don't answer when you try and schedule. They cancel on you all the time. You have been so frustrated for weeks on end, but you didn't say anything to begin with. You know this relationship is going nowhere, right? You are dreading running that outcome measure at the end of your plan of care because you know that it definitely hasn't improved at all. You feel this frustration. However, we have as clinicians, we have this feeling that we don't want to upset our patients. We really prioritize just keeping the peace. We don't want our patients to fire us. We want our patients to like us so much. We want to be liked. I think a lot of times we have the pressure from our companies to show progress and we're just afraid to have those hard conversations. 07:18 ENDING RELATIONSHIPS WITH PATIENTS We're afraid to just tell our patient that this relationship isn't working. And I want you all to reflect about, you know, how much heartache and time and effort could have been saved if we level set expectations and had those hard conversations right out of the gate? How much time could have been saved if we really discovered if this person was appropriate for therapy services to begin with in the very beginning? If we discovered if we were actually a good match for our patient and our patient was a good match for us? Instead of thinking that having those hard conversations and maybe discharging that patient early as a failure, like think about the opportunity that you can create when you discharge a patient. You end that relationship instead of dragging out a plan of care for eight weeks that is going to go nowhere. I think we have to remember that like ending a relationship with the patient, discharging them, whether it's because they're not appropriate for therapy services, they're not meeting the expectation, they're not being compliant, or maybe they're just not a good match for us in particular, right? They could be a good match for a colleague, but maybe for us in particular, it just doesn't work. We have to reflect it and realize that that's okay. That doesn't mean we don't bring value as clinicians. That just means that this relationship in particular was not a good match. And that's a good thing that you can find that out early. 09:52 STARTING RELATIONSHIPS WITH PATIENTS & SETTING EXPECTATIONS So instead of thinking about discharging a patient early, ending that relationship as a failure, I want you to think about it as an opportunity because there are so many patients out there who need our services, who want our fitness forward services. We want to find those people and we are not going to be able to find those people if we are staying in bad relationships with other patients where this is just not a good match. We need to remember that we have a choice, right? We have a choice to have hard conversations, to level set expectations, and we have a choice to end that relationship. Every single patient now that I approach with my home health patients, I think, is this someone that I want to enter a relationship with? Is this person a good match for therapy services? Is this a good match between just my personality and their personality, right? I know, like, hey, if this person isn't willing to put in the work, I can go be like LeBron James and take my talents elsewhere to someone else who is rearing to put in the work and get on board with therapy. So that is the first thing that I want you all to be thinking of as you walk into your patients going forward today and the rest of the week. So I am going to give you a couple ideas of expectations and how to make sure that you are getting the right person to go with your patient. I am going to give you a couple ideas of expectations that I have set with my patients and things that I have said that have been really helpful in starting that relationship out on a good foot and knowing pretty clearly right away how this plan of care is going to go, if this is going to be someone I keep on my mind, I am going to give you a couple ideas of expectations that I have set for you. So first of all, I want you to know that you don't get into this situation where your week is in and it is not going anywhere and you are frustrated and you are getting burnt out, right? And the patient, too, on their part, they are getting frustrated. This isn't even anything that they wanted to begin with, right? These are some ways that I have kind of nipped that in the bud with my home health clients. Many times home health patients have no idea what home health is. So the very first thing, the very first conversation I am having with them in level setting in terms of expectations, what the heck is home health? What does it look like? What can they expect, right? So I am talking about things like frequency of visits in a week. I am talking about things like duration of a visit and intensity of a visit that there is one person coming in their door, not multiple. These are things that patients who are in acute care should already know. And for any of you acute care therapists who are out here listening, I mentioned this before in a previous podcast, for the love of God, please level out these expectations first and foremost so that when that home health, when that clinician, home health clinician goes to see the patient, they already know what to expect. But like I said, many times patients who are, patients in home health have no freaking clue what they are in for. Many times they are coming from, for example, acute care where they are used to two people coming in, maybe a clinician and a tech and they bring in the ultra move or they bring in big pieces of equipment. And we know in home health that is not realistic. So setting expectations like that, there is one clinician going to be coming in to see you. I don't have fancy equipment and I don't have the extra sets of hands. Setting the expectation that I'm at most going to be seeing you two times a week. However, you are going to be having other clinicians, most likely nursing, OT, maybe speech, who are coming into your home throughout the entire week. Right. We know that a home health client could have, my God, five visits in one week. That can be incredibly overwhelming for a patient. That's something that we want to tell them about right out the gate. So just setting those initial expectations of what they can expect from home health services in general can go a long way. Many times that first week patients are so overwhelmed because they didn't know that people were going to be calling them constantly. Multiple clinicians were going to be coming in the door. They're thinking that they're going to have, you know, extra sets of hands to stand them up if they're like a max assist. We need to level set that immediately. Okay. So you get like the bare minimums out of the way. What is home health? What is it going to look like? 13:23 PUNCTUALITY IN HOME HEALTH Next, I am telling them what they can expect from me. And the very first thing I start with is that I tell them I am going to be here on time. Punctuality is incredibly important. If you talk to a lot of patients who are in home health, that is, and they've had other home health services before, that is one thing that bothers them a lot. Clinicians don't show up. Clinicians show up late. They want to know that they can rely on me from a punctuality standpoint. They want to know that I'm going to show up. So I put that out there right away. I am going to be here on time. You can count on me for that. If I am going to be late, I am going to call you as soon as possible. I appreciate your flexibility, but I know that you are able to cancel our session without penalty if your schedule cannot accommodate it. So right away, I am holding myself accountable. I am wanting them to feel like they can rely on me. Then I want them to feel that I am here for them. I am going to do everything in my power to show up for them in terms of helping them get to where they want to go. I want them to feel like, whew, this person gives me hope. So I am going to say something to them like, I will do everything in my power, in my capacity to advocate for you. I'm going to meet you where you're at, and we are going to work as a team to move towards a healthier, stronger, more purposeful life. Okay? I am going to tell them, I am going to hear your concerns. I am going to actively listen. If I cannot help, if I cannot solve your problem, I will do everything in my capacity to find someone who can. I right away want them to realize that I am trying to be that resource dealer. If I cannot solve the problem, I will find someone who can. And then lastly, I am holding myself accountable again. Hey, if I am not meeting these expectations I just laid out, please bring it to my attention right away. Right out the gate, right? I am setting expectations of things that they can expect from me and I am giving them the power to hold me accountable. That is so incredibly powerful when it comes to building a strong relationship with your patient. Okay, so next, I used to really lay in about what I expect from the patient in terms of bringing this fitness forward approach. They're going to have to work really hard. They're going to be sweating, da da da da da da. And I realized that that was way too much. That was coming on too hard and heavy. I saved that conversation about really expecting them to work hard and you're going to sweat and you may be sore. I saved it. Saved it for the next visit with them. When we're really getting into loading them up and putting them through an EMOM or an AMRAP or something like that. So I wouldn't, please learn from my mistake and don't throw that out at them right away. It's too much too early. What I do lay the expectation of is my visit time and scheduling compliance. And I'm very strict about this because too many clinicians in home health get the run around. They are exhausted because their patients are late or they're late. They're with patients for too much time. They're asking to be seen at crazy times. That burns clinicians out all the time. You have to set barriers and you should be doing that day one. So what has been successful for me is that I am telling my patients that they will have a 30 minute visit time. I know that's very unorthodox for acute, I'm sorry for home health because usually you're seeing patients for various times. However, I approach it as if it's outpatient. You get 30 minutes, not any more, not any less. They expect that. And how I have made that 30 minute visit work is that I am laying the expectation that I will be following up with you on with a phone call on my drive to your home. We are going to talk about what's happened this week. We're going to get a plan in place. I have a whole podcast that I talked specifically about that that I'll put in the comments here, but I'm giving them 30 minutes so they know when I walk in that door, we got to get to work because I'm only going to be there for a 30 minute time period. The next expectation I lay is that if there are more if there are three non medical cancels, we're done. I'm discharging them. If there are three non medical cancels, right, we got to give a lot of grace to these patients. They're freaking sick. Many times they go back to the hospital. They got a lot going on, but we have to hold them accountable as well. When our patient cancels, it screws up our day. We don't get paid for that patient, right? It affects all of our other patients and our scheduling. We have to hold them accountable. So I give them three strikes and then they're out and I'm discharging them. So those are the main expectations that I am saying to them they can expect from me and the things that I am saying. This is what I expect from you. Next, when we get further into conversations about goal setting, right, I am digging into their meaningful goal. If you listen to the MMOA crew, you know that we talk about make it meaningful, load it, dose it. I want to visualize exactly what they want out of this relationship. What are they trying to reach? What is that goal? What does it look like? I want to visualize it. When we are getting into that goal setting, I am asking them a very important question that helps dictate our plan of care and gives me a lot of info. I am asking them, how long do you think it will take to reach that goal? And what do you think it's going to take to get there? That is going to tell me a whole lot of information. Is this someone who is like come to me three times a week? I will do anything. I will do all my homework. I am. I am just willing to put in as much effort as I possibly can. Or is this someone who's going to be like, you are not coming into my house more than once a week. No way. And there is no way that I'm going to do any sort of therapy after that. Right? You have to approach those two people very, very differently. It's going to dictate your plan of care. What is the frequency that you start out with? What type of HEP do you start out with? Is this somebody that you have to give one very, very simple exercise to? Or can you give them a very simple exercise? You are going to get an idea of how compliant this individual is going to be right off the bat. So you're already thinking this may not be an eight week plan of care. This person is nowhere near ready to put in the work. So I'll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if they're going to be able to do that. So I'll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if we're going to continue. Incredibly important question to answer that it really helps dictate your plan of care. Okay, that's it. That's all I've got for you guys to recap. Really realize that you are entering a relationship with your patient. And just like any other relationship, you get to break up with them if you want. Right? If you're able to fire you, you're able to fire your patient as well. It's a relationship that you can have control over. Next, a couple things to start level setting those expectations. First off, what exactly is home health services going to be like? Next, lay the expectation of what the patient can expect from you. You will be there on time. You are going to advocate for them. If you have not solved the problem, you are going to find someone who can. Then you are going to lay the expectation of scheduling. I will be there for 30 minutes. You can expect that I will be there on time. You are going to give them three chances of three non-medical cancels before you discharge them. Then you talk about your goal setting. You get an idea of where they are at. What are they to put in the work? That's really going to help you develop that plan of care and know what this relationship is going to look like. All right, y'all. I hope that was helpful. Go ahead. I would love to hear you all, what you think about this. Try some of these expectation level setting when you go into your patients today and for the rest of the week. I'd love to hear comments, questions, and thoughts that you have. I will leave you with courses that are coming up in the MMOA division. We are all over the globe. Not the globe. We are all over the US. In September and the fall, we are super, super busy. In September, we are on the road. We have a course here in Charlotte and Colorado this weekend. These are open courses. We have more, but some of them are private. Then we are also in Oklahoma for September and October. Our eight-week online Essential Foundations and Advanced Concepts is starting up. Then we are also in Virginia, California, and New Jersey in October. Plenty of chances to catch us on the road or hit up one of our online classes. All right, guys. Have a wonderful rest of your Wednesday. 23:47 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. Thanks for watching.

Sep 5, 2023

Dr. Eric Chaconas // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Eric Chaconas discusses the benefits & risks of youth weightlifting, dispelling many common myths regarding the negative effects that lifting weights can have on children. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ERIC CHACONAS Morning everybody, Eric Chaconas here for the PT on Ice Daily Show. I am part of our Extremity Management team along with Lindsay Huey and Mark Gallant. Extremity Management is our really basic general orthopedic course that covers so many different conditions that you see of the shoulder, elbow, wrist and hand, hip, knee, foot, ankle. So it's two days, heavy lab, lots of fun, lots of movement, tons and tons of you performing the actual current best exercises that you would utilize in the clinic for all these different injuries and pain conditions that we see. As well as some of the most modern and evidence based manual therapy techniques that are utilized for all those same conditions. So we've got a number of upcoming open courses. Mark will be in Amarillo, Texas September 9th and 10th and then in Cincinnati, Ohio September 16th. And then we also have one in Rochester, Minnesota October 7th. So if you go to our website, PTOnice.com, click on live courses, you'll see Extremity Management down there in the second row. And that's how you can find out more details about that course. 01:31 WEIGHTLIFTING & KIDS So today we're going to get into this topic of weightlifting and kids. And so this comes from some of the experiences that I've had in coaching youth sports and in training clinically. What I did early in my career was performance based training for youth golfers. So I've had this conversation and then really just experiences I've had with my own kids and friends in the community here. I've had this conversation about kids and weightlifting with a lot of people, a lot of people over the years. And it is amazing to me how often you hear people say, I don't, I don't, it's not a good idea for a kid to lift weights because it can stunt your growth. That is like saying the earth is flat. That is one of the most outdated, inaccurate statements that can be made. What we know now is that that is absolutely false. There is no difference in risk of, and what you're talking about are growth plate injuries, right? If you say stunt your growth, you're talking about the epiphyseal plate. You're talking about a growth plate injury being more at risk or having higher prevalence in a young athlete or young individual who participates in weightlifting versus one who does not. So we're talking about pre-adolescence. We're talking about middle school age kids. We're talking about even elementary school age kids. And I don't think a lot of people are making that argument in high school age kids. 04:52 BARBELL WEIGHTLIFTING FOR YOUTH Usually most people are pretty accepting of the idea of weightlifting in high school. But where they push back on you is in middle school and elementary school. And so I think that's totally wrong. I think that's inaccurate. Now, again, it's a case by case basis and it's based on the kid and their maturity level and their ability to, you know, pay attention and be coachable and be well behaved enough to properly, you know, be safe. But for the most part, the argument that it could stunt your growth and that there is a higher risk of growth plate injury is completely unfounded. So that came from like old wives tales. And then in the 60s, there was a few case reports that show growth plate injuries. They talk about growth plate injuries being a little bit of a higher risk in young weightlifters versus those who are not. That's been completely refuted since then. There's well over a dozen studies that show that there is no difference in the general population, pre-adolescent population versus the pre-adolescent population who participates in weightlifting. There's no difference in growth plate injury rates. So there's no more risk of lifting weights than there is playing on the playground or playing soccer or running around with your friends playing tag. There's literally no greater risk with weightlifting. So I'm specifically talking about barbell lifts because I think a lot of people, here's the other issue. People will say, because like resistance training is promoted by the American Academy of Pediatricians, like eight years old kids should start resistance training. But, you know, they're talking about body weight exercises. They're talking about a lot of different stuff. And not most of organizations, most of these people are still pushing back on the idea of barbell weightlifting. I am saying barbell weightlifting is critically important for youth development, for the young athlete. And just for general, you know, it's really tough today with kids with smartphones and year-round sports, and they're getting pushed in all these different directions. I mean, everybody's, you know, playing travel, baseball and travel soccer, and it's year-round and it's the same sport year-round. And we're not doing a good job at developing well-rounded athletes. And we're not doing a good job developing foundational strength and speed and power. And that's where weightlifting really has a strong, important role. And so that's what I'm saying. What I'm saying is we've got it all wrong in that we are pushing these kids to play sports like crazy and specialize and focus on the sport so much, and we're not spending enough time focusing on training. They need to be trained. That's really what is really important. And so what age is appropriate? I mean, that's really a key question. What age is appropriate and what exercises are appropriate? I don't think there should be a limit to the age. I think it's individualized for the kid. When my kids, when my son specifically, when he was in third grade and my daughter not that far behind him, third grade is when they started back squatting and deadlifting. So I bought a 15-pound barbell when they were really young, about a 15-pound barbell, and taught them all the foundation, most of the foundational lifts. And this is one-on-one coaching. This is a very controlled and safe environment. I have not done well in group settings. I'm not promoting this in a group setting. I think it's hard when you have multiple kids and they start messing around and they're all kind of doing different stuff. I think that can be more challenging. But in a one-on-one safe environment where you are very focused and the kid is coachable, the kid is willing to learn, the kid wants to learn, and you have to introduce it slowly. And that's the other thing too. This isn't like we're doing some periodized program where we're hitting it every single week and this and that. At a young age, it's introduced slowly and it's integrated with all the other fun stuff that we're doing as far as play and everything else goes. But yeah, I think deadlifting is important. I think back squatting is important. I think people that are pushing back on that because of injury risk have got it completely wrong. I think that if the environment is safe, I think that they're progressively loaded in a progressive way that makes sense. You're breaking things down in a way that makes sense and we're not hitting with too much at once. And the kid sees the value in it and the kid sees the importance of it. The kid sees their progression. I think that is a really, really important valuable thing. So what's the harm? I think there's so much greater harm in not weightlifting. I think there is significantly greater risk in not weightlifting. The last thing I'm worried about is a growth plate injury. You know what I'm much more worried about? Smartphone use, mental health, emotional development, confidence, the ability to work hard and to grind and to learn grit and determination. When you know you're pushing yourself and you're kind of close to your max effort, I want a kid to feel that. I want a kid to know what that feels like. I could care less about the specific skill they're developing and some specific sport. 08:45 LIFELONG LOVE FOR PHYSICAL DEVELOPMENT I'm much more interested in the lifelong love and passion for working on your body and developing yourself physically and working hard and loving your body, loving yourself enough to devote time and effort and to invest in yourself because you want to get better. You want to be healthier and you want to approach each day as improving from the day before. I think that's really important. So I think the negative consequences of not doing that are significant. I think the negative consequences of doing that are minimal to none. And so I would encourage, I think as a clinician, I think that's an important thing for us to educate people on. So I think when you're seeing youth athletes, when you're seeing pediatric orthopedic injuries, that's a great opportunity to introduce a little bit of resistance training and to show people that it's safe and to show people that it's effective and to show them all the benefits of it. So hope that helps. Have a great day, everybody. 09:25 OUTRO If you want to learn more about our program, check out our virtual ICE online mentorship program at PTOnICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnICE.com and scroll to the bottom of the page to sign up.

Sep 4, 2023

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich emphasizes the importance of capturing and recording ideas when creating content. She stresses the need to write down ideas because they may be forgotten later during the content creation process. Jess suggests using a notes tab on your phone to jot down thoughts and ideas. Additionally, she encourages taking inspiration from what you see and not worrying about the possibility of stealing ideas or duplicating existing content. Jess emphasizes the importance of sharing your unique perspective and ideas, as someone who follows them may not be following you. Overall, the episode highlights the significance of documenting ideas to utilize them effectively when creating content. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 01:22 JESS GINGERICH Good morning PT on ICE Daily Show. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. As always, we have some wonderful opportunities for learning coming your way. If you go check out ptonice.com to see when we are going to be close to you. We have a two-day live course that's going to bridge the internal pelvic floor assessment with return to strength training, endurance training, gymnastics, and so much more. We also have an eight-week online course that is a wonderful starting place in treating the female athlete. If this is something that's been on your list, head over there and snag your spot. I'm going to actually take a turn and instead of talking about pelvic things, I'm going to talk about social media. Social media kind of from the lens of someone who has been doing it for two and a half years, so not all that long. I don't have a degree in it, so I would consider myself somewhat of an amateur with this, but also kind of talking about it in the space of pelvic health and how scary that can be because there are already a lot of really negative things around pelvic health and putting that on social media can be really difficult. 02:17 SOCIAL MEDIA & PELVIC HEALTH So again, I've been active on social media posting things about pelvic health, pregnancy, postpartum, and other various PT related things for about two and a half years. I was encouraged by the ICE faculty to just kind of do it, just do it, show up, post, don't think too much about it. And I remember feeling all of the things around this. I was nervous, I was scared, I was excited. I've felt things like, I just want to quit. I've also felt the things where I just want to push the gas pedal down and keep going. I've felt all of the feelings. So my nerves tend to get exacerbated when I think about, you know, what are people going to think about what I'm posting? What do I do when someone comments something mean or negative? What if I, when I share something, it's not enough? It is a topic, but there's a lot of different kind of things that you could post about it. Really the list kind of goes on. So what I want to do is I want to share some of the things that I've learned along the ways along the way, as well as breaking down some of those fears. 04:08 BREAKING DOWN CONTENT CREATION So first, if you have an idea, write it down, because you will not remember when you come back to it and you are thinking about the time that you're, you're creating content, filming stuff, you're not going to remember. So write it down, have something in your notes tab on your phone where you can write down and jot down kind of what you were thinking. If you see something that inspires you, just do it. You can take an idea and turn it around and make it where it's going to resonate with the people following you. Does not mean you're stealing an idea or that that's already out there. Post it because someone who's following me may not be following you. If you are feeling overwhelmed, take time off, turn your app off and go on a walk, do something different. That idea that post will still be there when your mental health is better. So let's break down some of the feelings. So what will people think of the post that you're posting? First of all, everyone's going to have an opinion. Everyone has an opinion. And what if they think instead of it being negative, what if they think it's helpful? What if it drives this person who needs you to view? Obviously you will have other opinions that trickle in and when they do, just think it will increase your engagement, meaning it will reach more people. The wonderful thing about having this kind of thought is that if you are an ICE trained physical therapist, you know the importance of positive messaging around anything. So if you are posting something and it's not negative, it's not going to encourage someone to not work out to stop what they're doing. Post it. What about all the negative comments that you see on so many other reels and posts? You will inevitably get those. They will come in, but sometimes it's really hard to read the context behind text. So when you first read a comment and you aren't filled with those butterflies and unicorns, like, oh, they really love this. This is awesome. Close the app, take a breath and think about the response you want to give. This is a great time to educate someone who doesn't know. Remember you are the expert and even like validating them can be very helpful. So this kind of leads me to my next point. What about not sharing enough? So for example, what if you get a comment from what like SoccerMom87 and she says something along the lines of you didn't address this? Well, that's a perfect time to come and say that's actually something that I was going to address on my next reel. Thank you for bringing that up. So now you have something that you can create another reel on and you didn't even have to think about it. I think sometimes people forget that you have a 12 second reel that you're trying to get some kind of educational piece around. And so you can break up your reels and that way you have content over the course of however many weeks. There are so many feelings around social media and the trolls will be there, but so will the people that are in desperate need to find the right person. So if you are sitting on your post, you've got several drafts in your Instagram drafts reels, post it, just post it, reread it, make sure there's no typos. And even if there are, that's okay. Just post it. I want to encourage all of you to go to my last reel. It is about running and peeing in your pants or maybe it's my second to last reel. I was totally off beat with the music that I found or that I use for it. I even made a funny face on the reel because I realized I was off beat, but I had a patient coming in. I wanted to get that content filmed and I wanted to get it posted. 08:00 JUST POST IT So I kind of said screw it and posted it anyways. And I've gotten a lot of love, a lot of like, hey, I love that you just kind of posted that and you recognized it. But I also have gotten some comments about the what ifs, like what you didn't post about this or what about that. And that's all I care about is that that's driving more traffic to this. I want people to know that they can run without peeing in their pants. And so the comment that was left, I just said, hey, that's a great point. I love it when this when that person can come into that visit. So if you are nervous, I want to encourage you all today's Labor Day. So I know most of you are off, but just post the reel or the carousel, whatever you have waiting in your drafts. And if you do have something that you post today and specifically one that you didn't want to post, I want you to tag me and I will love to share it and hope that it brings more people to you. So I hope you guys have a happy Monday and a wonderful Labor Day and we will see you next time. 09:33 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

Sep 1, 2023

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the evolution of cycling pedals, including clipped in riding, and changes in the safety & efficiency of clipless pedals. Take a listen to the episode or read the episode transcription below. If you're looking to learn professional bike fitting from our Endurance Athlete division, check out our live physical therapy courses . Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the P10i's Daily Show. 01:26 MATT KOESTER Alright guys, welcome to another episode of the PT on ICE Daily Show. I'm Matt Koester, lead faculty in the endurance athlete division with a specific specialty in bike fit. The title of today's episode, clipped in, clipless and clueless. I want to spend a little time today diving into a topic that I think is really fun. It's also really, really confusing, especially for people who don't understand the cycling industry, the cycling world. It's a very, very basic part of terminology that I think will help you to get a little bit more credibility having conversations with cyclists when you're discussing the pain that they're experiencing. Before we dive fully in on the topics for today though, I do want to take a moment and just give a quick shout out to our last bike fit host, bike fit course of the year. That's going to be down in Knoxville, Tennessee, September 23rd and 24th. Sadly a sad thing to say, our last one of the year, but we are super pumped for it. And if you're unable to make it and join us this year, have a good look into next year. We are currently ramping up probably what's going to be the biggest year for this course we've ever had. We'll be coast to coast and all over the place in between. So we're really, really excited for that. But if you like what you hear what we're talking about today, you want to learn more, you want to dive in, you're definitely going to have an opportunity to jump in in about a month. You can also learn from us on virtual ice where I'm going to be doing some podcast, some lectures on this content in a little while as well. So those are the things that are coming up down the road. 04:07 EVOLUTION OF PEDAL TECHNOLOGY As we shift into today's topic, as I mentioned clipped in or clipless those are some of the things that you're going to hear people talk about all the time and they can be relatively confusing and what we really mean is how is the foot interacting with the pedal? So the big part to talk about here right away is just terminology. I just want you to be able to hear somebody talk about this or bring it up yourself and actually know what the heck it is because otherwise it's really confusing. So in general, I brought some props today that I think will be helpful. If you're watching this on Instagram, it'll be really easy to keep up watching on YouTube. Same deal. If you're on the podcast, I certainly recommend you jump back onto one of these platforms so you can see if you're a visual learner because it'll help out in that sense. We're all pretty used to this style of pedal. It is just a flat pedal. Both sides look the same. Basically this is just going to go right into the crank. If you put your foot on it, they're going to go forward. That's as simple as it gets. At some point during the evolution of the sport of cycling, the idea was our feet are jumping around and we want to be more efficient on the bike. So how can we try to improve that sensation, be more connected to the bike? Well, the idea for the clipped in version of this, the original idea behind that was actually a cage or a strap that went over the foot and it had a little clip on the side that allows you to snap that thing down and it would lock your foot to the pedal. Some of them had plastic, some of them were really truly just more of a fabric cage, some of them were like a strap. Now, I don't have one of those with me today, but it is funny. My Nordstick rig mount actually is a perfect example of this. I'm going to use this for the purposes of this. Foot would slide into this space. It would be set down and then you would basically cinch and pull down on the strap on the side. What that would do for it was essentially lock the foot to the pedal. We were seeing cyclists get more efficient. The feet were mousing up the pedals. They were quicker, all kinds of good things there. 07:31 THE CLIPLESS PEDAL The next evolution of that was the clipless pedal. Now the clipless pedal or clipless pedal shoe interface, the idea was to get rid of this strap. I'll talk more about why you really want to get rid of that in a second. Just to explain that piece, if we talk about we went from flat pedal to one that had a cage over it or a strap to now this thing that we're used to seeing all the time, which has just these little pincers on it, these little things that grab onto what's at the bottom of the shoe. What that does is it operates kind of like den settings on ski boots and the way that they interact with your skis. When you step in, they click in, you're in a spot where now you can move around and do what you need to do, but if enough force is applied to it in a sketchy situation, whether beyond the mountain or on the road, they will come out. And in fact, on the bike, they come out pretty darn easy and it's usually modifiable to do so. The reason they're called clipless pedals, even though you are clipping in, is because they don't have that toe cage on them. And the main reason to get rid of that toe cage in many ways was actually a safety thing, as well as just an improvement upon the actual interaction between the foot and the pedal. The safety side of this is if I'm falling down and I'm going to the ground and I have an option to save myself by getting my foot off the pedal, if I'm running a clipless shoe or a clipless pedal interface right now, if I twist my foot a little bit or pull, it's going to come right off and I can put that thing on the ground and I'm going to be in a really good spot to save myself or at least not be attached to the bike when it goes down. Now the other side of that is if my foot is in this cage and I have strapped my foot down and it is nice and snug, when I go to tip over, my foot's not coming out of that. That's going to be really hard to get out. You're going to see those cyclists go with the bike, get slammed down to the ground. It's safer. That's the first part of it. That's kind of nice. It does seem a little bit scary to some folks to attach their feet to the pedals, especially when they're used to going from this to what now is this shoe that feels clunky and hard to walk in but snaps in just the same. Now that right there is just the general gist of it. So flat pedals, the original clip pedals just had a cage, went over the top. We go to clipless pedals. Those things are basically the shoe attaching to the pedal itself, easy to twist and pull in case of an emergency or kind of a sketchy situation. Now why does this matter to our patients? Why would they make that shift? I'm going to be honest with you that the first one that most people are going to actually say, it just looks more professional. It looks more legit. They've been riding with a couple of friends. Everybody's been riding clipped in and they're like, dude, why are you still riding flats? Well at that point, they're ready to make that jump. They've been doing this for a while. They're thinking to themselves, everybody else is doing it. They're thinking it's going to be more stable. They're thinking it's going to make me look better. You know, that's an important piece in this whole thing. You want to fill in with your peers when you're out for your rides. On our end though, and more importantly, it's going to give that person a reference point, a starting point, especially in the bike fit world. What we are trying to do is essentially get rid of as many variables as we can or at least control the variables that we can control. That way, when we talk about making modifications to some of these bike, we're actually going to know where we started from. In the bike fit process, it starts from the floor and it works its way up. We start at the feet, we go to the seat, and then we go to the hands or back to the feet if needed. In that scenario, there's a good chance we could spend two thirds of a 90 minute appointment doing just things with the feet, getting this all set up. In the case of somebody who has, let's say knee pain, I want to kind of pose this for why this nomenclature, why this stuff matters. Someone who's in a case where they have active knee pain while riding their bike. Let's liken this to somebody who comes in and says, I have knee pain with squatting. If I say, what type of bike are you riding? And they say something about their pedals and they're like, yeah, I've been riding flat pedals. What that tells me is that they have no idea where their feet are the majority of the time. Imagine somebody coming in who has knee pain with squats and you're like, hey, show me your squat. And they step back and they spread their feet out and they do one and then they kind of bring them in and they do another one and they're like, I don't really know where I want to be at and this is actually kind of what I do every time I'm at the gym. I don't know where I want my feet to be at. It'd be pretty hard to get good information from that, to not know where you're starting from. So in the case of somebody who's dealing with a specific pain complaint, it's nice to be able to at least educate them on, hey, I'm going to make sure that you have a reference on your flat pedal for where your foot should go. 09:45 SOLID FOOT POSITION WITH FLAT PEDALS But more importantly, if you're serious about this and you're doing it long term, we should get you a set of clipless pedals and a shoe that interacts with it appropriately. That way we can find the position that you're comfortable riding in. Because as soon as we know that we have a fixed position at the foot, we can then go adjust the seat and just other factors that are going to improve that person's knee pain. But if you don't know where their foot is relative to the pedal or relative to the crank arm and you go to adjust things on the seat, it's very unlikely you're going to get to where you want to be. If they move their foot even a half centimeter forward or back, all the angles that you used as a reference are going to be totally off. That can be a really frustrating place to start from. Now this isn't to say you can't do bike fits with somebody who is using flat pedals. We are going to talk about references. In the course a lot of times we talk about just saying that first MTP, that first knuckle, trying to get that in line with the pedal spindle, so this center piece as it attaches into the crank arm, is going to be a good reference for that person. But at the end of the day, if that person is A, riding on rough terrain like a mountain bike, every bump is going to shift their feet a little bit. Even with some of the best pedals out there where things stick well to the pins or the more pointy parts of the pedal. Shifting that person over to clipless pedals is going to allow them to stay in one spot the whole time. They may know the reference, but at least they're not going to get out of that reference position, so that's going to be really, really important for this person. Or that person, maybe they ride really consistent terrain, but they're getting better at the idea of improving their cadence. They're talking about trying to run 90 RPM for an extended period of time, which is the recommended RPM in most cases, especially on a road bike, for being the most efficient in any given gear for any given scenario, whether it's going up or down or in a good position. When you try to carry that much RPM on a road bike out in the street, it is actually pretty darn hard to keep your feet fixed in one position and staying still. That is actually a pretty big challenge. So for that individual, when they attach their foot to the pedal, all of a sudden now they can push the pace go faster because their feet aren't trying to slide off. There's less clunkiness in that pedal stroke. They're going to move a lot better at higher RPMs and be less frustrated trying to do so. More power down in those scenarios. Now the last thing for that person who is jumping into this or is curious about jumping into it, is what it does is it's going to, as I mentioned, smooth out the pedal stroke. So as somebody starts pedaling, in general we are putting the most of our power down. That is where we are most efficient. Our quads, our glutes, everything that drives down on the pedal, working with gravity, is what's going to propel us forward. However, that's not to say that it's not valuable to be able to pull through and pull up and over with the other foot. Now it's not your main power, it's not a big driver of the motion, but it does allow you to create a much more smooth and cyclical cycle stroke. 14:43 SAFETY & EFFICIENCY OF CLIPLESS PEDALS So the idea here is if you could have your feet attached to the pedals, you could have more influence over that pedal stroke. You can pull through, you can pull that foot up and over, you can counter what's happening on the other side so that things get much smoother and much more efficient. Athletes that go to a clipless pedal, that go to being clicked into the pedal, are going to have way better engagement when they're trying to run higher RPMs, pedal smoother, and be more efficient in the long run. Now the last thing I want to talk about is that safety piece, again, just because this is one of the things that always ends up being the determining factor for somebody jumping in or not. In general, people know that it's probably a more professional thing to do, but they're kind of like, ah, I don't know if it's for me. The truth is, there is a bit of a hurdle. There's a bit of a hurdle in terms of safety. Somebody gets on, they're nervous about getting on and off the bike, they think they're going to get to a stop sign and fall over, and in all reality, it does happen. I mean, it happens like the very first time everybody rides, you get one situation where you clip your right foot out because you're going to put your right foot down, but you end up leaning left and now your left foot's stuck in and you go over. It happens. You want to try to avoid it, but this is how you actually would do that, try to avoid it. The idea would be if you're on your bike trainer or with a friend holding it still, the idea is you click in, get your foot set, maybe you stand up, sit back down, take your foot out, put it back in. The idea is just get exposure to that mechanism and how that interacts so that you can get your foot in and out easily. As I mentioned really early on, we also have this little setting on the pedal that allows us to change, I kind of like the DIN settings on your skis, but you can change how easy it is for someone to get in or out of those pedals. For the beginner, getting out really easily might feel great. They might really, really like the idea that, okay, this is super easy to get in and out, but as soon as they go to put power down, they might be a little bit irritated by the fact that their foot keeps clicking out. They may want to crank that thing up because now they understand how to get in and out, they're more confident, they want to put the power down and pedal hard. Same way, an aggressive skier, he doesn't want those DIN settings super light. In fact, some people get to that point where they'd rather die than have them come off. People want those things firm so they can do what they need to do. So a couple of things just to wrap this whole piece up. The clipless pedal is a really interesting misnomer. The idea is it gets rid of the clip that used to be on the toe cage. It gets rid of that idea that now when I go to dismount the bike, my foot is locked in so I can't get off. So clipless pedals get rid of that locked in position and give you more of a temporary lockable position so that you can be more efficient while you're pedaling on the bike. To our patients, a lot of times it's just like the next evolution in their cycling journey. They end up wanting to go that route because everybody else is doing it. They know that it's a more professional look, it's a more professional feel, they know that it's a more efficient ride. For us, we love that because if we can get that person into that type of a shoe, into that type of pedal interface, we know that when we go to fit their bike, talk about the pain they're experiencing, we have a reference point that's going to be consistent and fixed the whole time. If we don't know where we're starting, it's hard to fix the issues that pop up. If you're going to come to a bike fit course, you're going to learn that we spent a lot of our time on the pedal and this is a big reason why. Understanding where somebody starts, understanding what you can modify and understanding how that can affect somebody's symptoms are paramount in this space. Alright, that's all I got for you. Have a great Friday, y'all. Appreciate your time. Thanks for jumping on. 16:23 OUTRO Hey, thanks for tuning in to the PT On Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning Check out our virtual ICE online mentorship program at PTOnIce.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Aug 31, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall highlights the key principles behind growing & scaling your practice, using McDonald's as an unlikely but successful example. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start so far. My name is Alan. Happy to be your host today. Currently, I have the pleasure of serving as Chief Operating Officer. I'm a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice, management, ownership, small business, leadership, that sort of thing. Leadership Thursday means it is also Gut Check Thursday. Gut Check Thursday this week is a workout I actually did this past Monday. It is 9, 15, 21 calories on a rowing machine, power snatches with a barbell, 75 pounds for gentlemen, 55 pounds for ladies, and pull ups. Ascending reps game automatically. You should proceed with caution as you get more tired. The reps go up, something we don't like to see too often. Also very redundant in this workout on pulling and grip, right? Pulling on the rower, you have grip on the barbell, and then you have grip and pulling up on the pull-up bar. So it gets redundant, gets really grippy, even with that light barbell. That barbell should be so light you could do all of those rounds unbroken if you really needed to. Maybe one break in the round of 15, maybe one or two breaks in the round of 21. Definitely should be aiming to get that workout done under or around the 10-minute mark. I did that, rested three minutes, and then did 9, 12, 15, rested three minutes, and did 6, 9, 12. I don't recommend doing the extra two rounds. Just stick with the 9, 15, 21. That's plenty of fitness for the day. Courses coming your way from us here at IEFCE. I want to highlight our Extremity Management division led by Lindsay Huey, Mark Gallant, and Cody Gingrich, the newest lead faculty to join the Extremity Management team. You can catch those three out on the road this fall. A couple of different courses coming your way. September 9th and 10th, Mark will be down in Amarillo, Texas. Lindsay will be out in Torrington, Wyoming. The next weekend, September 16th and 17th, Mark will be on the road in Cincinnati, Ohio. The weekend after that, Lindsay will be on the road September 23rd and 24th in Twin Falls, Idaho. The first weekend in October, the 7th and 8th, Lindsay will be up in Ridgefield, Connecticut, and Mark will be in Rochester, Minnesota. November 11th and 12th, Mark will be down in Woodstock, Georgia, which is north of Atlanta, kind of out in the suburbs. The weekend of November 18th and 19th, Mark will again be on the road, this time in Murfreesboro, Tennessee. That's a little bit southeast of Nashville. Cody's first weekend as a lead faculty in the division will be the weekend of December 2nd and 3rd. That'll be out in Newark, California. That's the Bay Area, the Fremont area. And then December 9th and 10th, the last chance to catch extremity management for the year will be in Fort Collins, Colorado with Lindsay. So that's what's coming your way from the extremity division. 03:21 GROWING & SCALING YOUR PRACTICE Today we're going to be talking about hiring from the viewpoint of growing and scaling your practice. And I want to highlight the McDonald's story. So I want to talk about kind of what's always in our mind when we're thinking about growing our team, which is that little voice in the back of our head that says, geez, I hope the person that I hire is mostly like me, right? When we think about growing our team, we're often thinking about how to basically mirror or replicate ourselves. And while that's not 100% possible, that is the goal as we grow and scale. That what we're really talking about when we're bringing new people on the team, we're growing our current practice. We're thinking about maybe even a second location. We're thinking about maintaining our standards of how we run our business, of how we practice physical therapy and preserving our company's culture. So we're going to talk about the who, the what and the how. The who today is going to be McDonald's. Yes, McDonald's, the Golden Arches, the fast food company. The what is going to be talking about how they grow and scale their businesses. And the how is going to be the foundational training that every member of the team has, how that relates to your team as a physical therapist growing your practice and how shared belief systems are really important. So as a company grows, those things tend to get diluted over time. Over multiple generations of leaders and employees, teammates, whatever you want to call the folks who work with you. As we tend to get many generations deep, we noticed a subtle decline in quality and culture of when you first went to the business, when it was a single owner operator, you knew the owner. You knew how things went. You had a relationship with that person. And maybe when you come back to that business, our business in this case being physical therapy, maybe you can't see that provider before. Maybe their schedule is full and they offer to have you see another provider. As the customer is the end user, how do we know that that person is good as the first person? And how do we know that the 10th person is as good as the third person? And so on and so forth. And unfortunately, what we see happen is companies tend to grow, especially as they tend to grow to new locations and maybe even start to franchise. We see that that stuff just gets diluted over and over again until the current business that we are going to no longer resembles the initial encounter with that business. Maybe even to the point that as the customer is the end user, we decide not to give that business our money anymore. So how do we avoid that? How do we avoid the customer coming to that conclusion? 07:26 THE WHO: MCDONALD'S Well, we need to start with the who. We need to start with McDonald's. If you're not familiar with McDonald's, we'll talk about that and we'll talk about how they grew and really the foundations that allow them to grow there. So love or hate them. Everybody has their thought immediately in their mind, their knee-jerk reaction about McDonald's, but they certainly know how to run a business. They know how to deliver a consistent product. That product, at least in my personal opinion, may be quite mediocre. But dang, when you go to McDonald's in Texas or McDonald's in Michigan or McDonald's in Seattle, it doesn't matter. McDonald's in Hong Kong, it is maybe mediocre, but it's consistently mediocre, right? A McDonald's hamburger in Texas tastes the same way as a McDonald's hamburger in New York and the fries are the same and the experience of purchasing from McDonald's is largely the same as well. So they know how to deliver a consistent product and we want to figure out how they do that. They also certainly know how to grow. McDonald's has been in business for 83 years, almost 100 years of continuous business. We've talked here on Leadership Thursday before about how many businesses don't make it to the one-year mark, to the five-year mark, that about the 10-year mark, 75% of all businesses are gone. They have gone out of business before they reach the 10-year mark. So to have been in business almost 100 years continuously is quite impressive. They are the largest restaurant business in human history. They have $24 billion a year in gross revenue. Now that is an amount of money that can be hard to conceptualize. Let me break it down for you. If you haven't heard of ATI Physical Therapy, they are the largest chain of physical therapy clinics in the world. They only grow $600 million a year in annual gross revenue. So any town that is big enough to have a McDonald's, a Walmart, probably also has an ATI Physical Therapy for reference. Nonetheless, McDonald's is almost 40 times larger. They are present in 120 of the 195 countries on the planet, and they are the fourth largest employer in human history. Of the largest employer on the planet currently is Walmart. The second is the Chinese Government Railroad. The third is the Chinese Government Police Service, and the fourth is McDonald's. So of the jobs that you could currently get, you can't go work for the Chinese Government Railroad or police service. You can't just go drop an application and start. We're talking about the second largest American-based employer on the planet. Now if you haven't seen the movie The Founder, I highly recommend you watch that movie. It's one of my most favorite movies. Every time I watch it, I take something away from it. Came out in 2016, and it's really kind of the tale of the start of McDonald's and the growth of McDonald's across the country and eventually the world. 11:27 THE WHAT: SUCCESSFUL GROWTH So that's the what we're going to talk about today. We're going to talk about the franchising of the McDonald's Corporation. Amazing movie. Nick Offerman and John Carroll Lynch play the McDonald's brothers who formed the first McDonald's out in California many, many, many, many years ago. And Michael Keaton does a great job playing Ray Kroc, the guy who finds the McDonald's brothers and becomes the person that franchises McDonald's into the business that it is today. So the original McDonald's started out in San Bernardino, California. It was a one-location restaurant run by the McDonald's brothers. They had a very systematic way of approaching a business. They practiced and trained and redesigned the restaurant again and again and again to optimize efficiency, to basically make burgers and fries and shakes as fast as possible in the almost pre-drive-through era of you had to drive to McDonald's and walk up to the window and order your food. And they created a wonderful, flourishing business that Ray Kroc stumbled upon. He actually was selling a machine that could make six milkshakes at once. And he was hand delivering it to the McDonald's brothers out in California when he watched just how busy their restaurant was all day long and decided this, these guys are onto something. If we could take this business and multiply it, we could really make a lot of money. So those brothers practiced. They had their employees practice work, right? They trained almost military style of running and operating their business. And they did so with a systematic approach, a fundamental approach to how to cook and serve food in a high quality, yes, but also a consistent and efficient manner. And it was built upon a common foundation of training and also of shared values of we want to deliver a high quality product, but we want to do it efficiently. People don't want to sit and wait 30 minutes for a hamburger. They want to be able to walk up to this window and a couple of minutes, get their food, pay and be on their way. Right. The person that's on lunch break or grabbing a bite to eat after work or before work or whatever, walk up, grab your food, go again in the pre drive through area, definitely the pre door dash era of delivering a high quality product. Very, very fast. So Ray Kroc stumbled upon these guys and started to franchise it. Initially did not go the right way. And I think it's important to know that it did not start off in an amazing way that immediately started cheapening ingredients, started using premixed milkshakes instead of actual milk in the milkshakes and initially started with a model that had really minimal control over new locations and leaders. And early on, and you'll see this if you watch the movie, McDonald's all over the country was completely random and different as far as what you might expect. You might find a McDonald's in Illinois that sold hamburgers and french fries and milkshakes, but you might go to a McDonald's in Wisconsin and find barbecue food. You might go to a McDonald's in St. Louis and find them selling tacos. So they kind of had a rocky start that they got away from their foundations. They no longer kept that regimented training, that regimented shared value systems. But I'll tell you the tale of how they turned it around. One of the cooks that worked at one of the original McDonald's, his name was Fred Turner In 1961, he created a training system called what is now known as Hamburg University of saying, hey, this is getting crazy. Every location that the customer goes to, they might be serving completely different food. There may be a completely different experience. They might be dirty at one location, unbelievably clean at the next, a different food just all over the place with consistency and quality. We have to fix this. And that kind of evolved with Fred Turner working alongside Ray Kroc into forming now what is known as the present day McDonald's, which again, the food may not be the highest quality, it might not taste the best, but darn it, it is consistent. And that is really the values that McDonald's presents today. Consistency and simplicity and uniformity with a goal and a shared belief system of quality, service and cleanliness. So they formed this university back in the 60s, Hamburg University. They now have locations in eight countries. They started in 1961. That guy, Fred Turner, who was just a cook, worked his way up and eventually became the CEO of McDonald's for 20 years and really kind of led the global expansion of McDonald's across the planet onto every street corner in America, into 120 countries across the planet. Down to really specific stuff. He was really insistent that fries had to be cut 0.28 inches thick, that one pound of beef should make exactly 10 1.6 ounce patties, so on and so forth. Consistency, the ability to replicate that business across not only shifts at the same location, but at every location across the town, across the state, across the country and eventually across the planet. So that is the who, that is the what. 13:59 THE HOW: SHARED TRAINING & BELIEFS Now we need to talk about how, how did they get there? Again, they had a rocky start, but how they arrived at where they're at now, again, one of the largest, most successful businesses in the history of our species. How did they get there? They get there these days by being very, very selective that each addition to their team is of similar quality to the rest of the team, that they have a shared belief system and that they all go through the same foundational training of when you are maybe a line cook or fry cook or you work the drive through McDonald's. Yes, you are just an hourly wage employee, but once you are maybe going to get promoted when the regional manager, when the owner decides your management material, you go to Hamburger University. If you are thinking about starting a McDonald's franchise, you also go to Hamburger University. They are very selective in who goes to Hamburger University. Only 1% of the people who apply get accepted. And the goal of Hamburger University is to teach managers and owners how to run a McDonald's to the McDonald's standard. Again, we have that common shared training foundation. We are hiring people with a shared common belief system. We are allowing the business to grow and scale without the end user, the customer being really able to notice any change in quality. McDonald's is doing it right. If you leave your house at 6 a.m. and you have a 12 hour road trip and you grab a coffee from McDonald's and a McMuffin at the start of your journey, if you stop at McDonald's four states away for lunch or dinner, it should feel almost exactly like the McDonald's that you stopped at at the start of your journey right by your house. It should really be no different. And even you have probably done this and if you haven't done this, you are a liar. You have gotten a drink at McDonald's in the morning on a long road trip and you have stopped maybe at multiple McDonald's along your route to get a refill of your drink. And again, if you haven't done that, you are probably lying. A lot of us have done that. So that replicated experience location over location over location. And I think we have a lot to learn from that model. And that model does not start with putting money first. It does not start with putting numbers first. It starts with making sure that we are incredibly selective of who we let join our team. And so that brings me to the how. How do we do that? We do that by being extraordinarily picky with who we let join our team. A lot of people will see your clinic, your business, whatever you are doing, being very successful and they want to invite themselves to come on board the ship. They are happy to stop by and drop off their resume and let you know that they are ready to start a position whenever you are ready to start paying them. And oftentimes we find ourselves as our business, our clinic, our practice is growing. We need people more than we care about exactly who that person is. And we have the mindset of we can train that person later. We can mentor that person later. All that matters is that I have more patients on my schedule than I can see. I have a month long wait list. I have a three month wait list. I have a six month wait list. And that's money I'm not capturing now. So I'm just going to hire that person who walked in the door and threw their resume on my desk. And we can't do that. Not if we want to replicate a really high quality experience, a consistent quality experience for our patients and our clients. Not enough businesses are picky enough at this process of making sure that person has the same beliefs that we do, making sure that we have a common shared foundation of training. Us here, we now only hire students who do a long rotation here or folks who have passed the ICE certification exam. That's where our standard is at now. That tells us that person either we have trained them in our training, our foundation as well, and we find out if they have our common belief systems or not, or we know that is on board already because they have passed such a rigorous certification as the ICE cert. But not enough of us are that picky. 17:23 WHEN GROWTH GOES WRONG And what happens if we don't do that? What happens when growth goes wrong? I want to just share a hypothetical example, speaking of the extremity management division today. Imagine that folks just have maybe even a little bit of a difference in what they believe and what they have been trained to do as physical therapists. And we say, you know what? They're only like 20% different. It doesn't matter. It doesn't really matter at the end of the day. Let's just hire this person anyways, even if they are maybe 20% different than the rest of the folks already on the team. Let's take an example of Lindsay and Mark from our extremity management team. Let's say that Mark believes that the foot, the ankle and foot, has no orthopedic value whatsoever. When he teaches his course, he just kind of glosses over that material and maybe even ends his class early. He ends faster than he planned to, right? Maybe he just kind of flips through the slides, shows a couple techniques, maybe an exercise, and he says, you know what? The ankle is really not that important to the body. Have a great weekend. Thanks for being here. Bye. And we're done at 3.30. Now, as we take that person who is now going to train more people underneath of them, the next person Mark trains is likely going to give even less attention to the ankle and foot. They're going to pass over even more of the fine details. And you can imagine if we take that now several generations deep, three, four, five generations deep, that that next person teaching extremity management may not even teach the ankle and foot, right? They may delete it from their slides entirely. Hey, we don't teach that in this course. Which is not true at all, right? Now we have a consistency problem in the product. What about the other end of the continuum? What if Lindsay believes the opposite? What if she believes the foot is the most important structure in the human body? What if she believes that great toe extension is linked to developing Alzheimer's disease? What if she spends so much time on the ankle and foot when she teaches extremity management that now her classes run until 7 p.m. on Sunday? Again, we have for a different reason, a consistency product, a consistency problem with the product we're delivering. Now again, that same example, as we get multiple generations deep, you could imagine the next person Lindsay trains underneath her maybe believes the foot is even more important and spends even more time on the ankle and foot. And maybe three, four, five generations deep, that person spends all of Sunday talking about the ankle and foot. We don't even talk about the hip and the knee anymore. Everything's about the ankle and the foot. And eventually what we come upon is a divergent offering of the same product. That the consistency of the product is diminished or absent entirely. And we have an entirely splinter product being offered. We're now offering two separate products from the same company, even though up many layers above in the leadership position, we're trying to figure out why the inconsistency is there. And it comes from not having that shared common training foundation and that shared belief system. So who is McDonald's? What is how they have franchised across the planet into one of the most successful businesses And the how is being really particular in who you let on your team and making sure that they already arrive with similar belief systems about how to practice physical therapy in a common training foundation. So many people arrive, new students, new grads with a wide variety of beliefs depending on where they went to school, what continued education courses they may have taken after it really can lead to that divergent offering of product that really creates a consistency and a quality product for your business over time. And again, in our mind is the original owner, the leader of the business. That's something we're trying to avoid at all costs. When we think about hiring new people, we're thinking about how can I essentially copy myself as much as possible so that when people come to see this new person I've hired or this eighth new person I've hired or my new location, how can I be sure that they get the same consistent product that I initially delivered when I started the business and it comes down to that shared common training foundation and that belief system. So that's the first part of this series. I want to take you all through the who, the what and the how. Next time I want to talk about once you have actually found that person, where do we go from there into the nitty gritty of things like operating agreements, things of making sure that our training foundation stays the same as we move through our practice, as we move through time together with these members on our team. I hope this was helpful. I hope you have fun with Gut Check Thursday. I hope you have a wonderful, fantastic Thursday and a great Labor Day weekend. We'll actually see you next week for a little bit of talk on carbohydrates on Fitness Athlete Friday. Have a great Thursday. Have a great weekend. Bye everybody! 21:52 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 29, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses how encouragement and support are crucial factors in helping patients overcome challenges and develop resilience. This episode emphasizes the significance of being there for patients and showing them that a healthier and stronger version of themselves is achievable, despite the short-term suffering they may experience. Lindsey acknowledges that this aspect of patient care cannot be measured on standardized scales or assessments, but it plays a vital role in the patient's journey towards better health. Additionally, the episode highlights the importance of providing encouragement to patients when they face setbacks or failures. It is essential to support them and let them know that it is okay to struggle. By reframing these setbacks as part of the process and emphasizing that it is better than not taking any action at all, healthcare providers can help patients maintain their motivation and continue working towards their goals. Furthermore, the episode emphasizes that patients should not be defined by their diagnosis or label. It is crucial to help patients understand that they have the power to make choices that can improve their well-being. Healthcare providers should assist patients in reframing their experiences and show them a different way to approach suffering. This involves forging connections, offering hope, and helping patients gain a new perspective on their situation. In addition to encouragement and support, the episode also mentions the importance of accountability. Patients may need someone to hold them accountable for their actions and help them stay on track with their goals. This can be achieved through forming new connections, such as involving family members or enlisting the support of a healthcare provider. By creating a sense of accountability, patients can stay motivated and make positive changes in their lives. Overall, the episode emphasizes that encouragement, support, and accountability are essential components of helping patients overcome challenges and build resilience. By providing these elements of care, healthcare providers can help patients navigate their journey towards better health and well-being. Lindsey emphasizes that simply modulating pain symptoms is not enough. They want to open up opportunities for patients to maximize their fitness, both physically and psychologically. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsay Hughey, one of our lead faculty for extremity management, along with Dr. Mark Gallant and Cody Gingrich. It's nice to see you all this morning. I am coming to you from Manitou Springs, Colorado. There are some mountains peeking in the background. This Clinical Tuesday, I am going to be chatting with you all about the stimulus of suffering and how in our folks in particular with knee and HIPAA can transform their current suffering to a strength. But I'll tell you it's not by giving up suffering, it's by transforming it. So we will take on this challenging subject today and consider how the suffering stimulus produces growth and satisfaction. But before we do, I would love to tell you about some upcoming courses that Mark and Cody and I have in the extremity division because there's only a handful of courses to catch us in 2023. So coming up is we are in Amarillo, Texas, September 9th and 10th. Mark will be there, so there are still spots left. Join him. And then September 16th, 17th, we'll also be in Cincinnati, Ohio. Moving into the fall, in October, October 7th and 8th, Cody will be in Rochester, Minnesota. So that'll be his first lead course. Join him. He is going to crush that. He has been on the extremity management team and ice team for so long. He brings such a wealth of knowledge. So that is going to be a blast of a course if you are nearby. And then Ridgefield, Connecticut, I added that course about three to four months ago. I'll be there with Melissa Reed. It's a really rad CrossFit gym, CrossFit 203. Lots of spots there, so join us. And then just a couple more opportunities in November and December. So check us out on ptlonice.com. But to the topic at hand. So I've come on here the last few months really chatting a lot about Hip OA and Knee OA and kind of that underlying systemic struggle that they have. And so in particular, we're going to talk about the mental physical struggle that they go through. So those folks with Hip OA and Knee OA, they often start to really identify with that bone on bone label, right? Osteoarthritis becomes who they are. It's how they plan their day. They plan their outings, their weekends, their shopping trips. It's all planned around how long a distance to walk, their energy level, the amount of steps that might be on board, wherever they're headed, how much pain they might be in, how much medicine they might have to take to get through that, or how much they'll pay for it later. So they are considering all of these factors. And it all comes back to like that label that diagnosis of, Oh, I have osteoarthritis. And this starts to really dictate their whole life. And it starts to creating quite a bit of disability limiting their interaction socially. It monopolizes their mental and emotional capacity a bit. And they're struggling. They are suffering. And this is on top of their pain, right in their knee or hip joints and in other areas in their body, because they're walking with the intelligent gait patterns. It's not just the physical impairments, right? Range of motion and strength. They are suffering physically and psychosocially. And we have to recognize this if we want to make an impact. And what's strange is that this suffering becomes a sort of comfort for them, because it's familiar, right? This is now their identity. 04:42 WHEN SUFFERING BECOMES COMFORT We often associate comfort in our society with happiness and well-being. But there's really this intriguing paradox that you start to become comfortable in your current suffering because it is familiar. And this happens to our folks with hip and knee OA in particular, their suffering becomes their comfort. It's what they rely on to dictate their life. Their whole identity is around the suffering. So the reason they don't go to the grocery store anymore, that they have their cousin do their shopping for them, the reason they ride the motorized car and don't walk through the store, the reason they don't take that flight to see their daughter because they can't help bear the thought of walking to that plane and the pain that will cause, or maybe the embarrassment of being pushed in a wheelchair, they're missing their bingo nights, birthday parties of family members, their church Bible studies. They're not able to mow the lawn anymore. They need their nephew or their grandson to do it. They're not doing their exercises because they hurt. They don't want to do them. They'd rather watch their shows. They're not going outside and enjoying the weather. This is suffering and it becomes this holding pattern of inactivity and excuse, which leads to what? It leads to more suffering. The familiarity of that routine to stay home, to not exercise, to eat out, maybe because it's convenient, because they no longer can stand to make a whole meal. This becomes comfortable. Folks are suffering though in another way with these choices, right? They're missing out on socializing. Their joints become more immobile the less they move. They become more painful with less activity and then plus that sequelae of untangible systemic inflammatory changes that are happening when you stop moving, right? Physically and then we can't even put a, you know, a tangible thing on the mental emotional changes that are happening internally and possibly affecting their ecosystems. They will not only stay in these patterns, think about your patients with HIP and NEOA or really anyone really suffering in any diagnosis. Folks tend to find solace in it. We are creatures of habit humans, right? And we stay in these holding patterns of suffering. Our job, we need to create a novel suffering stimulus for these folks. We have to help them see there's this opportunity challenge before them and guess what? They're going to continue to suffer, right? But in a different more productive way, right? And what I mean by that, it's doing your exercises regularly, getting 30 to 60 minutes of physical activity regularly, these things, planning a meal so you don't eat out or having someone come over, help you prepare that meal, things that are outside of comfort zone. Our job is we have to show them the dividends of adapting and learning and evolving lifestyle behaviors. They can change their activity level little by little. They can change their diet and nutrition, their fueling. They can change their hydration. This will all be hard. It will cause some suffering shifts, right? Because of the planning and the change associated with changing those behaviors, like waking up early to do exercises, right? If there's someone that works full time and they just say, I don't have any time to do my exercises for my hip and knee. It might be helping them develop a routine to take their vitamins or hydrate. It might just be asking for help, right? To have an exercise buddy in the morning to walk with. But these all take effort and it takes getting out of that comfortable routine of sitting, right? And doing less. It will definitely take failing, right? Patients, it's hard when you make lifestyle changes. Think about yourself, right? It's hard to make diet and lifestyle changes and nutrition, like eating more protein, drinking half your body weight in ounces. But if you're there, encouraging them, they'll continue to go back at it despite these failures. All of this causes some amount of suffering, right? This change out of normal routine to shift to more healthy lifestyle behaviors. It's one that involves sacrifice, but they have to be novel. It has to be something different, not their comfortable suffering. 09:17 PATIENT AUTONOMY & RESILIENCE We have to try to challenge and force adaption and learning and evolution surrounding their ecosystem, not just in their home program. And this ultimately leads to the patient's autonomy, right? Showing them that a healthier, stronger version of themselves is more resilient despite some short-term suffering. If you can be there to encourage them, right? When they do fail, this helps produce fortitude and resilience. And this can't be measured on an MPRS or KOS. I can't tell you an MCID of encouraging someone and the dividends associated with this. But if we can be there, right, to help them get back up on the saddle, maybe they take off doing their, they're doing great for a week with their physical activity and then they hit three days in a row where they don't, and they just don't feel like it. We have to be there to encourage them. When you fail, right, patients, this causes mental suffering. So as they shift behaviors, lifestyle behaviors, and maybe fail at them, we have to let them know that that's okay and that that's normal and that you're going to be with them. But this is better than sitting on the couch, not going out with your friends, planning your life around your osteoarthritis diagnosis. Our patients are not their diagnosis. They are not their label and they have to believe that. We have to help reframe that and I've talked about that in previous episodes you can check out. But the patients, they are, the some are their choices and we have to let them know that. We have to make them make better suffering choices. It is not okay if they miss doing their exercises, right, those three days. I'm not going to tell Nancy or Marilyn, it's okay. I'm going to say we need to get back at it, Marilyn. We need to get back up on that saddle. They need someone to tell them it's not okay. Along the way to the suffering and accountability, there's healthy byproducts, right, like forming new connection as your PT, right, as their healthcare provider. Maybe it's a family member that they're eliciting to help them be accountable to eat a little bit healthier diet or to drink that extra glass of water. We all need help and accountability to get through hard things and so help them realize that this is also an opportunity for connection to change their outlook and how they even connect with others around them. 12:21 THE SUFFERING STIMULUS The suffering stimulus creates change. Your values of the patient priority start to shift. I keep saying suffering stimulus and that's because in our course we talk a lot about dosage stimulus. In particular, we talk about it in the physical realm, right, like when we talk about strength, we say this is for functional confidence and competence or performance dominance. We work at this at five reps, five sets, greater than 80% one rep max intensity. We're working some sets, greater than 80% one rep max intensity. We're working so hard we need a three-minute rest break. We are doing this three to four days a week. In the rehab dose, it's eight to 20 reps, three to four sets, 30 to 80% intensity. This is for dysfunctional tissue issue, local issues, right, we might rest 60 to 90 seconds and then powers three reps, 10 sets, right, requiring a three-minute rest break because we're taxing the CNS to use strength quickly, right, power is force times velocity, right, these all have standard definitions and reps and set schemes and frequency. The suffering stimulus is a little bit different, right, this is an intangible dose but this is a dose that pushes a human outside of their mental and emotional comfort zone. It shifts their values and their priorities in their time choices, their nutrition choices, their exercise choices, lifestyle choices, even your friend choices. Some friends have to go, right, if they're the ones you're drinking with on the regular and that tell you to eat that extra piece of cake and those cheese fries, right, we might need to change our circle and that might even involve some family ties, right, our activity choices will change and there is a certain amount of suffering associated with that. The suffering stimulus frequency, it's a daily commitment, it's reps and sets, they are boundless but this yields in unmeasurable dividends of hope, resilience, confidence, and maybe a dash of fun if we do our job well to elicit and show them the power of doing exercise and how that changes life and how lifestyle behaviors enhances that even more. The suffering stimulus, it's a life-altering dose that we don't talk about enough. It's our job to show our patient that they can do this and support them in this journey and we do have to be honest that some folks are not going to really lean in to suffering, right, they find finding comfort in suffering. It really is a deeply personal journey, right. I want you to know this isn't about glorifying pain. I hate the saying no pain no gain, we don't say that but this is about recognizing that resilience and growth emerge from life's difficulties, from one's sufferings. We have to reframe that experience for the patient, show them a different way to suffer. It is a delicate balance. We have the privilege of serving humans on the regular, right, in their most vulnerable moments when they're in pain and they're hurting and they are suffering but let's forge connection, hope, and perspective change. Let's help them redirect to control the controllables. Let's help them find their why, paint that picture of what is most important to them, right, playing with grandkids, picking up their kids, running, it's always usually family, right, being able to keep running with their kiddos. Maybe it's running a marathon, maybe it's doing chores without restriction or mowing the lawn again, going to bingo. Let's give them the resources that hold them accountable to achieving these goals like gym access, community classes, connecting them with others with the same struggles. We know this if you've been to an ICE course and you've been part of our tribe for a while but we don't just want to change your hip or knee, shoulder pain, back pain, pelvic pain, right, we want to change your life. We want to modulate your pain symptoms to open the opportunity to maximize fitness but not just physically and not just through fitness-forward lifestyle behavior. We want to build and challenge your psychological fitness. We have to help our humans break their routine suffering for a novel suffering stimulus that challenges them not only physically but mentally to lean into hard-think mindset, lifestyle shifting behavior that yields a more healthy human. 15:47 PRODUCTIVE SUFFERING I want you to not only think about humoring suffering with hip and knee OA patients but even consider yourself, is there some comfortable suffering that you're currently taking part in that you maybe need to shift in to more productive suffering? Maybe it's tracking your food, maybe it's getting in zone two work more, maybe it's actually taking a rest day if you're a work outaholic, right, and allowing yourself dessert once a week. Consider how you can shift your patient to a suffering stimulus that changes their life and think about in your own life as well. Thank you for joining me this clinical Tuesday and if you feel so inclined share with me some ways that you have helped invoke the suffering stimulus personally or in your patients. The suffering stimulus is always a catalyst for change if you let it be. Happy Tuesday folks. 16:20 OUTRO Hey thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 28, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Rachel Moore discusses reintroducing exercise early to the postpartum athlete, including modified CrossFit workouts, gymnastics, core training, and impact training. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at sign up to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 01:22 RACHEL MOORE Good morning PT on ICE Daily Show. My name is Dr. Rachel Moore. I am on faculty with the pelvic division here at ICE, and I am coming at you live from a different space than I normally am today. I was in San Antonio this weekend with Christina Prevot at a pelvic course, and it was a blast. It was so much fun. We met so many amazing people. We always love our weekends out on the road. So if you are interested in jumping into one of our upcoming live cohorts, we've got Scottsdale, Arizona coming up September 23rd and 24th. That is our live course. It'll be myself and Alexis Morgan. And then September 30th and October 1st, we actually have a course in Canada. Christina Prevot will be leading that one. So if you are north of the border and you're interested in jumping into one of our live pelvic courses, great opportunity to do that coming up. We also have our pregnancy and postpartum newsletter. If you're interested in learning about all things pelvic, staying up to date on everything pelvic, it's a great way to get resources sent directly to your inbox. And you can find that link on the website. So you might hear my baby screaming in the background because he's eating. My mother-in-law is feeding him, so just ignore the baby. 02:46 MODIFYING CROSSFIT WORKOUTS I'm here to talk to you guys this morning about modifying workouts for the postpartum athlete, particularly in that early stage. So what I wanted to do is kind of break down one workout and talk about how somebody at four weeks, eight weeks or 12 weeks for the same athlete, maybe we would modify that workout. Modifying workouts can be confusing because there's no set standard of at this point you do this, at this point you do this. So kind of across the board, it's going to be very individualized depending on the athlete in front of you. This is something we dive into a ton in our online cohort and we have an entire assignment where we break down different types or the programming and talk about ways to modify it for a particular athlete. But just to kind of give you a little glimpse of what that looks like and just chit chat about it this morning, there are a few factors that we're going to really heavily consider when we're trying to decide what we want to do for a postpartum athlete. And before we dive into those, I want to talk about why. 04:09 GETTING ATHLETES BACK INTO THE GYM Why do we care about getting an athlete back in the gym, maybe at that three to four week mark rather than waiting until six weeks or even later? Why are we really emphasizing and why do we promote here at ICE getting our athletes back? For a lot of women, the gym is their community and it is their mental health support system. And so postpartum in and of itself can be an incredibly lonely time, especially if you don't have a village around you and especially if you feel like you're isolated from a village that you maybe have. So if we can find ways to get these women into their boxes back at the gym, maybe bringing baby along in their car seat or stroller or if there's child care, great. But bringing baby along, finding ways to modify the stimulus appropriate for somebody that's at that three, four week postpartum mark, we feel that that is incredibly advantageous for mom from both a physical health standpoint. So what are the factors we're going to look at when we're deciding what workouts need to be modified and how to modify them? For one, we want to know what mom did before she was postpartum. So did she work out in pregnancy? What did she do prior to getting pregnant? Had she been a CrossFitter for years when she found out she was pregnant? What was her previous level of strength and did that maintain throughout pregnancy or did she take a long time off and see this big deconditioning response? Method of delivery is another thing that matters really heavily. Some issues with their anterior core wall, but we typically expect to see that somebody who's had a vaginal delivery is going to have potentially more struggles with pelvic floor dysfunction with things like heavy lifting and running and that are going to challenge that anterior core wall. Again, that's not a hard and fast rule. That's not saying it's the only way. We see that overlap, but that's kind of the things that we can expect to see based on the type of delivery. We also need to know about the type of delivery that we expect to see. Especially if they're breastfeeding, we need to make sure we're having the discussion with them about making sure that they're getting enough calories in to support their body and help that not only postpartum healing that is occurring naturally, but also that recovery from being in the gym. We also really want to think about mirroring the stimulus of the workout. So we're not going to do the same things that somebody who is not postpartum, four weeks postpartum is doing, but we want to think about what the intended stimulus of that workout is and try to find ways that we can match that intended stimulus, whether that's muscle groups that are being hit, whether it's cardiovascular versus more muscular strength or what kind of factors we're shooting for and prioritizing in that workout. We want to preserve that with our modifications. So let's break down an athlete and a workout and let's talk about how we would how I would scale this athlete at four weeks postpartum, eight weeks postpartum and 12 weeks postpartum. So our athlete, we're going to call her Suzy. Suzy is a CrossFitter. She's been doing CrossFit for seven years. She just had her first baby. She exercised during her pregnancy until 38 weeks and then she just kind of felt like she wanted to rush. She was feeling like, meh, I'm not really wanting to push fitness right now. I'm just going to kind of take it easy. Her previous lifts, her one rep max back squat was 215 pounds pre-pregnancy. Her one rep max deadlift was 275 pounds pre-pregnancy. Her strict press pre-pregnancy was 95 pounds. And from a gymnastics standpoint, she was able to do kipping pull-ups, bar muscle-ups, chest to bars, and she was able to do double-enders and workouts. So an athlete that has pretty decent experience in CrossFit. It isn't brand new to this and continued to exercise during her pregnancy, had a vaginal delivery. How would we modify a workout for her at four weeks? So we're going to take a workout. It's going to be the same throughout just for the sake of not being confusing. And it's hard to kind of conceptualize and listen. So our workout, the RX version of this workout is five rounds for time, 40 double-enders, three wall walks, 15 toes to bar, and 20 double kettlebell deadlifts. At four weeks postpartum, how are we going to modify for Suzy? So we're going to maybe keep that same stimulus of five rounds. We could also decrease that, but for this exercise, we'll keep that same stimulus of five rounds for time. Instead of 40 double-enders, four weeks postpartum is pretty dang early to start doing that impact. So instead of just doing something like calf raises that would work her calves, but maybe not tax her cardiovascular system, I'm going to have Suzy do a 30 second either bike, row or ski, whatever feels the most comfortable at a comfortable pace. So she's not going breakneck. She's not going to like an eight, nine out of 10 RPE. She's just moving and getting her heart rate up for 30 seconds. Instead of wall walks, we're going to do a 30 second, 30 second, 30 second workout. So swapping the three wall walks out for 12 elevated plank shoulder taps, really focusing on that core connection piece. So focusing on that hollow body, maintaining that core brace, making sure that she's not pushing down into the basement and doing plank shoulder taps to an elevated surface that is challenging for her, but does not feel uncomfortable in any way. Instead of toes to bar, thinking about what the components of that toes to bar are with that lap pressed down and core component piece. I'm going to have her hook a band up to the rig and face away from it. She's going to hold a isometric lap pressed down. So she's going to engage her lats. If you're watching, you can see, but facing away from the rig, hands are in the van, pressing down, standing in that hollow body position, focusing on maintaining that core brace. Focusing on maintaining that core engagement. And I'm going to have her do knee marches. So we're going to swap out those 15 toes to bar for 15 standing knee marches with isometric lap pressed down to mimic that pressing with the knee raise. We could also, if we're thinking about flipping this, preserving grip or reintroducing grip, have her hold an active hang for 30 seconds as well. Those are two options for the same athlete. And you could also alternate from round to round. So maybe one round, we're doing that lap pressed down knee raise. And then that second round, we're doing that active hang and we're alternating between those two. And then finally, instead of the 20 double kettlebell deadlifts, we can even just take bodyweight good mornings. These get sneaky on you if you haven't worked your hammies in a while. So putting hands behind the neck, nice flat neutral spine, hinging forward and coming back up. So her workout again, five rounds for time, 30 seconds on a cardio machine bike rower ski, 12 elevated plank shoulder taps focusing on maintaining that core engagement, either 15 standing marches with isometric lap press downs or 30 seconds of an active hang or whatever amount of time she was able to maintain. And then 20 bodyweight good mornings. That would be the workout for somebody who is four weeks postpartum. She's showing up to the gym. She's hitting a similar intended stimulus. She's moving. She's in class with her friends and she's getting a workout in. Let's take this same athlete, same workout and pretend we have fast forwarded for whatever reason she's now eight weeks postpartum. At eight weeks post, five rounds for time, 40 toe taps or line hops. So we are introducing impact at this point. We can absolutely have maybe began this earlier at about that six week point. So introducing that impact 45 times is a high volume. So if this was something where we wanted to work on single unders, we could maybe cut that rep scheme to 15 or 20 and then still have her do those five rounds focusing on that less volume as we're introducing impact. So two options there from that impact standpoint instead of three full wall walks, maybe we're having her do three modified wall walks. So if you've done the crossfit open and you did a scale division with the wall walk, you start out on the floor, press up on your hands, feet go on the wall and you go hand behind, hand behind, hand forward, hand forward, come all the way back down. The chest hits the floor again. to start working on that core engagement, that active shoulder and getting up on the wall. Alternatively, she can work on a wall walk as high as she can go. So two options there as well. Instead of toes to bar, we're going to say that she's been working on her hangs, she's building that grip strength, she's got that hip swing down. We're going to swap that out for hanging knee raises and maybe 15 is too high volume so we can do 10 hanging knee raises, working on that good kip swing, pressing down as she brings her knees up and really pulling through the bar to get into that arch position. And then finally for the double kettlebell deadlift, we're going to let her send that and she's just going to choose a weight that she's able to hang on to that is an appropriate stimulus for her that she's not feeling any heaviness, pain or leakage. So for this athlete at eight weeks postpartum, five rounds for time, either 40 toe taps or line hops or decreasing that rep scheme and adding in single unders to work on that impact with the rope swing. Three modified wall walks or walking up as high as she can. Ten hanging knee raises and 20 double kettlebell deadlifts at a lighter weight. Let's take this athlete, hit the fast forward button and now we're 12 weeks postpartum. Same workout, same athlete. Five rounds for time. We're going to let her play with double unders. 12:27 INTRODUCING IMPACT So these 12 weeks postpartum, let's say we've been working on impact. Eight weeks we did some single unders or some line hops. That's four weeks of time to have built up the stimulus of maintaining or responding to that impact. So instead of setting a set number for her, I'm going to give her a time domain. I want you to spend about 30 seconds of effort working on your double under. Doesn't mean it has to be breakneck speed. Maybe she's getting two to three, getting into that pelvic recovery position, resting and then picking the rope back up. This is giving her time within that workout to work on the skills that we are hoping to get back to while progressing along in that impact. We're going to swap out wall walks. Maybe not three wall walks, maybe just two. She may be able to do three, but if not, then we are going to drop that number down to two. We can always scale volume with movements. Same thing for toes to bar. So maybe she's back to toes to bar. She's able to hang on to four or five and then she starts feeling some fatigue, hops down from the bar, jumps back up for that second set. Again, this is five rounds, so that cumulative volume does add up. So instead of 15 toes to bar, maybe we're dropping her down to eight toes to bar instead. And then finally, that double kettlebell deadlift, we're going to let her send it and we're going to think, okay, at eight weeks she may have done a certain weight. She's probably at a little bit heavier weight at this point. Maintaining able to breathe, not having leakage, not having heaviness, not having pain, but choosing a weight that feels great for her. Double kettlebell deadlifts are an incredibly functional thing if you're a mom, constantly picking up diaper bags and car seats and kiddos and all the things. So one workout, one person, three different timelines. There are options even within each timeline for this athlete. There is no one right answer when it comes to modifying a workout for an athlete. We need to consider the stimulus of the workout. We need to consider this athlete's history. We need to consider this athlete's recovery and we need to consider the athlete's goals. So when we take all of these things into account, this is kind of a day by day process starting out, but eventually we want to get to the point where our athletes understand how to make these modifications themselves and they feel comfortable. Okay, I can press the gas on this or maybe I need to take a step back on this. At the end of the day, our job is to help them figure this out as we are actively working towards getting back to doing all the things that it is that they want to do. I hope that makes sense. I know it's kind of hard without like, I'm a whiteboard person. So I hope you guys learned something this morning. This is an area that we cover in our online cohort. So if you are looking to learn more about modifying workouts for the postpartum athletes from a programming standpoint especially, hop into our online cohorts, come hang out with us live on the road. We've got tons of courses coming up between September to December and hopefully we'll see you guys soon. Bye! 18:02 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 25, 2023

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses using curved, self-powered treadmills for running & gait analysis, including the differences between metabolic output on overground running, motorized treadmills, and curved treadmills. In addition, she talks about pros & cons of using curved treadmills for gait analysis. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money-saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 RACHEL SELINA Alright, good morning everyone. Welcome to the PT on ICE Daily Show. My name is Rachel Selina and I am with our Endurance Athlete Division, so both our rehabilitation of the injured runner live and online. So first, sorry that this is a little bit later. I'm in Southeast Michigan and we had some crazy storms come through last night, so I have no power, I have no internet. So I am currently at my sister's house, so a little bit of a travel today to do this, but I'm glad to be here. So today we're going to dive into using curved treadmills for gait analysis. It's a question that comes up a lot in our live and online courses, which if you're hoping to get into the live course this year, we have only one more course for 2023. So the next or the last chance for this year to do rehabilitation of the injured runner live would be in Knoxville, Tennessee, November 4th and 5th. Like I said, that's our last course for the year. And then we have another online cohort coming up as well. That one is September 12th. It starts so you can jump into either one of those or both of those at PTonice.com. 02:38 CURVED TREADMILLS FOR GAIT ANALYSIS So like I said, we get asked this question a lot as to whether or not you can use a curved treadmill for gait analysis. And so by curved we mean like the non-motorized curved treadmills, which are common now in a lot of CrossFit gyms. So they're self-propelled. Probably the most common one is the Woodway Curve, and that's the one that's become more common in CrossFit too. There's a Rogue branded one. That's kind of the official treadmill of CrossFit and CrossFit Games. And then there's also like the Assault Fitness brand has a Assault runner. In true form is one that has another or another brand that has the same like type of treadmill. So there's some different ones out there, but they're all essentially the same. Like it's not motorized, so it's powered by the athlete. And it has that kind of curved surface instead of the flat belt that we would be used to seeing on a treadmill. So the claim by kind of manufacturers about these treadmills is that they better reflect over ground running, mostly in terms of the self pacing. So when you're outside and you're running, you can just kind of spontaneously decide, hey, I'm going to speed up and start speeding up or kind of not consciously. Decide to do that and you speed up or slow down. So you can do that on the curved treadmills because they're not motorized or you don't have to like push a button to tell it to speed up or slow down. You can just kind of naturally do what your body would do. So they're marketed as being more reflective of over ground running. They're also purported to decrease impact and therefore reduce your risk of injury. Right. Claim that they promote good running form, good running technique, and then also that they cause more posterior chain muscle activation during running. So that's kind of all like if you were to jump on any one of those websites for those brands of treadmills and kind of read about what they say the purpose of this treadmill is, that's what you would find. When we take it to the research, though, one, there's not that much yet of just good solid research as far as like how running on this type of treadmill actually does change your running form or how it causes muscles to activate or definitely not yet. Like, does it reduce risk of injuries? We don't have that yet. 05:16 GREATER METABOLIC DEMAND ON CURBED TREADMILLS What we do see kind of consistently in the research is that there is a greater metabolic demand from using these treadmills. So like for the same, you know, if you were to do a 5K and you did that outside, you did it on a standard treadmill, like with a motor and a flat belt, or you did it on a curved treadmill, it would it would be harder in terms of there'd be more oxygen uptake. You'd have a higher heart rate and higher RPE for like the same pace on the curved treadmill versus the other ones. And so that's consistent. Like that has maybe not great quality evidence, but there is that evidence out there from the research. We also see on the curved treadmills that we do get a little bit of a reduced ground contact time. So that's the like the amount of time your foot is actually in contact supporting your body on the treadmill. And we tend to see a shift or just like a, I don't know, not not in everybody, but we see that trend to take pressure off of the rear foot, especially when we're striking and go to a more mid foot or forefoot strike when we're using a curved treadmill. So that's really all like, and not even super conclusively, but that's all that consistently we see in the research about using a treadmill like that. Inconsistently is the muscle activation piece. Like there's there's not solid research to support that you have more posterior chain activation. One of the studies that looked at that was actually not using a curved treadmill. It was just using a flat treadmill that was self powered. So in that one, they saw like a little bit more soleus activation and a little bit more rectus femoris activation. But like I said, we can't necessarily apply that to the curved treadmill because it wasn't on a curved treadmill. Like that just might be something about being self powered, but can't say for sure. It also happens when we're on that curve. So some inconsistent stuff like maybe they don't quite do what we what we think they do, but we're not just not quite sure on that yet. In terms of how we use them in the clinic or in the gym, right, like if you want to do a running analysis, is this a viable option to do so? Can you use this treadmill and still get good data? So I'd say you can get good data. We just kind of have to take it in stride with what else we know is going on. So just like on a normal treadmill, we want someone to have a period of being able to adapt to that treadmill if they're not already comfortable running on a treadmill. So what we mean by that is if someone's coming in for a gait analysis, we want them to at least have had exposure to running on a treadmill before we assess the mechanics on a treadmill. Otherwise, you're going to get a lot of inconsistencies because they're just not comfortable running on that surface. So the same thing applies here. We definitely would want someone to have exposure to running on this curve type of treadmill if that's where we're going to then assess the mechanics. Otherwise, we're just not going to see a gait pattern that really is consistent with how they would typically run. So you could use it to make sure they have that period to be able to adapt. So usually that's like three sessions on the treadmill. It doesn't have to be full like you run for five miles three times. It can just be like 15 minutes, three separate times of getting used to that treadmill before you try to do the analysis. The other thing is that we have research for motorized treadmills. 09:45 RUNNING MECHANICS & TREADMILLS We have that research showing that someone's gait on a motorized treadmill, a standard one, is consistent with what their pattern would be over ground. So we can take what we see on that treadmill and assume that that's what we also would see if they're running outside. And we just don't have that yet for these curved treadmills. So we can't 100% assume that the pattern that someone would be showing us on that curved treadmill would be what they would go out and run like over ground. The claim, and I wasn't really able to find where this was coming from, but the claim is that running on that curved treadmill is actually more similar to running uphill. So the one kind of caveat there would be if someone runs uphill a lot, like they're doing a ton of maybe trail or just like big ascents, then it might be more accurate because you can't really on a standard run. You could run on an incline, but that's the one case where it might be more similar to their over ground running if they're running uphill. But that's not like the majority of our people, especially kind of in that more traditional gym or clinic setting. So we have to kind of take it with a grain of salt. What we're seeing on the treadmill might not be 100% reflective of what we would see over ground. The other thing though would be if someone, say you're in that gym setting, if someone is only going to really be running on this type of treadmill, by all means then assess their gait on that treadmill because that's how they're going to be running. So if someone only runs during CrossFit classes when running is programmed and that's where they'll do their run is on that treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of running on a treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of normal, maybe recreational runner, I don't think it's pointless. I think we can get some good data. We'll probably be able to pick up on big, just like big faults going on. We'll still be able to see from that coronal plane if they're, you know, from Dellenberg, how their knee separation is, all of that we still could see. We just need to keep in the back of our mind that this type of treadmill might reduce their tendency to overstride, like to have their foot land far in front of their center of mass. It might reduce that, and it might also make them run a little bit more biased towards their forefoot or midfoot, which we might not really see, like they might overground be more of a heel striker. So I think we just have to kind of keep those in mind. The one other kind of big, big picture thing to keep in mind is if we're going to use that type of treadmill for gait retraining, like we want to start changing someone's mechanics, there's going to be a few gait retraining drills. There's going to be a few gait retraining drills that are really challenging to do on that type of treadmill. So the main one would be retraining cadence. When we're retraining cadence, it's really important initially that the runner keep a consistent pace. So usually that's why like a standard treadmill is super useful because we can set their pace, right, say we're going to set it, their comfortable running pace is a 10 minute mile. So we can set that treadmill to 6.0 and we know the belt's going to stay at the same speed. So if we're encouraging them to increase their cadence, right, to listen to that metronome, to turn over their feet faster, we know that they can do that without speeding up. Because otherwise the tendency, if you just increase cadence without being able to control that belt speed, is just to go faster. All right, so if we're trying to retrain cadence on a curved treadmill, you can see the speed, but you would have to consciously like work to keep that speed the same while you're also trying to consciously pay attention to a cadence. So it would just be a really challenging setup to kind of internalize that cadence and learn that really well. 14:04 CURVED TREADMILLS & OVERSTRIDING For some of the other tools, though, like the curved treadmill might actually be a good way to help someone who does over stride to start to learn what it feels like to keep their foot closer. So the curved treadmill would almost force them to not over stride because they keep over striding, right, that they're going to be landing higher up on that curve. They're going to just make the belt go faster, which is why that treadmill causes you to kind of keep your foot closer. So it could be a good tool for someone who does over stride to get on that type of curved treadmill and start to feel, OK, this is what it's like to keep my foot closer to kind of find that that more centered spot. But we would also need to make sure as they learn that that we make sure that transitions for them back to over ground running. And I think that's just the big thing, right? Like, I'm excited to see more research that comes out on these treadmills to kind of show us, hopefully, where where the usefulness of them is and how it actually does really change our mechanics. So we know best how to use that. But I think as long as we keep in mind that, you know, some of the things we see might not be 100 percent reflective of over ground. If we can also get a little bit of an over ground sense of what this runner is doing, we can use both of those together to make this still a really good tool for assessing and for retraining. So that's it. I'd love to hear your thoughts. If you typically use this type of treadmill, whether from like you personally run on it a lot or you do a lot of assessment on it. I'd be curious your thoughts. So definitely put those in the comments. And then, like I said, if you are hoping to catch one of our live courses, our last one is coming up in November. So feel free to jump into that. We'd love to see you there. All right. Perfect. Have a great weekend, everyone, and thanks for being here! 15:43 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up. And we'll see you there.

Aug 24, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses being wrong about dogmatic approaches to physical therapy, the harmful influence of technology on daily life, and long-term changes to the American healthcare system. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a fantastic start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice management, small business ownership. Leadership Thursday means it is Gut Check Thursday as well. This week's Gut Check Thursday is a little test, Cooper's test in fact. This was a test created way back in 1968 by an Air Force Lieutenant Colonel Kenneth Cooper. He was a doctor in the Air Force and he wanted to figure out how to start to objectively assess the aerobic fitness of our military personnel, the Army and the Air Force, way back in 1968. This test is great. It has been studied a lot. It has a lot of normative data behind it. Very kind of similar to the six minute walk test that we use in the clinic with a lot of our patients to assess aerobic capacity. This is a 12 minute max distance run. Basically how far can you run in 12 minutes? So set a timer. The idea behind this test is that you would run it on a track or you would otherwise just basically run 12 minutes in a straight line. You don't want to end up running maybe in the CrossFit parking lot or the neighborhood where you have to turn and stop a lot. You really want to be able to pick up speed and stay at speed as long as possible. So make sure you're on a track. Make sure you're doing maybe six minutes out, six minutes back, or maybe 12 minutes straight out and then come on back with a walk. And then if you're on a treadmill, make sure you have the grade at 1% to imitate kind of the uneven nature of outdoor pavement. And then that's it. Figure out how far you ran in either meters or miles. There's some equations in the Instagram post to calculate, predict your VO2 max based on how far you ran. And then we've posted some normative tables as well. So this is a great test for ourselves. This is a great test for our athletes or patients as well to see how we stack up. So figure out Cooper's test. Yes, you can row it. You can bike it. Just be mindful that those are unloaded assessments of aerobic fitness so they don't quite translate directly to running. But as long as you retest under the same parameters, have at it with a biker row as well. Courses coming your way related directly to Leadership Thursday. Brick by brick, our practice management startup course starts again September 12th. That course just has one seat left. That's taught by yours truly. We cover everything you'll need to know about starting your physical therapy practice literally from step one of all the legal paperwork you'll need to figure out and file to get started. And then we get a little bit more into what it actually looks like to open and begin your practice. So that starts September 12th, one seat left. And then live courses I want to focus today on total spine thrust manipulation taught by our instructors Justin Dunaway, Jesse Witherington and Britt Lotteman. We have a couple courses coming your way through the end of the year. September 9th and 10th you can join Jesse down in Clearwater, Florida. September 16th and 17th you can join Britt out in Chicago. September 23rd and 24th Jesse again will be on the road this time in St. Mary's, Georgia kind of down in the southeast corner of Georgia by Savannah. October 7th and 8th, two chances to catch total spine thrust either in Columbia, South Carolina with Jesse or in Hendersonville, Tennessee right outside of Nashville with Justin Dunaway. November 4th and 5th Jesse will be out on the west coast, Simi Valley, California. And then two chances again in November before the end of the year November 18th and 19th. Britt will be on the road in Santa Rosa, California this time Northern California and Jesse will be in Albuquerque, New Mexico. So total spine thrusts coming your way. Today let's talk about this topic. So I do have some research to share with you regarding this topic but I really want to talk about the top three things I think I've been wrong about so far in my career. So we're going to talk about what it looks like to treat a comprehensive plan of care with a patient. We're going to talk about technology and we're going to talk about long-term changes to the health care system. 04:08 BEING WRONG ABOUT DOGMATIC APPROACHES TO PATIENT CARE So I want to start with talking about the kind of back and forth dogmatic guru battles that we see all day long on social media of manual therapy sucks, it doesn't do anything, you shouldn't do any manual therapy, if you do manual therapy you're committing malpractice. And then the far other side of that same continuum of if that's exercise only then the belief that manual therapy is the only thing we do that matters that we can somehow cure or fix patients with our hands, with our dry needling, our cupping, our spinal manipulation, whatever stuff we do with our hands. So two different kind of camps fighting and barking at each other on social media and then talking about the research supporting one side or the other or both or neither. So what I've realized and keep in mind I'm coming from a point where I have sat in both of these camps at different points in my career of coming into school as a background as an exercise physiologist, of having no way and no knowledge of how to put my hands on people because I was an exercise physiologist so my intervention, the only intervention allowed to me was exercise. So coming into grad school with a belief that exercise is medicine as taught by the American College of Sports Medicine and that exercise is the way that creates the long-term fix and that manual therapy has no value. So I certainly sat in that camp in the beginning of my PT school career and then I've sat in the other side of the campus while getting into PT school learning more about manual therapy residencies and fellowships and diving really deep into the weeds especially behind spinal manipulation and dry needling and going to the other side of manual therapy is one of the most robust tools we can offer and a little bit of exercise maybe at the end for the patient to keep up their progress in between but being very heavily in the manual therapy camp and holding the the previous belief that maybe folks who are in the exercise only camp are there just because they're not that good at manual therapy so I certainly held that belief for a while. Now I would say I'm in in neither camp and maybe not even in the middle of coming to the belief of the unfortunate belief that we just can't talk or exercise patients into better lifestyle choices no matter how much we have the answer of some sort of combination of both maybe one more than the other is needed for our patients depending on who they are and where they're at in kind of their health and fitness journey and this can be maybe I think the most frustrating part of being a physical therapist and being a health care provider in general of knowing the answer right of knowing that exercise and a solid nutrition plan go a very long way into helping you become and stay a healthy fit individual but that from time to time some hands-on treatment is needed so knowing knowing the answer walking the path but really unfortunately not being able to just give that to another person especially maybe a patient that at the beginning of their plan of care has no formal relationship with us yet. I myself have an unshakable belief that I will continue to probably encounter some minor musculoskeletal injuries within lines of statistical norms due to the impossible ability to balance a lot of different things essentially balancing workload versus recovery of there's going to be days where I don't sleep enough there's going to be days where I don't eat enough there's going to be days where maybe my training volume is higher than I wanted to be my overall life volume is going to be higher than I wanted to and otherwise I put myself at a greater risk for an injury and sometimes we'll actually encounter an injury so I believe that is just part of the journey of health and fitness. I also have an equally unshakable belief that the current meat suit that my brain sits in has been evolving and adapting to stress for over two million years and that it's a naturally resilient structure that's capable of healing itself from most injuries maybe not a car accident or getting hit by a bus but certainly encountering some shoulder pain or knee pain in the gym or out on the run or something like that so that's what I believe but it is hard to transfer that to another person that my third unshakable belief is that it does not matter how much I trust my own body how much I believe that the body can heal itself I can't just take that belief from my brain and put it into somebody else's brain no matter how much I want that to happen no matter how much I talk to that patient in front of me we just can't talk people better we can't talk people into better lifestyle choices we kind of have to show them and that can come from a couple of different angles that can come from having them do some manual therapy techniques maybe even self-manual therapy techniques that helps alleviate your own symptoms to help connect that stress recovery adaptation cycle maybe some exercises or maybe both but otherwise we we do need to show people that this this thing that I've been wrong about is that seeing is believing and 99 percent of people can't be talked better the interesting thing is we have more and more research supporting this now we have some fantastic articles coming out of the pain neuroscience education space that support this that we cannot just talk people better we cannot talk people out of pain we cannot talk people into being healthier we have to show them both by our own example but also by them seeing the success as well and part of that comes from showing them some sort of change manual therapy exercise based doesn't matter whatever you think the patient needs so they begin to buy in to I'm not broken I'm resilient my body can fix itself I don't need surgery I don't need an MRI I don't need pills but that we can't just talk that person better really fantastic article if you have not read it yet by shala and colleagues 2021 the journal of manual and manipulative therapy saying that same thing literally the title of the paper is can we talk patients better and the conclusion is no we can't that we need to combine these things and that the most successful interventions for pain are multimodal they involve yes education discussion of sleep and diet but they do also involve manual therapy and they do also involve exercise it's everything together it's and not or most physical therapy studies if you read the methodology if you read the inclusion and exclusion criteria and if you read and find out in these papers why they initially studied a thousand people but only 760 people completed the study what happened to those other people well yes people get busy yes people get injured or whatever else they drop out of the study but in a lot of these studies folks drop out because they're not getting better they are maybe even going to get care somewhere else outside of the research study which you can imagine creates a lot of confounding variables that makes us need to exclude that person's data from the study there's a lot of really cool research now looking at that of that if we do not offer hands-on care there seems to be a sub-population of people who will leave our care and go get it somewhere else that if you try to talk somebody better and you say i am not going to do anything hands-on because i'm going to make you addicted to manual therapy there are people who will leave your clinic and immediately go get a massage or go see a chiropractor or maybe go see another physical therapist they will go get the care they think they need somewhere else sometimes immediately after your appointment and we need to to be cognizant of that likewise there are people who believe that if there's nothing hands-on as far as doing exercise of them being hands-on that the therapy has less value and likewise they will leave your clinic and go get extra care somewhere else so we need to be cognizant of that as well i think often of i get my hair cut every three weeks on thursday afternoon i see the same stylist i've seen her for years now she has had what i believe to be a pretty gnarly case of achilles tendonopathy from overdoing it increasing run volume i see her i've seen her progression of having a soft brace on to having a walking boot to now having a full cast on of chasing down what she thinks is going to help her in the health care system even though she talks to me for about an hour every three weeks and i try to talk about anything i can to get her to try literally anything else except pills and casting and surgery and imaging and she still won't come down to my clinic to see me even though i've offered to treat her for free of i cannot take the beliefs in my mind and put them in somebody else's mind they have to come unfortunately to that conclusion on their own so being wrong about being able to talk people better about being able to exercise people better and more understanding and recognition as my career has gone on that i need to recognize that every single person who comes into the clinic is different they have different beliefs and i need to recognize what those are and address them accordingly some people may need to start with a bunch of front-loaded physical therapy some people may not like to be touched at all they don't want to do any manual therapy they only want to do exercise and maybe some sort of blend for folks in between. 04:08 THE DANGERS OF TOO MUCH TECHNOLOGY The second thing I've been wrong about is technology if you know me you probably have the belief in your mind that i am the biggest nerd you've ever met and i'm okay with that i grew up playing world of warcraft you can find me in my limited spare time probably trying to sneak in a video game or two every now and again so i'm certainly a giant fan of technology but as my career has gone on as i've gotten older i now have the belief that i think technology creates more problems than it solves the previous point was a great example of we would probably not have these dogmatic arguments and be so fervent in these different camps if we did not have technology to use to yell at each other from across the planet that the computer the internet the mobile device the whatever you're using has revolutionized humanity maybe for the better but i think nowadays more bad than good that having access to all the combined knowledge of our species is amazing but also being a button push or click away from constant contact with friends family frenemies work whatever can be really bad for us especially our mental health of you maybe you're this person maybe you are the spouse of this person or a friend of this person of that person who says did you see what so and so just posted this person is is my wife in our relationship of getting really upset at what other people put on social media and kind of letting it ruin your day and i think that happens a lot in modern society i think back to a question that i was asked very very early on and again i used to have the belief that more technology was better that we could talk other practitioners into better practice habits if we just argued with them on social media if we yelled at them on twitter and about nine years ago jeff moore saw me in an argument on twitter and just sent me a simple message that said hey do you think this is the best use of your time to advance the profession of physical therapy and obviously probably most things in our our life if we ask ourselves that question is this the best use of my time the answer is probably no but definitely to that question the answer was no definitely not and so i often ask myself that question a lot and what i've found over the years is that question and that answer that question takes me further and further away from engaging a lot on social media if you follow my social media now you see pictures of my son in my workouts and that's pretty much it right if far by far and large disengaged from physical therapy social media as a whole i don't listen to any podcasts anymore i listen to the news in the car and music when i work out and that's pretty much it so i've pushed technology away as i've gone through my career as i've gone through my life and i think i'm the better for it and i think having access to all of the gadgets that come along with technology is really doing us a disservice as well of i used to be a big proponent of whoop if you've listened to us here before if you've come to our fitness athlete classes you've heard us talk about whoop and other devices like that and likewise i think those cause more harm and good that having a constant stream of data letting us know you're not moving enough hey you need to move you need to exercise you're not eating enough you're not eating right you're not eating enough you're not sleeping enough you're drinking too much you're overeating this specific type of food i think those constant technological inputs into our life really set us up for a lot of unhappiness of folks who look at a whoop and think what if my resting heart rate is high because i had a beer last night what if it's low because i underate what if my respiratory rate is high because i'm sick what if i have coven 19 what if i have cove 23 what if i put strawberries up my butt would my fart smell better like we can what if this stuff to death and we i think we are doing that with our technology that i do think there is a sub-population of people who have to see that data that have to see whoop say hey every time you report drinking two or more beers you have an 18 reduction in your sleep quality i do think there is a group of people who need to be smacked in the face with that realization of again they can't be told that by somebody else a friend or a family member they have to be showing that objective empirical data but i also think there's an equal sub-population of people who will go completely insane festering about that stuff of worrying themselves to death about what does this data mean i shouldn't exercise today uh maybe i ate so wrong my resting heart rate my hrv is messed up i'm just gonna fast today or i'm not gonna work out for a week and they literally what if themselves to death about this stuff until probably the end result is that most of those people just ditch the gadgets i no longer wear a whoop i haven't wore one for many many years i have a pretty neat cassio g-shock this is a solar powered watch its only thing it does is tell time and then i have a fitbit which tracks my steps i try to hit 25 000 steps a day and that's it right i have no access to any sort of heart rate data or sleep data and i think i'm all the better for it so i think technology is really doing a disservice and i think the more we can intentionally disconnect from some of these data streams and communication streams we will find that we're a lot happier for doing so. 20:07 LONG-TERM CHANGES TO THE AMERICAN HEALTHCARE SYSTEM My third belief is maybe a little bit pessimistic that i think unless something considerable changes with the american health care system i think the way that our health care system currently works is not going to alter significantly at least in our lifetimes that when we step back and zoom out and look at how a lot of stuff in our life is run they're run by for-profit companies the power company is a for-profit company the internet company is a for-profit company the health care clinic company is a for-profit company the insurance company is a for-profit company so we need to ask ourselves are we just victims of people trying to maximize profit and that's why we can't really seem to get ahead in a lot of big system changes and i think the answer that question is yes that's 70 percent of all americans still get their health insurance through their employer so they receive health insurance insurance from a for-profit employer that's run by a for-profit agency the insurance company that uses that insurance at a for-profit health care company so it's no wonder that we are trying to keep margins really narrow high profit low expense and at the end result the person that suffers is usually the health care provider and the patient while the overarching organizations post record profit after record profit year after year after year that both the input and output sides of the system have a vested interest in minimizing costs and maximizing profit and at some point we need to acknowledge and recognize that we also need to recognize acknowledge that with some exception health care providers are really uninvolved or minimally involved with the ownership and management usually of the business that they work for insurance companies are led by led by corporate executives and large health care systems are also led by corporate executives and if we look who sits in the leadership positions of a lot of these companies they're not health care providers they are investment bankers venture capitalists that sort of thing they're interested in profit it really starts to explain and i hope that this doesn't come off as a conspiracy theorist of why our outcomes are so poor despite how expensive our health care system is and that we really need to see big system changes if we're really going to make a dent in the issues that we have which is 90 of humans are sedentary 70 of of americans have chronic pain and we seem to be going backwards despite how hard we get up and go to work ourselves individually every day what do those changes need to look like i don't know i'm not i'm not a big picture person i'm kind of a logistics person but i think that's kind of the frustration that we all experience day to day of yes our individual patients are getting better but why are we still seeing people who got a knee replacement two days after going to see a provider about knee pain why have they not tried physical therapy first why have they not tried literally anything else first except getting booked right into surgery we feel those frustrations we wonder where those are coming from and it's no surprise i think it comes from our giant for-profit health care system as a whole so three things i've been wrong about been wrong about being on one side of the fence or the other the belief that we can talk or fix somebody with our hands or just help them with exercise only that we can take the beliefs in our mind about our bodies and the proper plan of care at least in our mind and put that into somebody else's brain been wrong about leveraging maybe too much technology especially both in personal and professional life and been wrong about the belief of really creating long-term systemic change in the health care system so i'd love to hear what you've been wrong about i'd love to hear questions comments discussion about this topic as well i hope you all have a fantastic thursday have fun with with cooper's tests if you're going to be at a live course this weekend enjoy yourself other than that have a great thursday bye everybody. 21:41 OUTRO Hey, thanks for tuning into the pt on ice daily show if you enjoyed this content head on over to itunes and leave us a review and be sure to check us out on facebook and instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning cus from home check out our virtual ice online mentorship program at pt on ice.com while you're there sign up for our hump day hustling newsletter for a free email every wednesday morning with our top five research articles and social media posts that we think are worth reading head over to pt on ice.com and scroll to the bottom of the page to sign up

Aug 23, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Dustin Jones discusses recent changes to the Modern Management of the Older Adult Division and its mission to help clinicians provide the best possible care to older adults in their community as the provider of choice. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:33 DUSTIN JONES We are live on Instagram. We are live on YouTube. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the faculty members within the older adult division. This is Older Adult Wednesday. Today we are going to be talking about what is MMOA? What is this division? What are we about and what are we trying to achieve? We are going to spend some time diving into this because we have so many new folks that are new to the ICE community. We want to make sure that you're crystal clear on what MMOA is about and if you'd want to join forces with us. Before we go into the goods, I want to mention a few courses we have. We have a few live courses coming up in the next couple of weeks. We're going to be in Southern California this upcoming weekend with Alex Germano. I'm going to be in Windsor, Colorado outside of Fort Collins on the 9th, so the weekend after Labor Day. I believe Julie Brower is going to be down in Fort Mill, South Carolina, so you can catch MMOA live on the road the next couple of weeks. 02:43 MODERN MANAGEMENT OF THE OLDER ADULT What is MMOA? Modern Management of the Older Adult. Our division, we just went through our big live revamp, so our MMOA live course is all new material and we're spending a lot of time reflecting on what we are about as a division. What are our goals? What is our mission? How can we get to that mission and what traits do we want our MMOA team to really demonstrate? I want to share this publicly just so you all are very clear of what we're about, so our goals and where we're headed and to propose that you join forces with us to achieve that mission of really changing the game for physical therapists, occupational therapists, fitness professionals that are working with older adults. So MMOA, Modern Management of the Older Adult, it really grew out of a big problem that we still see that we're still fighting. That older adults by and large in our society are underserved in so many areas, but in the context of rehabilitation, in the context of fitness as well, that most individuals, most professionals that are working with older adults will look at a date of birth. They'll look at medical diagnoses. They'll look at the medications that they're on and make assumptions about what that person is able to do. And when those assumptions don't line up with reality, we have a very, very unfortunate situation where people are not being served appropriately. They're being underdosed. They're being handled with kid gloves and we're not getting the results with these folks, the life changing results with these folks that we can get. That is a huge issue that pains every single MMOA faculty to see and we are on mission to try and solve that problem. How do we solve that problem? It is you. It is you that is watching this on Instagram, on YouTube, that is listening to this on the podcast. It is you, the rehab or fitness professional that has, we believe, has the most qualified skills to influence this population compared to any other healthcare provider. And we mean that. When we look at the research of how we can really influence older adults, it continually points back to that fitness forward approach. That exercise, that movement is such a big lever that we can pull to change these people's And you all watching and listening to this are the best professionals in the context of healthcare to administer this to this population that we love so dearly. Another big problem that we see that we're trying to solve is we have so many clinicians, so many fitness professionals, especially coming up in their training that they think, man, I want to work with the athletes. I want to work with the sports teams. I want to do the fun, sexy outpatient ortho clinic. And we go through our training and our training talks about a lot of things, but by and large, not a lot about older adults and how to best serve these individuals. And then we get out into the real world and what happens? You wanted to work with the sports team. You wanted to work with athletes, you know, from 8 a.m. to 5 p.m. or whatever. And who are you working with? By and large, on average, over half of your all's caseload, everybody watching this or listening to this, over half of your caseload is likely someone that is on Medicare, someone that is over 65 years old. And are you equipped to serve that person? And what happens when you're not equipped and yet you have these folks as the majority of your caseload, there becomes a big mismatch, right? It can be frustrating. It can be challenging and could lead to a lack of fulfillment and enjoyment in your work. And we're trying to absolutely crush that, to show you, the clinician, the fitness professional, of the life-changing impact you can have on these folks. When you use your skill set and you embrace that old-not-weak mindset, that you give interventions that actually meet that person where they're at to drive change, that it can be some of the most fulfilling work that you can do in the context of rehab and fitness, that you can change someone's life in a matter of weeks in certain situations with this population. And that has really driven a lot of the MMOA faculty. And we just want to spread that and share that just far and wide, as much as we can through many different means. So those are the big problems. The solution that we are trying to provide is we're trying to create an army. We're trying to create a community of like-minded clinicians that are locking shields to really fight ageism, to fight the under-dosage in our profession, and to show people what is possible when we serve these folks with an evidence-informed, fitness-forward approach. We do that through many different avenues. We'll do that through this podcast that you're watching or listening to, the PT on Ice Daily Show. We also have an MMOA podcast that's specifically older adult material. We have a Facebook group of about 5,000 clinicians from across the world that serves as a resource for so many individuals in terms of certain research cases. So much good conversation is going on in that group. We have our MMOA Digest. It's a bi-weekly email where we're sending out all the relevant information related to geriatrics. And then we have our courses, our certification. 07:49 CERT-MMOA Cert MMOA. This is the certification that is our promise to clinicians. That if you go through our certifications, three courses, MMOA Live, our two online courses, Essential Foundations and Advanced Concepts, that you will confidently be able to serve that person, that older adult that walks through your door, or you walk into their home, or you walk into their hospital room. It's also a promise that when you see those letters behind someone's name, you can trust them. Our goal is that cert MMOA means I am 100% confident that my mother, that my father, that my grandmother could go to you and you are going to deliver an evidence informed and a fitness forward approach to my family member. That is what we're trying to do, selfishly trying to do to ensure that that cert MMOA holds some weight and you've got the goods. And so there's a group of 10 individuals from across the country that are working towards trying to solve these problems and providing the solution through those different means. We absolutely love what we do and it is such an honor to serve you all and to interact with all the students when we're out on the weekends and live courses and the online courses as well. And this team, this team of 10 all-stars of folks that really embrace that old not weak mindset that have been through our curriculum are spreading this information far and wide to try and equip you, the rehab and fitness professional, to better serve your older adult patients or clients. And each member is going to demonstrate three main traits. We call this our DNA. And what we're going to do over the course of the next couple of weeks on our MMOA channel or Instagram account, we're going to go live and really dive into what these DNA traits are and the specifics of them and how we may see that play out whenever you come to a live course, whenever you interact with us online as well in essential foundations or advanced concepts. These three DNA traits that we're all going to embody is that we're all leaders. Regardless of your role on the team, we're all leading someone and there are certain characteristics and traits of leaders that we embody. We're also teachers. We understand this material, but we're also methodical in how we relay that information to our students so you can use that come Monday. And then last but not least, we're performers. We are performing. We're trying to entertain you so to continue to engage and learn. And whenever we're having fun and you're having fun, we know learning goes up across the board. You will never come to an MMOA course and see someone read off of a PowerPoint presentation for three straight hours while you're sitting in your butt getting a pressure ulcer. That ain't happening, right? We're going to have fun. We're going to get the music cranking. We're going to be moving. It's going to be an absolute blast. So over the next couple of weeks, we're going to dive in. What does it mean to be a leader? What does it mean to be a teacher? What does it mean to be a performer? And how are you going to see that within the MMOA division? So tune in there. We'll be posting over there, but I just want to take this opportunity just with all the folks on here now, I just want to say a big thank you. We've had a lot of change as a division, a lot of growth as well. We're interacting with so many of you all in person on Instagram, you know, in our courses as well. And it is an absolute honor to get to do this, to get to share our passion with you all through these means. And you all just really fill our cup up. When you share, when you execute, you know, that particular tip or intervention, or you just share, man, I got to use this on Monday after this course, that makes it all worth it for us. So we're just incredibly grateful for you. All right. If you have any thoughts on that, or if you've experienced some of this in our course, we'd love to hear in the comments, but just wanted to share this, put it out into the world, and we're going to continue to break down our DNA leaders, teachers, performers over on the MMOA account. We're grateful for y'all. You have a lovely rest of your Wednesday. Talk to you soon. 11:46 Outro Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 22, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant debunks common myths surrounding the IT band. Mark emphasizes the importance of exercise in enhancing function. He mentions two types of exercises: local tissue exercises and functional activities. Local tissue exercises are designed to respect the irritability and stress levels of the tissues. These exercises may include variations of hinge movements, knee bends, or squats that are unloaded enough for the individual to handle. They provide a healthy stimulus to the tissues and help build strength and capacity. Functional activities, such as step downs, squats, and deadlifts, are also incorporated into the treatment plan. Mark explains that coaching these functional movements is crucial in helping the individual return to their normal activities. By gradually increasing the training volume and appropriately dosing the force, they can both manage symptoms and provide a beneficial stimulus to the tissues. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRODUCTION Alright, what is up PT on ice crew? Hope you're doing well on this Tuesday morning. I'm Dr. Mark Gallant coming at you here on clinical Tuesday. Lead faculty of the extremity management division alongside Lindsey Huey and Eric Chaconis. Want to talk to you today about IT band syndrome and some common myths. Before we get into that, we've got a few upcoming courses. So I'll be in Amarillo, Texas, September 9th and 10th. So a lot of tickets flying off the shelves for that one. So make sure if you're in Texas and want to check us out on for extremity management, that you get some seats to that. And then the following weekend, I'll be in Cincinnati, Ohio at Onward Cincinnati. So love to see you out there for that one as well. Again, for any of the ice courses, if you have not already signed up for the ice course that you want for the fall of 2023, the courses that are on the website are the only courses that are going to be added for this year. So make sure make sure you hop on there and sign up as soon as you can. 02:38 COMMON ITB BANDS So IT band myth. So IT band syndrome is one of those syndromes that we had a lot of ideas that came out of research from the 70s, 60s, even early 80s that for whatever reason or another have stood the test of time and stayed in our profession for over 50 years. And that's influenced a lot of the way that we treat a lot of the common manual therapy we see, the interventions we see. And we've got a lot better research that's come out in the last 10, 15 years to direct us how to treat these these IT band patients. And so we want to look at that. This is not to bash the researchers that have come before us. So Renee and Ober and those folks that did a lot of the research in the 1970s. We owe everything we know now to them. And I sincerely hope in five years, six years, a lot of you are looking back at these podcasts and go, man, like all all the stuff that Mark was saying or his colleagues at ICE, it seems kind of silly now. That's what we want to happen. We want you all to take everything we're we're looking at now and make it way better over the next five or six years. So so thanks to Ober. Thanks for Renee. And now we can stand on their shoulders and really move forward. So what were some of the common myths that came out of that research in the 70s? Well, the first one is that the IT band, the iliotibial band track starts at the proximal hip with the TFL and glute. And then it has a very simple unidimensional insertion point at Gertie's tubercle. So one single insertional point for that big, massive iliotibial band structure. What we now know is that the the iliotibial band insertion point is actually quite more complex than that. It attaches at the tibia. It attaches at the lateral femoral condyle. It attaches to the patella. And not only does it attach at multiple sites, these attachments are firm. So so that that distal IT band is not really moving very much at all. The second myth is that the IT band is tight. That that iliotibial band is going to get tight and it's going to limit that person's hip adduction. What we now know is that the structures that are most commonly going to limit someone's adduction are the glute medius, the glute men and the joint capsule. So the IT band is rarely going to be the primary driver of limited adduction. And the TFL, the glute max, the structures that it attaches to are also not typically going to be the primary driver of adduction. What we then see is the third big myth that that iliotibial band syndrome is a pain dominant syndrome being caused by a friction of that iliotibial band rubbing along the lateral structures of the knee because it has a unit dimensional insertion point. Because that thing is tight that it's starting to rub. And that makes a lot of sense going after those those old ideas. Right. If you've got a certain kind of problem, you can go to the doctor's office and you can get a prescription. If you've got a single insertion point and there's extra force causing that that to be tight and it starts to rub, certainly we can see tissues being irritated because we now know that it's got a complex insertion that's really firm, that the IT band is rarely tight. What we now know is that the typical pain presentation is often being caused by repeated force due to an increase in volume change in that person's activity and the lack of frontal plane control. So the most common thing you're going to see is someone really picks up their volume of running. They've got they've got poor control over the hip, knee and ankle. And that knee starts to ping in when you get that at a really, really high volume, the opportunity for the lateral structures structures of the knee to become sensitized gets significantly increased. Another one we see it in is as folks who do a lot of downhill running, they increase their trail running their downhill running by by high volume. So you're getting a ton more load into those those structures and you're getting that lack of frontal plane control and those tissues are going to get irritated. So what are we going to do about that tissue irritation? So so like any other pathology that we're going to treat, our first step is to calm things down. We want to put out that fire initially. 05:30 CALMING DOWN TISSUE IRRITATION So with IT band syndrome, the primary thing that you're going to do to put out their fire is you're going to you're going to get control of their volume. All right, Chris, you were running 10 miles a day, five days a week. We're going to cut that down to five miles a day for three days and see if we can calm that tissue down. So it's rarely full on abstinence. Where we like to start is can we find that sweet spot where your symptoms are starting to calm down and we're still keeping you involved in your functional activity? So whether it's running Olympic lifting, whatever the activity may be, can we control the amount of load, the volume of force that's going into that system and get those symptoms to calm down? In addition, using using our manual therapy techniques to modulate pain. So you're dry needling, your myofascial decompression, your soft tissue mobilization. You're going to base these off irritability. If that person's high on their irritability, then we're often going to needle massage and cup tissues that are a little more distal to where the pain is at that lateral knee. So looking a lot at the glutes, maybe lower down on the ankle. And then as symptoms calm down, we can get at the tissues more more close to that knee, that tibialis anterior, the distal vastus lateralis, the short head of the biceps and really try to modulate people's our patient symptoms and and get those tissues a little healthier. From there at the same time, so we're not waiting until the pain modulation comes down, we're going to start doing some therapeutic exercise to get those tissues to tolerate load better. So we've got to strike that balance of we're trying to lower their symptoms and we want some healthy, good force to go into their tissues. So oftentimes that can be open chain exercises. So they're going to have typically a little less load on the tissue because you're not dealing with so many structures. You're not dealing with ground reaction forces. So keeping that that low to improve the overall tissue health and then progressing them into more closed chain exercises that are going to stimulate those tissues in a little bit closer environment to their typical activity. So things like hip hikes, closed chain clamshells, your side steps, all those sort of things. Then we want to get into some functional exercise. Can we get compound movements that are going to be close to the activity that that person is typically doing with those compound movements for IT band? We're looking at things like step downs, single leg squats, all of those type of activities. Kickstand deadlifts are another good one. 08:25 PT 1.0 & MOVING FORWARD Now we're PT 1.0. A thing that we did in our profession that we would like to move on from now is we said, OK, we're going to do our local tissue stuff. And when you get good enough at the local tissue stuff, then we're going to graduate you into doing these functional components. What we what we know now is we want to get all of this involved as early as possible so that we can influence the nervous system better and make that person less fearful of doing these these more challenging activities. So you're going to hit your local tissue exercises, respecting their irritability, respecting the amount of stress that that tissue can handle. And you're going to start doing variations of functional activities that they can tolerate again with their pain level, their irritability and their stress. So finding a hinge variation that's unloaded enough that the person can perform, finding a knee bend variation or squat variation, single leg squat variation that's unloaded enough that that individual can handle. So that's two components, local tissue with three components, pain modulation with our manual therapy, local tissue exercises to get some healthy stimulus into those tissues. Looking at a functional activity, squats, deadlifts, all those sort of things. All these are happening relatively at the same time. And then the fourth piece is looking at the activity that caused the problem. Was it running? Can we get them on the treadmill and do do a run a run gate analysis? Shout out to Jason, Megan and Rachel in the in the injured runner division. Can we look at their their Olympic lifting? Are they getting IT band syndrome because they started doing split jerks all the time and that position of their knees a little bit irritating? You know, the whole CMFA crew, can you really look at and coach well through a video analysis what that person is doing on their their Olympic lifting and start moving them forward there? So we're going to modulate the pain by controlling their volume. We're going to modulate the pain by using some manual therapy to influence the central nervous system to calm those tissues down. We're going to start exercising, getting good healthy stimulus while respecting irritability into the tissues through open chain and closed chain local tissue exercises. We're going to get a big functional movement, step down, squat, deadlift to start building robustness and capacity overall. And we're going to coach them on the functional activity that may have been the aggravating, whether that's running, downhill running or or their Olympic weightlifting. Now, what this does that's really cool is it positions you as a wildly unique provider to this individual. We are the only profession or one of few professions that are able to control that entire experience for that person. We've got the education where we can control their training volume. We can say, hey, look, I looked at your programming. Looks like you had a huge jump here and all of a sudden you're doing like three times the volume. Let's see if we can cut that back a bit. You can poke them with some needles. You can do massage. You can do myofascial decompression. You can do joint manipulation to calm that lateral knee down. You're the expert in local tissue exercise. You know, if I put this amount of force into this tissue and dose it appropriately, we can both keep symptoms calm down and give a good healthy stimulus to that tissue. You got to know how to coach the step down, the squat, the deadlift to get them back to their functional movements. And we've got to start getting better at being able to do those run gate analysis, video analysis for the big lifts, the Olympic lift, the squat, all those that we can really coach those well. And that will uniquely put you in a position to take that person through a whole plan of care and get them back to the things they love. That will really position you as the best possible guide. So again, to recap, IT band syndrome, we no longer believe that this is a friction based component because we now know that the IT band is firmly anchored to that lateral knee at the tibia, the femur and the patella. We know it's more of a volume increase and a lack of frontal plane control that's really irritating the system. If we can get that frontal plane control by getting a better step down, a better squat, better functional movement, use our local exercise to get better healthy stimulus into that lateral knee so those tissues can tolerate increased stress and improving our efficiency with the movements that we want to do, our running, our Olympic lifting, those sort of movements. Hope this helps. Love to discuss this more in the chat bar. Can't wait to see you all on the road in a few weeks. Hope you have a great rest of your Tuesday. 13:01 OUTRO Hey, thanks for tuning in to the P.T. on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at P.T. on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to P.T. on Ice dot com and scroll to the bottom of the page to sign up.

Aug 21, 2023

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Christina Prevett breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION 00:00 INTRO Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 01:22 CHRISTINA PREVETT Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox. 02:48 ACUTE EFFECTS OF RESISTANCE TRAINING Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison. 04:24 ACUTE CHANGES TO THE PELVIC FLOOR And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment. 09:23 VAGINAL DESCENT AND EXERCISE The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were. 12:57 RESISTANCE TRAINING & PROLAPSE And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic floor when the pelvic floor gets a workout. Again, I don't think for anybody in the ice fitness forward community that that is necessarily a surprising finding, but it is definitely pushing some of the narratives in pelvic health and I think pushing them in a really necessary direction to try and change this narrative around the fear-focused language of resistance training in the pelvic floor. If you are interested in those studies, I'll post their DOIs below in the comment section. I am so excited to be talking about this research. Again, if you are a research nerd like me and you want to see the new studies that are coming out in this space, which these two studies are going to be in our newsletter this next week, I encourage you to go to ptonice.com slash resources to look for the pelvic newsletter. I am really excited to see some of the changes happening within our course and I just can't wait to continue connecting with you all about research in the pelvic health space. All right. Have a great day, everyone, and I will talk to you soon. 16:40 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 18, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's show. 01:27 APRIL DOMINICK Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we'll focus on three postpartum physical scars that are often invisible to the rehab provider. We'll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let's chat about all things, updates and course offerings for the ICE Pelvic Division. If you're looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We've got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person. 03:23 PHYSICAL SCARS POSTPARTUM Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren't always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it's important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there's no physical sign that they and their body have gone through this incredibly challenging feat. There's no cast for like when we have for a broken bone. There's no crutches for that ankle sprain. There's no sling to support the wounds. Unless maybe they have their newborn with them, there's really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we'll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let's circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that's going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let's unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It's as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that's smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we're thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity. 07:33 PERINEAL SCARRING Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that's between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that's either naturally or via an episiotomy. And that's going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It's small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that's going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F's with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we're thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions. 09:01 C-SECTION SCARRING And then we have our C-section scar. So where is it? I'll talk about the most common cut that is done is called the bikini cut. And then it's about four to five inches long and it's stretched across the lower abdominals. In terms of time to heal, that's going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that's about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it's approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis. 14:01 CORE-CENTRIC MOVEMENTS & EXERCISE In terms of considerations for return back to exercise specifically for a C-section scar, we're thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let's talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we'll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We're talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That's just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you're talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They'll need about 400 to 500 extra calories. Okay, let's talk about return to exercise. Generally speaking, when we're talking about return to exercise for someone who's early postpartum, it's a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that's a time to determine the body's capacity for tolerating exercise. As a provider, it's helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let's talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that's pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it's increased pressure at the abdomen from a set of dumbbells when they're doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we're thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we're going to find their guidepost in terms of how much impact their body can tolerate, whether it's starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training. 18:07 PAIN WITH INTERCOURSE Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be from a finger, a toy, or a partner student, Natalia. So it's estimated that 43% of women report pain with intercourse in that first six months early postpartum. And this is something major that we should be thinking about when someone is maybe sharing with us things that are going on with penetrative intercourse for them. A C-section or perineal tear can contribute to painful intercourse. There's a greater risk associated with pain with intercourse with an episiotomy versus a natural perineal tear. Just as we would practice scar desensitization in any other part of the body, we're going to do the same here at the vagina. And a pelvic PT is going to be really great in assisting and making recommendations for internal massage, stretching, or using a dilator set. So let's recap. Today we talked about three main scars that a postpartum person may have. A uterine scar, a perineal scar, or an abdominal scar from a C-section. Remember to respect these healing timelines. They will be unique to each person. The next time you have a client who's early postpartum on your schedule, encourage them to start small. Go slow for returning to exercise and intimacy. Educate them on progressive overload and how that may not be a straight line for them. Maybe a series of peaks and valleys that are impacted by external factors such as sleep, fuel their body's current physical capacity. Communicate with them. Get curious about their invisible physical scars as they may not feel comfortable telling you and offering you that information that, Oh, they have pain at their vagina at the bottom of a deep squat or their abdominal incision site is really bothering them when they're doing a hollow hold or hanging from the bar. So they will no doubt be thankful if their provider considers these scars, asks about them, and because they're not often discussed. So thanks for tuning in, everyone. I hope you gain some awareness of these physical invisible scars that a postpartum person may be dealing with. Next episode, I'll be discussing the emotional invisible scars in the postpartum period. Cheers y'all. 20:28 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 18, 2023

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show. 01:26 MITCH BABCOCK Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses. 02:16 POST CROSSFIT GAMES All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on. 04:35 SETTING & REFRAMING GOALS What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training? 06:30 INVESTING IN FOUNDATIONAL STRENGTH And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work. 10:06 LONG DURATION ZONE TWO WORK Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week. 13:21 MORE CONSISTENCY IN THE GYM From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym. We need to get stronger at the things that matter and we need a better conditioning, a better engine to be able to do more things. And then the lifestyle stuff comes along with that. We're going to be one hour in the gym and the 23 hours out of the gym. What are we doing with the 23 hours out of the gym? Can I set a bedtime? Can I get better sleep quality? Can I eat better? Can I reduce my alcohol consumption? All of those little details that will stack up and aggregate over a year or six months or nine months into a much fitter version of yourself. The stronger and healthier you get, the longer you're going to live. And ultimately that needs to be all of our game plan. Why are we doing this? The oldest, not the oldest member, the most tenured member of my gym, we call him the Godfather just for that reason, says all the time, I'm just trying to still be doing CrossFit when I'm 70. Like every decision he makes in the gym day by day, he keeps that greater focus. He's not coming into the gym saying this is the year I make it to the games. He's coming into the gym every day saying, I need to make a decision that's right today so that I can still be doing CrossFit when I'm 70. Because I know that if I'm still doing CrossFit when I'm 70, I can be doing all the things in my retirement that I want to be doing. So keep the long term vision in play. We're looking to be able to do this over a lifespan. Stretch out and increase your lifespan, the number of healthy, good years you're living. That's what ultimately this is all about for us. So here's some small actionable goals that people like you and me can really bite off and really set our sights on over the next six or 12 months. Throw our hat in the ring when the Open comes around next year and say, hey, you know what, because I put that work in starting in August, I'm really a much better version of myself now in February. Comment below if one of these, if you've got a goal that we listed off and you're like, look, I need to jump on that. Drop a comment below whether that's YouTube, whether that's Instagram, whether that's on a podcast format. Let us know. Reach out to us. And then as always, if you need help with any of these things, that's what we're here for. So talking about all things lifestyle related in our live course as well. Excited to see those of you that are going to make it for your first time out at one of those courses. We're hitting the road heavy this fall. So looking to see you guys out there. In the meantime, if you're training today, have a great session. Get some caffeine in you and ramp it up. I will see you guys out on the road very soon. Have a great day, everyone. 15:56 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Aug 17, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses average arrival rates in physical therapy, what the research says about how to improve arrival rates, leveraging technology to improve arrival rates, and creating policies & systems that ensure your clinic still gets paid for missed appointments. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Good morning, everybody. Welcome to the PT on ICE daily show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and the faculty member on our fitness athlete division. We're here on Thursdays. We talk all things leadership Thursday, small business ownership, practice management, that sort of thing. Leadership Thursday also means it is gut check Thursday. This week we have a 17 minute AMRAP, as many rounds and reps as possible in 17 minutes of the following 21 plate ground to overhead. Our Rx weight there for guys 45 for ladies 25. So grabbing a bumper plate, hinging down, tapping one side of the plate between your feet and then up and over overhead, almost like a snatch. Moving into 15 cows on the rower for guys 12 for ladies and then finishing with a small dose nine burpees to plate. So looking for somewhere between three to five rounds of that great workout for home, the garage, the basement, the clinic. Just need a rower and a bumper plate. Great to maybe take out to the park as well and sub the row for some running or something like that. So that is gut check Thursday. Course is coming your way. We have so many about to enter a very, very busy season for ICE here as we get into the fall, get away from the summer, school starts back up, that sort of thing. We have a couple hundred courses coming your way between now and the end of the year. So if you're looking for live courses, head on over to p10ice.com, click on our courses and check out our map to see what's coming to your neck of the woods. Some online courses I want to highlight. Pretty much all of our entire catalog of eight week online courses are starting back up after Labor Day. So if you don't know about our online courses, they are eight weeks online. They are synchronous, which means that you meet with us every week. They are not completely self study, a mixture of lecture, of reading, of homework and of live meetups. They're meant to simulate the feeling of a two day live course, but stretched across eight weeks to make it a little bit more accessible, save you a little bit of money on travel. So online courses, pretty much like I said, all of them are starting after Labor Day. We have ICE Pelvic Online. That's our entry level online pregnancy and postpartum course. That's going to start September 4th. We have Fitness Athlete Essential Foundations taught by yours truly Mitch Babcock, Kelly Benfee and Guillermo Contreras. That's going to start September 11th. The very next day, September 12th, Brick by Brick is going to start very relevant course to this day of the week to Thursdays. We talk all things practice, startup and ownership and management in that course. Injured Runner Online also starts September 12th and then Virtual ICE will open back up September 26th for our next quarter of enrollment. So let's get into today's topic. Let's talk about how do we handle, how do we get better at when a patient reschedules, cancels or no shows. I want to talk today about three main topics. I'm going to talk about what are the average no show cancellation rates, what we would call an arrival rate across the country, across physical therapy, what's normal, what's abnormal. I want to talk about how to improve those arrival rates. And then I want to talk about how to get paid when somebody does not show up for those appointments. 05:46 ARRIVAL RATES IN PHYSICAL THERAPY So let's start at the beginning and let's talk about what is a normal rate. If you have been practicing physical therapy for a while, if you have been practicing in a traditional clinic, you may have heard that the common recommendation for the maximum arrival rate is about 93%. That is to say that 93% of your appointments show up for their appointment that day. That there's some margin of error. We recognize that 100% of people probably won't make it, but pretty typical. 93% is the standard that's set and sometimes enforced by the clinic that you work for. Maybe if you fall below that, maybe you get a warning, maybe you get a talking to, or maybe they actually dock your pay for visits underneath that 93%. What's awesome about this topic is that we actually have a lot of research, surprisingly, supporting the numbers that I'm about to tell you. So we have a great survey back from 2015 of about 7,000 outpatient physical therapists. This is from Bo Kinski and colleagues, sorry if I mispronounced this, of 7,000 outpatient PT's looking at a couple of different things. Looking at finding the average cancellation no-show rate, but also finding what things seem to help fix that. So across the country, we see an average no-show cancellation rate of actually about 10 to 14%. So thinking you may have been told 93% is the gold standard, in reality, somewhere between 85 to 90% is actually probably more realistic. If you had 10 patients scheduled for the day, you could expect maybe eight of them to show up for the appointment. You could expect maybe one to two appointments to be unfilled. I like this survey because it goes a couple levels deeper. It asks why. Now knowing that rate, knowing that 10 to 14% rate, why do people not show up for the appointment? What is the number one cause? The number one reason why patients do not attend their appointment is not that they can't afford it, not that they don't like you, it's that they forgot and that the clinic that they went to physical therapy to had no reminder system. So that's a huge error, that's a very easy fix. When we delineate outpatient physical therapy from hospital-based outpatient physical therapy, so private practice versus hospital-based, we see that hospital-based clinics actually the no-show cancellation rate of a private practice clinic. Why is that? I would imagine it's probably due to having a modern reminder system, but again, that number of 93% isn't the gold standard that we think it is. In private practice, we can expect maybe 85 to 90% arrival rate, a little bit lower in hospital-based, maybe 75 to 80% arrival rate. Now this survey looked at the concept of a multi-method reminder system. What does that mean? That means that the patient received multiple reminders across multiple communication methods. That they usually received some sort of automated phone call reminding them of their appointment. They received probably a text message and then maybe also an email message. So they received two to three different reminders ahead of their appointment across different modalities, basically reminding the patient as much as possible of their upcoming appointment. Now they found that those clinics that used a multi-method reminder system had a significant reduction in no-show cancellation rates, about a 50% reduction. So they cut their no-show cancellation rate in half just by having a reminder system. And we're going to talk about how to set that up at your clinic here in a minute. The second reason that clinics did better with no-show cancellation rate was those clinics who had a 24-hour appointment change policy. That is inside of 24 hours, you will be penalized if you cancel or reschedule or no-show your appointment versus if you give more than a 24-hour notice that you need to reschedule your appointment or otherwise cancel it. So those clinics which had a 24-hour policy and enforced that policy on their patients also had a reduction in their no-show cancellation rate. So that brings us to the question of if 10 to 14% is the mean of the average of no-show cancellation rates across the country, then how realistic is 7%? The answer is not very, right? Even if you are treating one-on-one for an hour and you maybe only have eight patients on your caseload for the day, it's probably unrealistic to expect 100% of those people to show up every day. That we have to recognize at some level that the reason we see so much overbooking in traditional physical therapy clinics is it's just that leadership strategy to limit the impact of those inevitable no-show cancellation rates. That if you see eight patients in a day and 10 to 15% don't make it, you may see five to seven patients. So kind of the aggressive leadership solution here is just to make you see more patients. That if you see twice as many patients and you still have that 10 to 15% no-show cancellation rate, then you'll still see more patients than originally intended and scheduled to and the clinic won't lose as much profit. But that being said, that is an aggressive way. That is a way that puts all of the burden of the work on the therapist and none of it on the ownership, none of it on the leadership and none of it kind of on the backend logistical side of the clinic. Instead of making you see more patients, why don't we just have a 24-hour policy that we enforce? And if we're not using a reminder system, why don't we start using one? Why don't we do some more conservative approaches to reduce that no-show cancellation rate, especially now knowing that we have research that supports, does those actually improve our no-show cancellation rates? So let's talk about that. 08:48 IMPROVING ARRIVAL RATES Let's talk about aside from having a reminder system, aside from strategies to remind patients to get to the clinic and aside from having a policy, how can we approve improve those arrival rates? You know us here at ICE, if you've been listening to us for a while, Jeff Moore, our CEO says it best. The first thing you can do to make patients show up to physical therapy more is make sure that you're focused on getting good and not getting busy. That when people see results, when they begin to associate value with their physical therapy appointment, they come to their appointment more often. I think this is so overlooked, especially in a higher volume clinic where a therapist may be expected to see multiple patients per hour. By providing lower quality care, patients aren't able to get results or they're not able to get results as fast as maybe they want to. They don't really associate physical therapy as a valuable use of their time and it makes sense that they find better stuff to do and that you get that message at 4.55 p.m. that your 5 p.m. patient is not going to make it in today. So really focus on getting good, not getting busy. We also need to recognize that people are not stupid. When they show up to PT and they see that you are working with three other people at the same time and you have forgotten about them in the corner at the TheraBand station or on the recumbent bike or the pulleys, again, that really begins to lower the value proposition that patients have with physical therapy and it's not surprising again that they begin to find better stuff to do with that hour of their time. The counter argument here is that you can get so good as a physical therapist, I'm good enough that I can see multiple patients at once or patients aren't as fragile as we think. We don't need to give them one-on-one care, but we need to recognize that at some level, patients are paying for it, especially if they're paying cash for a one-on-one visit. They are expecting one-on-one treatment. Even if you are an insurance-based clinic and using a patient's insurance, that insurance is still paying you based on one-on-one care. And not only that, but the patient expectation is that you are going to give them the care that they need. And I often relate this to other professions of you would lose your mind if you had a therapy appointment with a psychologist, a mental therapy appointment, if you showed up and there were three other people getting mental health therapy at the same time as you. No one would put up with that, but for some reason, it's just expected and normalized that that's the kind of care that we give in physical therapy. So then it's no wonder that patients, again, find something better to do with their time for the hour. So really focus on getting good and not getting busy, of taking really quality care of that patient that you have on your schedule for that hour. And you'll be surprised how much they come back to physical therapy when they see their range of motion improving, when they see their balance improving, when they feel stronger, when their pain is getting better, whatever their goals are, as they can see progress towards their goals, it's much more likely that they're going to come back to physical therapy. And I think that is often overlooked. My second point with improving arrival rates is to leverage technology, implement that multi-method reminder system. It's 2023. There is no reason why your clinic does not have automated reminders, text, email, phone, whatever. It's all built in to a modern EMR. If your EMR does not do this, you need to get an EMR that does this. If your front desk person is still calling people by hand to remind them of their appointment, you're a little bit behind the curve, right? to do the work for you so that you can focus on treating your patients while the technology sends out those reminders for you. We need to recognize that people are busy and that the more we can be prominent in front of mind with reminders, the more likely people are to attend their appointments. We have research that supports this, right? We can cut these no-show cancellation rates in half with a multi-method reminder system, but also it gives the patient a chance to reschedule if they know they already can't make it, right? That text reminder, when they get that phone call, when they get that email, it gives them multiple chances to reschedule. And if they don't, it also kind of builds the case for you against them that you gave them plenty of chances to reschedule and they still did not. And that makes it a little bit easier to charge them money, which we'll talk about in a few seconds here. So remember, we can cut that rate in half, that no-show cancellation rate in half with a multi-method reminder system. So if you're still using Google Drive as your EMR, if you're still using paper documentation and scanning it into a computer, consider getting a modern EMR. They're not that expensive. EMRs, we're big fans of Jane here, obviously, at ICE, other EMRs, Prompt, PT Everywhere, pretty much all the modern web-based EMRs are going to offer reminders and more often than not, they're free for you to use. So why not use them, right? It's one more push of a button when you're building out that patient chart for them to get reminders. In addition to reminders, leverage technology to create an online booking and waitlist system so that when you do send that reminder, it should come with a link where it says, hey, if you can't keep this appointment, please click here, right? So that your appointment comes off my schedule and that you get a little link to rebook at a time that works better for you. So we still keep that visit on the schedule, but we also open up that visit to maybe somebody else who can use it so that we don't have a missed slot on our schedule. Pretty much just like reminders, modern EMRs are very good at having automation with waitlists of where when a patient reschedules and a slot opens up, usually automatically or with the push of a button, you can pull people in from your waitlist and make sure that that slot stays filled without having that patient get charged for cancellation or no-show because they were able to go in on their own and reschedule their own appointment. So make sure we're leveraging technology whenever possible to do this work for us. My last point here on improving arrival rates is probably something that we don't consider very often of making sure in that initial evaluation that the patient actually has the time and or money to come to their physical therapy appointments. I feel like a lot of time patients feel beholden to maybe a referral they had from a doctor or what you tell them of some sort of verbal contract of the doctor said I have to come here three times a week for six weeks or maybe that's what you wrote on your documentation is the physical therapist and they feel like they have to come no matter what, even if they know they do not have the time or money. I feel like this is something that should be discussed as we're wrapping up our initial evaluations that just doesn't get done. As we're building the bike for that patient, we're explaining our findings, we're demonstrating that we can help that person reach their goals by showing them some improvement in that first visit and as we begin to discuss what that plan of care might look like, also making sure that the patient is on board, right, including the patient that conversation of hey, Diane, this seems to be a pretty irritable tendinopathy. You know, I think I would like to see you here in the clinic twice a week, probably for at least the next four weeks. And instead of stopping there, take it one step further. How do you feel about that? Right? What do you think about my plan for your care? And we don't necessarily have to ask, hey, can you afford this? Or do you have the time for this? But that's what we're hinting at of how do you feel about coming here twice a week for four weeks? How do you feel about coming here once a week for the next four weeks and getting the patient's input because that's a great time for them to say, that's going to be tough with my schedule. You know, I have 17 kids or I work 30 jobs. I won't be able to do that, right? That's a great time to make sure that person does not get put on your schedule for a bunch of visits that they're not going to attend. And then making sure we're following the law, right? No surprises act that was passed last year that were very transparent with how long we think the plan of care is going to take and what that's going to cost that patient. Whether you're charging cash, whether you're billing insurance, you need to provide that information upfront to the patient. I would argue you should be doing it even if it's not the law, just so you don't have people on your schedule who are not going to show up. But being very forthright and how long you think it's going to take and what's that going to cost and get that patient's input on it before we talk about scheduling out for their visits. 19:05 GETTING PAID FOR MISSED APPOINTMENTS My last point here of talking about what average arrival rates are, what improves arrival rates is how do we get paid when somebody does not show up to the clinic? This is another area where I think physical therapists are very uncomfortable with asking people for money to come to rather not come to their appointment. And it's an area where again, when we look at the research, what improves arrival rates, multi-method reminder system and having a rescheduled cancellation policy that is enforced. If you don't enforce it, you can't get paid for these missed visits. And if you try to enforce it like halfway through the plan of care, the patient is probably going to be upset versus if you're straightforward from the start in your intake paperwork and with your expectations before they begin physical therapy, it's not as jarring to that patient when you charge them for that canceled or rescheduled appointment. So remember, combination of a reminder system and a clearly stated 24-hour rescheduling policy that's enforced are the keys to reducing your no-show cancellation rate by as much as 50%. So first things first, create a policy. What do you want your policy to be? Make sure that policy is very clear, very transparent and that patients see it before they actually come to the clinic. So for us here at Health HQ, this is the first thing that patients see when they go through their intake paperwork. They see our cancellation no-show policy. They see our rates. They know what they're going to be charged. They know the maximum they can be expected to pay out of pocket if they do have insurance and they're going to see what they can be expected to be charged if they cancel or reschedule appointment within 24 hours. So ensure you have a policy, make sure it's actually written out, make sure that it gets in front of patients before they commit to a plan of care and then decide on what you want to charge that person. Decide on what your rate will be. I would argue it should be what you would want to get paid for that hour even if the patient had come. A lot of clinics will have what I would call a dinky, kind of a really lackluster enforcement policy where maybe if you don't show up to your appointment, you're charged $10 or $15. That's really not enough for people to have skin in the game. Being charged $10 or $15, especially if you don't actually enforce it, is really not going to set the expectations for your patients the way you want it. For us, we want to be sure the patient, sorry, the therapist gets paid as if they had seen that patient even if the patient no shows or cancels. So we charge $75 and we enforce it. Right? How do we enforce it? Well, you should probably start obtaining payment methods before the plan of care begins. So again, somewhere in your intake, transparent, clear, laid out should be what you charge for cancellation, a no show, a reschedule, the amount, and that you should take a payment method and have that payment method on file even before the initial evaluation happens so that even if they don't show up to the evaluation, your therapists are able to get paid for that hour. And then actually enforce it. You have to enforce it. You have to rip the bandaid off and actually do it. If you don't do it until somebody has done this to you 19 times, it's going to be difficult to actually start enforcing it because you've let them get away with it so many times. Maybe your personal policy in your mind is that everybody gets one freebie. Whatever that is, stick to that and then start actually enforcing it. What you'll find is that when you enforce it, guess what? The first time that patient gets charged that money, guess what they never miss again? Physical therapy. Or they reschedule so that they don't leave an empty spot on your calendar book. So recognize that we have to enforce this. Yes, it's uncomfortable, but the more you do it, the sooner you do it in the plan of care, the more you'll find patients will either adhere to it or they might decide therapy with you is not for them and that's okay too because the end result is we want people on our schedule who are actually going to come to physical therapy. We need to recognize that this is not unusual. Oftentimes we said, well, this isn't something physical therapists do. They don't charge people for not coming to appointments. Literally every other industry on the planet does this. When you make an appointment to get your haircut or whatever personal beauty grooming thing you do, they have a reschedule cancel no show policy where if you don't show up to your appointment for whatever reason, you're probably going to get charged a little bit of money. Massage therapists do this. Lawyers do this a lot. You have to pay money upfront to even talk to a lawyer, right? You have to have that retainer money on file. Dentists do this. Other healthcare providers do this. This is very, very common across a wide range of industries except for physical therapy. People often ask me, why do you think that is? I think it's because we spend a lot of time with our patients and we begin to almost view some of our patients maybe as friends or at least acquaintances, which makes it that much harder to begin to charge that person for missing a physical therapy appointment. So we need to recognize that yes, it is difficult, but again, every other business does this. Every other industry does this. The sooner and more comfortable you get with enforcing this, the less awkward it's going to feel. And remember, leverage technology to fill those missed appointment slots so that ideally the therapist still gets paid for that person not showing up, but maybe they can also fit another patient into that spot still. I love when I pull up our schedule and I see that somebody has canceled, they've been charged for it, and we've been able to pull another patient from the wait list to fill that same slot. That therapist went to work, came to work here that day thinking, I'm going to see seven people and they actually got paid as if they had seen nine. That's fantastic, right? That's way better than systems where you may be expected to clock out if a patient doesn't show up and not get paid at all for your time, or you may be expected to clean the toilets or something like that in that missed time versus actually getting paid for that time and either being able to use that time for whatever you want or trying to fit another patient into that slot. So remember, it's really important here. This is all an end, not or situation that there are different components to this that we need to implement. It's not just we need to charge people for not showing up. It's not just we need to have a reminder system that we need to understand that at some level, having 100% arrival rate is unlikely. People not showing up is unavoidable, whether kids, family emergencies, that sort of thing. But there are things that can be done to reduce those rates. They're not unavoidable that we can deliver great outcomes to patients so that they do not find other reasons and other things to do instead of coming to physical therapy. We absolutely have to get with the program and begin to leverage technology, begin to send these reminders out if we're not doing it already, begin to use technology to have a waitlist system so that we can fill empty slots quickly, create and actually enforce a policy, get credit cards on file, begin to actually charge people for not coming to those appointments, hold them accountable, hold their feet to the fire, but also recognize and have that conversation early on of what is realistic for that patient. Do they actually have the time and money to come to therapy two or three times a week? Or do we need to look at maybe, hey, I can see you once every other week, but you're going to have to be really judicious at home with your homework because you're not coming here as much. So having those conversations early and often in the plan of care so they don't come back to bite us later on and then utilize technology to get paid for those visits and fill those empty slots. So reschedules, cancels, no shows, not to the end of the world, things we can do better to get better at them, I should say. Leverage technology, enforce a policy. So I hope this was helpful. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you're going to be on a live course this weekend, have a wonderful weekend with our faculty on the road. We'll see you all next time. Bye everybody. 24:17 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 16, 2023

Dr. Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Christina Prevett discusses the need for falls prevention initiatives to shift their focus towards early identification of individuals at risk for falls. By doing so, healthcare professionals can implement targeted interventions and reduce the occurrence of falls before they happen. Christina emphasizes that outcome measures should be used to guide interventions. She mentions the Mini-BEST as a specific outcome measure that assesses various aspects of balance and mobility. By administering this measure at the beginning of a session, the clinician can immediately identify areas of deficit and tailor their intervention accordingly. For example, if the person shows deficits in dynamic gait and reactive posture control, the clinician can focus on exercises and strategies to improve these specific areas. Overall, the episode highlights the importance of outcome measures in falls prevention and emphasizes that they should not be conducted for the sake of it. Instead, outcome measures should provide meaningful and actionable information that guides clinical reasoning and informs interventions. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:33 CHRISTINA PREVETT Hello, everybody, and welcome to the PT on ICE Daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division, part of our geriatrics team. Everyone, we are flying high this week because we got everybody from our MMOA division to descend on Lexington, Kentucky at Jeff and Dustin's Stronger Life facility, which was beautiful. And we got to show the world some of what we have been working on, which is some revamped material. So we got to really focus on dialing in live to be about lab. We were moving all weekend. It was so fun and so amazing. If you were thinking about joining MMOA live, we have a couple of opportunities coming up in the remainder of this month. So this weekend, Dustin and Jeff are going to be in Bedford, Texas, and Julie and Ellen are going to be in, oh my gosh, I'm blanking on where they are. They're in Minnesota. And then there I was like, I know this. And then the next weekend, Alex is going to be in California. And so if you are looking for where MMOA is going to be, we have a ton of courses into the end of 2023. We are not adding any more locations for MMOA live in 2023. So if you're kind of waiting for one to come closer to you for the end of this year, that isn't going to happen if it's not there now because we're kind of locked in. We have lots of offerings that's going to come up for 2024. So if you're looking to see that live material, that is where to go. 03:29 A FRAMEWORK FOR BALANCE INTERVENTION OK, so today I wanted to talk a little bit about a framework for balance intervention. When it comes to balance, I think it's a bit tougher for us to put this marker of effort or intensity on, maybe more so than other styles of fitness. What I mean by that is when we think about aerobic training, it's easy for us to conceptualize effort because we're seeing that perspiration, we're seeing that heart rate response. And that's correlating to our rates of perceived exertion. When it comes to resistance training, right, the amount of effort is either going to fatigue kind of in those higher rep ranges or our personal preference is getting to fatigue and effort through higher load. And again, it corresponds to changes in rates of perceived exertion. When we're trying to conceptualize intensity and then we're really trying to dial in our balance interventions, it's a bit tougher, right? We don't really have the same magnitude or the same outcome measures with respect to gauging intensity well. And so within MMOA, we really try and create this framework for individuals to help guide them through this kind of thought process and then create a kind of stepwise framework within our mind for how we implement this in clinical practice. The way that we do this is by first looking at the mechanism at which individuals are falling or where they are having near falls. This is important, right? 05:00 FALLS PREVENTION INITIATIVES Our falls prevention initiatives are only preventative if we are identifying individuals early rather than waiting for them to get hurt and then working in secondary tertiary prevention. We want to be able to identify those who are at risk for falls before that fall has happened, which unfortunately is not as common in our health care system as it stands right now. So we want to figure out the mechanism. We want to identify risk factors that are intrinsic to the individual and extrinsic around their environment. And then in order for us to put objective data on those things, we need to take that information from our subjective and use the appropriate outcome measure in order for us to have a good data point or multiple data points in order to guide our interventions. And then we want to make sure that those outcome measures that we are selecting are giving us tangible information, right? We don't want to be doing outcome measures for the sake of doing outcome measures. We want to do our outcome measures so that they can guide our clinical reasoning. And so let's kind of go through this very briefly and speak to the different aspects of this framework. So the first thing is mechanism, right? When we are asking about our person subjective, many times they're kind of cursory with their storytelling. A lot of individuals are when they're speaking about falls. Oh, well, I stubbed my toe and I fell over. What were you doing when you stepped your toe? What was your frame of mind? Were you really rushing to get from point A to point B? Were you really tired because it was late at night? Were you holding something in your hand when you tripped and that created an other barrier or other cognitive load in your mind that created more of a predisposition to not be able to keep your center of mass over your base of support and respond to that perturbation? Was it that there is a visual issue going on and you were having trouble with depth perception? We need to kind of dig really deep into some of these stories because that's really going to triage this risk factor profile in our brain. But you're probably thinking, well, Christina, a lot of my clients just can't do that or they don't remember or they are not able to give us some of that really tangible information. And I hear you. And so when we don't have that information, the next step is for us to go to the literature and look at what are common scenarios that lead to falls in different settings. Right. And how much do those mechanisms and that group of individuals that are being conceptualized in this research study relate to the people that are in front of you? An example is if you're an outpatient orthopedic therapist looking at some of the acute care mechanisms of falls may be relevant, but probably is less relevant to you. So you're going to be wanting to know, well, what is happening for our community dwelling older adults? What is their profile look like? What age group are individuals looking at in this study? And then how does this relate to my current caseload or people that I have that I am seeing right now? And so there is a recent study that came out in 2023 that was doing a prospective. So following older adults forward in Boston that was looking, for example, at mechanisms of falls in community dwelling older adults. So what they did was every month they sent older adults in this study. So they consented to this study. They were in their 70s or older. They sent a postcard to them and asked some questions. Did you have a fall in the last month? If yes, what was the mechanism? What were you doing at the time of the fall? And what was the cause of that fall with what you were doing? And I think this is interesting because they are two different things, right? 09:26 SLIP & TRIP TRAINING So the cause of the fall in our community dwelling older adults over 70, for example, more than half was a slip or a trip. The activity when they were having that slip or trip was walking forward. That gives us a lot of information in terms of where we start with our older adults. We're not going to start standing on one leg. We're going to start with slip and trip training. We're going to look at reactive stepping, volitional step training. Maybe we'll do that in standing first to see where a person's control is, but we want to see what happens when they start having perturbations. And so if that slip or trip is happening going forward, it also tells us that that perturbation is often backwards or lateral. People aren't falling forwards, right? It's that they're slipping and coming to the side or they're slipping and coming back. And that's a really important piece of information for us. And then it's going to guide where we go. So the next thing is now we're going to look at a person's risk factors, right? So extrinsic risk factors when individuals are having slips and trips was, was this in the wintertime and they're slipping on ice? Was this a step? Was this a rug that we know we're never going to get rid of, but we may ask about trying to tape down? These are things that we may be considering when we are looking at these mechanisms or are asking these questions. And so that's extrinsic. So we're taking this mechanism. We're looking at some extrinsic factors. And then the intrinsic people are going to be telling us in their narrative that they may feel like their balance isn't really great, or they're having trouble holding on to objects and navigating around their home or navigating outside. Or they recognize that the pain in their knee is making them not feel as strong or confident in their gait. And it's going to create them to have a hesitation to react when a perturbation happens because they've had times where their leg has given out. Or they they don't feel like they're strong enough to move their feet, right? They're they're telling us these things in their subjective. And so when we take that information, now it's going to guide us into our outcome measures. So if individuals are saying that they're having falls because of a strength deficit or a weakness issue in their lower extremity, we may want to make sure that we have a general mobility or a strength focused measure in our assessment to get a good idea of where our triage list is going to be. So we may use a five times it to stand or a 30 seconds to stand test, or we may go a bit more general and go to the short physical performance battery because the mechanism of their fall is showing us that potentially that being that capacity to move their feet is coming from a weakness issue. 11:54 REACTIVE POSTURAL CONTROL We are also going to want to in this example, look at their reactive postural control. We heavily leverage the mini best because there is a subsection of the mini best that looks at reactive postural control in each direction. So we're going to look at a person's capacity to react to a forward perturbation, backward perturbation and lateral perturbation. Right. If a person is having pain in the lower extremity, they're worried about it and we do a lateral perturbation, they may not move their feet out. They may want to cross because they're worried that that painful knee on that left hand side is not going to support their weight. So their reaction may be a step out to the right and a crossover to the right because of that painful knee. So now we've learned two things, right? We know that their pain is a contributing factor to their falls mechanism. It's an intrinsic risk factor that's creating troubles with clearance. It's impacting their gait, whether it's causing deviations in their gait or it's making them not lift their foot enough and now slips and trips are more common. And we recognize that their lateral posturing, the way that they are moving to the side is impaired. So now we've really dialed in our assessment, right? We've gotten a good idea about what's going on and we've picked the outcome measures that are going to give us that information. Because if we just focused, for example, on a burg. Because that is our go to balance assessment, not only are community dwelling older adults more likely to sealing that out, but it's not really getting to the two really big issues that they spoke to in their subjective assessment, right? They are probably going to be able to stand up once and do a pivot transfer. But that five time or 30 seconds to stand that's requiring a repeated chair stand is going to hit into maybe their pain thresholds that they're going to start having some compensatory mechanisms. And they're talking about having perturbations in a forward movement pattern. So the burg is in capturing backwards and lateral perturbations. So we have to be using those mechanisms and risk factors that they're discussing with us in their subjective and then leveraging the outcome measures that have strong reliability, validity, responsiveness, interpretability in order for us to have a good idea of what the next step is. But we're not going to do outcome measures for the sake of doing outcome measures. The next step is that we need to use those and leverage them in our interventions. One of the reasons why we also love the mini best is that oftentimes the way that we implement this is not day one. It's a little bit more of a longer intervention or sorry, it's a longer outcome measure. But we use it at the beginning of a session because it drives us into our intervention immediately. So if we have, for example, there's the anticipatory sub scales, sensory orientation, dynamic gate and reactive posture control. If we think that dynamic gate and reactive posture control are the two areas that based on a person's objective, they may struggle with more. We may use those, see where they're starting to have these deficits. It may be obstacle navigation, for example, with that still going with this example of having slips and trips because of a painful knee and seeing gate deviations where they're not clearing obstacles as readily as they used to when pain was a bit more managed. And they may have issues with reactive postural control backward and laterally. And we're going to see that it's coming to the left because it's their left knee that's painful. So now we have a lot of good information. We have a lot of good data. We use those outcome measures and we're directly going into intervention, right? Like I may use a clock yourself app and block out the forward stepping and I'm going to be focusing on reacting backwards. Or I may take out the right hand side of the clock and I want them to react to the left. And that is going to do at different cadences and then see, you know, what does the threshold look like? What does the step length look like? Does pain start to increase? What is that pain threshold like? How long does that pain take to come back down? And we're also intervening. We can also take, you know, some of these obstacle courses and put them into our interventions that day. Throw all of them together and put them into a round for time or an AMRAP where they're going back and forth between reactive stepping and obstacle courses. And now you're working on some strength because they're doing bigger clearances. We may put a step up in that obstacle course and then we're working on reactive control to the side that they're experiencing difficulties. So when we kind of take a step back, when we slot in what we see into this framework, it can be really helpful. So to bring this full circle, we want to think about balance intensity just like anything else. It's just like aerobic training. It's just like resistance training, but we cannot get good outcomes with bad data. So how do we do this? Our subjective, we need to dial in on mechanisms and risk factors. We need to be asking questions. If we do not have the answers to those questions, we're going to rely on the evidence of where older adults in different settings tend to fall. Then we're going to use outcome measures and we're going to select the outcome measures, if we can, based on our setting, that are going to give us the information we need to see where those thresholds are. From there, we're going to drive ourselves right into intervention based on where those deficits lie. And we're going to get to an intensity where individuals are either weary, we're pushing into potentially some low-grade pain, or they are self-reporting high amounts of fatigue or nervousness. 17:31 PROGRESSIVE OVERLOAD & FEAR So we may be doing some graded exposure into fear. And that is a form of progressive overload, especially in the geriatric space where fear of falling is a big risk vector for future falls. So kind of bringing this full circle, here is the framework for you when you have a person coming in who is having falls or is worried about their balance. And it'll allow you to really dial in your interventions. Let me know if you have any other questions. What are your thoughts on this? I would love to have a dialogue. If you are interested in learning more about some of this research, we just put that 2023 paper into MMOA Digest. So every two weeks there is a research email that we send out that allows you to stay up to date with the evidence. We put all of our new courses on there, so definitely go to ptnice.com slash resources and sign up for Digest. If you are not on Hump Day Hustling, please make sure you do that too. That is all different types of research from all of our divisions. Have a wonderful Wednesday. Bye everyone. 18:34 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you are interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE Online Mentorship Program at ptonice.com. While you are there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top 5 research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 11, 2023

Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Kelly Benfey discusses her experience competing at the 2023 CrossFit Games, the role of rehabilitation providers in competitive sport, and the capacity of the human body for exercise as it ages. Take a listen to the episode or read the episode transcription below. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:33 KELLY BENFEY Good morning and welcome to the PT on ICE Daily Show. It's Fitness Athlete Friday and my name is Kelly Benfey. I just wrapped up an amazing CrossFit season where I got to compete at the CrossFit Games. And so what we're going to get to talk about this Fitness Athlete Friday is going to be a couple takeaways from the CrossFit Games that I think are relevant in the rehab space. Before we jump into that, though, within our Fitness Athlete crew, we have a couple of online courses coming up that I just want to bring to your attention. So we just wrapped up an awesome cohort with our clinical management of the Fitness Athlete Essential Foundations course online. And so our next course is going to be kicking off in a few weeks on September 11th. That course always fills up. So if you're thinking about it, please jump in with us, grab your spot right now. And then if you've already taken that and you're looking to continue developing your skill set, our Advanced Concepts course that's only offered two times a year is also starting September 17th. So rarer opportunity to hop in on that one. So if you've been looking to take this course, that's going to get started quite soon. And then we have a handful of live courses for the remainder of the year. So all of that information is going to be on PTice.com, PTonice.com. So we hope to catch you live on the road. I'd love to see you all. So we'll be getting back on the road for the remainder of this year to finish strong. So let's get into our topic. Of course, I could talk about this stuff all day if you know me. So we're talking CrossFit Games takeaways. A couple of things that I experienced and found were relevant in the rehab space. This is Fitness Athlete Friday, so we get to geek out on all things, CrossFit Games, CrossFit competition, all that good stuff. So number one, I have five different things that we'll kind of work through. 03:35 HUMAN CAPABILITY So number one, I always leave the CrossFit Games feeling absolutely motivated and inspired by what the human is actually capable of doing. So I really it was it was just such an honor to be on the same field as some of these amazing, amazing athletes, be behind the scenes and all that good stuff. So a couple highlights that I saw now just to I competed in the team division. So it actually didn't allow me to watch as much as the individual competition. I'm still working through catching up on that all the live the live coverage that they had. But I got to be within the team division. So one of the athletes in the team division, she clean and jerked 250 pounds and then a couple hours later ran a 5K, 4.5 ish K, 5K in under 20 minutes. So it just always impresses me that people can excel in things that I also excel in the strength events, yet also push their aerobic capacity and monostructural skills to an insane level as well. So it was just absolutely mind blowing to see athletes also just I know how hard we worked on my team and just having other athletes really push the boundaries. I find to be super inspiring as a competitive athlete. And then moving moving towards almost even debatably more inspiring. 04:11 OLDER ADULTS PUSHING BOUNDARIES The age group divisions are always just such a blast to watch. I wish they had a little bit more coverage because arguably that's more these are more the athletes that are relatable and even more inspiring. For example, the 60 plus division, I believe the 60 60 to 64 division, both men and women had bar muscle ups in their last event. So these are our older adults crushing it, doing high skill level at a very high competitive level. Just absolutely amazing. And like I had the opportunity, my mom came and watch. She's going to watch me and have a blast, obviously, but she's not necessarily going to see like watch me and think, oh, wow, that's something I can do. She's going to see something in her age division and then become inspired of, hey, maybe I'm going to start my barbell class in my gym, for example. So I just think the human capabilities, even in our older adult divisions, is just as important as what the individual and team athletes are doing. The professional athletes, if you will. And then we also have the adaptive visions that are starting to grow and the upper extremity adaptive athletes were performing rope climbs. Rope climbs are hard enough when you have two upper extremities to grip onto the rope with. They were doing it with one and we're also sealing our lower adaptive lower extremity adaptive divisions, doing things like box jumps and maxing out their clean and jerk and snatch and really just taking no opportunity to have an excuse to not push their fitness forward and continue to be athletic and competitive in their sport. So I absolutely love seeing those. I wish I got to see a little bit more of it. I wish we got to view a little bit more of it on the broadcast, so hopefully we'll be able to continue pushing that forward. I just saw a couple posts of highlighting those athletes, so keep keep those in the forefront of your mind. That's what's really inspiring to more people, I think, in this world, in our country. OK, so the next three points that I want to kind of work through all kind of build off of each other. 09:20 INJURY RATES & PROGRAMMING So one thing that I thought was really relevant this year at the Games was the programming. And like I said, I have paid attention a lot to a lot more detail of our team division programming, but I just wanted to bring your attention as a rehab professional, as a movement specialist that's working with athletes all the time. I think it was important to note this. So just a couple examples. So in our competition, we had four days of competition. On day one, we had overhead squats at 135 pounds and 95 pounds. Then day two, we had a one rep, one rep max snatch. And then on day three, we had more snatches at 185 pounds and 135 pounds with running. So that's back to back days that we're seeing a barbell shoulder stability type exercise that is very demanding on the shoulders. In general programming, we would probably look to spread the frequency out of when we're doing things like overhead squat and snatching. Being able to do those back to back days can challenge the shoulder and challenges your ability to recover and perform repeatedly. Another thing that I noticed as on our day two, we had a strict ring muscle up to a front support hold. So going through that pole to deep press and hold at the top of the unstable rings is really challenging for the shoulders. And then right into day three, we had 30 synchro ring muscle ups on the long straps, which are tough. And then 63 more parallet bar dips. So that's a lot of vertical pressing for the shoulder to get through back to back days. And so I've personally experienced issues with pressing with shoulder pain. I've worked with a handful of athletes that recently have been that's a common theme in our clinic that I'm working with. So that is I remember if I was in the middle of having a flare up of that shoulder pain presentation, it would be really hard to be able to do that back to back days because you can always push through one workout. Adrenaline is a really strong drug, I would say that helps you get through it. But the next day when you wake up and things are a little bit inflamed, it's really hard to be able to repeat those motions. So that was just one thing I noticed that was not necessarily what I would have expected in programming, just how frequently the same movement is tested. And it's one thing to test the fitness of it, but it's also one thing to test the tissue capacity. So those are things that the my rehab mind was kind of evaluating while I was going through it, which brings me kind of into that next point I want to bring up was injury rates this year. I'm not sure if I just noticed more injuries and pain happening. A lot of KT tape being thrown on our limbs because I was in the background. But there did seem to be a lot of withdrawals from individual and team, excuse me, team athletes this year. We know the injury rates in CrossFit, the highest injury rates that we're seeing are in the shoulder joint. And based on that programming, it kind of makes sense. It makes sense that we're seeing a lot of shoulder issues. And so just from an athlete's perspective, it's absolutely devastating. It's so upsetting to have to withdraw from an injury, whether it's yourself, whether it's a teammate. We put so much time, money, effort and dedication to an entire long season. This started in February. So working day in and day out, making decisions based on that this specific weekend. It's just an absolute shame to see an athlete have to pull out of competition because of shoulder pain or whatever issue they may have. So I know I got to talk to a couple of the teams that had to withdraw. And the common theme that they were telling me was like, oh, yeah, I had this lingering issue for a while. I just retweaked it about two weeks ago. So they weren't necessarily the Roman Krenikov situation where they just, unfortunately, came down and rolled an ankle and had a new injury. This was a couple of these things were like lingering elbow issues that are really tested in the moment of competition with all the stress on board. Exposing to really deep positions of that dip position. If we have lingering shoulder stuff going on when you're pushing to 150 percent of your capacity, it's not likely that you're going to come out OK sometimes. So as soon as some of the workouts were announced, these athletes were like, well, I'm not feeling too great about this. So I take it's just such a shame because I think as rehab professionals, we need to have the skill set to be able to address these issues that our competitive athletes are experiencing and make sure that we're not just getting them back to be able to do a ring muscle up and take an ibuprofen. That's a whole other issue. We don't want our athletes to be doing that, obviously, but we want to be able to get them back to baseline and then beyond baseline because that originally that shoulder with that skill set got injured. So it's definitely up to us to be able to have the resources and provide rehab for these athletes that they find valuable. Not every single one of these athletes has a team of physical therapists that are top notch, that are traveling with them, that are on like on them 100 percent of the time. And so it is very likely that you may come across a CrossFit Games team athlete that's going to need to go through four days of competition with repetitively dips and butterfly pull ups and pulling, pulling whatever it may be. All these really challenging things for our shoulder girl to be able to tolerate. So that just I walked away being thankful that I came out unscathed, essentially, because if you followed any of my CrossFit career, I've had issues with my shoulder before. And strength always is super protective against injury. And I feel really lucky, essentially, to have all the knowledge that I have to put myself in the best scenario. Even within my teammates, we had a shoulder issue that we had to train around a little bit where we couldn't our best choice wasn't to continuing to do 30 muscle ups the week before, for example. But we rehab the crap out of it and put ourselves in the best situation possible to be able to come away without withdrawing by any means and putting up a pretty good performance over the course of the weekend. So that just brings me to want to plug our courses just one more time. So I mentioned the beginning, we have a couple of online courses coming up. I would say 75% of the clinical decision, clinical decisions I'm making on a daily basis are all things that I learned from these courses. The other 25% is probably all the other stuff I learned from my ice courses. So I know I'm biased, but I promise I'm not lying. If you at any point would feel nervous, nervous if I came into your clinic saying I can't do ring muscle ups, help. Please hop in one of our courses. It's really a fun, fun way to spend your eight weeks online. And so the last point I wanted to make kind of along the same theme was the importance of stress and recovery. So if you are an ice in the ice world, I'm sure you have heard us talk about the importance of stress and stress that the body takes on and how it helps us or doesn't help us recover well. 11:04 COMPETITIVE ATHLETES & REHAB And competing in the CrossFit Games this past weekend really made this become like full picture for me. I prioritize sleep, I prioritize what I'm putting in my body, and I prioritize managing stress as well as I can with all of the training that we were doing. But at the CrossFit Games, I will say I was probably at a peak stress level in my life. I don't live there on a daily basis, but the couple of weeks leading up to it, highly stressed and enduring also highly stressed. For example, day one, the volume wasn't really high. We were coming off of two sessions a day, up to two hours per session. So training heaps, I would say. And day one, all I did was three leg assault climbs, 30 overhead squats and then four laps on the bike track, which was aerobically really challenging, but not high impact. And the next day when I woke up, my fitness tracker is showing me my heart, HRV is plummeting. I felt like I did probably triple that amount of volume at minimum. And I was really surprised because volume wise wasn't crazy, wasn't out of my realm. But I felt the I think what I was feeling was the high level of stress that competition brought on. So and just to circle back a little bit, if you're having lingering shoulder pain, it's probably not going to get better with how much we're ramping up as far as volume in the eight weeks leading up to the CrossFit Games. 15:10 HIGH STRESS IN COMPETITION And then in the high, high stress environment, it's also going to be asking a lot to be able to recover and repeat these highly demanding movements like snatching, overhead squatting into ring muscle ups, to fatigue into dips where we're highly fatigued and moving at 150 percent of our capacity, essentially. So it just really is that's another way that I think bringing like stress and managing our recovery is just too important to ignore as the physical therapist, because we all know that person that's chronically stressed, chronically in that sympathetic state that maybe they are going into the gym and adding more weight. More stress onto their body. It's I absolutely can understand how they probably don't feel well at the end of the day, day in and day out. And so you have the ability as their rehab pro to help change their foundation of what they feel on a daily basis, too. So don't forget those things when you're dealing with any type of person that comes into your clinic. Stress management can really hit hard on so many levels and prevent maybe just set them up to rehab even better with all the good rehab skills you're doing with them in the clinic. And then lastly, I just wanted to share a couple of highlights because I feel like I had so many so much amazing support from our ice community. So just a quick couple personal highlights. Having been a spectator of the CrossFit Games for the five or six years or so has been in Madison. It was just such a cool opportunity to be able to push the Bob to do ring muscle ups with the long, long straps on the Zeus rig to use that four person axle bar for the deadlift. Those are things that you just never would see in a norm or any other CrossFit competition that's really only going to be at the CrossFit Games. So I remember pushing the Bob to the finish line and just reflecting on North Park, like, how cool is this? I've always wondered how it felt. So that was a really cool personal highlight that was really motivating throughout the weekend. Another personal highlight was our one rep max snatch. I have had some issues with shoulder pain and snatching and tweaked my elbow before from kind of poor movement patterns. So all season I was in a bit of a snatch funk. I'm sure you can relate if you are an athlete that tries to snatch frequently. It's sometimes good, it's sometimes not good. And so just about two or three weeks before the CrossFit Games, everything kind of clicked and I was able to hit a PR and perform really well on stage. So as an athlete, it just felt really special to be able to showcase the hard work that I put into that movement all season. And then lastly, I just had the best time with so many friends and family that were there to support at the CrossFit Games. I had my gym community from Milwaukee, my gym community from Chicago when I lived there, my ice community was there, our onward community. We had such a large cheering section, essentially. And trust me, that helped us get through that whole weekend. So thank you so much for everybody that was there, that sent messages, that supported us. It was such an honor to be able to represent this crew and we had a blast doing it. So thank you, thank you, thank you. So those are my takeaways from the CrossFit Games. I would like, like I said, this is stuff I can talk about all day, every day. So if you have any thoughts on programming, injury rates, anything you noticed from your spectating view, I would love to chat about it. So feel free to comment and tag me on this post, send me a message. Other than that, have a wonderful weekend and we will see you next or on Monday with our PT on Ice Daily Show. Have a great weekend. 19:06 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on Ice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Aug 10, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore challenges the common belief that vacations and time off are necessary to decrease stress levels. He argues that the expectations around time off may not align with reality, often leading to discontentment. Jeff suggests reconceptualizing the idea of time off and vacations to have better trajectories and lower stress levels. Jeff then discusses what creates low stress levels and a healthy ecosystem. He addresses the issue of returning from vacations to a chronically disorganized routine. Jeff explains that when our day-to-day lives lack discipline and organization, we often find ourselves in a cycle of feeling like we need a vacation, being disappointed by its inability to meet our expectations, and feeling worse off as a result. Jeff emphasizes the importance of taking ownership of our day-to-day routines and reorganizing them to break free from this cycle. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Alright team, what is up? Welcome to the PT on ICE Daily Show. Welcome to Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice. Thrilled to have you here live via Instagram or YouTube. Thrilled to have you on the recording if that's the way you're taking in the show. It is Gut Check Thursday. Let's get right down to business. What is the workout that all of the Ice Train folks are going to be taking on this week? It is as follows. 35, 25, 15, 5. So we have 4 rounds descending in volume. They are going to be double dumbbell push press but not real heavy, 35 and 20. And then ab mat sit ups are going to be paired with that. Okay, so you've got your 35 dumbbell push press drop down. You get your 35 ab mat sit ups. In between each round, you're going to run 200 meters and the rounds are going to be 35, 25, 15, 5. Okay so you should be able to keep a pretty high intensity up because the volume on those rounds are dropping. Make sure you get a snippet of that. Put it on Instagram. Let us know what's up. Hashtag Ice Train. We love seeing everybody throwing down on those Gut Check Thursday workouts. Real quick, courses coming up. I want to highlight cervical spine. If you want to be out there solving neck pain, radiculopathy, headaches, all the things that come with that upper quarter region, get to this class. We've got 3 options coming up. August 26, 7. It's going to be at Onward Charlotte. September 9, 10. It's going to be at Onward Atlanta. In October 14, 15. Going to be at Onward Greenville. So going to be in North Carolina, going to be in Georgia, going to be in South Carolina. So belt there and hit that course. Learn those skills. Serve those patients well. Okay, welcome back to Leadership Thursday. 02:01 VACATON & WORK-LIFE BALANCE We are going to have a conversation about why I think we've gotten vacations wrong. And I want to talk a little bit about the origin of this episode. So the other day I posted on Instagram some of the best advice I've ever received. It was from a friend. It was many, many years ago. And he said to me, if you play between the ages of 25 and 35, you will work hard for the rest of your life. If you work hard between the ages of 25 and 35, you will play for the rest of your life. And as I've watched now coming up on wrapping up the second decade of my career, I've seen a lot of people finish off their careers, seen a lot of people start them, myself going through my own. A lot of observation and the amount of truth embedded in that quote has been nothing short of shocking. When you get in the right lane early, and you get to you get with the right people early, you wind up doing what you love and excelling at it. And of course, just like investing, the earlier you do that, the more it compounds. And it really creates a scenario where the back two thirds of your career not only are more of what you love, but really decompress the stress. On the other hand, if you kind of get yourself into a financial hole and you're not in the right lane, and you're nearing the halfway point of your career, it really becomes a tough thing to dig out of. And it just sets you up for a bit more of a grind on the back end. Now we could have a whole episode about that quote alone, but that quote got a lot of feedback. And anytime you talk about working hard, you tend to get a lot of DMs and messages about the need for people to avoid burnout. And specifically that people need vacations and time off to decrease their stress levels. 03:46 EXPECTATIONS AROUND TIME OFF That's what I want to zone in on because I think that our expectations around time off are really, really aired, if you will. And the problem with your expectations not being aligned with reality is that discontent is the inevitable result of that. So let's see if we can't reconceptualize this a bit and wind up with better trajectories. So think about what creates low stress levels. So if we're going to talk about stress levels, what creates low stress levels? What creates a healthy ecosystem? The answer is the following. Now we could put nine bullets here, but let's go with the really, really big rocks. That when you have them dialed in, your stress levels tend to be low, your nervous system tends to be really under wraps, you tend to feel really dialed. Probably the biggest one we'd all agree on is sleep quality. The consistency of it we know is the primary driver. But the other small things, having it cold in the room, having it dark when you're eating food, not having those late meals, sleep consistency is probably, or sleep quality, driven primarily by consistency, is one of the biggest drivers to day to day having low stress, having more energy. Number two is a regular fitness routine. You're getting to the gym at the same time that you're engaging in quality fitness. Number three is nutrition, that you're eating a quality, clean, well-balanced diet. Sufficient in protein, void, hopefully, of a lot of nonsense and processed foods, that you're eating quality nutrition. When you're doing these things that we preach about all the time, your ecosystem tends to be optimal, your stress levels tend to be low, you tend to feel your best when those variables are dialed in. Now think about how those variables fare when you're on vacation. And I think we would all agree the answer is poorly. You're sleeping in a totally foreign environment, your consistency of your sleep is all over the map, you're trying to get some fitness in but it's random, it's not nearly as structured as usual, and your nutrition, let's be honest, leaves a lot to be desired. It's usually very fun food, you're usually trying a lot of new things, but you tend to be eating late at night, it affects your sleep quality, all of the primary metrics that create that really well-defined healthy, low-stress human are significantly disrupted, specifically when you're on vacation. Now does this mean, right, and I think it's worth saying that if that's not the case, if those things, if your sleep quality, your gym routine, your nutrition, if those things are better when you're on vacation, your day-to-day routine needs a serious second look. So if you don't have those things dialed in better on your day-to-day and your usual environment compared to when you are out in some random state or country where you've got no control of the other variables, if you do better on those things out there, you need a serious look at your level of discipline and organization on your day-to-day life. But I think for the vast majority, as we would agree, those things are pretty dialed when we're at home and they are very erratic when we're on vacation. Now does this mean that we shouldn't take vacations? And the answer to that is of course not, right? A lot of the coolest memories in your life, right? The things that you're going to do that you're going to look back on and say, gosh, that was crazy or do you remember that? And the stories that fill your life, a lot of those things are going to be formed when you're on vacation. Your perspective will expand, right? You're going to be in new environments. You're going to be seeing new people. You're going to be looking at things differently because you're outside of your usual routine. Your relationships with those that you go on will often deepen, whether it's your partner or your family or your friends, right? You rarely spend that kind of concentrated time and it creates incredible opportunity for those relationships to deepen. All of these incredible things are going to happen when you're on vacation. What will not happen though is usually that your stress level will drop because the things that drive that are generally disrupted. So then what's the secret sauce? 08:18 DEVELOPING A ROUTINE FOR VACATION The secret sauce is developing a routine that allows you to look forward to, but never need a vacation. That's the most important thing, right? You can't wait to do it. It's going to be a blast. You know those memories are going to be formed, but you don't need it because your routine day to day is so dialed that you feel outstanding, even under the presence of high workload because you've dialed in those metrics. So developing a routine that allows you to look forward to it, but not be desperate for it, not require it. And number two enables you to bounce back upon your return because if you do vacations right, a lot of that stuff is probably disrupted and you're probably coming home, hopefully thinking the classic quote, I can't wait to get back into my routine. That is a very healthy thing to be thinking, right? Like, hey, we went out there, we collected incredible memories, we got new perspective, we deepened relationships, we did all of the enriching things that vacation can bring. But now I'm pumped to get back into my dialed in routine because that's what's going to drop back down my stress level. That's what's going to allow me to perform optimally. So hopefully you're coming back to a routine that's dialed that not only did you not even need the vacation in the first place, you're bouncing back in two to three days, as opposed to having that post vacation hangover for weeks on end where you can't get your act together, which only increases your stress, which makes you need to step away again. And now you're in this vicious cycle of trying to survive when you're there and always wanting to be gone. The exact opposite should be true. You should love when you're gone and be taking a ton from that, but you should be strengthening while you're home to be able to enable that. Not weakening while you're home, hoping that it can do something that it can't when you step away. That's the challenge. The bottom line is people need more disciplined lives to decrease their stress levels. And people need vacations to enrich their existence. Unfortunately, a lack of discipline in our day to day lives requires a need and a desire for vacations chronically and a hope that they can do something that they usually won't. Simply because the organization of them doesn't tend to organize our nervous system. It tends to disrupt it, which in the right amount, when you've already got it balanced, is an amazing stimulus to get you to think differently, to get you to freshen up, if you will. 11:14 TAKING OWNERSHIP OF ROUTINE But if you are coming back to a routine that's chronically disorganized, you're going to be in that vicious cycle of, I feel like I need a vacation. The vacation didn't do what I wanted it to do. Now I'm a little bit worse off. And we go back and forth and back and forth. And there's really no getting out of that wheel until we reorganize and take ownership of what we're doing on the day to day. Then we can enjoy the vacations and be strengthened by our routine. So just want to put that out there because so often people are saying that people need vacations to decrease stress. I think we can live in a way that we don't need that at all. And yet we do get great things from those breaks and can certainly take them as opportunity allows. Hope that makes some sense. Had some great conversations this week. Feel free to continue those in the comments. Everybody have a wonderful Thursday. Thanks for being here on Leadership Thursday.

Aug 9, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Jeff Musgrave discusses a randomized control trial that investigates the impact of inflammation and different intensities of strength training on global inflammatory load and immune response. The study involved 81 participants, aged 65 to 75, who underwent a 12-week strength training program at varying intensities. Thigh muscle volume was measured using computed tomography, and blood tests were conducted to assess inflammation markers. The results of the study revealed that moderate and high intensity strength training yielded superior improvements compared to moderate and low intensity training. Participants in the moderate and high intensity group experienced a 15% increase in thigh muscle volume, while those in the moderate and low intensity group only saw a 9% increase. Furthermore, the moderate and high intensity group exhibited reduced thigh fat volume, decreased pro-inflammatory cytokines, increased anti-inflammatory cytokines, and elevated free floating leukocytes. Jeff underscores the significance of incorporating moderate to high intensity strength training for older adults, particularly those in the 65 to 75 age range. He highlights the sedentary and overweight state of many older adults in the US, emphasizing the need to address frailty in this population. Jeff also discusses the risks associated with not implementing moderate to high intensity strength training, including increased inflammation, decreased muscle volume, and heightened body fat. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:43 JEFF MUSGRAVE Welcome to the PT on ICE Daily Show. It is Wednesday, so that means it is all things geriatrics. We like to call this Geri on ICE. So can't wait to get into a deep dive of this randomized control trial that just dropped last month in July, talking about inflammation, various intensities of strength training, how that impacts our global inflammatory load, as well as things like our immune response. And then we're going to deep dive after the article into what happens if you don't follow the results of this study and if you do, what the opportunity is for your patients. But before we get into that, we've got lots of opportunities. If you want to continue the learning process, if you want to sharpen the sword when it comes to working with older adults, we have got just a handful of seats left in Essential Foundation. So if you want to jump in, you need to do that quick. There are only a few seats left. We can still get you on boarded. You're not going to miss a thing. If you want to hop in for advanced concepts, you've already had Essential Foundations. The next cohort is going to be October 10th. And then if you want to see us live on the road, the revamp is releasing this weekend. I cannot wait. All of the faculty of the older adult division are descending on Lexington, Kentucky. We're coming to the bluegrass to show show out with this new content. It's going to be super fun. If you miss getting your seat for that this weekend, next weekend, we're going to be both in Bedford, Texas, as well as in Minneapolis, Minnesota. 06:20 IMPACT= OF MODERATE AND HIGH INTENSITY STRENGTH TRAINING FOR OLDER ADULTS So as promised, the study, Intensity Effects of Strengthening Exercise on Thigh Muscle Volume, Pro and Anti-Inflammatory Cytokines, Immunocytes in the Elderly, a randomized control trial. So this trial had 81 participants. We've got adults 65 to 75 years old. 39 of those were male. 41 of those were female. And they were taken through a 12 week strength training program at various intensities. Baseline measures were thigh muscle volume via a computed tomography and blood test. They also did their due diligence. We know how important nutrition is to get an idea, at least of their caloric intake. Now, did not go into detail of how much protein, how much fat, how many carbs. Didn't look at macros, but they did identify that all the adults in the study were consuming about the same calories on average. So the control group spent 10 to 15 minutes doing meditation and stretching. Not things that are awful, but definitely the control group when we're talking about effects of strength training. The experimental group did 50 minutes of exercise three days a week. They had squatting, they did pressing movements, spine flexion and extension on Mondays and Fridays. On Wednesdays, they hit those knee flexors, extensors. They did ankle planar flexion, chest flies and rows. All of this was primarily done on machines, machine based exercises. And then when they broke down the different intensities, what they did is they recalculated each month and they worked them off different repetition maxes. So the low intensity strength training group worked off of a 10 rep max, a 9 rep max and then an 8 rep max. If you're looking consecutively across those three months as it was a 12 week study. The moderate intensity group hit 10 rep max, 9 and 8 rep maxes and recalculated their strength each month. And then the high intensity group worked off an 8 rep max, a 7 rep max and a 6 rep max. So I thought that was pretty cool that they recalculated their strength and then they used the same measure there of course to calculate their intensity for their strength training. So, after 12 weeks of strength training, the moderate and high intensity strength training group had superior improvements in their thigh muscle volume. Their thigh muscles got larger at a percentage of about 15% versus 9% on the moderate and low side of things. They showed reduced thigh fat volume, reduced pro-inflammatory cytokines, increased anti-inflammatory cytokines as well as increased their free floating leukocytes. Lots of $10 terms in there, but the reality is when we're looking at the impact of moderate or low intensity versus moderate and high intensity. It was statistically significant that moderate and high intensity strength training for older adults superior. Whether you're talking about adding muscle, reducing fat, reducing inflammation and even bolstering the immune system, which really I thought was super cool. So that's the basics of the study. If you've been hanging around the Institute of Clinical Excellence in this community, you're not going to be surprised to hear the results of the study. But what I want you to do is I want us to go a level deeper. 09:30 AGING & STRENGTH TRAINING INTERVENTIONS I want you to think about your patients on your caseload that are 65 to 75 years old. The state of the union on older adults, especially in the US more so than other places in the world, is we are inactive. We are overweight. We are not hitting ACSM guidelines. Most older adults in that 65 plus category are on somewhere on the continuum of frailty. They have low physical reserve. They have low physical resiliency. They are vulnerable to injury and decline, losing their independence. So most of our clients are on this very rapid downward trajectory. And we have got at our hands the tools, rehab clinicians. We are able to intervene with strength training intervention. If we will go moderate to high intensity, we know we can increase their muscle mass. We can reduce reduce their body fat. We can reduce inflammation. And let's think about some of the conditions that are on board outside of low reserve, low resiliency. We like to think about a thing called one repetition max living. They are very near their 100 percent capacity to get out of a chair. Think about your client who cannot stand from their normal chair without using their arms. Their one repetition max squat is less than body weight. And think about how many times they have to stand up and sit down throughout the day, giving a near one repetition max effort. Crazy! How exhausting is life for those people that are barely able to do their activities of daily living? I want you to also think about some of these global inflammatory conditions. These inflammatory markers increase the risk of progressions in arthritis, cardiovascular disease, metabolic syndromes like diabetes. Think about how many of our patients are sitting in this very vulnerable situation. So we've got this picture of our older adults on the decline, probably on the frailty spectrum. If they're on our caseload, probably have arthritis, probably have inflammatory conditions. Then we think about the opportunity that we have if we just add high intensity strength training intervention. Think about the change that you can make for them. How you can bolster their strength, their function. Get them away from that line of independence where they can just not barely get through their activities, but start building some sizeable reserve. Think about how much we can do if we hit moderate to high intensity. If they don't have inflammatory conditions yet, think about isolating them from that risk. And then not even covered in the study because these were not primary measures they were tracking, but just knowing the literature for older adults. 12:06 FRAILITY & AGING INTERVENTIONS Think about the benefit of heavier loads that's not even discussed in this study. Think about their bone density. Think about their confidence. If they know they can lift way more than they have to in daily life, is that going to impact their confidence? Is having more confidence going to help them lift with better mechanics more confidently? Is it going to help them balance in unusual scenarios more confidently? Absolutely. Confidence in that psychological impact. Don't count that out. So just think about all the opportunities with heavier load. And then what I want you to think about is maybe you're still on the fence with this stuff and you're like, I don't know if that's safe. I'm a little concerned. Maybe you don't feel quite equipped or you've not seen that modeled before and you're a little bit nervous. But I want you to think about this. I want you to think about the risk and what happens to these older adults in a very vulnerable situation if you don't. If you don't hit them with moderate to high intensity, I want to outline some of the results of the control group. During just that 12 week period where they did not perform moderate to high intensity or any strength training whatsoever, their resting inflammation went up. Their muscle volume went down. Their body fat went up. Their leukocytes went down. They became way more vulnerable in a 12 week period, just 12 weeks of not doing what they should be on the strength training train. Think about what happened to markers that were not tested. Think about their bone density. Think about their ability to get through their day with enough reserve and enough strength to really make it through the day. Just think about all the missed opportunities. I'm going to recap real quick. I know I'm super pumped about this. This is what it's all about, team. But I want you to think about the opportunity with moderate to high strength training interventions. Based on this randomized control trial, we can feel confident that we're going to increase their muscle thigh volume. Thinking about things like sarcopenia, frailty, all those categories. We can reduce their body fat. We can reduce pro-inflammatory markers. We can increase anti-inflammatory markers. We can bolster the immune system. Just based on this study, forget about bone density. Forget about one rep max living. Forget about confidence. We know those things just from this study. Then I want you to think about what you can do for your patients if you start these interventions. Think about how powerful of a tool you have. You have the keys to the castle in your pocket. If we can just go a little bit heavier. Remember, it's relative. It is relative. Yes, I will be sharing the link to this study in the caption. What happens if you don't? If you don't, we know this steady decline of frailty, deconditioning is going to continue. We know based on this study that if we don't intervene here, our older adults are going to become more frail. They're going to lose reserve. They're going to lose more muscle mass, be at higher risk of sarcopenia. We know that they're going to have higher inflammatory markers. They're going to be more at risk for progression in arthritis, metabolic conditions, cardiovascular disease. Just think about what processes you're allowing to hasten on. What's going to happen to your client if you don't get on board? Team, super spicy, super pumped about this. Got a little impassioned about this. I'll be sharing the link to this study in the caption. Super cool. Lots to think about here. Would love to hear your thoughts. Would love to hear if you have any success stories of clients that you've been using, moderate to high intensity strength training, and what the results have been. Otherwise, team, I hope you have a wonderful Wednesday and we will see you soon. 14:10 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 8, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses recent research evaluating the effects of training programs that prioritize the back squat vs. the barbell hip thrust. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What is up PT on Ice Crew, Dr. Mark Gallant here having some trouble with YouTube webcams this morning so we're going to be solely on Instagram and we'll get it downloaded for you on the on the back end for the YouTube. Again, I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey, Eric Chaconis. We're going to get into some hip thrusts versus back squats today. Before we do that, if you've been looking to sign up for an ice physio course, the courses that are on the website now are the only courses that are going to be there for the remainder of 2023. So if you've been on the fence thinking about jumping in, those fall courses are the fall courses. So go ahead and get that dialed up and come join us on the road. If you've been looking to join the extremity management faculty on the road, Lindsey is going to be in Rochester Hills, Michigan this weekend. So if you want to it's a beautiful time of year in Michigan. If you want to jump up there, grab a seat. The course with Lindsey that's still available. And then I'll be in Amarillo, Texas September 9th and 10th. So I'd definitely love to see you all out on the road. One of the things that Lindsey and I and Cody and Kristen and all the staff for extremity management, one thing we're always trying to help do is to simplify our exercise selection and dosage so that for any n equals one patient that comes into the clinic, it's a bit easier for us as clinicians to go like, based on these parameters, this will likely be the best choice exercise and the best choice dosage for this individual. 02:39 HIP THRUSTS VS. BACK SQUATS And we had an article released last month. It's not even published in a journal yet. It came out of Auburn University. That's going to help us do just that. So the lead author on the paper is Daniel Plotkin with Brett Contreras, aka the glute guy, also being an author on the paper. And what they did in this paper is they wanted to compare. If we gave a group of people hip thrusts for nine weeks, and we gave another group of people back squats for nine weeks, of those folks getting those individual programs, who would have the greatest strength gains and who would have the greatest hypertrophy gains to the glute max specifically. So that's what they looked at. They took a group of individuals, about 34 individuals, who were 18 to 30, who had not done any significant training in over five years and were relatively healthy. So BMI under 30. So relatively young, relatively healthy and under trained. At baseline, what they assessed was they assessed three rep max for their back squat. They assessed three rep max for their barbell hip thruster, three rep max for a deadlift, and hip extension against a force plate to see how much output that glute max was doing. They also, which is kind of cool, they threw them through an MRI tube. And that's how they got a measure of how dense and how robust their glute max tissue was. So they threw everyone, day one, through that MRI, got an assessment of how thick their glute max was, how thick that booty was, and then they reassessed that after nine weeks. The final piece they assessed was they took EMG output for both the back squat and the hip thrust. So what did they do for an intervention? So over the course of nine weeks, one group got hip thrusts and one group got barbell back squat. Each group did nine weeks. Week one, they did three sets of eight to 12 reps. Week two, they did four sets of eight to 12 reps. Weeks three through six, they did five sets of eight to 12 reps. And then week seven through nine, they did six sets of eight to 12 reps. So over the course of the program, they were getting a lot more volume as time went on. The way they controlled for the intensity, if a person was able to do more than 12 repetitions at any given set, they bumped the weight up. If they were unable to get to eight reps, they lowered the weight down. So they always wanted to keep it between those eight to 12 reps while making it approaching failure. So getting close to failure for each of those individuals to really challenge those tissues overall. So each group did twice a week, only back squat for the back squat group, two days a week with those loading parameters. Hip thrust, twice a week, only hip thrust for that nine weeks with those loading parameters. 05:12 THE LAW OF SPECIFICITY What shook out at the end of the nine weeks was pretty cool. We're starting to see some strength and conditioning principles that are becoming clearer for us as better studies come along, as time goes on. The number one thing that we continue to see is the law of specificity. If you want your client to get better at back squats, have them do back squats. If you want your client to get better at hip thrusts, have them do hip thrusts. If you want your client to get better at deadlifts, have them deadlift. You want them to get better at step ups, have them step up, so on and so on. And that's exactly what we saw in this study. The group that did barbell back squat got significantly stronger at their three rep max back squat at the end of that nine weeks with only minimal gains in their barbell hip thrust, in their deadlift, in their force plate. They made gains in those other things. They were not nearly as significant as the gains as they made on the specific exercise they were doing. Same for the barbell hip thrust. The group that did the barbell hip thrust made significant gains in their three rep max on the barbell hip thrust. We did not see the same significance in their back squat, in their deadlift, and in their isometric hip extension against the force plate. Again, they made some gains, not as significant as the specific exercise. So again, we're seeing this article reinforce. If you want to get better at a specific thing, that person will need to do that thing as soon as their tissues can tolerate it, as soon as they're ready. Get them doing the thing that they desire to get better at. The other cool thing about this paper was hypertrophy. What we saw with hypertrophy with this study is both groups hypertrophied their glute max equally. So it didn't matter whether you were in the back squat group, whether you were in the hip thrust group, both groups showed glute gains. 09:58 HYPERTROPHY AND EXERCISE SELECTION And what we're seeing in a lot of the hypertrophy research is exactly this, where as long as the tissue is being stimulated at a challenging level and enough volume, that's good enough for the tissue to grow. So this study met those two criteria. It had an extreme amount of volume. So getting up to six sets of eight to 12 reps is a ton of time under tension for a tissue. And by controlling that they always wanted those folks to be approaching failure at a challenging range between eight to 12 reps, we got both high volume and high intensity. If those two parameters are on board and the tissue is getting some stimulus, almost always we're going to see some local tissue change or some growth. So again, law of specificity, do the thing that the person wants to do. And if you're looking for local tissue changes, hypertrophy, it seems to not matter as much which specific exercise. As long as the tissue is being challenged at an appropriate volume and at an appropriate intensity. The other interesting thing about this study was the EMG output did not seem to matter. So the barbell hip thrust had a higher EMG output for the glutes and that did not correlate to either strength gains or to more hypertrophy. Again, the strength games came from specificity. The hypertrophy gains came on board because the intensity was appropriated up. Now, looking at any study, we always want to be aware that there's problems with every study or challenges to any study that comes across the board. There are no perfect studies out there. The challenges with this study were it was a relatively low population. So there were 34 individuals, 18 in the hip thrust group, 16 in the squat group. So a fairly small population. They were all young and relatively healthy, which is going to be different than our general physical therapy population. And they were all significantly undertrained. So no one that was accepted in the study had more than one day a week for over five years of weightlifting experience. So appreciate that likely these gains that we saw in strength and these gains that we saw in hypertrophy are somewhat attributed to that. These folks were so significantly undertrained. And we've all seen that the more undertrained the person is, the easier it is for them to adapt early on. Also, with this, nine weeks is a fairly short amount of time to have a strength and conditioning or a hypertrophy program show results. It's likely that because they were undertrained is why we saw results in nine weeks. With our general physical therapy clients, some of whom may have been weightlifting for 15, 20, 30 years, we would expect a bit longer time to get true tissue adaptations and to get true strength adaptations. So again, to recap, study showed hip thrust versus barbell back squat. If you want to get better at the hip thrust, do the hip thrust. If you want to get better at the barbell back squat, you want to get stronger at that, do the barbell back squat. If you want to hypertrophy, whichever exercise you want to choose is great as long as you've got the intensity and the volume. The final cool thing that this study showed was that when someone did the barbell back squat, they had a ton of adductor activation and ton of quad activation and a ton of glute activation versus the hip thrust, which had primarily glute activation with far less hip adductor or quad activation. So if you've got a patient who comes in and they're in a lot of pain and you say, man, they've got some knee pain on board, their adductors seem a bit irritable, those quads are all gummed up. And we want to make sure that that athlete or that client is maintaining powerful hip extension, which is one of the most important movements for all humans. Then let's bias early on to the barbell hip thrust because it's not going to challenge those adductors and those quads. When that patient starts to get better and their adductors and their quads are not as irritable and they're not as gummed up, then let's go straight after that squat. Or on the flip side, you have no tissue irritability on board and that person's daily life requires a lot of squatting. It's going to behoove you to go right after that squat instead of spending time on the hip thrust early on. In reality, we've beaten a dead horse with this saying over the years and not more. For most of our folks, you're going to want to program hip thrust. You're going to want to program some squats. You're going to throw your deadlifts in there to have a nice well-rounded program. Law of specificity. Make sure the intensity is good. Make sure the volume is good. Have a great Tuesday treating clients. Can't wait to see you all on the road. Have a great rest of your day. Always grateful to be speaking on this podcast and hope to see you all soon. 11:37 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 7, 2023

Dr. Jess Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses considerations for postpartum exercise include the type of birth, birth trauma, sleep deprivation, and nutrition. It is important to take into account the impact of the birth on the postpartum exercise plan, especially if it was traumatic physically or emotionally. Respecting the individual's experience is crucial. Additionally, sleep deprivation and nutrition should be considered. If a mother is struggling to get proper nutrition due to the demands of caring for a newborn, adjustments may need to be made to the exercise plan. It is also important to consider specific goals when designing a postpartum exercise plan. The episode highlights three recommended exercises to initiate postpartum impact: heel drops, alternating hops, and jump rope exercises. Heel drops involve going up onto your toes and dropping your heels down. Alternating hops are done by moving side to side and can be performed with or without a jump rope. Using a jump rope adds an extra challenge and requires coordination. The third exercise is small hops with both feet. These exercises are ideal for postpartum women who want to regain strength and fitness after giving birth. However, it is crucial to consider the type of birth, any birth trauma, sleep deprivation, and nutrition when starting these exercises. Monitoring for symptoms such as leakage, pressure, pain, and bleeding is also important during the progression into impact exercises. Breastfeeding moms should be advised to wear a supportive bra during exercise for added comfort. Jess emphasizes the importance of utilizing progressive overload principles when starting with small impact movements and gradually increasing intensity. She stresses the significance of meeting the individual where they are and understanding that progressive overload is a natural part of the process. This means that as the individual progresses and adapts to the small impact movements, they should gradually increase the intensity of their exercises to continue challenging their pelvic floor muscles and promoting strength and function. Jess also highlights the importance of speaking positively about exercise and the pelvic floor, as it encourages individuals to stay active and avoid deconditioning. By incorporating progressive overload principles, individuals can safely and effectively strengthen their pelvic floor muscles while minimizing the risk of injury or negative symptoms. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice and you can browse through several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on Ice Daily Show. 01:25 JESSICA GINGERICH Good morning PT on Ice podcast. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. So we just finished up a wonderful weekend of the CrossFit Games. We have a huge congratulations to extend to Dr. Kelly Benfey. She is on faculty with the CMFA division. Her team took 16th place this weekend and boy was that fun to watch her compete. So I was on virtual ice last Tuesday and what I want to do today is talk a little bit about that virtual ice. So I've been on here the last couple times talking about the benefits of certain things early in the early postpartum period. So within that first 12 weeks postpartum. So I wanted to continue that and just what a wonderful time to do it as we did have a mom on the podium this year. So Ariel Loewen took third place. She has a child as she's a mom and she's just out here crushing the fitness space. So before we dive into that we're going to talk about early impact which is going to be really fun. We're going to start to reframe that a little bit but we do have courses coming your way. So hop on the website PT on Ice dot com to check that out. We have two courses here with the pelvic division. We have an eight week online course that bridges everything from gymnastics and barbell lifting to handstand push-ups to everything with the pelvic space with using the internal exam to help get people back to where they need to go. And then we have a two day live course and that one is just really fun. We get moving a lot. So if that is something that's on your list go ahead and head over there to secure your spot. 03:45 THE FOURTH TRIMESTER So we are going to talk about that early impact in the fourth trimester. So the fourth trimester is the first 12 weeks postpartum. There's a lot of things that matter here but I want to start to reconceptualize the phrase of this or certain things put a lot of pressure on your pelvic floor. So we know that growing a fetus is going to put more demand on the anterior abdominal wall as well as the pelvic floor as well as a lot of other systems in the body. So does a sneeze. Like when we sneeze it puts a lot of pressure on the pelvic floor. When we lift weights it puts a lot of pressure on the pelvic floor. When we lift our child that then wiggles around it's going to put a lot of pressure on the pelvic floor. The phrase this puts a lot of pressure on your pelvic floor we want to maybe refrain from doing that can be a very fearful message. And also one that's just incorrect at this point. We want to do it in a way that is going to allow the pelvic floor to succeed. We don't want to blast through symptoms of leakage or heaviness or pain but we need to start reconceptualizing this especially speaking to our clients. So now before we jump in, no pun intended there, impact, we want to understand the demands placed on the pelvic floor in the day to day. So number one when you have a baby whether it's a c-section or a vaginal delivery we do have a healing process. So with a vaginal birth if there is no tissue trauma, so this is a vaginal birth with no tearing, no episiotomy and episiotomy is where they would cut to allow more room. We know that the tissues stretch approximately three times, 300 times their original length. So right then and there we can put that as tissue trauma, right? That is tissue trauma without any disruption to the sarcomeres or the skin or the connective tissue. Patients will need about four to six weeks for healing but this doesn't mean that we can't do nothing for four to six weeks. Now there's going to be probably a lot of questions that come with this because everyone is different, right? So we need to understand that and set the expectation early can be super helpful. So in educating our patients I love to give a timeline. So I usually say between six and twelve weeks, sometimes six and eight weeks depending on where that person is. And that's kind of nice because then when they get back to doing impact things that's now something where they're like oh I was kind of anticipating twelve weeks instead of now, right? And so that gap is pretty big but at least it allows them to be like okay I have this set date or timeframe if you will where we're going to start working back to that. 04:16 PRESSURE ON THE PELVIC FLOOR Number two, we need to start talking about toileting. We need to teach people how to poop. We need to teach people how to pee. If we are not asking that question, are you burying down when you go to the bathroom? Are you pushing your pee out? You're going to be missing a big mark here. Your pelvic floor is reflexive. So as pressure gets put down on it, it should be turning on. So if you're going to the bathroom and you're burying down, we're putting a lot of pressure on the organs if you will. However, we're also putting pressure on the pelvic floor that's likely kicking it on and if it's not, it's just pushing it downward. So we need to be asking about that. We need to be encouraging a squatty potty. We need to be encouraging fluid, water intake, fiber intake and really the time spent on the toilet and this goes for males too. So spending a lot of time on the toilet just isn't what you want to do. If they are the person that takes their phone in with them, you could even tell them hey let's try not taking your phone in to see if you get off the toilet sooner. 08:12 BLADDER IRRITANTS So number three, we do have oral intake. So we talked about water intake just a second ago, but just recognizing that beverages like carbonation, alcohol, artificial sweeteners, they could be bladder irritants. And so I went to the gym this morning and I did one of the CrossFit Games workouts today called Halina, which is a three rounds of 400 meter run, 12 bar muscle ups and then 21 dumbbell snatches. I went at 7.15 so I had coffee and I had to go to the bathroom probably three times before I went and did the workout because that is a bladder irritant for me. So when we talk about bladder irritants, we are not saying stop having these things. It's just saying hey this may be a trigger and so if this is happening to you, that's okay. Just recognize that if you have double unders or running or something, box jumps, that may be we try to have the coffee after the workout or maybe you have one cup instead of two or can we sandwich that coffee with some water to dilute the urine a bit. That's one of the big things is not necessarily taking those things away but just telling them hey this could just be a bladder irritant for you. It looks different for everyone. Number four and probably one of the biggest ones is the symptom threshold. Helping your client find their symptom threshold is going to mean that they're going to be reaching their symptoms. They are going to likely be leaking. They're going to likely be maybe feeling like they're going to leak and that can be a very daunting thing but it's going to give us a lot of feedback, a lot of them feedback and it's going to give them a lot of freedom when they're in the gym. If you reach this threshold, take a second, pause, take a breath. Maybe we do a little bit of jumping and then we back off and we do the bike and get a sprint in. Or we do another option for jumping. I'm going to talk about some options here in a second. Speaking positively about exercise and their pelvic floor is huge. They are not going to ruin their pelvic floor. I would rather, we would rather have someone stay active in the gym or whatever that looks like for them rather than telling them they're going to ruin something so they stop and then fast forward 30 years later and now they're in a skilled nursing home sooner because they're massively deconditioned or they have a massive injury because of being deconditioned. Now that we have some guidance on the return factors that we want to manipulate and play around with, let's start using pressure rather than, or rather forces if you will, to strengthen the pelvic floor. Now there are considerations we need to keep in mind, like the type of birth, we talked about that earlier. Birth trauma, so this could actually be physical as well as emotional. So if you have someone who is identifying that their birth is pretty traumatic, we're going to respect that. Sleep deprivation, nutrition, if your mom is having a hard time getting protein in and carbs in and good fats in because every time she goes to eat her baby starts to cry, that's something to just talk about and maybe we push that back a little bit and that's okay. And then of course specific goals. So our top three exercises to initiate post-part or impact in that time is going to be heel drops. So that's where you'll go up onto your toes and drop your heels down. Alternating hops is just going to be alternating side to side. You can do that without a jump rope or with a jump rope. Doing it with a jump rope is actually very difficult. It takes a lot of coordination. And then small hops. And that is going to just be small hops with two feet. Something to keep in mind in here are breastfeeding moms that can be very uncomfortable. So just talking to them about wearing a very supportive bra when they come to that visit. As always, we are going to ask about symptoms during your progressions into impact. So the symptoms are going to be leakage, pressure, pain, and then also bleeding. So in that early trimester we want to just keep an eye on bleeding. It is normal to have an uptick in bleeding, but we want it to not be like that they're passing clots after they start upping their intensity. Keeping the conversation positive even if they're hitting symptoms early and we're regressing. All we're doing is we're meeting them where they are and understanding that progressive overload is going to happen. And even talking to them about that is a really fun thing. So to recap, pressure doesn't have to be a bad word when talking about the pelvic floor. Understand other factors that may be influencing the pelvic floor, such as toileting, nutrition, type of birth. And essentially linking that to their symptom threshold. Utilizing small impact movements at first and start to initiate those progressive overload principles. So I'll leave you with that. Have a great Monday and we'll see you next time. 13:40 OUTRO Hey, thanks for tuning in to the PT On Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 4, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the efficacy of mobility programs to produce meaningful, function change in range of motion for patients & athletes. Take a listen to the episode or read the episode transcription below. Article referenced If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:32 ALAN FREDENDALL Good morning everybody, welcome to the PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and lead faculty here in our fitness athlete division. It is Fitness Athlete Friday, we would argue it's the best start day of the week. We talk all things CrossFit, functional fitness, powerlifting, Olympic weightlifting, endurance athletes, runners, bikers, swimmers, everything related to the person who's regulationally active here on Fridays. Before we get started with today's topic, we're going to be tackling mobility. We're going to define mobility versus flexibility. We're going to discuss a recently published paper showing the effects of long term stretching on mobility changes and address concerns related to that paper. Before we get started, let's talk about a couple of announcements. It is the CrossFit Games individual and team competitions began yesterday. Age group and adaptive athletes began Tuesday. We have a day competition all week long. You can catch it on ESPN. You can catch it on YouTube. Our very own Kelly Benfee here from the fitness athlete division will be competing with her team. Plus 64 CrossFit Army end game in the team division. So you can check her out. She had a couple of events yesterday and she's got events every day the rest of the weekend. Speaking of fitness festivals, the I Got Your Six Fitness Festival will be June 21st and 23rd down in Charleston, South Carolina with our friends at Warrior WOD. We had the virtual competition this year, but next year it's going to be in person. So it's a ways away, but look forward to that calendar if you want to come down to Charleston and join us for a weekend of approachable fitness courses coming away from us here in the fitness athlete division. Your next chance to catch our live course will be September 9th and 10th. That will be in Bismarck, North Dakota with Mitch Babcock or the end of September, September 30th and October 1st. You can catch Zach Long out on the West Coast. He'll be in Newark, California. That's in the Bay Area. Our online courses, Clinical Management Fitness Athlete Essential Foundations, our eight week entry level online course begins again September 11th and Fitness Athlete Advanced Concepts, our level two online course begins September 17th. So mobility, let's talk about it. How much can we really move the needle? My goal today is to define mobility as it's often talked about in kind of common terms with athletes in the gym, patients in the clinic when they talk about mobility, defining mobility versus defining flexibility. Talking about a paper that was published a couple of weeks ago, looking at the effects of long term stretching specifically at ankle mobility, which is a joint we're always after to improve the range of motion within and then really how to approach mobility from a practical clinical standpoint. 2:01 EFINING MOBILITY VS. FLEXIBILITY So let's start first with defining mobility versus flexibility because they're often used interchangeably and that's not the correct way to use them. Then when we talk about flexibility, we're talking about the capacity of soft tissues of muscles, tendons, ligaments to be passively stretched, whether me as the therapist stretches you the patient or whether you stretch yourself using your own body, using stretch straps, things like that. The ability to passively stretch muscle tissue at a specific joint. Now mobility is different. Mobility is the ability of a joint to actively move through a range of motion. And of course, we're always chasing a full range of motion. So the ability, for example, of the need to advance across the toes in active closed chain dorsiflexion, the ability of the hip to externally rotate or flex sitting down into a squat, that would be an assessment of mobility, actively moving the joint through the range of motion. And you, the patient or athlete moving yourself through the range of motion, aka how much motion can you actually access? Because we see some folks have a big difference between their flexibility and their mobility. We may be able to passively move their ankle, passively move their leg into a normal or above average range of motion. But when that person stands up, they re-encounter gravity and they try to actively move that joint. We can sometimes see a big difference between mobility and flexibility. And that brings us to a really important point that a lot of what we see in marketing, in programs, in our own home programs for athletes and patients is that we say we're prescribing mobility. But really, what we are giving for the most part is flexibility, that a lot of passive stretching is what is given out, which can improve flexibility. Yes, but may not always result in any sort of functional change in mobility. We see a ton of programs all over social media, especially in the fitness athlete space, that are marketed at improving mobility. But when we actually look at the content of those programs, things like ROMWOD, things like GOWOD, things like whatever WOD, that we actually see a lot of passive stretching, a lot of flexibility. And so it's no wonder that folks come in and have been doing one of these programs for weeks, months, years, and have not seen any sort of beneficial improvements. In their mobility, their ability to actively move joints through a range of motion, because they have not been doing any sort of mobility work, they have been doing a lot of flexibility work. And we know those two things don't always translate. We don't always see a bunch of flexibility work translate into any sort of improvements in actual meaningful functional mobility. 7:32 THE RESEARCH ON STRETCHING So what does the research say? There's a bunch of research on passive stretching. There's a bunch of research on the benefits specifically of eccentric loading to improve range of motion, to improve active mobility. And we've always kind of wondered the question of what is the dose response relationship with flexibility training, with stretching? We have a great paper that came out last month in the Journal of Strength and Conditioning Research by Wernicke and colleagues. I'll post the link on Instagram and in the show notes on the podcast that sought to answer that question. So this was a study that sought to look at the effects on maximal voluntary muscular contraction, flexibility and muscle thickness of the ankle plantar flexors. Now, the experimental group had a lot of stretching prescribed. Specifically, they stretched six times a day for 10 minutes each session for six weeks. So about 42 total hours of stretching through the calf complex, an hour per day for 42 days. They perform the stretching with a night splint type orthotic of a boot that prepositions the foot into ankle dorsiflexion with the addition of a strap assist to pull their ankle into additional dorsiflexion if able. So essentially stretching the gastric complex 10 minutes, six times a day for six weeks. Now, what did the results show? The results did show an improvement in range of motion of when they remeasured ankle dorsiflexion. There were improvements that reached statistical significance. But really, when we look at the results, when we look at the actual data itself and not the summary of data in the discussion, we look at the raw data. What do we think about the results? We think that the functional improvement here is probably questionable. Then we actually look at the ranges of motion increases experienced by these subjects that most folks experience the change of about 0.25 to 0.5 centimeters or about one tenth to two tenths of an inch of an improvement in ankle dorsiflexion. Now, when we measure functional ankle dorsiflexion in the clinic, we use the closed chain half kneeling knee to wall task to measure the ability of the knee to advance over the toes with a planted heel. We show this assessment in our online essential foundations course, and we show this in our live seminar as well. And what we'd like to see there is that an athlete with the heel flat can advance their knee over their toes about four inches. That ideally they would contact the wall. We know if they can contact the wall, they have about four inches of motion there or possibly more. But that is enough motion, for example, to be able to advance the knees over the toes and sit down into a nice full depth squat. And so when we look at changes of 0.1 inches in a test where we're looking to see four full inches of range of motion, we realize that's not really that much of a functional improvement of yes, the results did reach statistical significance. But the practical application here is very, very, very minimal of that person. If we improve their ankle dorsiflexion and it was, for example, zero inches, somebody like me, somebody with a very stiff ankle, particularly my right ankle that has about zero inches of closed chain dorsiflexion. What good really is 0.1 to 0.2 inches of closed chain dorsiflexion improvement? The answer is not. It's not right. It's not a functional improvement. It's not a meaningful improvement. Yes, it was a statistically significant improvement, but in real life, it would not help that person move any better. It would not improve that person's mobility, even though their flexibility, yes, has technically changed. So we need to be mindful of how to actually interpret results of studies like this. We also need to now talk about what is the practical application of a study like this to practice, because this study came out and a lot of social media posts were made, a lot of podcasts were made that said, look, you're just not stretching enough. If you stretch an hour a day for six weeks, you can see an improvement in joint range of motion. And yes, again, while true, not functional. 10:14 APPLYING RESEARCH TO PRACTICE We also have to step back and really analyze the methodology of this paper and also analyze things like the inclusion and exclusion criteria of this paper. We're probably unlikely to find an actual real person, a patient or athlete who's going to do six hours a week, an hour per day, seven days a week for many, many weeks of flexibility training, essentially, right? We hear time is the biggest barrier to exercise. We hear time is the biggest barrier to home exercise program compliance. So it doesn't really make sense that if we can't get somebody to perform a 12 minute remom for the home exercise program, what's the likelihood that they're going to do an hour a day of home exercise program on top of maybe also trying to exercise an hour or more per day? The answer is unlikely. Right. We know that if we if we dose that out to somebody, there are very few patients who are going to come back and say, yep, I did. I did six sessions a day, 10 minutes per session, and I did it every day, seven days a week, just like you prescribed, doctor. That's a very unlikely result. So we need to be mindful of that when we're talking about applying this to real actual people. We also really need to dig into the inclusion criteria and look at the baseline assessments in a study like this, because this study would portray that some of these folks were stiff and saw improvements. Some of these folks had OK mobility and saw improvements. But really, when we look at the baseline assessments, the quote unquote stiffest person in the study still had three point four inches of closed chain dorsal flexion, right? More than enough ankle mobility to be able to squat to depth, assuming nothing was wrong mobility wise in that person's hip or knee. That person would have all the dorsal flexion needed to be able to, for example, functionally squat to depth. So we have to ask ourselves, is this actually representative of the populations that we treat? Is it representative of somebody who might come to us and say they need help with their mobility? What's the likelihood that they're actually going to do an hour a day of this type of training? And also, this is not the person that's going to present in our clinic, right? Of the person who can close chain dorsal flex at least three point four inches. You're not even going to consider that their ankle is stiff and maybe even prescribe some mobility stuff for their ankle to them, because they already possess all the range of motion needed to squat. On the high end in these subjects, they were beyond three point four inches, right? There were people with four, five, six, some folks close to seven inches of closed chain dorsal flexion. Way above average mobility. And so we need to recognize and ask the question of why are we studying the effects of flexibility and mobility on people who already have adequate, above average, perfect or excellent mobility, right? We see this a lot in medical research of we study the effects of, for example, resistance training on bone loading in older adults, and we exclude people with osteoporosis and osteopenia and folks who have any sort of issue that might throw an extra variable into the study. And what we find ourselves is studying interventions on people who don't need the intervention, right? And this study is exactly that case of we are studying the effects of flexibility training on the mobility of people who don't need any help with their flexibility or mobility. So again, can we generalize studies like this to the general population? Probably not. And for a lot of reasons, the ones we've already discussed here. And what we need to realize when we look at this data and look at a big picture is when we look at the results of studies like this, when we look at all the data aggregated, yes, but also unaggregated on those data tables, what are we looking at? That we tend to find that folks fall into buckets, that we can classify them. We know that, for example, with low back pain, we can find people who are flexion intolerant, extension intolerant, shear intolerant. We know they may or may not respond to directional preference type exercises, but people tend to fall in classification buckets based on what's going on. And we need to recognize that mobility is no different. Even looking at this study, looking at the baseline measurements of folks, we have folks who appear to have great mobility, who improved with intervention. We have folks who have great mobility, who did not improve with interventions. We had folks with poor mobility, who improved with intervention. And then we had the most unfortunate group of all, folks with poor mobility, who did not seem to improve with intervention. So we need to recognize that the person we're working with in the clinic, in the gym, probably fits into one of those buckets. If they are somebody who is interested in working on the mobility, even if we may not need it, right? We have that person who can hinge all the way to the floor with a perfectly flat back and locked out knees and touch their palms to the floor. A very bendy, flexible individual who is asking you for help on their mobility, right? That person does not need mobility help. They do not need flexibility help. But yet they are maybe seeking some extra mobility programming. We have folks with poor mobility, who need mobility training, who we know will not work on it anyways, especially an hour a day. So we see that our patients and athletes fall into these buckets, and we need to recognize which bucket they may fall into. We may not know early on how they're going to respond to interventions, especially if they haven't tried anything previously, but we'll know very quickly across the plan of care of their physical therapy if they're going to be somebody who responds to interventions like these. So what do we actually do with that person in front of us? Well, I think what we don't do enough is ask people a few simple questions of I see that you have some mobility things you could work on. How much time do you actually have for this? I don't think we ask that question enough. I think we give people what we want to see them do, what we hope they will do, and then we're often disappointed when they don't do it because we haven't asked first of all how much time they're willing to dedicate to it. I appreciate over the years how I've started to ask this question, and people have been very honest of I'm never going to do this at home. I'm only going to do this when I come here to physical therapy. Well, I appreciate that honesty, right? Because I'm not going to waste my time writing out a really detailed program that you're not going to do. So I think starting with that, excuse me, that question is very, very important. And then also recognizing and being really, really thorough and methodical in your reassessments along the way so you know if this person appears to be somebody who's going to respond to mobility type interventions. This study in particular has a lot of issues with the methodology, only including people who already possess a lot of nice functional mobility. It did a lot of long-term passive stretching, and we also need to recognize that primarily due to the way the intervention was done in this study, they primarily stretched the gastroc but assessed mobility and range of motion by the closed chain dorsiflexion test, which really looks at soleus muscle flexibility more so than gastroc. So we're stretching the gastroc, but assessing the ability of the knee to advance over the toes in a kneeling position, which is really looking at the soleus muscle complex. So we need to recognize the limitations of this study, and in our own practice of actually making sure we're giving the right mobility to the right person based on the deficits that we're finding in their assessment. We hear often, what are some great shoulder stretches? Well, it depends on what is limiting your shoulder mobility. If I give you a bunch of lat stretches and you seem to be really limited in external rotation because of maybe something going on in your subscap or your internal rotators not related to your lat, if you pass all of the screens we see for the lat, then giving you a bunch of lat stretching, a bunch of shoulder stretching, it's really not going to benefit and improve the mobility we need to work on. So we need to be sure we're working in the right area and addressing the right area with our exercises as well. So mobility, how much can we move the needle? Well, it really depends. It seems to be maybe a genetic component. It seems to be a combination of how well people respond to this type of training, and we also need to recognize that it appears to take a lot of time, possibly more time than the patient or athlete in front of us actually has. So understand the difference between flexibility and mobility. Flexibility, the ability for us to stretch muscles passively or a patient or athlete to stretch themselves passively versus mobility, the ability of the person to actively move their joints through a range of motion under gravity, functional movements, things like a squat, a lot of close chain type movements. We have research that looks at long-term stretching, but we know the quality of the research is not that great and the practical application of the research itself is not that great. Yes, we can reference the study and say if you're willing to stretch six hours a week, you might see changes in your ankle mobility, but again, we don't know that for sure. In practice, we know that our athletes and patients tend to fall in buckets. We need to be able to recognize those folks where they lie in our assessment. And again, always ask the question of how much do you really want to work on this? How much time do you really have to work on this? Somebody who says I have an extra hour a day before bed at night. Okay, that's a person who maybe could try out an hour of flexibility training before bed. Whether you give them a program, whether they sign up for something like ROM WOD, GO WOD, Mobility WOD, whatever WOD, Stretch WOD, the millions of programs out there. Or somebody who goes I'm not going to do this at all. I know myself, I'm not going to do this at night before bed. I'm not going to do it in the morning. I'm not going to do it before I work out and I'm not going to do it after I work out. Okay, that is a person that we probably should not spend our time on trying to give a bunch of mobility homework already knowing that they're pretty intentional and honest that they're not going to do it. So mobility, can we move the needle? Maybe. Jury's still out. We still need to see more research, of course, more impactful research, more functional research, and more practical research. Research that actually looks at what sort of changes can we expect to make in maybe 12 to 15 minutes a day? The range of time that we're probably prescribing to most of our patients and athletes. So I hope this was helpful. I hope you have a fantastic Friday. Hope you have a great weekend. If you're going to be at a live course, enjoy yourself. Enjoy the CrossFit Games. Watch Kelly Benfee and Ruth Huron. Have a great Friday. Have a great weekend. Bye everybody. 20:32 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. You

Aug 3, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes the importance of considering individual circumstances and not allowing blanket statements to hinder progress. While the general principle of "do less better" is often advocated for efficiency and clarity, Jeff acknowledges that there are exceptions to this approach. Jeff encourages listeners to think about situations where a person may come into the clinic with psychological barriers or feeling overwhelmed. In these cases, Jeffg suggests that overwhelming the individual with multiple interventions or exercises may actually be beneficial. By providing a variety of options and allowing the person to choose one or two to focus on, it can help shift their psychology and get them on board with the treatment plan. Jeff also mentions that this concept applies not only to exercise but also to other aspects of healthcare, such as sleep hygiene and diet. Instead of overwhelming individuals with a long list of changes to make, it is more effective to start with one or two manageable changes. This approach makes it more approachable and minimizes barriers to compliance. Overall, the episode highlights the importance of considering individual circumstances and being flexible in treatment approaches. While the general principle of "do less better" is valuable, it is essential to recognize that there are times when overwhelming individuals with options or interventions can be beneficial in getting them on board and moving in the right direction. Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Alright team, what's up? Welcome to the PT on Ice Daily show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and thrilled to be here on a Leadership Thursday. Always wonderful to have you on Instagram, on YouTube if you're live streaming or over on the podcast. Thank you so much for carving out a few minutes for us today. It is Thursday, it means it's Gut Check Thursday, and it is a doozy. So many of you are at the CrossFit Games, you're probably going to be throwing this workout down together. I know it comes from our friends at Mayhem, they're probably going to be doing it as well. But the workout is, and it would be simple if it was just the first part, it is a hundred for time at a relatively manageable weight. Okay, so we've got 75-55 on the bar. Many of you probably remember the 100 clean and jerks for time that we've done I think twice now. The problem is you also have an EMOM of 15 air squats, and that's going to make it a different kind of stimulus, and that includes starting at zero. The first thing you're going to do when the timer goes off or Gut Check Thursday is you're going to bang out 15 air squats, then you're going to grab your bar and start rocking your power snatches. You're going to keep doing this every minute, 15 air squats, as many power snatches as you can until you've accumulated 100 power snatches at 75 or 55 pounds. Can't wait to see some of the post commit, I already saw one this morning, somebody said their low back was on fire, I'm sure that's the case, I can't wait to try it. Probably going to knock that out here on Saturday afternoon. Alright, as far as upcoming courses go, I want to highlight, speaking of power snatches, I want to highlight our Fitness Athlete Live courses because the ones that are coming up, I see those courses swelling. So Mitch is going to be in Bismarck, and that is going to be on 9-9. So that's in four weeks, a little over four weeks. That class is already pushing 30 people, we're about at capacity, so if you want to jump into Bismarck, you're going to need to probably do that in the next week or so. Similar story for Newark, California, Zach is going to be down there on October 7th, and again, I'm seeing that course edge towards capacity, so if you want to jump in Fitness Athlete Live, you're going to want to make that move pretty quick. We do have Linwood, Virginia following that, so it goes Bismarck, 9-9, it goes Newark, 9-30, it goes Linwood, Virginia, 10-7. If you want to jump into one of those courses, try to make it happen in the next week or so to make sure you get your seat. Alright, it is Leadership Thursday, but this one's a little bit more clinical, but I do think that it really revolves around leading people, so I think it's appropriate for this day of the week. 02:56 "DO MORE, BETTER" I want to talk about doing it more, better sometimes. Now the obvious caveat we have to open with is the fact that we have preached do less better on this show, in this company, for the better part of a decade almost constantly, and there are good reasons for that because the majority of times, doing less better is what makes it work, is what makes for an efficient avail, is what allows you to know which intervention you did actually have the effect. If you're doing a million things with a small dosage, you have no clue what moved the needle. More importantly, your patient doesn't know, so they don't know what to focus on, they don't know what to attach their outcome to. If you're doing a ton of things, it gets messy, it lacks clarity, and it's very hard to get treatment effect. Additionally, it's very hard to give sufficient dose of anything if you're doing everything. Do less better is a hallmark statement and should generally be observed. The challenge I want to make for all of us, including myself this morning, is it always the case though? Is there sometimes, and there should be exceptions to all of this stuff, are there sometimes where overwhelm is exactly what the doctor ordered? Are there times we have to go big? Right now, what's very in vogue, and I generally like this, is things like don't do more than three exercises. There's actually a bit of research showing from a compliance perspective that statement makes sense. If you give somebody a whole laundry list of things to do, they're not going to do any of them. But it's not just exercise. We're hearing these comments around things like sleep hygiene. Don't try to make a bunch of changes, just make one. We hear it around diet. Don't change a ton of things, just start with one or two. I myself preach this all the time. Make it approachable, try to minimize barriers, just choose one or two. But I want us to pause for a second to make sure we don't just make this our default And think about when the opposite might make more sense. 06:30 MANAGING RELUCTANT PATIENTS I want us to think about that reluctant encounter. What I mean is that person who comes into your clinic and you can tell they are really suspect, they're suspicious about whether or not this is really going to work. And you know this person. This is not the person who gets rehab consistently. It's not the person who's already bought into this being the primary treatment choice. It's the person who's like, I don't know about this. My doctor said come so I'm here, but I just don't know about this. Think about that person who's really reluctant. For some people, for that person in particular, this might be the only time that they're going to be in this stage where they're even considering this route. It's not the route they've used in the past. They're really unsure about it, but they've heard some good things. They were told to be here. It's a small window of opportunity. You might only get one at bat with this patient. You can all picture this person. You've got him on your caseload right now. You can just feel what their energy is. I don't know about this. I don't think this is going to get the job done. You might only get one shot at this person. And I want to make a two-part argument about how we manage this individual, especially at that first encounter, which might be the only encounter if things go wrong. The absolute worst outcome with that person is nothing. The absolute worst outcome is no change because it's kind of what they think is going to happen. This is a waste of my time. This isn't going to work. Getting no change is the worst possible outcome. The second argument I'll make is that while I totally agree, especially this person, won't do a bunch of things for a long period of time, they will not do the long litany of exercises, they won't make a million changes, they won't do those things for a long time, but I think they will do it for four or five days. I think they will make a really aggressive change because they're wondering if their time is being well spent. They almost want to prove it wrong sometimes. Like, see, it didn't work. While I don't think a long list of massive lifestyle or exercise changes is sustainable for that person long term, I do think they'll do it for a few days, especially if we tell them, hey, listen, this is not sustainable for a long period of time. What we're trying to see is if we can move this needle. So let's figure it out once and for all and right out of the gates. What if we go this route where we tell them, you don't have to do this for a long time, we're going to put all the guns on early, we're going to see if anything changes. If nothing changes with a high dose, we can both agree that this isn't going to work. But if something does change, what we can then do is begin to look at what you've got on the board and we can tease that down to the things that were the most manageable for you to alter. And that's the stuff that we can ride out into the sunset. Right. Then we can pare down the program. What I'm saying is, should we be asking a ton upfront, prove that change will happen with the highest dose that they can tolerate and then refine and make it sustainable? Should we be telling them, I'm going to ask you never to continue this, but I want to know if we can make a difference and then we'll choose the things that were the easiest for you to stay with. And that's going to be our long term program. It's not for everyone. It's not even for most. 08:38 SWING FOR THE FENCES But on those people who are particularly doubtful that PT will work, I think we need to swing for the fences. And I'm bringing this episode to you because I've had numerous conversations recently with people who did the less better thing, right? Small changes that were easy for the patient that didn't do anything. Where the patient was like, I don't really think I felt a difference. That's fine. In someone who's committed to rehab being the solution, that is not fine. In someone who's testing you out to see whether or not they're wasting their time. On that second person, we need to identify them and say, look, they're only going to give us one chance. We don't need to make it sustainable. We need to make it noticeable. I want to say that one more time. In the highly speculative person, we don't need to make it sustainable. We can worry about sustainability later. We need to make it noticeable. We need to tell them what I'm about to ask is you're going to eliminate a bunch of stuff from your diet. You're going to change a bunch of things about your sleep environment. You are not going to have to maintain these long term. This is going to tell both of us if you're in the right spot. Once that person comes back and you've all had the person who's made really drastic diet changes, think about fasting or total sugar elimination. What do they come back and say? They say really drastic things like, my gosh, I feel less swollen all over my body. I had carpal tunnel as well and that feels better. I used to have headaches and now I don't. They tend to see things happen because they made such a drastic change to the ecosystem. In the unsure speculative patient, that is exactly what the doctor ordered because the number one goal with them is psychological. We've got to get them to believe, oh my gosh, this stuff can actually have an effect on my condition. Now the moment they realize that these are the things that I should be tweaking to make a change, now we alter that program to make it sustainable and do less better. 11:29 OVERCOMING PSYCHOLOGICAL BARRIERS But I am making a call to action on this episode that for the reluctant individual, for the person with the psychological barrier, doing more in the very short term to show them that what won't happen is nothing is the most important thing to get that initial piece of traction that allows you to then refine, pare down and make sustainable a program they now believe in. Give it some thought. Is there a place to go with overdoses, overwhelm, to shift psychology, to get that goal in mind and get that patient on board? I hope it makes sense. In general, I'm always going to believe in do less better but there are always exceptions and let's make sure that we're not letting a blanket statement prevent those people from moving in the right direction. Cheers everybody, PT on ICE.com, you know where the goods live. All of you at the CrossFit Games, good luck. Kelly Benfey, especially good luck. I hope the 64 Army crushes it this weekend. I will certainly be watching from right here. Cheers everybody, take care. 12:20 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning Check out our virtual ICE online mentorship program at PT on ICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE.com and scroll to the bottom of the page to sign up.

Aug 2, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the idea that passion alone is not sufficient for thriving in a career. She mentions that while it is possible to sustain a career solely based on passion, it is not sustainable in the long run. Julie shares personal experiences and acknowledges that many colleagues and friends have also encountered this issue. She emphasizes the importance of considering the entire ecosystem, including supportive management, colleagues with similar philosophies, and a network of supportive friends, family, and partners. Without this support system, Julie warns that burnout is likely to occur and that the initial passion will start to diminish. The episode emphasizes the need for a supportive ecosystem, where managers value and understand the contributions individuals bring to their work. Julie also mentions the importance of growth and opportunities for advancement, as well as being surrounded by like-minded individuals who share a fitness-forward approach. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:43 JULIE BRAUER Good morning, crew. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. I'm brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Excited to talk to you all this morning about five things I've changed my mind about in Jerry PT over the past, I think it's like eight-ish years now of my career. So I actually have a list of like eight or nine. It keeps growing as I keep thinking about things, but I'm going to try and keep it to around five. And so my hope is that over the past eight years of all the mistakes I've made and the paths I went down and the things I've learned, I'm hoping that someone out there listening today, if I can inspire and encourage you to think a little bit differently, to do a little bit differently, if I can save you a little bit of heartache that I've experienced, then I will call this a 100% success. Okay, so these aren't necessarily in order of importance except this first one. So number one of five things that changed my mind about in Jerry rehab, changing settings will fix your burnout. Changing settings will fix your burnout. It will not. If you are in a situation where you feel really unhappy, you feel burnt out with the job that you currently have and the setting that you currently are in, please know that the grass is not always green around the other side. I promise it's not. 03:08 "CHANGING SETTINGS WON'T FIX BURNOUT" It's not necessarily that changing settings is going to fix your burnout. Identifying why you are burned out and doing something about the root of the problem is going to fix your burnout. So I'm not going to get into this too, too deeply because I've done an entire podcast specifically talking about burnout and those of you who are thinking home health will fix that. So if you are interested in that specific podcast, send me a message and I will send you the link. But as an overview, I just want you all to know that you have to identify why first before you jump ship. So the why could be a multitude of different things. Is it truly that you are not passionate about an athletic population and you actually are passionate about a more acute, medically complex population of older adults? Is it that you really want flexibility in your schedule and you can't stand the back to back, the back to back schedule of inpatient rehab? You have to be able to verbalize and write these things down about why you are so burned out in your job. 04:51 BURNOUT IN DIFFERENT THERAPY SETTINGS I spent many years starting out in acute care, getting burned out, thinking that I was going to love inpatient rehab. I was convinced I'm going to have more time with my patients. I'm going to be able to follow them. I'm going to be able to do higher level therapy with them. It's going to be so much better. I went into inpatient rehab. I absolutely hated it. And then I was like, all right, home health, total flexibility. I'm going to be able to see less patients a day. That's definitely going to be the setting for me. Nope, that wasn't it either. What I was doing is thinking that changing up setting was just what I needed to do. And in reality, for me, I came to the conclusion that full time clinical care is what was burning me out. It did not matter what the setting was. And I wish that I would have realized that very, very early on in this process. Now, I learned a lot and I'm really happy that I have experience in all of these settings. However, I could have been much further along in really dialing in what I want to spend my time and effort towards. If I would have thought of that earlier. So those of you that are really burned out, you're thinking about jumping ship. Don't do it. Start to really evaluate those things. Okay, next, you can give a really high quality session and a really efficient session without timing yourself. This is simple. No, you can't know. You absolutely cannot give a really high quality session that is also efficient unless you have yourself on a clock. For the entire session and truly throughout your entire day of doing your job. I think it's really hard because we go from PT school where all we have to do in a day is study, right? Like if our eyes are open, we are like, well, I have to learn the brachial plexus today. And that's all I have to do. So all I'm going to do is sit here for hours upon hours upon hours and study and memorize things from a book. And then we get into clinical and then we get into the real world where we have this thing called productivity. We have to meet while we are also trying to maintain our sanity. And all of a sudden, it is very overwhelming to try and bring quality at the same time as being efficient. So my call to action to you all is put a clock on yourself for your entire day. When you are with your patients, when you are not with your patients, it will change your life. I promise you when I started doing this in home health and you start this just like you start anything, like if you are starting to train for a race, for example, and you know you have to hit certain macros, you need to just start by tracking. What do you normally eat? How many calories are you actually bringing in? So you don't change anything at first. You just track. So you time yourself all of your breaks, your bathroom breaks, your snack breaks, your chatting with colleague breaks, the amount of time it takes you if you are in home health to drive to patient to patient, the amount of time that you are sitting in acute care at the desk and documenting. You time everything. In addition to how long you are actually spending with your patient and how long you are actually doing those subtitles of your session like education or neuromuscular read or gate training, whatever it is, you time everything. You will realize all of your inefficiencies. You will realize, wow, my hourly rate is actually crap. So when I timed myself when I was in home health, I timed everything. And I realized that if I was spending 60 minutes with the patient and I was actually hustling to get everything else done, calling doctors, etc, etc. I was making $40 an hour. Not ideal. Once I started timing myself and figuring out where I could cut, I went from $40 an hour to over $60 an hour. I have an entire podcast just on how to improve efficiency in home health. Again, if you were interested in that, message me and I'll send you the link. So again, my call to action for you all is use your phone. Your lap timer on your stopwatch is really helpful. Wear your Apple watch time every single thing. Start there, track it for a week, and then start chipping away at where you can cut places where you're really inefficient. Not only will you be able to give time back to yourself, which is what we want at the end of the day because taking care of humans all day is exhausting, but your patient sessions, you will get them so much more fit in so much less time. That's a win-win. So start timing yourself. 10:53 PT's DON'T NEED TO TAKE PATIENTS TO THE BATHROOM All right, next. PTs don't need to take patients to the bathroom. PTs don't need to take patients to the bathroom. That is an OT's job. That is a nurse's job. That is a tech's job. Man, this is one thing that I may be like the most sorry about. What I feel so guilty about for years in my career is that I'm with the patients and I'm wrapping things up, right? I know that I want to get out that door so I can get to my next patient. I'm done. I've done my PT thing and they ask me to take them to the bathroom. It's that moment you're like, I really need to get out this door. And what would I say many times? You know what? OT is coming to see you later this afternoon. They will take you to the bathroom and work on toileting. Then for right now, I'm going to press that button and your nurse is going to come and take you to the bathroom. So many of you have been there. I know you are. I know you've done this. But guys, what do we know happens or not happens? We press that button. Nobody comes. Our patient is sitting there uncomfortable. They may not actually get to the bathroom for a very, very long time. What we know from the literature why we have to change our mind about this and start doing this differently is that many falls in acute care. A very high percentage of them happen in the bathroom. This is avoidable because what is happening? Our patients ring the bell. Nobody comes. And then they have the choice of urinating on themselves or continuing to, and sitting there and waiting or breaking the rules and trying to rush to the bathroom where maybe they're on pain meds, their balance is off, they slip, et cetera, et cetera. We need to realize that is our job. We are not above any freaking job when we are with those patients in acute care. They need their butt wiped. We wipe their freaking butt. That is our job. It is patient care. We are all in this together to get that patient out of this DM hospital and back to their life wiping their butt, taking it in the bathroom. That's included. The very basics of giving this dignity back to this human. It is not a particular person's job. And think about it, even from a self-serving perspective, how much information you learn from taking a patient to the bathroom. You are watching them transfer. It gives them motivation to get out of bed versus like, let's get out of bed and go on a walk and lift these weights, right? You get to see how their ambulatory capacity, right? You get to see their balance. You get to see their problem solving, their stand pivot, how they have e-central control getting down to that toilet. Are they able to problem solve how to sequence those steps? Can they grab the toilet paper? Do they know how to use it? You get so much valuable information. And maybe watching someone toilet and saying, I know that looks off. It seems like they don't know how to sequence this, but I don't know the language to put to it. And I don't, this isn't really something that I understand how to treat, right? Yes, your OT partners are going to be able to take that baton that you hand them after you give them an information. And they're going to be able to do a much better job in that specific task, right? It's collaboration. We need to be setting our patients up for success. Never, ever, ever, ever from today forward, please PTAs ever tell your patient, that is someone else's job, someone else's job. I'll go tell the nurse when I leave. It is your job. You should start planning for this in your sessions. Just give some time before you absolutely have to get out that door. Give five, six minutes to a lot for this patient needing to use the bathroom. It is your job. We are part of a team and you can prevent something drastic happening like falls or someone losing their dignity by literally having to urinate on themselves. 18:21 ALTERNATIVE HOME EXERCISE OPTIONS Next, weights are the best pieces of equipment to initiate loading with older adults. Weights are the best pieces of equipment to initiate loading with older adults. Look, I love being able to get my older adults, especially those who are pretty medically complex and deconditioned, lifting weights, right? All of you all, this ice crew, your fitness forward, you are incredibly enthusiastic about this. However, if we focus too much on that, I think we can be actually increasing the barrier to loading versus decreasing it, which is our job. We need to realize that the best equipment older adults are using to introduce loading are not necessarily weights. The best equipment are the objects, the animals, the people, the boxes, whatever the odd things are that are in someone's life, an older adult's life, that they will lift, push, carry, pull, hinge. Those are the best pieces of equipment to introduce loading for an older adult. That may not be a weight ever, ever. If it is, amazing. I love it. Bonus points. The best equipment is the one that our patient is actually going to use. I love how enthusiastic we are. And if we can get our older adults lifting weights, wonderful. But ask yourself, like, is this sustainable? Is this only going to be something that they do with me? What am I doing to allow sustainability and longevity of loading with this older adult that they will continue to do after I am no longer caring for them? When our plan of care is over, have I decreased the entry point to loading so much that they have a technique that they can use on their own? Are they going to buy those weights off of Amazon that you've told them? Are they going to have a family member go and buy the dumbbells from Walmart? If they're not, then you better have another option. You better have something that they can use around their home that's less intimidating, that's cheaper, whatever it is. And not over here. Try to introduce the weights, but also give them something that's incredibly, incredibly convenient, right? Where you're decreasing the barrier of making the right choice, which is introducing loading, and we need to make it convenient. So I would argue that while I would bring weights in my backpack, walking around the hospital, I will bring weights in my trunk when I go to see my patients in home health. A resistance band, not a TheraBand, a rogue resistance band, many times was the best piece of equipment to introduce loading to an older adult. It's not intimidating. It's versatile. Not only can you use it to introduce loading and resistance, but I love to use those resistance bands for balance reactions. You can do a lot of perturbations with them. You can put them on the floor and use them as like an agility ladder. They are incredibly versatile. They're light. They're easy to carry around with you. Many older adults are not intimidated by them. Many times, a resistance band is the way to go. Many patients, I am not getting weights into their homes for these really sick folks in home health. It's just not going to happen. They're not going to make it there. So you need to make sure that you have something that is going to be practical for them and it's going to be sustainable. For me, it has been a resistance band. Give that some thought. Maybe go onto Amazon today when you're ordering your other stuff and getting your cart ready for Prime. Add a rogue or some other brand. It doesn't have to be rogue, but a actual resistance band to your cart. Okay. Last one here before we go. 23:53 SUPPORTIVE ECOSYSTEMS IN YOUR CAREER Last one, most unpopular opinion. You can thrive in your career on passion alone. You can thrive in your career on passion alone. I don't think this is true. I have experienced, and I know many of you have experienced this, many of my dear friends and colleagues have experienced this, that you can survive in your career on passion alone, but it's not sustainable. You have to think of your entire ecosystem. If the only thing that is able to get you up and get you out of bed and get you going to your clinic, your hospital, your patient's home is that you love treating older adults. You love the relationships you build. You were so called to better serve this population. If that's it, if you do not have supportive management, if you do not have colleagues that think in the same way that you do and share your same philosophy, if you don't have supportive friends, family, partners, you are going to really start to burn out. That passion is going, that fire is going to start to diminish. It may not go out completely, but damn, it's going to be a lot harder to keep that going. It is absolutely critical that you are in a supportive ecosystem, that your managers value you. They understand the value that you're bringing. They offer you opportunities to grow and advance and to really stretch your skills that you are surrounded by other people who feel the same way, who want to charge forward with a fitness forward approach. You need to have friends and family and people that you're maintaining your relationships with, and they need to be supportive of what you're going after. You need to create that ecosystem. When you don't have that, I think so many, and I believe this for a long time, as much as I care about this mission, this thing, this job, older adults, as much as I care about it, it will be tempered. That fire will not burn as bright if we do not have the support from all those different parts of our ecosystem. It just gets to a point where maybe you're just running on fumes. Start to think about who your ecosystem is within your job, your managers, your colleagues. Do you have growth? Are you challenged? Are you very passionately connected to your team, to the mission, and about your personal relationships? How are they supporting you? How many individuals have you built up around you that are there to support you? Really start thinking about that. Okay, that's it. I think that was five. Just to review, five things I've changed, or maybe six, five things I've changed my mind about in Jerry Rehab. Changing settings will fix your burnout. You can be efficient and give a high quality session without timing yourself. PTs don't need to take patients to the bathroom. Weights are the best pieces of equipment to use to introduce loading to older adults. You can thrive in your career on passion alone. Five things I've had a massive, massive thought switch as I've gone through my career. Hopefully you all found some of those things to be really helpful. It gave you some things to think about. Please, if any of that spoke to you, do one thing today to change how you think or change what you do. To close this out, I will let you guys know what we have coming up in the older adult division. We have tons of courses. We are going to be in Lexington next weekend. That's our MMOA summit. The entire crew is going to be there. We get to check out Stronger Life with Jeff and Dustin. They're spot there. We absolutely can't wait. We are in Texas, Minnesota, and California for the rest of August. Then MMOA Central Foundations starts next Wednesday. One week from today, our online cohort starts. That cohort is filling up rather quickly. We took a little bit of a break in June and July. If you're interested in that course, I would not wait. I would get your ticket ASAP. All right, guys. Have a wonderful rest of your Wednesday. 25:49 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 1, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the significance of addressing the underlying ecosystem challenge to achieve better outcomes for patients. She specifically highlights the prevalence of poor diet and obesity as contributing factors to this challenge. Lindsey points out that there is evidence suggesting a link between these factors and knee pain, as overweight and obesity are often observed in individuals experiencing knee pain. Lindsey emphasizes that focusing solely on physical therapy interventions, such as knee range of motion and strength exercises, is insufficient. Instead, she argues that healthcare professionals, including physical therapists, need to consider the broader ecosystem in which patients exist. This includes addressing mindset, mindfulness, exercise, diet, and sleep. To guide patients along this path, Lindsey suggests that physical therapists can play a role by providing support and education. She compares physical therapists to shepherds, who can assist patients in navigating and making positive changes in their overall lifestyle. By addressing the underlying ecosystem challenge, Lindsey believes that better outcomes can be achieved for patients. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How's it going? Welcome to Clinical Tuesday. I'm Dr. Lindsay Hughey coming to you live from Edgerton, Wisconsin. So good to see you all today. I am going to chat with you about playing offensive medicine in our folks with degenerative meniscal injury. Before I dive in to what that looks like, I'd love to share with you a little bit about courses Mark and I have coming up in extremity management. So we have a couple options in August and actually one of them, well we did have a couple options, we only have one now because all the tickets in Fremont, Nebraska August 19th and 20th are actually sold out. So our last ticket went I think yesterday. So the only option in August to check us out and learn all things best dosage and tendinopathy care of the upper and lower quarter is Rochester Hills. So August 12th and 13th I will be teaching there and so join me if you can. And then in September Mark has two options for you on September 9th and 10th out of Amarillo, Texas and then September 16th, 17th out of Ohio. So Cincinnati will be coming your way. And then some fall and winter courses but again opportunities are dwindling. We hope if we don't see you this summer to see you in the fall or winter. 01:48 STOP THE SCOPE But let's chat about how do we play offense for degenerative meniscal injury because today is really a call, another call to stop the scope. I've hopped on here before over a year ago, I'm kind of charging us with those folks that have that gradual onset of symptoms of pain in their knee, maybe a little bit of swelling but have no specific injury or twisting event that happened that's more related to a degenerative process or like or I would like to refer to as a living life process. They don't need arthroscopic meniscectomy. And so we had more literature just come out this year to really bolster that argument of why physical therapy is really the number one choice, exercise medicine is the way to go. But I would like to first highlight that new literature that came out in January of why it's not appropriate to have surgery for these folks and then to also take a moment to reflect on why are we still seeing the arthroscopic partial meniscectomies being done if we keep finding literature that says let's not do this. And then also reflect on how can we do better as a profession to stop this continued over medicalization. So I first just want to briefly review in January 2023 we had a systematic review and meta-analysis come out from the Osteoarthritis and Cartilage Journal and we actually did share that on hump day hustling a while back. But this systematic review and meta-analysis again let us know that degenerative meniscal injury, the scope is not the way. And so let me unpack a little bit about this study because it was pretty inclusive this systematic review and meta-analysis. They looked at tons of RCTs so that the pool data of all patients was 605 patients. The study populations in each of the RCTs ranged somewhere between 44 and 319 so decent size overall in each study. The mean age of these folks was about 55 with the standard deviation of 7.5 so kind of that middle age and then majority were female about 52.4 percent. So you also see an even distribution almost of males and females in this study and then mean BMI was 26.5 standard deviation 3.7 you know below or above that. And what they investigated was the effectiveness of using arthroscopic partial manisectomy and they compared that via non-surgical so either sham which was exercise treatment or some form of exercise program so every RCT they looked at had to have the comparator of exercise. And degenerative meniscal findings were confirmed on MRI in all of the studies. The primary outcomes were knee pain, overall knee function, and then health-related quality of life and they looked at outcomes for up to two years so we see again a long-term follow-up in these RCTs this collection of RCTs that they looked at. And so the conclusions January 2023 so we're you know over six months out over half a year through and the conclusion was for insidious onset of knee pain so non-traumatic with MRI confirming degenerative meniscal tear in adults arthroscopic partial manisectomy is not the answer. 05:15 "NO CLINICALLY RELEVANT EFFECTS OF PARTIAL ARTHOSCOPIC MENISECTOMY" Literally if I'm going to quote verbatim no clinically relevant effect of arthroscopic partial meniscectomy was detected for overall knee function health-related quality of life or mental health. They did find one small marginal difference in pain levels a couple points but there was no evidence that there was superiority in having surgery. In fact they even took a look to see are there subgroups of patients right that might have a greater benefit from APM that were just not recognizing and when they looked and compared again the non-surgical to sham exercise therapy they did not see a subgroup that existed. They made other conclusions to say most degenerative meniscal tears are going to improve over time without the need for that arthroscopic partial menisectomy. Other findings that I think are really important to point out before we kind of reflect on why if we have this evidence do we keep seeing surgeries being done is that when they looked at the individuals in the studies those with BMI over 30 so obese individuals compared to the healthy BMIs less than 25 they had a 4.7 fold increased risk of progressing to knee osteoarthritis whether they had surgery or not. It was really a call to action when they found this in this pool data of all these folks is that body weight reduction strategies need to be on board for pain and function effects. 07:28 "...NO SIGNIFICANT ADVANTAGE OVER NON-SURGICAL TREATMENT" So just to send it home about this study and what they said one of the final things that they wrote in their conclusion was and I'm going to read it verbatim we recommend that physicians minimize the use of arthroscopic partial mastectomy to treat patients with degenerative meniscal tears because there is no significant advantage over non-surgical treatment. This is the osteoarthritis journal right this is a pretty high tier journal osteoarthritis and cartilage journal making this statement. So why are we still seeing a ton of them? Why does this keep happening where we see patients I have one of my caseload right now right why is this happening? Well we're obviously not reading the literature as a health care team and as physicians right because patients still think this is a primary defense. I'd love to reflect on that even 10 years ago in 2013 we had a study from Yim et al where they compared meniscectomy versus non-operative strength care and this was in 103 patients them and the same exact message was there there are no significant difference between arthroscopic meniscectomy and non-operative management with strengthening exercises again when we look at knee pain function and satisfaction at the two-year mark. So even 10 years ago we had this evidence but yet it's not translating to practice that's a lot of surgeries a lot of over-medicalization so I we need to really step it up here in our not only in ingesting this information but advocating that this is not a new message. In this article they point out that in 2017 so the systematic review and meta-analysis that we just reviewed that in 2017 an expert panel that regarding the degenerative meniscal injury said that the use of arthroscopic partial meniscectomy in nearly all patients with degenerative knee disease that several guidelines do not support this procedure. They've literally made clear statements against it again yet we're still seeing it so we can do better here and that probably takes some building relationships with surgeons right and chatting with them and letting them know like PT first get them to us right but really advocating that message in the community because we know that's not always going to work talking to the health care team. I think this message needs to be broadcasted widely more widely than it is currently. The other reason I think we keep seeing it besides like poor translation from what we're reading to the general public is there's this image mismatch so we see this a lot in the extremities and if you've been to our extremity of course you know we have a lot of conversations around this in different areas of the body shoulder hip knee but you see degeneration on the MRI right but there is no clear link that that's the cause of their pain symptoms it's an incidental finding but yet patients think oh you know my knee is really banged up right they leave hearing this message of harm rather than hearing you know I'm glad this is a normal age-related change so there's the image is linked inaccurately to pain and so again another opportunity to educate in this space and then the other reason I think that we keep seeing a ton of them being done regardless of what we know in the literature regardless of what we know that imaging doesn't tell the whole story is that there's this message put out about the fear of progression right if you do not get this meniscectomy you will go on to having knee OA or early onset knee OA which will lead to a knee replacement. 11:12 "IT'S DOING MORE HARM THAN GOOD" Let's stop allowing this message to be passed on it is harmful right it's doing more harmful than good and we don't actually know that right any fear-based messaging is not the way and so that message that is a thought virus and if our patients are coming into us or even like people in our community right our family or friends um we have to really um call BS on that right because we don't know that for sure and we're not seeing that link so finally kind of the background of the that we just had in January 2023 tell us that having surgery is not the way we've kind of reflected on why do we keep seeing this so what do we actually finally do about it well promote PT first faster right when someone's knee is starting to ache right stop ignoring it get into PT stop going to a medical provider even primary care orthopedic first come to physical therapy first so we can help you um with your hip and your knee pain and your um any associated muscle weakness or swelling so that we can get these healthy messages into our folks and into the community these folks get lost in the system letting them know that it is very common what they're experiencing and a plan for success that's our job that's our wheelhouse we need to manage expectation too so folks right some of our patients are going to want to do the surgery anyway right despite any of the things we can tell them about the evidence right they're set on it their belief and expectation it's going to help well i need you to manage those expectations as well because surgery after surgery i don't know about you all but all the ones i see doesn't actually take away their pain and swelling in fact the surgeons have actually told my patients you can expect swelling for up to six months which is literally the reason they came in there they want to feel better and they want the swelling to go away well guess what at least for six months it's not going to happen folks so letting them know that in a kinder less passionate way probably so while these folks might return to work or sport they're going to have ongoing symptoms and that's swelling so letting them know that that even if they opt for that it's still going to be a challenge they're still going to need pt so i tend to want to say why not play offensive time along those six months where you don't have to um respect healing time frames after surgery where we can really get after strength around that that knee and that hip the other thing we need to reflect on and how we can do better is that it's not just promote pt faster it's not just managing expectation but we have to understand the underlying ecosystem challenge that is present in a lot of these folks we see and especially in the systematic review and analysis that came out in january 2023 we see an underlying poor diet and we the reason we can know that it's related somehow to diet is it's we see overweight and obesity being precedent being present excuse me and so we have to understand that we have to intervene in these folks not just on knee range of motion and knee and hip strength and proprioception but we actually have to consider there's that underlying ecosystem piece and here's where pts can help too right we can help with mindset mindfulness exercise diet sleep and really guide them along that path as a shepherd we can help so we need to know that we can help right so some of us maybe don't even realize that our own you know 2018 cpg guidelines at the josp t let us know that exercise is medicine and whether patients do opt for surgery not that guideline really points out that supervised exercise so how many folks you see after arthroscopic partial metastatic go on they have the surgery and then the docs just give them a standard h.e.p. right so they go on having swelling quad like because they don't have an individualized program with progressive resistance exercise let those folks know too you need to be a part of their care in our own clinical practice guidelines say that it's not good enough to just do a an h.e.p. that's not tailored to the individual and then what that cpg highlights is we're always going to do a mix of hip and knee strengthening we will have manual therapy on board we will do proprioceptive activity and neuro re-ed for those joining this morning thank you to summarize where we are at when thinking about our degenerative meniscal care we need to advocate against surgery with that insidious onset of knee pain we need to share this evidence far and wide that it is not recommended as frontline defense we need to stop the fear messaging as a health care profession and let folks know that degenerative changes found on images are normal signs of living their life and that pain does not equate to imaging findings we need to dose hope and let folks know that at that two-year mark we can see just as great of improvements in pain function satisfaction of care with just p.t. right and i don't take the just p.t. lightly we don't need that overmedicalization p.t. first is the way i'd rather see a patient taking control of their ecosystem and knee health for two years rather than that wait and see approach will surgery help stop the scope folks have a happy tuesday and thank you for joining me 16:35 OUTRO Hey thanks for tuning in to the PT on ICE Daily Show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home check out our virtual ice online mentorship program at pt on ice dot com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to www.ptonice.com and scroll to the bottom of the page to sign up

Jul 31, 2023

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses how virtual pelvic floor care can prove beneficial for physical therapists in both virtual and in-person settings. Alexis shares that engaging in virtual pelvic floor care has significantly improved her overall abilities as a physical therapist, particularly in asking questions and gathering necessary information. She also notes that virtual care seamlessly integrates into both virtual and in-person worlds. Alexis highly recommends physical therapists to explore virtual pelvic floor care as it can be incredibly helpful. Furthermore, she mentions that a future podcast episode will delve into objective exams for pelvic floor virtual PT, indicating the importance of further exploring virtual care. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show 01:27 ALEXIS MORGAN Good morning, Instagram. Good morning, PT on ICE Daily Show. My name is Dr. Alexis Morgan. I am one of the faculty with the Ice Pelvic Division. Really happy to have you all here joining me this Monday morning. My voice is a little raw from the weekend. We were just in Denver, Colorado, right outside of Denver at Onward Denver in Parker. This whole weekend, April and I spent with an awesome, awesome group of individuals and we were going through all of our material in our live course. We did our internal exams, supine and standing, and dove into all issues of pelvic floor dysfunction. We of course didn't stop there. We progressed through everything that our athletes are doing at the gym. So talking about how pelvic floor dysfunction fits into weightlifting and Valsalva and using a weightlifting belt and jumping and running and doing gymnastics. We had an absolute blast with this last weekend and we hope that you all will join us in the future for not only our live course but also our online course. I want to talk with you all today about virtual pelvic floor PT. We get a lot of questions asked over Instagram and on our Ice Students Facebook page. Sometimes we answer you all directly with some help. A lot of times we like to use your questions to teach everyone else about the topic that you asked. 03:10 VIRTUAL PELVIC FLOOR PT This particular topic actually came from an Ice student who was wanting to know some more information about how to really apply what we talk about in our live and online courses into the virtual setting. And so that's exactly what I want to dive into today. Kind of similar to what we talk about really in all of our courses is that our subjective exam should be very detailed. It should be specific and we should be taking a while to do our subjective exams. I will say that when it comes to doing an assessment virtually, the subjective becomes huge. Not everything but a vast majority of especially that initial assessment. I'll talk through some ways that we do some objective exams but I want to before we even get there really emphasize to you all the importance of that subjective exam particularly in the virtual setting. So when I say be specific, there's a couple of things I mean with this. Depending on the issue that they may be coming to you for, whether that's leaking urine, whether that's pelvic organ prolapse or feelings of heaviness or vaginal bulge, that might be leaking bowels, whether that's anal incontinence with stool or potentially with flatulence. Maybe it's constipation. Whatever that may be, we want to get very specific on their problem. Again, this is true in person and in virtual but it really does become extremely important in this setting because all you've got to track changes are your words. By you having conversations and by asking questions, that's how you track the person's change. So it's not in session, which sometimes we can gather on that first virtual, but definitely between sessions. It's really, really important. So maybe you use the patient specific functional scale where they fill this out ahead of time or maybe you help them out and ask them further questions when they tell you they leak with double unders. 06:26 LEAKING WITH DOUBLE UNDERS When I hear I'm leaking with double unders, that is not enough information for me to help you just yet. I've got a lot more questions and you should too because depending on how they answer, it could really change how you're going to treat them for that leaking. Not all leaking with jump rope is treated in the same way. And we've talked about this so much yesterday in our live course as we were going through jumping rope. But what we need to do is ask questions. So when does the leaking occur? When in that workout? And tell me what jumping rope looks like to you. Is it single unders? Is it double unders? If it's double unders, is it always doubles? Did you just gain that skill or is that an old skill for you? At what point during the workout? If it's early on, that's going to be different than if it's later on, right? I'm starting to think fatigue plays a role in their leaking. If it's later on in a workout, does it matter about which exact workout it is? What is the volume with that? That's going to be different, right? If it's 50 double unders versus 500 double unders, that's going to be different. And so we need to figure that out and we need to ask those questions. So you can use the patient specific functional scale and make that work for you. You can also use the PFDI, a specific to pelvic floor questionnaire. Now that is not an open box. That is marking, marking symptoms on a questionnaire. But what we've got to do is we've got to get information about their specific number one problem that they have. And moving forward, we need to understand what is their entire pelvic floor environment like. So we're going to ask questions and see if they have issues in other pelvic floor realms. Realizing we understand the number one reason why you came to me and I promise you I'm going to help you with that. But sometimes some of these other issues kind of play into your main leaking problem. Or as we're addressing your leaking, we can also address these other issues and together everything within your pelvic floor is going to function better. So a couple of those questions, again, depending on what they're coming in for, whether that's vaginal or bowel issues, you're going to ask, are you experiencing any leaking with maybe coughing or laughing, sneezing? And even with that, sometimes people are like, no, I don't leak with sneezing, but I do have to cross my legs together aggressively in order not to pee. OK, that's a problem, right? We're going to add that to our list. Do you feel like you can fully void? How frequently are you peeing? This one's a hard question for people to answer, but I generally want to know like, is it every 5, 10, 15 minutes or is it more like every hour or two? If it's very frequent, like every 15 minutes, that's going to be something that we note down and address early on. If it's every hour or two, we're going to lower that on our list. We may get to that if it's every hour and bothersome, we may not get to that. If there is high frequency, we're going to send them with a bladder diary and that's going to be one of our first trial treatments that we do with them. 12:00 STRAINING TO POOP We want to actually pull up the Bristol stool chart. I always laugh when I pull this up. I'm like, OK, listen, I'm going to ask you a weird question. I promise it's relevant. And then I pull up the Bristol stool chart and I say, give me a range like where do your poops normally fall within this Bristol stool chart? Looking at that to see, we want to see around that three or four that are relatively normal. But if it's above or below that, we're thinking, what does diet and hydration look like? And that may lead us into more questions. How frequently are we having a bowel movement? Is it every one to three days? Because that's normal. Or is it six times a day or every six days? Those are not normal. And so we can dive into that. Do you feel like you have to strain really hard in order to have your bowel movement? We have evidence and plenty of it on straining to poop. And we need to be teaching people not to do that for their pelvic floor health. It's a very simple and effective intervention. Do you use a squatty potty or do you use something under your feet to bring your knees up higher than your hips? For most cases, that's going to dramatically improve the ability to go have a bowel movement. And that's really, really helpful. And again, is there any leaking, any anal incontinence that is, again, flatulence or potentially stool? All of these, again, are good questions to ask, even if they're not coming in with bowel problems for you to resolve. We want to go through this with them. And then vaginally, we're going to ask some questions as well. Do you have any pain with insertion? So that insertion could be anything from a tampon to a penis, sex toy, or speculum exams. Do you have any pain with that insertion? And asking, do you have any loss of air, especially with our active individuals who might be going upside down, whether that's in yoga, Pilates, CrossFit? Sometimes people can have loss of air or queefing. And we want to know about that because all of these things really paint a picture for us. Now, usually, this takes up quite a bit of time. I mean, I've been talking about what questions to ask for the last 10 minutes with absolutely no answers behind them. So this typically is a really good starting point and often is the vast majority of my first virtual pelvic floor assessment. However, I like to leave time for a few more questions and then getting into education as my trial treatment. So the few other questions that we always want to know is what is exercise or movement look like, how is sleep, and what do you do for stress management? Some of these questions you can ask in your intake paperwork. You may want to go over that with them as well. But looking at them as a whole person and looking at their pelvic floor issues as a whole. And then from here, we do trial treatments as education. So depending on how they answer any of these questions, typically, and it's beyond the scope of this podcast to really talk about various education pieces for each of those questions, but I'm going to educate and I'm going to intervene. So maybe that is let's start hydrating. Get yourself a favorite water bottle and I actually want you to hydrate. Or potentially it's the opposite if they're over hydrating. Maybe it's can we decrease that intake throughout the day or right before bed? Maybe it's get a squatty potty or get your toddler's stool that's right in front of the sink and slide that under your feet for when you need to have bowel movement. Going back to our initial example of the leaking with double unders, perhaps it is I want you to video yourself doing double unders from the side view and the front view and send it back to me. But between now and then, I want you to make sure that we are videoing it at the end of you're having that leaking. And after we get that, I'm going to have you take more rest breaks if that's what they need. Or maybe it's go into your single unders since double unders are always causing leaking and throughout our plan of care, we are going to dive into that. I try to find some piece of education and something that we know will help them resolve a little bit of their issue and get us rolling with this. We talk about it in our live course, but we have good evidence for education actually improving pelvic floor symptoms. And I think there's no better place to really feel that as a practitioner to feel the difference in the amount of education that you can provide and the amount of change that can occur. There's no better place than in this virtual care where truly we are guides. I can do nothing with my hands. I can do nothing with my body to change how that individual is functioning. I purely have to use my voice and teach and ask questions. If you have not done virtual pelvic floor care, I would highly recommend it. It has made me a much better physical therapist altogether, much better at asking these questions and getting the information that I need. And it blends into both worlds, both virtual and in person. So if you haven't done it, I highly recommend getting some patients in that virtual care because it can be really helpful. That needs to be all for today. I have a lot more that I could say, especially if we dive into the objective exam and how to do that. But I think that's going to need to be a podcast part two for virtual care. So I will do that the next time I hop on to the daily show and talk with you all about how we do objective exams for pelvic floor virtual PT. Thank you all so much for joining me and listening in this Monday morning. Or if you're listening later on the podcast, thank you for listening. One quick note, it is CrossFit Games Week and we are so, so excited to be cheering on our very own Kelly Bimpy at the Games with her team this year. So tune in to the Games. If you're going to be there, let us know. There's several of us ICE faculty that are going to be at the Games. We would love to see you and say hello. And I don't know, maybe we can snag a workout in or something. But we are so excited. It is Games Week. Have an awesome week. Hopefully we'll see you up north. If not, catch you later. Have a good one. 19:26 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 28, 2023

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses how manipulating reps within a set can alter the intended stimulus of the set to bias towards power, strength, hypertrophy, or endurance gains. Guillermo discusses new research highlighting that depending on population, some individuals may still experience strength gains at lower loads & higher rep counts and that most individuals will improve hypertrophy regardless of rep dosage. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one on one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show. 01:32 GUILLERMO CONTRERAS Good morning, crew. Welcome to the PT on ICE Daily Show. Welcome to one of the best days of the week, if not the best day of the week, Fitness Athlete Friday. I am with you. My name is Guillermo Contreras, part of the teaching team with the fitness athlete crew of the Institute of Clinical Excellence, talking all things delightful and super interesting, such as the rep continuum. So I'm going to leave you a little bit guessing as to what that means and dive into some fun stuff as in where are we going to be over the next couple of months? Where can you catch us on the road before the year ends? For our live courses, we have more than a handful coming up here in the next several months, starting in September on the weekend of September 9th and 10th. We'll be in Bismarck, North Dakota. In October, we will be technically September, October, September 30th and October 1st. We are going to head out to the West Coast to Newark, California. A couple weeks later, October, a week later, October 7th and 8th, we're going to stay in the West Coast. We'll be in Linwood, Washington. Moving into November, we'll be double, double teaming for, I guess, I don't know if that's the right phrase, but two different locations on November 4th and 5th, San Antonio, Texas and Hoover, Alabama. So moving from the West Coast down to the South. November 18th and 19th, we will be in Holmes Beach, Holmes Beach, Florida. I'm not sure where that is, but Florida. And then lastly, in December, we are going to be in Metair, Louisiana, as well as Colorado Springs on the weekend of December 9th and 10th. So there you go. If you've been looking to take a live course with the Central Foundation, or with fitness athlete courses, one, two, three, four, five, six, seven, eight opportunities for you between now and the end of the year to catch us on the road and be able to take that course and join us. And hopefully we get to meet you out there. If you are looking to do the online courses, Essential Foundations currently is going on their seventh week of this current cohort. So we're finishing up in about a week and a half. That take about a month off. And then we're going to kick off the next Essential Foundations cohort on September 11th. So if you've been looking to get started with the fitness athlete coursework, try to get an idea of what you would do when you work with fitness athletes, get more comfortable with the barbell movements, the squat, the deadlift, the press, what CrossFit is in general, some introduction to programming as well as the gymnastics movements, such as the pull-up. Would love to have you join us on September 11th as we kick off the new Essential Foundations cohort. These courses do tend to sell out online. So signing up sooner rather than later behooves you if you're interested in it and you want to get it in before the end of the year. Advanced Concepts as well. I think that only has two cohorts a year. So only twice a year that you can actually sign up and take Advanced Concepts. That second time right now is going to be on September 17th. Advanced Concepts does always sell out. It's a more high level course. You're going to learn a much deeper dive into programming, into modifications, into the high level gymnastics movements, such as handstand push-ups, muscle ups, high level Olympic weightlifting, breakdown and progressions. A lot of really deep dive stuff. A lot of brain work and physical work you'll be doing for this course. So that one starts up on September 17th. So please be sure to sign up again sooner rather than later for that one because that one does absolutely sell out early. Sometimes a couple months early. So sign up now if you're looking to complete your coursework to get your fitness athlete certification or if it's just something that's been on your bucket list you've been dying to take but you have not and you want to get it in before the end of the year. Fantastic. So that's what we have on the docket for fitness athlete. This morning the topic at hand is the rep continuum or the repetition continuum. For those who are not sure what that entirely means, what we're looking at with the rep continuum is, I just realized my camera is really blurry over here but that's okay. Is what we commonly know as the strength endurance continuum which for the majority of us or anyone who's been in like the strength and conditioning realm what that means is okay what are the optimal rep ranges and loads that you want to use when you're trying to train strength, when you're trying to train hypertrophy and when you're trying to train more like localized muscular endurance. And for the longest time we have had the accepted theory that it is one to five reps at 80 to 100 rep 100 percent run at max. Hypertrophy is going to be eight to 12 reps at 60 to 80 percent one rep max and endurance is going to be 15 or more reps at anything below 60 percent of your one rep max. That's what's been commonly known and so in 2021 Bradshon building company down at the NSCA right they decided to do a lit review look at everything they could out there and got a better understanding of is it truly that is that the only way or are those the only things we know or are there actually other ways to gain strength gain hypertrophy gain gain endurance in our muscles and is that truly the most optimal way that we can do these things or is there other ways that we can kind of build it up can we use lighter loads can we use moderate loads can we use heavy loads and play around and dive into these different realms. So again they did a very very significantly large lit review and their purpose of the paper was to critically scrutinize the research on the repetition continuum highlight gaps in literature and draw practical conclusions for exercise prescription. Based on the evidence they proposed a new paradigm whereby muscular rotation can be obtained and in some cases optimized across a wide spectrum of loading zones. So that is that kind of the basis for the paper and it's a long one it's probably like 11 pages and you have like a bunch of pages of exactly the the the protocols that they use in all these different studies that they reviewed and I'm just going to try and do my very best to summarize what they kind of found in each section and then at the end if you don't want to like listen to this whole thing you're listening later on just jump to the last maybe like minute or so and I'm going to try and kind of concisely conclude everything there. When it came to strength strength as we know it is supposed to be ideally that one to five rep range 80 to 100 percent one rep max heavy heavy loads is how we're going to build strength and what they found in this here is that trained individuals people have been doing it for a while tended to show improvement in strength even with light loads so people who have been doing it for a while people who who already lift heavy and such when they use lighter loads in different variations there actually is an increase in overall strength albeit they they mentioned in a caveat that it is to a lesser extent than the use of heavy loads. Um they also mentioned that typically what they see is as you reach that genetic ceiling like where your where your strength is kind of at its highest or going to be pretty high the greatest benefit is going to be in heavy loads with specific movements that you're trying to get stronger and again that should be something that all of us are probably saying like no duh right that's that's the set principle right you learn that in undergrad kinesiology right specific adaptations to impose demands when you get someone that's a higher level at the very highest level and you're trying to get them stronger the way to get them stronger is to apply specific stressors to elicit a specific progressive improvement in strength that's what they saw there so what we see is with heavy loads or when we want to build strength you can do it with low loads there are ways you're going to build low loads and that practical application the clinical application is that all the studies i guess the majority of studies that found that low loads improved strength their way of testing strength was using isometric dynamometry therefore the isokinetic or isotonic leg extension leg curl hip extension you name it they used single joint mechanisms to test that single joint single movement strength from a practical application that can very easily mean for us in the rehab realm if we are trying to get someone's quad stronger if you're trying to improve specifically quad strength hamstring strength whatever it may be there is a point where we can use lower loads to high intensities right all across the board effort was dependent on improvement maximal or hard efforts with low loads showed improvement when individuals cut off before maximal effort before fatigue before stress there was not the same amount of improvement whether it was strength hypertrophy or muscular endurance so low loads can be used on single joint movements however strength is most often applied in compound movements coordinated multi-joint efforts i.e. squats deadlifts presses lunges all those type of things and so we want to make sure that if we are trying to help someone improve their squat improve their deadlift strength improve their rowing strength we're trying to create these compound movements that are are functional in nature to what they're doing we have to be getting comfortable with the barbell movements we have to be comfortable loading them heavily right so if you're going to be working with athletes who are doing functional movements you better be loading them with functional movements you better be loading them heavy with functional movements if the goal is to do actual strength improvement and that actually is nice because it it shows two things right one yes the one to five rep range eighty one hundred percent max of these movements is where we want to be for strength and two if we're trying to do very specific rotator cuff bicep quad hamstring strengthening then it's okay to use lower loads maximize that intensity range and we're going to see strength improvements there if we're very specific with what we're doing there number two moving on to hypertrophy hypertrophy getting the gains bigger bigger arms shoulders back legs quads hamstrings you name it everything there well we typically see in the realm of like bodybuilding in the realm of anyone who's trying to put on mass is we're going to be doing somewhere around that eight to twelve rep range sixty to eighty percent so submaximal loads add an effort when you get to that mid-range you're creating some sort of mechanical stress that causes that muscle to basically in essence break down a little then build back up and get stronger as long as you know all the fuel and everything is there for it and in the study the meta analysis showed comparing high loads which are greater than 60 percent of one rep max versus low loads which are less than 60 percent one rep max is that there was no real difference in hypertrophy which is kind of interesting right you can again offer an example of you can use low or high loads moderate loads kind of in that range to build hypertrophy the notable effort though again that they mentioned in here is that when individuals were using low loads the effort was much higher so it was a higher level of effort because it is critical for maximizing hypertrophic adaptations so again if our goal is to have someone who has a very very atrophied quad and we are not going to try and pursue something that allows for 60 to 80 percent of that one rep max relatively heavy loads right moderately heavy loads that are challenging and fatiguing and stressful then we'd better be using low loads but eliciting a maximal effort where they are working hard for 15 18 20 reps whatever it may be that kind of ties in a little bit with with anyone who kind of plays around with blood flow restriction training where you're doing 30 15 15 and you're maximizing that effort there it's a very low load somewhere around 20 30 percent of one rep max for a lot of reps there too but that's again there's another topic there right effort is dependent on this are we are we using maximal or high level of effort to maximize hypertrophic gains strength gains etc the one thing this study did show the review did show was cool is that for from an age-related standpoint the light load training appears to be as effective as heavy training so when we're looking at our older adults where we might see more of those joint related conditions when they can't sometimes tolerate heavy loads on their knees on their hips whatever it may be using light loads at this this higher effort level might induce a similar hypertrophic change because it's going to stimulate both type one and type two muscle fibers when we're using lower loads we're in essence what they mentioned in this review is those type one fibers might be stimulated stimulated more because you're doing more of an endurance or long bout of exercise and effort which is going to stimulate those more when you're having it's more type two muscle fibers so either way we're building them both up and we're trying to build hypertrophy in that way so there we go and even in the really said that some researchers propose that you should train both like high level volume with high effort and lower volume with higher effort as well again working in those things there too so minimum threshold though if we have to like throw a number out there is where they're in there it's somewhere in the range of 30 one rep max right we should not be training anything below 30 of our one rep max or if you're using rp like a three out of ten so hopefully that makes sense right low loads are fine high loads are fine they're both good again as i mentioned with strength and now hypertrophy effort is dependent right we need to be working hard we need to be pushing individuals and lastly there's the endurance response right less than uh greater than less than 60 percent of one rep max 15 or more repetitions right lots and lots and lots of reps trying to really fatigue those things out and um in the look review right this is probably the shortest section in there that kind of looked at and it kind of just demonstrated that like there's a lack of dose response relationship right whether you were doing uh high loads or moderate loads light loads there wasn't a significant change in overall muscular endurance and i believe uh the lighter loads for endurance were more beneficial for like lower extremities which would make sense right you're running it's a lot of like impact and going doing a lot of air squats uh things like that's going to help build that muscular endurance uh versus doing like really heavy back squats and hoping that's going to translate to doing a 5k or doing like a really long hike and stuff like that it can there's aspects of it that will help but with resiliency and like injury prevention we're talking like muscular endurance so it's the ability to go longer in that way you can look at a powerlifter who just does powerlifting and know that they ain't doing like a 5k anytime sooner a long cycle right so those those are the main kind of areas we looked at right so again a lot a lot of talk there a lot of like little details about this lit review and what i want to specify again this conclusion right what is what is the grand arching scheme or grand arching topic uh or takeaway from this it is that what we're looking at trying to build strength strength related advantages of heavier load are dose dependent right so if we are going to have someone get stronger at the squat the deadlift or the press they better be doing heavy squats heavy deadlifts and heavy presses if we want someone to specifically improve quad strength we can do squats we can do step ups we can also do isometric leg extensions at lighter loads for higher volume and what matters here is the effort and also if you are trying to train for a specific thing you're trying to help someone improve their squat or increase strength with squat they better be squatting right specific adaptations to impose demand for strength is the greatest area that we see that that has to be specified there strength is going to improve strength hypertrophy we can use high loads we can use low loads we can use moderate loads if you want to build muscle we can use them all the one thing they mentioned though is you have to remember with low loads it's a lot more effort dependent there's going to be a higher amount of metabolic stress which can lead to just general discomfort in the muscle and some people don't like that so the the likelihood of them sticking around to doing for doing like three sets of 18 at maximal effort where they're feeling like an eight or nine out of 10 difficulty is not there the compliance might not be there high loads you need more volumes more more volume right so you can you only do two or three sets two or three reps i'm sorry at 80 90 percent which means you're probably doing seven eight nine sets to get the appropriate amount of volume to elicit the hypertrophy response and what we know is that's not fun if you've ever done 10 sets of three something really really heavy that is a miserable session and it's also hard on your on your joints on your tissues it's a lot of stress so if anything is off in your training continuum whether it be your sleep your recovery your nutrition right you're going to feel that much much more which is why we probably go with that middle moderate range where it's hard enough difficult enough but it's not going to elicit any type of ill feeling or pain discomfort etc and then lastly with endurance as i mentioned already the lighter loads are going to be more beneficial for the lower extremity musculature otherwise it's pretty much equivocal like whether you use heavy loads or lighter loads for endurance you're not going to see too significant of a difference as far as gains go in that area cool i will link the study in the comments for anyone who wants to check it out for themselves that's all i got for you this morning on this fitness athlete friday if you're doing some hypertrophy work today play with some heavy load play some moderate load play some light load if you're doing some strength work get after that barbell get heavy with it and hopefully everyone enjoys their weekend thank you for tuning in and we'll catch you next week on the pt on ice daily show take care again 19:04 OUTRO Hey, thanks for tuning in to the PT on ICE Daily show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home check out our virtual ice online mentorship program at www.ptonice.com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to ptonice.com and scroll to the bottom of the page to sign up

Jul 27, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the state of physical therapy in 2023 with regards to pay. In this episode, the question of whether pursuing a career in physical therapy is worth it is addressed. It acknowledges that individuals may have concerns about the return on investment for the time and money spent on education and training to become a physical therapist. Alan mentions that some may be discouraged by the long time it takes to see a return on their investment, as it can take 15 to 20 years to pay off the debt associated with advanced certifications or residencies. To address this concern, Alan suggests the need for better guidance for future physical therapists in terms of education and career choices. He emphasizes the importance of providing information to students considering entering the profession, as well as those already in school or practicing as physical therapists. Alan suggests informing future PTs about alternative routes to becoming a physical therapist that may be quicker and more cost-effective, such as completing prerequisites at a community college and transferring to a four-year program if necessary. The episode also highlights that not all PT schools require a bachelor's degree and that there are various paths to becoming a physical therapist. Alan suggests providing better guidance to students during observation hours or while they are still in high school or undergrad, to inform them about the available options and help them make informed decisions about their education and career paths. References Take a listen to the podcast episode or read the full transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO Good morning, happy Thursday morning. Welcome to the PT on ICE Daily Show. I hope your morning is off to a great start. I'm happy to be here today as your host. My name is Alan. I currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. Here on Thursdays we talk all things Leadership Thursday, small business ownership, practice management related to physical therapy, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. Today's Gut Check Thursday is a little kind of cardio party, bodyweight only, combination of running and some bodyweight reps. So it starts off with descending distance. So we start with a thousand meter run and then we hit 25 burpees and then we hit an 800 meter run and then we hit 50 air squats and then we hit a 600 meter run and then we hit 75 walking lunges and then we finish with a 400 meter run. So just a little bit shy of a 3k run, about a mile and three quarters of running and then some bodyweight reps as well. Probably for most folks in the 20 to 30 minute time domain, certainly those of you who are faster runners and those of you who really want to push the pace can really get after the run and those bodyweight reps and really get your heart rate up. Or this is also a great workout even though it's Gut Check Thursday, if you're feeling beat up at this point in the week to just take those runs nice and easy, take those bodyweight reps nice and easy and kind of treat it more like an active recovery piece. So that's Gut Check Thursday for this week. Courses coming your way, we have a whole bunch of courses coming up in August, the weekend of August 5th and 6th. We have Paul down in Greenville, South Carolina for dry needling lower body and then we have Alex Germano in Frederick, Maryland for Older Adult Live. The next weekend August 12th and 13th, we have Lindsay Huey here in Michigan, Rochester Hills, Michigan for extremity management. We have the Older Adult Live Summit, that's going to be all of the older adult lead faculty and TAs at Stronger Life headquarters in Lexington, Kentucky. I'm going to that course, that's going to be a great weekend. We also have out on the west coast, Justin Dunaway for Total Spine Thrust out in Bellingham, Washington. The weekend of August 19th and 20th, Lindsay Huey is again on the road with extremity management, this time in Fremont, Nebraska, right outside of Omaha. Paul will again be on the road for dry needling, this time with lower body out in Phoenix, Arizona. And then two chances at Older Adult Live, either in Bedford, Texas right outside of Dallas or in Minnetonka, Minnesota. And in the last weekend of August, August 26th and 27th, cervical spine management will be at Onward Charlotte with Jordan Berry. Older Adult Live will be in Carpinteria, California, that's out on the west coast, just north of LA for Older Adult Live. And then again, Paul will be on the road for dry needling, this time upper body, same venue the next weekend in Phoenix. So we have back to back dry needling weekends at the same venue out at Exos in Phoenix. If you're looking to get both courses knocked out in a short amount of time, you can look at those courses at the end of August. So that's what's coming your way for courses. Again, everything related to ice can be found at ptniice.com. Today's topic, the state of physical therapy 2023. Now, you might be thinking, Alan, that sounds arrogant. Who are you to inform me on the current state of physical therapy in 2023? And before we get started, I just want to say this is coming directly from our national member organization, the American Physical Therapy Association. So if you're not aware right now, the House of Delegates is going on kind of the annual meetup of state delegates from every state meeting and discussing various policy related things to physical therapy, kind of like the Congress of American Physical Therapy. And today's topic is really focused on what was announced related to both pay and residency from APTA. This was at the end of last week. So they released a publication, a series of infographics called the state of physical therapy in 2023. They talked about PT pay over the past about two decades, the past 20 years, they talked about the state of physical therapy, residency and board certification. And probably most importantly, for the first time, really ever, they released some concrete data on pay related to going through a residency and obtaining a board certification, how much extra money can you expect to make. So let's start first with the pay of it's interesting that this was released, because it doesn't bode well for physical therapy that the the information released by APTA shows pay changes from 2004 to 2021. So about a 17 year change, showing that the national average for pay in 2004 was about $68,000, and that it is now about $91,000 in 2021. They also released a breakdown based on geographical region showing a little bit more geographical specific information, especially as it relates to cost of living. But they summarize it all average it all out for that national average. Now you might be thinking Alan, that sounds great, man. 68,000 to 91,000 is significant. That's almost a $30,000 increase. But we have to step back and say, that's not how money works. That's not how economics works. That's not how math works. That if we track money across 17 years, we have to of course, adjust for inflation. And then if we do indeed adjust for inflation from 2004 to 2021, then if we were making an average of 68,000 in 2004, we should be making over $110,000 in 2021. Now, we know inflation has been crazy the past couple years. So it's probably going to be even above 110,000. But we know based on the data released that we are not meeting inflation, which is to say that nationwide on average, across the country, physical therapy pay has been flat or even negative for about the past 20 years, which is a little bit concerning that we have had so many years of essentially flat pay. Based on forecasting from 2021 forward, if we keep this same trend, physical therapist average pay in 2030 should be $135,000 a year. Now, I don't know about you, but I'm not going to hold my breath on that. I don't think it will ever get that high, even in higher cost of living areas. So that my first point is the state of pay is quite concerning that our pay in general is flat or maybe even adjusting for inflation a little bit negative. And that's something we need to be concerned about both is employees and employers of what steps can we take to reduce costs so that we can continue to improve pay and continue to at least match pay based on inflation with the folks that are working on our teams with us. On the employee side of things, this should be concerning to you because if you are below this, this means you're even more flat or possibly even more negative than the national average of if you are not getting a raise every year that is at least in line with inflation, you are technically losing money. The cost of everything in your life that costs money is more expensive. If your pay is not matching that, then you are slowly losing ground financially. So we need to know the state of physical therapy in 2023 is that pay seems to be flat, which is concerning. The second data point, the second infographic released by APTA listed out board certification specialties based on a percentage of physical therapists who hold that board certification. We know that there are 26,308 physical therapists who are board certified out of about a licensed population of 300,000 or so. The vast majority of folks who hold board certification hold a board certification in orthopedics. Almost 60% of those 26,000 people have a certification orthopedics. So right away you should be thinking, wow, very saturated market right of pursuing that OCS of pursuing that residency and board certification orthopedics is really not going to make you stand out that much when the vast majority of people who are board certified are already board certified in orthopedics. After orthopedics board certification really kind of falls off a cliff. 13% of board certified physical therapists hold board certification with their NCS in neurological physical therapy. 10% have their GCS in geriatric physical therapy. 9% are sports certified, hold their SCS. 7% pediatric certified with the PCS. Only 2% women's health certified with the WCS. And then it really falls off a cliff even more. 1% of those folks who have board certification have a cardiopulmonary board certification, the CCS, and then about half a percent each for clinical electrophysiology, the ECS, and half a percent for the OPT, the oncological physical therapy specialty. So you should know where most of us work in outpatient orthopedics is already saturated market and it's even saturated with board certification. So just know if you're thinking in your mind, man, I want to do that orthopedic residency. Man, I really want to go get that OCS. It's really going to make me stand out. You should think again based on this data. Again, based on flat pay, based on the market saturation, you should be thinking twice before you think OCS is really going to make me stand out among orthopedic clinicians. Not really, right? A lot of people already have it. That gets into my third point of what pay increase can you expect for going through your residency obtaining your board certification? This is a question many people have and now thanks to APTA we have some concrete data on it. The short answer is you shouldn't expect much of a pay increase at all. An average of $2.27 more per hour for having a board certification or about $3,500 more per year after taxes. You should know the pay bump based on certification varies greatly. When we pull back from that average and look at those individual board certifications, what stands out? Clinical electrophysiology stands out a lot. Those folks make about $27 more per hour. We know that's a very subspecialized area of physical therapy where most people don't work. Only about 100 people in the country have that board certification. It jumps up a little bit from the average. We look at the NCS, the board certification for neurological physical therapy, about $7.55 more an hour. The OCS, about $3.89 more per hour. Unfortunately, after that, the rest of the board certifications you can expect to really not make much more per hour if anything more than your base pay. For example, women's health certification, the WCS is right at baseline pay for physical therapists, which is to say you can expect to make no more money above baseline than you do with or without the certification. Now you might be thinking, well, $2.27 more per hour on average is $2.27 more per hour than not having it, so why not go through my residency? Why not go and sit for the board certification and try to get that little pay bump? It's really important to actually go through and understand how much it costs you to get to that point and really do the math to think, is it going to be worth it for me? We need to take the account of money and time that takes into going into residency and sitting for and passing your board certification. Then we look at costs. The average residency program is about a 16-course series, usually somewhere between 12 and 24 months long. About a quarter to half of those courses are going to be in-person, which means you need to travel. It's essentially the same as going to a weekend continuing education course, so you need to buy a plane ticket and get a hotel or a rental car and all that kind of stuff that comes with travel. The rest of the courses are online or virtual lab experiences, but in general, on average across all residency programs, you can expect to pay about $15,000 for that residency and tuition, and you can expect to have some travel costs as well to attend those live weekend courses. The board exam itself is also not cheap or free. It's about a $1,000 cost for the application fee, and it's $1,500 to take the test. It's about $2,500, and that assumes that everything is correct with your application and that you pass the test on the first time. If you are missing stuff for your application or you fail the test, then obviously that cost will go beyond $2,500. In a residency, you should know that most residency programs pay you about 70% of what they would pay a full-time physical therapist, although you may also be expected to carry a full clinical caseload. What does that look like? Here at Health HQ, if we were to reduce everybody's pay to 70%, that looks like folks here would make about $30,000 less per year. Across an average of an 18-month program, that means you would make about $46,000 less than you would somebody working here full-time. So when we take all these little costs, they don't seem really that bad by themselves, but they're all part of the process to work yourself towards completing that residency and to eventually take your board certification and obtain that credential after your name. What's that total cost? It's about $60,000 to $65,000. And we look at tuition for residency, travel for weekend courses, application fees, testing fees, and lost clinical revenue because you are either doing mentorship hours or otherwise you're doing unpaid stuff in the clinic that across about a 12 to 24-month span, you're missing out on about $65,000. Some of that is lost revenue and some of that is money you have to directly pay. So now when we zoom out and think, if I make $3,500 extra per year having this board certification, how do I know it's worth it? Well, when we do the math, you need to understand that it's going to take you about 18 and a half years to break even on that investment. That an average increase of pay of $3,500 per year with a cost of a combination of lost revenue and paying into tuition and travel and fees of about $65,000, it's going to take you about 18 and a half years to break even and then finally begin to move ahead and quote unquote profit off that initial investment. So that's quite staggering, right? I'm 37 of thinking if I went to my wife and said, hey, I want to spend $65,000, I want to be gone from home even more than I already am. By the way, this investment that we're going to make of time and money will start paying it off to me when I'm 55 years old. My wife would be very upset if I went and said that to her. And I imagine a lot of you would be in the same boat of that is an extremely long time to see some sort of return on that investment. So this brings me to my last point here of the question that many folks have, whether you are watching this, listening to this, and you're thinking about entering the profession, whether you're already in school or whether you're already a member of the profession of the answer to the question of physical therapy, is it worth it, worth it? How do we know that? Where does our role play already as members of the profession? Well, we should probably do a lot better job at guiding future PTs of when we have students in the clinic who are doing observation hours, who are maybe still in undergrad or maybe even in high school of really guiding them as much as we can and letting them know, yes, it's possible to become a physical therapist, it's possible to do it in a manner that's quicker and cheaper, that there are many different routes to become a physical therapist and that if you are truly looking to get ahead in life financially and you want to have a rewarding career as a physical therapist, it's probably going to look like some combination of doing most of your prereqs at a community college, getting as many hours done in a community college as you can, get it done cheap, get it done fast, maybe even be able to work a little bit and only transfer to a four-year school if you need to take classes at that four-year program or your PT program requires a bachelor's. There are a lot of PT schools that do not require a bachelor's. They simply require 80 to 100 credits of prereq work and in some cases you can get most or all of that done at a community college. That's going to get you to PT school a lot faster and cheaper than a four-year program, especially if you don't need that bachelor's degree. And then looking at PT schools, we need to do a better job at directing these future students towards programs that maybe offer a hybrid or a flipped classroom model where they can do the majority of their didactic work online and meet up in person less often to be able to do in-person hands-on stuff that needs to be done in a lab setting. Again, the goal there is to get through PT school faster and cheaper than a traditional model so that when we look at the traditional route through PT school of a four-year or maybe even a five-year undergrad program to get your prereqs and a three-year grad school experience of a lot of folks coming out a hundred to two hundred thousand dollars in debt seven or eight years of school. That looks like a lot when we know that there are faster, cheaper routes that maybe we can get community college done in three years and maybe we can get PT school done in two years. So we enter the workforce sooner and hopefully we did it cheaper so we have less student loan debt as we start to work. That is the way we need to talk to current PT or sorry future PTs. Speaking to current PTs, the education really needs to be on don't fall for the trap. The data is here, it's clear, it's from the organization that's selling you the program of don't get caught on their hamster wheel. Don't get caught in a lifetime of school of a four or five-year undergrad program, a three-year PT school program, a two-year residency program, a five-year fellowship program where you might spend 10 to 15 years in school. You might have five hundred thousand dollars in student loan or credit card debt before you actually start to grind away at that debt, making money even if yes you will make more money per hour of it will probably take you the majority of your career to pay off that investment. So don't get caught on that hamster wheel. What should you do instead? Well we're biased but we think you should pursue meaningful education that yes improves your clinical reasoning but also lets you expose yourself to new clinical subspecialties that lets you attract new and different patients to your clinic to serve them well so they keep coming back so your caseload is fuller, you're having more fun in the clinic, and hopefully along the way you're making more money while not having this giant burden of debt hanging against your shoulder that you need to pay off. So where's the state of physical therapy in 2023? Pay is flat or negative. The pay for increased subspecialties, board certification, letters after your name does not seem to be there and what little bit is there might take you the majority of your career to actually start to pay off and see a return on your investment. Help guide future PTs on better ways to make their way to and through PT school and if you're a current PT just know that if you're thinking a board certification, a residency is really going to set me apart, there's not a lot of people especially in orthopedics that's not the case and just know that it's going to take a very long time to pay off that investment potentially somewhere between 15 to 20 years if you're still thinking about pursuing that advanced certification, that advanced residency. So I hope this helps. This is great information to have. We'll post links directly to what we share from APTA. We'll post those both in the show notes on the podcast as well in the comments here on Instagram. So we'd love to hear comments and discussion about this. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you're going to be at a live course this weekend, I hope you have a fantastic time. Have a good weekend. Bye everybody.

Jul 25, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses carrying as a valuable skill unique to humans as hunter-gatherers. She points out that humans, with their opposable thumbs, are well-suited to carry objects for long distances and extended periods. However, Lindsey also notes that this skill is being lost in modern society due to sedentary lifestyles and technological advancements. Lindsey references Michael Easter's book, "Comfort Crisis," which challenges readers to step outside their comfort zones and recognize the importance of carrying as a skill. She suggests that carrying should be trained and incorporated into various healthcare professions, regardless of the specific patient population being treated. The episode highlights the benefits of training carries. It mentions that carrying trains aerobic tolerance and grip strength, and it is a primary functional skill for picking up and transporting objects over long distances. Lindsey encourages listeners to consider how incorporating carries into their practice can lead to long-lasting functional changes for their patients, enabling them to carry objects without assistance and without needing frequent breaks. Additionally, the episode emphasizes that training carries not only benefits specific body parts like the trunk, shoulders, and spine but also the entire system. The act of walking while carrying is described as the "magic" of training carries, as it trains the cardiovascular system, respiratory system, and central nervous system. The episode concludes by stating that not training carries means missing out on a unique opportunity, regardless of the specific issue being treated (upper quarter, spine, or lower quarter). Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 LINDSEY HUGHEY Good morning, PT on Ice Daily Show. How is it going? I am Dr. Lindsay Hughey. I will be your host this morning. We are going to chat all things Cary today. But before I do, I would love to just tell you a little bit about some courses that the Extremity Management Division has coming up. There are a host of opportunities. So just this upcoming weekend, I'll be in Madison right before the CrossFit Games. We're so excited to cheer Kelly on and her team, representing her team this morning. My shirt just came in. We're so pumped for that. But if there are a couple spots, like one or two left, so if you're on the fence, sign up now because those spots will probably go. But moving throughout the summer, we have lots of opportunity. So the next opportunity will be August 12 and 13, Rochester Hills, Michigan. There's lots of spots left in there. That's one of our more empty courses. So sign up for that. Because we're not in Nebraska, the following weekend, the 19th and 20th, is actually almost stacked. I don't think there are any spots left, maybe just a couple. So then your next opportunity would be in September with Mark. And there's lots of opportunities to jump in there in Amarillo, Texas. And that is September 9 and 10. He would love to see you there. And then September 16, 17. So we're moving more into the fall season. Cincinnati, Ohio. Mark has some spots there. Take a look on PT on ICE.com. If you're looking for a little bit later in the year, there are opportunities through the winter to join us. But we're not putting any more courses on the books for this year. So 2023. So opportunities are dwindling. But if you want to learn about met best management in your dosage strategies and about tendinopathy and how to load the upper and lower quarter, we would love to have you join us. All right. Today's topic I mentioned is carrying, right? And if you've been to our extrogyn management course, you know that carry lab is a big fun part of the end of day one. And then if you've been to MMOA, you know, carries are really important there as well. And most of our divisions at some point probably talk about the value of carrying. And a little bit about the background that got me inspired to chat about the value of training carries in our patient. It's really from a book I just recently read by Michael Easter Comfort Crisis. It's really challenged me to think about kind of how the evolution of technology and advancement in our society has really evolved away some of our valuable apex predator skills because we have more sedentary lifestyles and just our job demands and our ability to do that. And so we're losing a skill that's really unique to us as hunter gatherers. And because we have the opposable thumb, we are like the prime species to carry objects for long distances for a long time. And we aren't training ourselves in that way, even though we are the most well suited species to do so. And that book, dive into that if you're interested in it because it really challenged my thinking about everything we do in our world today is pretty comfortable. And the book really challenges you to get outside of your comfort. I'd love us to challenge us as a profession, no matter if you treat pediatrics, older adults, summer and summer. In the middle, treat in acute care, treat in home care, treat in outpatient orthopedics, training fitness athletes that carry is a skill that needs to be trained no matter what whether you're seeing upper or lower quarter, or whether you're seeing someone with a spine condition. Let's not keep losing this skill. Even I want you to think before I kind of dive into the three reasons why I think we don't want to lose training carries and their importance is you can even see it in the objects we do carry right like our book bag. Even I want you to think before I kind of dive into the three reasons why I think we don't want to lose training carries and their importance is you can even see it in the objects we do carry right like our book bags, or if you travel a lot your suitcases we even have roller apparatuses to make carrying easier. In our clinics, we need to make carrying harder. One of the three things and value that carries bring our number one from an extremity management perspective is it trains the shoulder elbow wrist hand, right, to be functional to work in this locked out engaged fashion. We have tons of evidence in the relationship between grip strength and mortality. If you have a weak grip, your mortality is poor. We even see it likened to associations with tons of metabolic diseases, and specifically frailty in our older adults. We need to train grip strength, because of that strength that it gives our grip, but that it trains our shoulder elbow wrist hand as well. But not only does it just train the upper quarter. We are actually training the spine, we are training the spine to hold the line as Mitch Babcock would say, right, because it's not just about locking out and training our shoulder elbow wrist hand in a stacked fashion, but we're actually challenging the trunk for those watching on YouTube or on Instagram I'm kind of, if we do this lateral lean we're not getting the benefit right, it's a stack trunk the whole time right while we load. This helps to be not only train the spine to take on load and asymmetrical load right if we're holding it in one side. But it also can be protective of our spine because we teach our spine how to light up right all of our lumbar stabilizers. And if you were to pick up an object that was pretty heavy right now, you will notice that it actually trains the lower body as well right it demands that the glutes the quads the hamstrings all kick in rather than this lazy like me unlocked position you have to actually stack not only the trunk, but your lower body to hold and carry well. It trains the entire system, the whole system gets the goods when we train carries. But guess what the magic isn't just in training shoulder elbow wrist hand and in training the spine. The magic is in the walk, so we don't just have someone carry and stand there. Right. If we think back to hunter gatherer we would carry over long long distances right to bring that meat back home. We need to train folks to carry and hold an object locked out and move and walk so the magic is actually getting our folks moving with weight. This trains our cardiovascular system. This trains our respiratory system and even our CNS right to take on load and be able to go for long durations. If you aren't draining carries you are missing out on a unique opportunity. It doesn't matter if it's an upper quarter issue a spine issue even a lower quarter issue. You need to be training your carries in your folks that are in your clinic or in the hospital, because this is a primary functional skill to be able to pick up objects and carry them for long distances. It trains aerobic tolerance, it trains grip strength and ability. Let's not let this skill be lost to our species. Let's not let this one evolve out. I want you to think about today how you can use carries in the clinic and kind of reflect on what if we got our humans, our patients carrying more for longer. Think of the healthy long lasting functional changes we could make, but not just functional in the ability to carry their objects without needing help from a family member, right or needing to take multiple respites. But I want you to think about mortality, right. We need clear links to grip strength and mortality. Offensive extremity care across the lifespan, young to old requires carries. I hope you'll consider putting this in your plan of care this week. Thank you for your time to join me on this short and sweet PT on Ice. Take care folks. Happy Tuesday. 08:40 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Jul 24, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses that PTs need to be aware of the signs and symptoms of preeclampsia in pregnant women. Preeclampsia is a high blood pressure-related condition that typically occurs after the 20th week of pregnancy. It can also manifest during delivery and postpartum, although it is less common in the postpartum period. The three main symptoms of preeclampsia are swelling of the face and hands, persistent headaches, and pain in the upper right abdomen or right shoulder. PTs should be familiar with these symptoms and know when to refer their patients for further evaluation or treatment. It is crucial for PTs to monitor vital signs, especially in the postpartum period, as they may be the first healthcare professionals to detect an increase in blood pressure. Preeclampsia is the leading cause of mortality in pregnant women, so early detection and management are essential to prevent it from progressing into a life-threatening condition. While PTs may not be responsible for ordering tests or directly managing preeclampsia, they should be aware of the condition and its potential impact on their patients. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show. 01:27 RACHEL MOORE All right. Good morning, PT on ICE Daily Show. It is Monday morning. I am here with the ICE Pelvic Division here to chat with you guys this morning about preeclampsia. This is a topic that is actually really near and dear to my own heart because I had preeclampsia with both of my pregnancies. So it's a really interesting topic. There's been a lot of kind of conversation about this topic in the prenatal space lately because there's a new test that just came out recently. We're going to chat about that here in a bit. Before we dive in, I want to kick this off going over our upcoming courses for the pelvic division. We've got two live courses coming up soon. We've got Denver, Colorado this upcoming weekend with Alexis Morgan and April Dominic. That is the 29th, 30th, and 31st, Friday to Sunday, this upcoming weekend. And then we also have in September in Scottsdale, Arizona, a live course coming up as well. Our live courses are two-day courses. We talk about all kinds of stuff from pregnancy to postpartum. We are in lab a majority of the time. We're practicing skills. We're going over these movements. We're talking about scaling and modifying. We also do the internal assessment and we do the internal assessment not only in supine but also in standing. So it's a really great way to dive into the internal side of pelvic floor if that's not something you're already doing or maybe learn a new way to do pelvic floor assessments if you are already a pelvic floor PT. It's a super fun course. Hop in one of those courses coming up. We've got several other ones listed online on the website. We've got at least one a month until the end of the year. So we're going to be cruising through. Hope to see you guys on the road. Let's talk about preeclampsia. So what is preeclampsia first? That's kind of the first thing we need to talk about. Preeclampsia is a high blood pressure related condition that typically begins any time after the 20th week of pregnancy. It can happen in pregnancy. It can happen during delivery and it can also happen postpartum. It is less common to happen postpartum, but just because it is less common does not mean that it doesn't happen and that is something we need to be aware of, especially if you're in the prenatal space seeing postpartum women. Personally, before we dive in, my story, I had postpartum preeclampsia with my daughter and it wasn't caught until I was two weeks postpartum and I say wasn't caught until I was really fortunate that it even was because I went to a midwife for my delivery and I had a two week postpartum visit and when I went in my blood pressure was like 198 over 110 and she immediately sent me downstairs to the emergency room and I had no idea that there was even anything wrong. I didn't know that I was feeling bad. I thought that it was just kind of the norm for being postpartum and so that's how we caught it in the first pregnancy. And then my second kiddo, we knew that it was something to be on the lookout for and sure enough within 72 hours of my delivery, I was fine and then it was like a truck hit and I had high blood pressure. So something to keep on your radar. It can develop into a life threatening condition. So preeclampsia itself is not necessarily life threatening. What is life threatening is eclampsia, which is the progression of preeclampsia and that is a condition that is characterized by seizures and strokes and it can also progress into help syndrome, which means the abbreviation is hemolysis, elevated liver enzymes and low platelet count. Essentially this is a condition where your red blood cells are damaged and interferes with blood clotting and typically your liver is involved as well. So your liver starts kind of going into failure essentially. Eclampsia and help are both medical emergencies. So we want to be catching preeclampsia when we can so that we can prevent that sequelae into these life threatening conditions. The way that preeclampsia is diagnosed is typically with repeat high blood pressure readings and there's also a urine test that can be done to check for protein in the urine. However, you don't have to have protein in the urine in order to be diagnosed. So this is something that used to be kind of together that you had to have both, but what things have kind of shaken out over the years is that you can have preeclampsia, you can have the high blood pressures, but not necessarily progress to the high protein in the urine. So it's not necessarily something that is utilized as a gold standard. You have to have this thing in order to be diagnosed anymore. Typically if somebody is diagnosed with preeclampsia or they're in their second pregnancy or subsequent pregnancies and they know that they had preeclampsia earlier on, a lot of OBs will prescribe taking baby aspirin during pregnancy. That's not obviously within our scope to suggest, but just something to kind of keep in mind that there are things that can be done quote unquote. Statistically this preeclampsia affects one in 25 pregnancies. It is the leading cause of maternal mortality worldwide and along with a lot of other prenatal health conditions. This affects women of color, particularly black women, significantly more than white women, 60% more likely to develop preeclampsia and that is largely due to the disparities in healthcare for women of color. It's really unclear who gets preeclampsia. So there's a long list of risk factors which we'll chat through, but you can have none of these and you can still get preeclampsia. You can have all of these and not get preeclampsia. You can do all the right things and still get preeclampsia and that's something that can be really tough, particularly if you're treating athletes or people who are in a more healthy lifestyle who are saying like, well I exercised, I ate healthy, I did all of these things and then I still got it, can feel like I did something wrong or like a failure almost. But preeclampsia is a condition that's really not well understood. We're learning a lot more about it as time has gone on. However, there's just not a lot of like real true understanding about what is the cause of preeclampsia. So some of the things that put you in the higher risk category would be having a previous pregnancy with preeclampsia, carrying multiples, so twins, triplets, so on and so forth, chronic hypertension prior to pregnancy, having kidney disease or diabetes, and then any autoimmune condition. All of those are going to put you in the higher risk category for developing preeclampsia, not to say that yes, you are going to get it, but a higher risk. Moderate risk for developing preeclampsia would be a first time pregnancy. So either first time pregnancy puts you moderate risk, previous pregnancy with preeclampsia puts you high risk. BMI over 30, family history of preeclampsia, maternal age advanced quote unquote, so above 35 years of age. IVF can also increase the risk of preeclampsia development and then complications in previous pregnancies. Not even necessarily just preeclampsia, but just complications in general. There's a lot of discussion about what is the reason people get preeclampsia and what it's really boiled down to based on what we know and what we've learned about preeclampsia over the years is that it's most likely related to the structure of the placenta and the creation of blood vessels in early pregnancy. So there's not a lot that quote unquote can be done later in pregnancy necessarily. It's something that is kind of determined and laid out earlier on and then presents itself later in pregnancy. There's really no great way to prevent it. Like I said, you can do all the right things. You can check all the boxes and it can still come up at that later or at those later stages of pregnancy. We really advocate at ICE for getting our postpartum patients in early postpartum for that first visit. So within like two weeks of delivery, kind of touching base, being that healthcare checkpoint because a lot of women aren't getting that from their healthcare providers potentially. And this is a really important thing for us to keep in mind when we're screening our patients postpartum. Typically blood pressure is going to peak within three to six days after delivery. So if you're seeing your patient within the first week, that would be fantastic. It is so important to take vitals. It's always important to take vitals, but especially in the postpartum client, they may have no idea that they're feeling bad or that their blood pressure is high. You might be the first person that watches or sees this upwards trend of blood pressure. So something that's really important. We can be the first touch point within the healthcare system of picking this up if they're not going to a physician earlier on or a birth care provider earlier on in that postpartum period. So what are the biggest signs and symptoms of preeclampsia and how does it relate to our job as PTs? There's three big symptoms that I see with preeclampsia that really kind of like light up. So that could be something musculoskeletal or it could be something that we could have our hands on the pot and correcting or it could not. The top three that I'm thinking are going to be swelling of face and hands or swelling in general. A lot of times we see it in the lower legs in pregnancy, a headache that won't go away and then pain in the upper right abdomen or in the upper or the right shoulder. So that's going to be up in this area here. If you're not, if you're listening, it's kind of the bottom side under part of rib cage, right upper quadrant pain and referring up into the shoulder. The other three symptoms that are really larger for symptoms are going to be nausea and vomiting, especially in later pregnancy. So if there's somebody that didn't have nausea and vomiting and then all of a sudden they're developing it, that would be kind of a red flag. A sudden weight gain. Same thing we know in the third trimester, baby is growing rapidly and as such mom is going to be gaining weight, but a significant sudden weight gain would be a big red flag there. Difficulty breathing is always going to be something that we want to kick our moms over to their healthcare providers for sure. If it's just like I'm out of breath when I stand up and then it goes away, that's one thing. But if it's like a significant shortness of breath, that's a problem. And then vision changes. Vision changes are going to be one of the biggest things to help differentiate for sure. Are these quote unquote normal pregnancy changes or is this something different? Because typically we don't see people seeing floaters or seeing spots or having major vision changes in any other situation in pregnancy. Whereas we could maybe see them having some discomfort in their abdomen or maybe see them having headaches. That's one factor that is really going to point us towards like, okay, you have this thing and vision changes, it's time to go to your doctor and get looked at. So let's talk about those big three things that I said at the beginning. Swelling, headaches and upper abdomen pain. Our job as PTs, right, is to help with musculoskeletal problems. We see people with swelling. We help people manage inflammation and swelling. Even in the pregnancy space when we have patients coming in with a lot of like leg swelling and things like that or varicosities, we help a lot with that. We talk to people about that muscle pumping action and utilizing the muscles around their cardio or their venous system to help facilitate that upwards flow of blood and fluid. And so we know that we can impact this. However, if we're seeing this progress into like hands and face, that would be a sign that that might not be your typical prenatal swelling. And that's something that needs to be referred out. That upper abdominal pain, if you have somebody come in and tell you like, oh, I have, like baby's just growing a lot. I've had, I have pain in my upper abdomen. Typically they're not going to tell you I have right upper quadrant pain. A lot of the times they think it's a rib. So they'll say like, oh yeah, my rib hurts really bad or oh, it's my like my ligaments or my abs are hurting really bad. We want to follow that up with a lot of questions. Some of the biggest questions that we want to know, is it both sides or is it just the right side? So if it's both sides, that doesn't necessarily mean that there might not be something going on, but it's less likely if it versus if it's purely just that right side consistently. We want to know if it's related to anything timing wise. So is it worse after you eat? Is it worse or better after you exercise? Is it relieved by exercise or stretching? So maybe you're a little uncomfortable and then you start moving and your tissues start warming up and then you feel better versus I work out and nothing changes at all. I stretch and nothing changes at all. No position that I get into makes this better or worse. True musculoskeletal pain is going to behave differently than pain that is created by a referred pain from an organ, which is what that right upper quadrant pain in preeclampsia is. So those are some big follow up questions we need to be asking. A lot of pregnant women, especially later in pregnancy, just assume that aches and pains and stretching discomfort and things like that are normal. And to an extent we expect it, but if we hear that right upper quadrant or like my shoulder, my right shoulder, my right neck area, that should be a sign for us to start looking at these other factors as well and just make sure that nothing is being missed. On the flip side of pregnancy, in the postpartum timeline, a lot of the signs of preeclampsia can be brushed aside because of that like fatigue and exhaustion, lack of sleep, all of the things that come along with having a newborn. So I see this a lot, especially in first time moms where any type of symptom for maybe not necessarily even just preeclampsia, but symptoms of anything are just brushed under the rug as normal because they know like, well, I know I'm not going to feel 100%. And so it's probably fine or it's probably normal. We want to make sure that we're educating our patients of red flags to look for when we're seeing them prenatally so that when they're in their early postpartum period, they know what to look for and what they need to be calling their doctors about or following up on to make sure that things don't progress into more serious situations and conditions. Things like blurred vision or maybe not seeing spots, but just like feeling a little foggy headaches or just like that general feeling of like unwell can really be brushed aside. And so we want to make sure we're telling them if you're seeing vision changes, call your doctor. If your headache is there and it's just not going away, no matter how much water you drink, if you take a nap, if you stretch, none of that's helping it. Just go ahead and check in and see how that's going. The education that we can provide prenatally to make sure that our patients are empowered in the postpartum period can be incredibly important in making sure that things are caught, especially in that timeline because we know in pregnancy, especially later pregnancy, mom is going to be going in for frequent visits to their birth care provider, especially like 35, 36 weeks on those are weekly visits. It's pretty easy, quote unquote, to catch things that are changing. In this case, a lot of women are only seeing their physicians or their OBs or their midwives at that six week point. Maybe they have a telehealth visit touch point in there in the middle, but most cases people are not going to their doctor until after that six week point. And we need to make sure that they know what the red flags are, not just for preeclampsia, really for all of the things, but especially for this episode for preeclampsia so that they know if they need to go in and be seen for sure. Most women are not taking their blood pressure at home every day. And so that's something that we can really talk to them about ahead of time. Like, hey, just in the morning when you wake up, take your blood pressure, throw a cuff on and just track it for the first couple of weeks and see if there's any changes. That information can be really valuable if she is also feeling kind of crummy. There's a new test that just came out. The FDA just approved it recently. It's been pretty highly talked about for some pluses and minuses. It's a blood test that measures protein, two proteins that are put out in the case of preeclampsia. And it's essentially a predictive test. So this test is done between 25 to 23 to 35 weeks pregnancy. And it's job is 96% validity of predicting if somebody is going to develop into severe preeclampsia. So the test that was done in order for this test to get preapproval was taking women that already had hypertension or had low severity, quote unquote, preeclampsia, and they followed them and the test could predict within two weeks if they were going to progress into severe preeclampsia. There's some discussion about this test because on one hand, people that are criticizing it are saying it's just another test that costs money, right? That could be fear inducing in people potentially. It's not 100% guarantee that you're going to get severe preeclampsia. And the biggest discussion about this is what are you going to change clinically that you weren't already doing? So if you have somebody who's coming in, they have high blood pressure already, which would be an indication that they could benefit from this test to know, you're probably already keeping an eye and managing that patient a certain way and knowing whether or not they're going to progress to severe preeclampsia within two weeks isn't necessarily going to change the protocols that you're already doing for that hypertension. Same thing with a low severity preeclampsia. If you know somebody has low severity preeclampsia, it's likely not going to change anything other than you're going to be on the lookout regardless, which you would have been anyway. On the flip side, people that are really excited about this test are really talking a lot about the benefits of it clinically, especially in areas with disparities in healthcare. So again, we talked earlier about black women being 60% more likely to develop preeclampsia and a lot of times that comes from poor care and not being believed when they're talking about their symptoms. And so this test gives the opportunity to show like, this is a real pain, this is a real thing and it could be developing into a life threatening condition and it needs to be addressed. So that's one benefit. Another benefit is if you are somebody that's in like a rural area or an area that doesn't have great access to resources that maybe could be life saving for mom or baby, it's an opportunity to transfer somebody to a hospital system that is better equipped to handle a more severe preeclampsia patient rather than a smaller hospital that maybe doesn't have like a NICU or maybe doesn't have the type of care level that somebody with a more severe medical condition would potentially need. The other thing in the prenatal space is women that are coming in with some symptoms or discomfort potentially shortening their hospital stay. If the physicians know, okay, they have low severity preeclampsia, we did this test, they're not likely to progress into severe preeclampsia. They don't need high doses of steroids for baby's lungs to be developed in order for an early delivery. They're probably going to be fine just continuing on their pregnancy with close monitoring. And so that's something that hopefully could impact shorter hospital stays, allowing mom to get moving going from there as far as the impact on their health and their outcomes in the hospital. So there's some pluses and minuses. It's a new test. It was just approved by the FDA recently. So it's something that we're going to see kind of shake out across the prenatal and postpartum space. It'll be interesting to see how much it is offered and if it becomes kind of like a standard of care versus if it is something that people just pay extra and go above and beyond for. It'll be really interesting. Doesn't necessarily affect our role as PTs in the sense that we're not the ones that are going to be ordering that test clearly. But it's just something that we need to keep an eye on and be aware of as something that can be potentially done for our patients or something that our patients may be having. To wrap things up, preeclampsia, number one mortality or highest cause of mortality in pregnant women, high blood pressure condition that can progress into a life threatening condition if not addressed and caught early or addressed and caught whether or not that is through delivery or whatever other ways that they manage it. As PTs, our job is going to be to know what the signs and symptoms are and know when it is a time to send out to be done a more close workup on those symptoms. Those are going to be things like swelling of the hands and face, right upper quadrant pain, a headache that won't go away with any type of our typical quote unquote management of those symptoms, nausea and vomiting that comes out of nowhere in that third trimester, sudden weight gain, difficulty breathing and seeing spots. If your patients are talking to you about these symptoms, tell them to go follow up with their provider. And on the flip side of that, you talk to your patients about those symptoms if you're seeing them prenatally so they know what the red flags are for postpartum, they know what to look for so that in that six weeks that they are potentially not having a visit with a healthcare provider, they're not alone on an island, give them that buoy of information so that they know if they need to address it. That's all I have for you guys today on the postpartum and prenatal preeclampsia episode of Ice Pelvic. This is a topic that we do talk a little bit about in our courses. So if you want to learn more, dive into our courses, we talk about when maybe exercise is indicated or contraindicated. There's a lot of new information about that where some of the old school things that we thought maybe are not actually accurate or don't benefit our patients to put them on restrictions. We can absolutely dive into that more in our courses. So sign up for our online course, sign up for our live course, come hang out with us on the road. I hope you guys have a fantastic Monday and I will see you guys around. 25:08 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 21, 2023

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long. In today's episode, Zach shares his favorite exercises for low back strengthening, including the reverse hyperextension, heavy horizontal rowing, and Jefferson curls. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:25 ZACH LONG Welcome to the PT on ICE Daily Show here on the Best Day of the Week on the podcast. It is Fitness Athlete Friday. I'm excited to be with you here today. I'm Zach Long. I'm one of the lead faculty members inside of our fitness athlete division. And today we're going to talk about a few of my favorite exercises for low back strength. Before we do that, two pieces to get out of the way. Number one, congratulations Joe Hanisko, one of our faculty members here inside the fitness athlete division. He and his wife Aubrey just had their first child, so congrats Joe. Second, upcoming courses we have inside the fitness athlete division. Advanced Concepts, eight weeks online, starts up September 17th. That always sells out, so if you've already taken essentials and you want to move on and take advance, you need to go sign up for that really soon because it will sell out several weeks in advance. Upcoming live courses we have September, we're in Bismarck, North Dakota, as well as Newark, California. October, just outside of Seattle. In November, we're in Hoover, so look forward to seeing you on the road. Or in Advanced Concepts. So let's jump into today's topic and that's bulletproof back exercises. So one thing that we talk about a lot in so many of our courses, but especially in Fitness Athlete Live, is that there's just this principle of rehabilitation. Like when a tissue is injured, what do we strengthen? We strengthen that tissue, right? If you're dealing with Achilles tendinopathy, we're doing Achilles tendon loading. If you're dealing with patellofemoral pain, we're getting your quads and your glutes really strong. We strengthen the tissues around what is injured. That's a principle of rehab. But all of a sudden when we start talking about low back pain, that principle like goes out of the window. And so much of our profession then says, no, we're not going to get the back strong. Instead, we're going to worry about the glutes not activating. We're going to worry about psoas tightness. We're going to worry about transversus abdominis activation. And while I'm not saying any of that is not completely irrelevant, I'm just saying that a principle of rehab is that we strengthen the area that is injured. So when somebody has back pain, we should probably make that back a little bit stronger. And so I want to share five of my favorite exercises for doing that today. And number one for back strength is going to be the reverse hyperextension. So this is a piece of equipment that you don't see a lot of physical therapy clinics. So I'm going to describe it for those of you that aren't familiar. Imagine you have a high-low table that goes up about five feet off the ground. And it's got this nice cushiony pad on top of the table. And you lay your torso on that with your legs hanging vertically off of that. And then you lift your legs up. So it's essentially just doing like a Romanian deadlift, except your upper body's horizontal to the ground and locked in place, and you're lifting your legs up. So there's reverse hyper machines, but this can also be done a number of different ways. I have patients doing it off of beds, off of incline benches, over exercise balls, over a barbell in J-cups on a rack, over a glute ham developer. A lot of different ways to do reverse hypers. But they are a phenomenal exercise for building a little bit of low back strength and endurance. And I'd say this is probably one of my most frequently prescribed low back exercises, because it works so well, even on your highly irritable patients, so frequently they can do this and get a huge pump into those muscles around their lower back, which of course is going to help tremendously out with pain and with working through a little bit of inflammation and getting fluids moving a little bit. So really make sure you check out reverse hypers. If you've never done those before, I would highly encourage you to take a look at different reverse hyper variations. You can find some videos of that on my YouTube or my Instagram if you need some ideas on how to do that, or you can just shoot me a message and I'll send you that video. But it is a great exercise to start with. Exercise number two, any form of heavy rows. I think we very frequently think of bent over rows and other movements like that as an upper back or mid back exercise, but they're so underrated in terms of what the low back has to do in terms of holding an isometric contraction. So I love really heavy rows. So bent over rows or really, really, really love pin lay rows. So if you're not familiar with pin lay rows, here's another great exercise for you to go train and explore within your own personal fitness journey. So barbells on the ground with bumper plates on it, you hinge over quite a bit to grab the bar and you're doing a row with every time the bar goes all the way back down to the ground. And what I really focus on with my pin lay rows is that my lumbar spine stays locked in place. I let my thoracic spine round and extend a little bit as I row. And that's just a phenomenal exercise to build total spine strength. So really for sure, check out pin lay rows if you've never done those before. Next movement is a series of movements actually. So that's anything off of a glute ham developer. Not very many physical therapy clinics have a glute ham developer, but a lot of gyms do. And so a glute ham developer is an exercise, a piece of exercise equipment that has a lot of different potential variations that you can do. But really I like to do tons of isometric holds off of the glute ham developer. So the glute ham developer has this little foot plate. So you lock your feet in place and then your thighs into this other pad. And then your upper body is free hanging out here. So you can hold your upper body parallel to the ground and you're now going to do a really good isometric of your low back, your glutes, your hamstrings to hold that global extension position. But you can then do different things like hold some light dumbbells and do rows to make that a little bit more challenging. You could turn it into a hinge movement by doing back or hip extensions, either loaded or unloaded, but so many different variations of exercises that can be done off a glute ham developer to load the post of your chain and the back specifically that you really want to make sure you check those things out. Up next, Jefferson curls. So Jefferson curls tend to get physical therapists a little bit fired up because everybody seems to be on one side of the equation or the other. So Jefferson curls, where we work on segmentally flexing the spine and taking the spine from an upright position, going into global flexion with light load behind it. I love Jefferson curls because so frequently in our culture, people are absolutely terrified of flexing their spine, especially with any load. And so the lightly load that and make people feel more confident that their back can get out of neutral position and not explode. Like we see Instagram infographics happen all the time by unfortunate influencers. The Jefferson curl is a great way to build confidence that the spine can be flexed. I love this to build a little bit of submaximal strength out of positioning. I love it also for my athletes that have some neural tension. We've worked through so much of that neural tension, but I know they're going back to a sport like CrossFit where they're going to be doing a ton of hinging motion. I like to use the Jefferson curl as the in range, make sure we completely clear out any of that stiffness that might be remaining. So that's exercise number four. And you all know exercise number five, last exercise. If you've been to an ice course, whether this is total spine thrust, modern management of older adult, lumbar spine management, or fitness athlete, you know what the next exercise is. And that is the freaking dead left because that is the best exercise that has ever been invented to build low back strength as well as human's confidence in their body. It is shocking and amazing how often somebody pulls a weight off the ground that they didn't know that they could do. They didn't know that they were strong enough to do it, or they didn't know that their back wasn't so fragile that they couldn't pick up that 95 pound bar, that 125 pound bar, that 225 pound bar. They pick it up and all of a sudden, their chest pops up a little bit. They walk out of the clinic a couple inches taller because they're so much more confident in their body when they learn how to pull a heavy weight off the ground. And it's something that they weren't expecting. Dead lifts can be conventional dead lifts, sumo dead lifts. They can be kettlebell dead lifts, so many different options for it, but get your people pulling heavy weights off the ground because that builds a lot of confidence in the human body. One of our favorite research articles from that comes out from Taglia Theory and colleagues in 2020. So they looked at individuals doing low load motor control exercises and manual therapy compared to a group that did heavy loading. So they're doing squats and dead lifts and a ton of other exercises that load the spine heavy. And what they actually found was that the heavy group, the group that were getting after it lifting heavy loads, had significantly reduced levels of kinesiophobia, which when it comes to low back pain, we all know that's the key. Our patients, after they've had an experience of low back pain, are terrified of their backs. And anything we can do that reduces kinesiophobia and makes them feel more confident is really important. And in that Taglia Theory and colleagues article in 2020, low load motor control exercises, your bird dogs, your clam shells, those sorts of movements, they don't make people less fearful of their back, although they do help with their pain. Heavy loading helps with pain and makes people more confident in their body. And that's what it's all about. So five different exercises there. We've got reverse hypers, we've got heavy rows, we've got glute ham developer work, Jefferson curls, and the greatest exercise of all, the dead lift to make your patients stronger in their low back, more confident in their low back, and getting back to doing the things that they love. So I hope you enjoy this episode. As always, reach out to us if you have ideas for future topics you'd love to hear of, and we look forward to seeing you on the road. Have a great weekend, everybody. 11:12 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 20, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall introduces the concept of servant leadership in the workplace, discusses the four main characteristics of servant leaders, research supporting the use of servant leadersihp at work, and the intersection of "burnout" & lack of servant leadership at work. Take a listen to today's episode or check out the transcription below. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ALAN FREDENDALL Good morning, PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on the Daily Show here on Leadership Thursday. We talk all things leadership, small business management, practice ownership, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday. I tested this this past Tuesday. Pretty simple, but doesn't mean it's easy. Ten rounds for time, ten calories on a fan bike, that assault bike or eco bike for gentlemen and seven calories for ladies, followed by ten pull ups. So the challenge here is going to be to keep that bike as fast as you can while trying as big of a sets of pull ups as you possibly can. Just a warning, that's a lot of pull ups. If you're not used to that much pull up volume, surely you can grind through this and get through that many pull ups, but it's probably going to leave you quite beat up. I know myself today, my lats, my biceps a little bit are sore. So if you're not used to that kind of volume, maybe scale that down, maybe eight rounds for time, maybe seven rounds for time, maybe even five or six rounds for time. Maybe keep the calories on the bike, but cut the pull ups in half, maybe ten, seven cows on the bike, five pull ups, ten rounds, something like that. And overall, try to keep it between 15 to 20 minutes aiming for maybe a minute to two minutes per round or faster. So again, pretty simple. Get off the bike, do some pull ups, go back to the bike. You're going to hit a wall on the pull ups eventually, just a matter of how long you can hang on before those start to fall apart. Some courses coming your way next weekend, the weekend of July 29th and July 30th. We have upper body dry needling down in Dallas, Fort Worth area. That course has two seats left out in Denver. We have Alexis with our ice, ice, ice pelvic live course that same weekend, two chances to catch older adult live either with Alex Germano up in Boise, Idaho, or with Christina Prevot down in Watkinsville, Georgia. That's about 90 minutes east of Atlanta out towards the Athens area. And then extremity management will be in Madison, Wisconsin that weekend with Lindsay. The weekend of August 5th and 6th, again, dry needling will be out on the road with Paul, this time lower body in Greenville, South Carolina at Onward Greenville. Older adult live will again be on the road with Alex Germano, this time in Frederick, Maryland. The weekend of August 12th and 13th, dry needling will again be out on the road, this time lower body with Paul out in Salt Lake City. Extremity with Lindsay on the road again, this time in Rochester Hills, Michigan. Total spine thrust will be up in Bellingham, Washington with Justin Dunaway. And then you have another chance at older adult live, this time with all of the faculty and teaching assistants at the older adult live summit that will be in Lexington, Kentucky at Stronger Life. I will be there for that one. That's going to be a great weekend. So if you can make it down to Lexington that weekend, you should. Finally, the weekend of August 19th and 20th, again, dry needling will be on the road with Paul, lower body in Phoenix. Extremity will again be on the road with Lindsay, this time in Fremont, Nebraska. That's right outside of Omaha. Older adult live will be in Bedford, Texas right outside of Dallas or up in Minnetonka, Minnesota. That will be right outside of the Minneapolis area. So those are the courses coming your way in the next month from ICE. Today's topic, servant leadership. We have touched on this a little bit before, but we're going to get really nitty gritty today and we're going to more importantly talk about some of the research supporting the use of servant leadership in practice. So servant leadership, what is it, how to get better at it. We're going to define it. We're going to list the characteristics. We're going to give some examples of high quality servant leadership and talk about the research supporting the use of servant leadership. So first things first, what is servant leadership? You may have heard of this. You may have seen some books maybe in the airport, in the business section or something like that about servant leadership. It is a leadership principle founded in 1970 by a gentleman by the name of Robert Greenleaf. And it was an essay basically published called The Servant as Leader. And the idea behind servant leadership is leaders are essentially individuals that look and act no different than any other member of the work team of no matter what you're doing, you are hauling garbage away. You are a physical therapist. You work on a computer doing data entry or software development or something that servant leaders, true servant leaders are yes, maybe the owner of the company. Yes, in charge of a team of people, but they're also on the ground still doing the day to that composes the work of whatever the business is trying to accomplish, whatever product or service they are trying to offer. Team members then should be easily relatable to the leader because they are essentially doing the same thing. Maybe the servant leader is not doing as much of it, but they have certainly started in whatever work they are now leading and they are still doing some or most parts of it day to day. The whole idea here is that when someone is not a servant leader, we don't necessarily notice when someone is a servant leader, but we certainly notice when someone is not a servant leader that when their fellow servant, when their fellow teammates, employee, colleague, however you want to define yourself is absent, when that person is gone, the team itself, the work that the team does overall feels less organized, less functional. That day to day looking at a group of people, you might not be able to figure out who the leader is because again, they are doing the day to day work of the organization much like everybody else that works there, but when they are not on the job, things just don't function as well. They keep things organized, they understand a lot more details of the work to be done because usually they are people who have spent a lot of their time doing it. They may have been, for example, physical therapists in practice for 5, 10, 15, 20 years. They may have all of the knowledge of the back end work of the business and when they are not there, yes, work continues, but it's just not as productive. Work gets a little bit slower, it gets a little bit harder to do and overall the idea behind servant leadership is that having the servant leader there makes everyone else's job just a little bit easier, not only by performing their share of the work, but by helping everybody else stay organized and on task as well. This is in stark contrast to almost every other business philosophy and leadership philosophy Most businesses are running kind of a leader first mindset where the goal of the leader is to squeeze productivity out of people. This is obviously very common in physical therapy, but it's common across business in general of oftentimes the leader of a physical therapy clinic of a large company may not even be a physical therapist or may not even know the work that happens at that organization. They are just there to essentially be a boss, to crack the whip, to squeeze productivity out of people, to make sure deadlines get met and things like deliverables get delivered and otherwise kind of push the organization along even if it's not functioning well and even if the people in the trenches doing the work may think, boy, what would really help right now is an extra set of hands. That doesn't happen in a leader first culture, but it does happen in a servant leadership culture. So let's talk about characteristics of servant leadership. So there are four main characteristics. The first is that a servant leader always approaches work with an unselfish mindset. That is to say, there is no task beneath a servant leader. If the leader expects the toilets to be cleaned at the start of each day, if it's not done, it is not beneath the servant leader to go in and clean the toilets themselves. They still practice whatever profession they are leading. They are still a practicing physical therapist, a practicing software developer, whatever. And they still perform a lot of the mundane day to day tasks that not only do they expect of others, but are necessary for the organization to function and thrive. You will find these people still cleaning windows, cleaning up those tiny little pieces of toilet paper that get ripped off the roll and in bathrooms. You will still find them treating patients. You will still find them doing their documentation. You will still find them doing all the things that they expect the people that work for them to do on a daily basis. I think often here at ICE of I'm very familiar with what it's like to spend an entire day or maybe multiple days with a delayed flight or a canceled flight or trying to drive across the country to make it to teach to a course of understanding what it's like to do the really boring, mundane, kind of agonizing tasks day to day of a job, of driving across the country to bring equipment to make a course happen. That is stuff that I have done in the past. That is stuff that I still do. And I am able to relate to when that happens to others who work here at ICE because I have done it myself. Again, that is in stark contrast to the way that a lot of organizations are run where the person in charge may not have any idea of the actual work that goes on in the company. They are just there to boss people around and ask for reports and that sort of thing. Essentially, approaching work with an unselfish mindset is saying that I know exactly what it's like to do your job and I'm also not above doing it and I probably still do a lot of it. The second main characteristic of a servant leader is that they encourage diversity of thought. That the leader's ideas aren't necessarily best just because they are the leader's ideas, but because they come from the leader after that they have incorporated everybody else's thoughts, feedback, and opinions of everybody on the team. That large decisions should be team decisions. Large decisions should be team decisions. The third characteristic of a servant leader is that they create a culture of trust. That they are not some lofty, unapproachable individual that maybe works in a different state that maybe now works in the Caribbean from some island or something because they're so rich and they jet in every now and again to collect their checks or yell at some people or fire somebody or something like that. That they are just a regular person that still comes to work every day, that still gets up, still gets their kids breakfast and gets them on the bus to school and still comes in to work just like everybody else on the job site. They don't just come to work to boss people around, they come to work to work and to guide others to be more productive in their work, not to just come and make new rules and punish people and then go hit the golf course. The last and maybe the most important characteristic of servant leadership is that servant leaders foster leadership in other people. That they recognize that true long-term success, true long-term sustainability at a job, true long-term productive, profitable work comes from building a successful, often multi-generational team of yes, in the moment I'm thinking of tasks that need to be accomplished and deadlines that need to be met and costs and expenses, but I'm also in the back of my mind thinking who here is next going to sit in my seat and I'm trying to give that person advice and guidance and mentorship so that someday they can also be a leader within the company and that treating everybody within the company as a potential leader not only empowers them, builds a culture of trust, but really fosters leadership in them in a way that when the leader happens to not be there, things don't fall apart of like oops, we can't even unlock the door to let patients in for the day because the boss is out of town today until noon, of fostering leadership in others and having others take over some of the leadership tasks of the job. Most businesses are only created with the goal of growing them big enough to sell them and essentially just to acquire wealth, to be sold at some point for a profit. There is often not a lot that goes into the fostering of other leaders to take over the company to keep the company continuing running. It's often thought of I hope I can make this go long enough so that I can sell it someday and get a big golden paycheck and then it's somebody else's problem. Not many people approach work with the mindset of who's going to take over my position after me and continue to grow this thing into a successful multi-generational business. So that's what servant leadership is. The characteristics of a servant leader. What is some really nice research that supports the incorporation of servant leadership in the workforce? So none of these papers are going to be found in physical therapy journals or fitness journals. These are all going to be from managerial science journals. Really really interesting stuff that you really you can't put down that you can't keep flipping the page. But I want to share three articles with you that I hope hit home. The first is research on reduced employee turnover nutrition. This comes from a paper from Cash App and rang rang a car. Sorry if I butchered that. This is from the Journal of the Reviews of managerial science. Thrilling. This is from 2014 looking at servant leadership in the workforce and finding that when servant leadership was put into place the direct effects of servant leadership on employee perception results in reduced job turnover. That employees report that the workplace is seen as a positive place to be. That employees report having higher levels of pride in the work that they perform when they're on the job. That they feel they are rewarded accordingly and that they genuinely this is a direct quote generally enjoy the company of the people that they work with. It's a fun enjoyable place to be. It's great when there's a lot of synergy between coworkers and it's not just a place where you clock in and you clock out. Servant leaders model the behavior expected of others and that is very rewarding to everybody else that works there and to the organization as a whole. The second paper I want to cite is on life improvements outside of the workforce. So everything that's not work what changes in somebody's life when they work in a job where the leader is a servant leader. This is from Zimmerle, Holzinger and Richter from 2007 from the Journal of Corporate Ethics and Corporate Governance. Again another page turner. This paper reported overall reduced levels of stress and an improved ability to spend time with friends and family and meet the needs of the family unit at home outside of the workplace when the workplace was run by a servant leader. Subject reported that when their work needs felt met they had more bandwidth, more mental energy to support others outside of work, to support their spouse, to support their children, to support other members of their family and friends outside of the workforce. And just concluding that when a servant leader is in charge work is not this kind of hellacious place where all we're trying to do is make it to the end of the day. That it's just this block of time on the calendar that we have to grind through and suffer through and it's really kind of this hellacious experience. Subject reported that we leave work feeling maybe at least not as drained as maybe other positions but maybe even leaving work for the day feeling energized, having more time, more energy to go do other more enjoyable stuff. Again spend time with friends, spend time with family members that when work itself is enjoyable and rewarding it's a sustainable pace that allows both work life and family and outside work life to really function and thrive. Our last paper here is that servant led workplaces are sustainable workplaces. This is from Chukotai and colleagues in 2017 from the Journal of Applied Research in Qualities of Life and finding that servant leaders carefully manage work with the use of deadlines but also with rewards and even distribution of work allocation and regular performance evaluations so people have an idea of how they're doing, how to get better and they don't feel like they're doing an uneven amount of work for less than their fair share of pay. There's a lot on social media now about burnout and imposter syndrome and all this stuff and how to just get through your work day and the truth of the matter is most of us feel burned out, most of us feel overwhelmed because we're able to perceive that we're doing an uneven amount of work for an uneven amount of pay right. We are doing more work than our bosses do for less money than they make. As soon as your brain perceives that you start to get a really disgruntled feeling in your mind and that is the nucleus that turns into burnout, that turns into maybe I don't want to be a physical therapist anymore, maybe I want to sell real estate. That is palpable in the workplace. As soon as you walk into a business you can tell when the people there are kind of just staring straight forward, they have that dead look in their eyes and you can tell that they are not happy to be there, they are not thriving. That servant led workplaces are focused on the results, not the effort of telling people to get all of their work, get X amount of work done immediately and the rationale is because I said so. For example, very common in physical therapy right, get all of your documentation done by the end of the day. Why? Well because I said so and I'm in charge. Maybe the biller has already gone home for the day and there's no way that that documentation is going to turn into claims anyways. So what the hell does it matter that I get this done by 6pm if it's not going to be looked at until tomorrow morning or if it's Friday it's not going to be looked at until Monday? Why am I at work until 8pm or 10pm at home doing my notes when they're just going to sit unaddressed for a day, two days, three days? That is kind of a boss led work environment versus a servant led work environment that says hey, get X amount of work done by Y date and you will get Z reward right? Get all of your documentation by the next pay period and that's it right? I don't care when you do it, I don't care if you do it a little bit every day, I don't care if you wait until Sunday night and do all of it at once. Like I literally don't care about the effort that it takes to get the work done, I just care about the results of the work, that the work is high quality and then it gets done. I don't care how you practice physical therapy, as long as patients get better, they leave physical therapy feeling better, they are healthier, fitter, stronger people leaving physical therapy, I don't care how you got there right? So servant led workplaces are focused on results and not just doing effort to say that effort has been done. This is objective, measurable and repeatable led work. We can track this stuff, yes, if we care about data and reports, but ultimately again we care about the results and not the effort. And so ask yourself, am I burned out because I believe that I'm not skilled enough, that I'm not competent enough as a clinician or am I really burned out because I work in a boss led workplace and not a servant led workplace? And I think you'll find that most of you considering leaving the profession, considering changing jobs are really aware in the back of your head that you are not working for a servant leader. You may be working for somebody who doesn't even live in your state, right? You may be working for somebody who's not even a physical therapist. The owners of your company may be investment bankers from New York City or Chicago or LA and you are just going to work to generate money so they can go on really nice vacations and have a cabin and a yacht. And again, the moment your brain starts to perceive that, that's really where kind of that disgruntled feeling comes in. And I would urge you to look around that there are many clinics out there, there are many workplaces out there that are led by servant leaders and you really just need to tell yourself that you're not going to settle until you find that place where you come in, work is maybe not necessarily overly energizing, but it certainly doesn't take so much out of you that you feel drained for the day, that you have to go home at 5 p.m. and go to bed for the day and all you can do is lay on the couch and watch TV until you fall asleep. A really high quality workplace led by a servant leader can be a fun environment, it can be an energizing environment, it can leave you with enough energy in the tank to where you can go home and do whatever you want with the rest of your day and the rest of your life and that you don't feel like you're just doing work to get work done, to check the box on things like reports and to produce data for somebody to look at and rubber stamp it. So again, don't settle until you find that nice servant led workplace. So servant leadership, what is it? It is a servant mindset, it is somebody who comes to work with the mindset of they have done that job before, they're likely still doing that job, they're able to help you get better at doing it so you don't have to spend as much physical and mental energy doing it as well, right? They are often great mentors, they lead their workplace in a way that makes it more organized, that makes it easier to work at and maybe even makes it a fun energizing place to work at. They embody four main characteristics, they approach work with an unselfish mindset, no task is beneath them, they encourage diversity of thought, they have meetings where they ask for your thoughts and opinions on decisions, again large decisions are team decisions, they create a large culture of trust, they're not this lofty individual living in Costa Rica, they are standing next to you, they are in the other room treating a patient and that they foster leadership in others, they challenge you to take over some of the reins the whole idea is creating a sustainable multi-generational business. Know that there's a lot of research supporting this, that it often leads to less turnover, it leads to higher quality of life outside of work for employees and then overall it leads to a sustainable work environment where people don't feel that quote unquote burnout feeling. And recognize that burnout is often not remedied by taking more vacations or reading more It's found by working for people who are servant leaders, of not being afraid to move yourself in a position or maybe even move yourself geographically to find a really high quality servant led workplace. They are out there, you just need to tell yourself that you're not going to settle until you find it. So servant leadership, I hope that was helpful, I hope you have fun with Gut Check Thursday, if you're going to be at a live course this weekend I hope you have a fantastic time, have a great Thursday, have a great weekend, bye everybody. 22:20 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 19, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Dustin Jones explores the concept of creating impactful memories for customers and how it can enhance business success through word-of-mouth marketing. He shares examples from the restaurant industry, illustrating how exceeding customer expectations can cultivate lifelong customers and improve business growth through positive word-of-mouth. Dustin emphasizes the significance of creating "legends," which are memorable experiences that surprise and make customers feel special. These legends become synonymous with the business and leave a lasting impression on customers. When businesses go above and beyond to provide such memorable experiences, it not only fulfills the customers but also benefits the business owners. Dustin encourages listeners to consider what legends they can create in their own businesses. It could be as simple as acknowledging a customer's birthday with a card or text, or going the extra mile by taking a discharged patient to play pickleball or organizing a group trip. The possibilities are endless, and creating legends can have a positive impact on the business, the community, and the overall satisfaction of everyone involved. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show. 01:43 DUSTIN JONES PT on ICE Daily Show. It's Dustin Jones here. It is Wednesday. We're going to be talking about making legends. What, how, and then the why behind this. Making legends is going to be about how to create memorable, impactful experiences for your patients and why it's good for them, it's good for you from your professional standpoint, and good for your business. All right. So what I want to talk about first before we get into this are the modern management of the older adult courses that are coming up. We are picking back up. We usually kind of take a little break during the summer, regroup, do our revamps, update all the literature and the slides, and we're hitting the ground running. So we're going to be in Boise, Idaho, in Watkinsville, Georgia at the end of July 29th and 30th, and August 5th we'll be in Frederick, Maryland. And then on August 12th, we will be in Lexington for the MMOA Summit where all the MMOA faculty are going to come together and deliver the brand new revamp of MMOA Live. We're super pumped about that. And then we have Essential Foundations, our online course starting August 9th. All right. Legends. Let's talk about this. I'm really excited about this topic. This has been something I've been thinking about since about February when I read the book Unreasonable Hospitality. So this is a book that you probably heard some of the ICE faculty talk about that Jeff Moore recommended. Anytime Jeff Moore recommends a book, you should probably check it out. The guy doesn't recommend a lot of books, but when he is very critical of a lot of books, so when he says, hey, this is worth reading, you probably should add that to your list. And this definitely proved to be true with this book. So Unreasonable Hospitality, I'll just give you the 30,000 foot view. Will Guderia is a restaurateur, very successful in that business or that industry. And he kind of talks about some of the principles that he used to create such impactful businesses, restaurants in particular, and how a lot of those principles that he used also translate over to business in general. And just so many different industries can benefit from kind of that hospitality mindset. And so he talks about a lot of different practical strategies that all of us can use in the rehab and the fitness profession. But he speaks to one particular of how we try to create legends. And when he says the word legends, what he's really talking about is creating impactful memories for folks where they are surprised, they feel special, and they will never forget. That moment and the business that is associated with that moment. He's got all kinds of crazy examples from the restaurant business, where he just went above and beyond what people were expecting and thus created customers for life. And that really improved his business, word of mouth marketing, and a lot of different things that made their job more fulfilling. And so he speaks about that concept of legends a lot in the book. And I walked away from that book just thinking about, man, we have such a huge opportunity to create legends in the rehab space, in the fitness space. And I'm going to talk through, you know, just through that of why we may want to do that, and then particularly the how and give you some examples. So in terms of the why, the first thing that I want to acknowledge is that when we go above and beyond and provide a memorable experience for folks and do it in the mirror, that they're kind of surprised and taken back. That is very fulfilling for us. I'll give you one example. Ellen Sefi. So she teaches with MOA. She has created lots of legends for a lot of her patients. She had one patient in particular that she was treating in a more acute setting. I forget the exact situation, but she this this patient had a long road to recovery. And Ellen ended up switching jobs into outpatient as that that patient was kind of leaving that acute setting and going into outpatient. So Ellen was able to treat her in that setting. This is a long road road to recovery for that individual. And Ellen worked with this person to help her get back to being able to hike. That was a big goal for this patient. And I think this is where a lot of us kind of stop, right, is we get people to the point where they can do the thing, right? Whatever that particular goal is for this patient, it was hiking. So she worked on her lower extremity strength. She worked on her dynamic balance. She worked on her endurance and she checked the box of all the kind of prereqs to be able to go on a hike in Colorado. And that's where we stop. And that's where we have such a huge opportunity to take a one step further and create a legend. And what Ellen did is she actually organized a hike and did a 14 or with this patient, right? She gave her the prerequisite skills and abilities required to achieve that goal. But then she facilitated that goal to actually happen. And she went on that journey with that patient that for Ellen, that's one of the most memorable professional moments for her. The fulfillment of being able to see of all your hard work and time that you have invested in this person, that they're able to do something epic like that. That is so fulfilling. So it's good for you. It's also good for your business because that happens. What do you think that patient is going to tell all their friends and their whole networks? Do you think she took a thousand selfies on the top of that summit and posted it all over social media? And guess how many patients Ellen probably had from that word of mouth, from impacting that patient on such a big level that it really sets you apart from a lot of your competition that aren't doing that. They're just checking the box. They're just improving strength, improving endurance. And you're actually facilitating your patients climbing 14 years, right? That has a compounding effect over time. It's going to be good for your business. All right. So that's the what of the legends. That's the why. It's good for you, for your fulfillment, for your career. It's also good for your clinic, your business as well. And so I want to get kind of dive into some practical examples of how we can create legends in the context of rehab and or fitness. I think we can do this in very simple manners and we can do this in kind of big, big, monumentous events as well. On the small side of things, just think about how you can surprise your patients, make them feel special. This is could be as simple as acknowledging someone's birthday. You have their date of birth that you send them a card, a gift card, whatever that just that simple act kind of puts you above them. Beyond most clinics and in gyms, for that matter, it could be that easy. It could be that simple. It could be more like what Ellen did, where she worked on building physical capacity with a patient, which is usually the case in our plans of care. Right. We're trying to get them stronger, improving their endurance, improving their balance, all that fun stuff that is tied to a patient centered goal. Right. We're already asking a lot of those things. What if you take it another step further to facilitate them being able to participate in whatever that activity is? Right. I'm not saying you got to climb a 14 or like Ellen did, but what if you proactively, you know, organize the hike that they could go on? What if you address the barriers that they may have on going on that hike, like going ahead and printing out directions of going ahead and planning out the day, recommending restaurants to hit up after the hike, just reducing barriers and facilitating that or even connecting them with a local hiking group that's going to increase their odds of actually doing the thing that you help them be able to do. Right. We could do it in that manner. Ellen took someone up a 14 or for me, especially in the context of home health, this happened a good bit where it was usually something a lot simpler than going to climb in a 14000 foot mountain. It was, you know, once that person was discharged from homebound status that we would go and do something in the community that they loved about. One in particular, I will never forget this. Me and my wife went on a double date on Valentine's Day at Waffle House with Walton Peony Smith in Columbus, Ohio, that I was discharged in Peony. She was no longer considered to be homebound. And it was right around Valentine's Day. And she had just regained the ability to navigate her community safely and efficiently. And so we crushed the All-Star Special. I still remember that meal. It was absolutely amazing. A double date on Valentine's Day at Waffle House. Something like that is just takes things to the whole another level that I will never forget. Very fulfilling from the professional standpoint. Peony will never forget. And then all of her friends, her family won't forget either. And when they want PT, guess who they're going to be calling. Right. We could take it up another notch. And this is something that we have been trying to do more at Stronger Life. We have a couple examples of this recently, which has really fueled me wanting to talk about this. One is that we had four individuals compete at the National Senior Games. These four women have basically never ran their life before, about 12 months ago. They qualified at the state games last year and then went to Pittsburgh last week to compete in the National Senior Games. And one of our athletes, Carolyn Holmes, 89 year old woman, got third in the 5K. And her whole family, three kids from all across the country, their kids, and then she had a couple of great grandkids were all there to witness this. And I will never forget this. Carolyn Holmes, 89 years old, running across the finish line with her eight year old great granddaughter. We got Carolyn stronger. We improved her endurance. We improved her balance. We checked all those boxes. But we created the opportunity for them to really flex their muscles and really pursue something that they had never even thought that they would be able to do. And then to do that in front of their community, in front of their family and then the whole Stronger Life community watching this from afar. Those are potent moments. Those are legends that I will never forget. Hands down, my most fulfilling professional moment. Carolyn will never forget that. And anybody watching that story will never forget what happened on that day. It's good for me. It's good for Stronger Life. This is good for our communities. It's a win win win for everybody involved. All right. We've got another one coming up this winter where we're taking 25 of our members to Costa Rica in an all inclusive adventure retreat where we work on their balance, their strength, all this stuff inside the gym. And then we create the opportunity for them to use those skills and do things that they never thought were possible. Right. These are legends. They're good for you. They're good for your business. They're good for your community. So I want you to think what legends can you create in the context of your own business? Some of you, it may be, all right, I need to acknowledge that someone had a birthday and just write a card and send it or send the text or whatever it may be. Some of you may think, oh, man, I may end up taking that patient that I just discharged actually to go to the pickleball court and play some pickleball with them or connect them with that pickleball group. And some of y'all may climb a 14 or some of y'all may organize a group trip to the Caribbean. I don't know. But there's so many opportunities for us to take things to that next level to create legends. I've really enjoyed this. I think you will as well. And I know your business will benefit, too. All right. Let me know your thoughts in the comments. If you have any legendary stories or any ideas, I would love to hear what you're going to do. We'll get lots of ideas in the comments, which will be very helpful to make this more practical. All right. You have a good rest of your Wednesday. I'll talk to you all soon. 13:24 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Jul 18, 2023

Dr. Dave Finkelstein // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division faculty member Dave Finkelstein makes his debut on the podcast to discuss the importance of asking patients if there is anything important they want to cover or do in their session. This question is often overlooked by therapists, but it is seen as one of the most important questions they can ask. By asking this question, therapists are allowing their patients to take control of their care and be in the driver's seat. The aim is to promote a sense of self-efficacy in the patients' care and give them the opportunity to express what is truly important to them. The episode highlights that therapists may be surprised by their patients' responses to this question. While some patients may be open to whatever the therapist suggests for the session, others may have specific concerns or topics they want to address. It is crucial for therapists to listen to these concerns and not dismiss them for their own predetermined plans. By addressing what is important to the patients, therapists can alleviate their fears and concerns and demonstrate that they are truly listening and invested in their well-being. Furthermore, the episode emphasizes that asking this question helps to strengthen the therapeutic alliance between the therapist and the patient. By showing attentiveness to the patients' needs and concerns, it enhances the trust and rapport between them. This, in turn, can lead to better treatment outcomes and a more positive therapeutic experience for the patient. In this episode, the host discusses the importance of asking specific questions to patients in order to determine the direction of their care. The host shares five specific questions that can be asked to gather important information from patients. The first question is, "How did you feel after the last session?" This question allows healthcare providers to understand how their intervention or treatment has affected the patient's symptoms. By knowing how the patient felt after the previous session, healthcare providers can make informed decisions about the next steps in their care. The second question is, "How are you progressing with your goal?" This question helps healthcare providers assess the patient's progress towards a specific goal. It allows them to gauge whether the current treatment plan is effective or if adjustments need to be made. The third question is about the patient's adherence to their exercise program. The question is, "How often are you keeping up with your exercises?" This question helps healthcare providers identify any barriers the patient may be facing in following their exercise program. It also allows them to assess the effectiveness of the home exercise program. The fourth question is, "How are you feeling today?" This question helps establish a baseline for the patient's current condition. By understanding how the patient is feeling at the start of the session, healthcare providers can evaluate the impact of their intervention or treatment. The fifth and final question is, "Is there anything specific you would like to discuss or address today?" This question gives the patient an opportunity to express their concerns, priorities, or any specific topics they would like to discuss during the session. It allows the patient to take an active role in their care and helps build a sense of self-efficacy. Overall, these five questions provide valuable information for healthcare providers to determine the direction of a patient's care. By asking these questions, healthcare providers can gather subjective information, assess progress, identify barriers, evaluate the effectiveness of interventions, and address the patient's priorities and concerns. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 DAVE FINKELSTEIN Alright, good morning to the PT on ICE Daily Show. I am your host today. My name is Dr. David Finkelstein and I have the pleasure of serving as a TA in the spine division. I am a TA in the cervical and lumbar spine management courses. The topic today is ask for directions. But before we jump into the topic for today, I wanted to highlight a few of the upcoming courses that we have in the spine management division. So on September 23rd, we actually have all three of our lead faculty leading courses that weekend. Zach is going to be in Henrico, Virginia at Onward Richmond. Jordan is going to be in Baton Rouge, Louisiana at Delta Physical Therapy. And Brian is going to be in Parker, Colorado at Onward Denver. So if you're looking to hop into a lumbar spine management courses, all three of those gentlemen are going to be running courses on September 23rd. If you're looking to jump into a cervical spine management course, Jordan is going to be in Brookfield, Wisconsin on July 22nd at Onward Milwaukee. Jordan will also be in Charlotte, North Carolina, August 26th at his home base of Onward Charlotte. And then Zach on September 9th is going to be in Roswell, Georgia at Onward Atlanta. So looking to jump into a cervical spine management course, those are going to be your next few opportunities in the coming months. All right, so let's jump in the topic today. The topic is called Ask for Directions. And the idea came from a conversation that I had with one of my coworkers. She was talking about one of her patients that seemed to plateau in their care, and she didn't know which direction to go in terms of directing her care. So when we're working with our patients, they're going to be giving us a lot of subjective information as the weeks go on. And my hope with today's podcast is to give you all some specific questions to ask your patients to know which direction that you want to go with their care. Right. So I have five questions that I want you to consider, and there were more prompts. So that way you can dive a little bit more into those questions as you ask them. All right. So question number one, how did you feel after last time? I love starting with this question because it helps us know how the patient felt with our intervention after our last session. Right. Usually our patients will say something along the lines of, I felt good. Don't accept that as your answer and then type into your documentation system and then move on. Right. We want to know how our intervention affected them. So you want to dive into that a little bit more. So when the patient says good, ask them, what does good mean? How good did you feel after last session? How long did that good feel for? Right. So that way we know how effective our intervention was. And if they did feel good after last time, that might be something along the lines of you want to increase the vigor, continue on with the dosage of, of what you did last time to help prolong that good sensation that they felt. Conversely, if they didn't feel good after last time, if they tell you, you know what, Dave, I actually didn't feel so hot after last time. I felt quite a bit worse. Don't panic. That's actually good news in a way because it helps you know that you were in the right place, but maybe your vigor was a little bit too much or maybe your dosage was a little bit too much. Right. Because if you weren't in the right place, their symptoms wouldn't have changed. Or conversely, they might've done something between the last session and your current session that also could have flared up their symptoms, unpacking it a bit more. Maybe John said, you know, I felt pretty good after last time, but then I mowed the lawn and then picked up a few boxes and then I did X, Y, Z. And then after that, I felt a little bit worse. So it helps you know exactly if it was your intervention or if it was something that they did afterwards. Right. It also helps you know if you establish their irritability correctly after the initial evaluation. So if you did your particular intervention, you thought they were low irritability and you intervene in an area and nothing really changed, you might want to consider going a little bit more vigorous into your examination or into your vigor to see if you can really elicit their symptoms. And then conversely, if they felt like really flared up after last time, maybe your vigor was a little bit too much and you overestimated their irritability. Right. So in both ways, that's a really good starting place when you ask the patient. So that first question is how did you feel after last time? Question number two, how did you progress towards X goal in our cervical and lumbar spine management courses? We talk about obtaining a subjective asterisk. Basically, that's something that the patient that's important to the patient that you want to measure, but you can't measure in the clinic. So what that looks like is how many times someone woke up in there in the night because of their pain or how long into their commute they're able to sit for before they have an onset of symptoms. Right. So if you ask them, John, how did you feel after or how are you progressing with your commute? And John tells you, you know what, Dave, actually, it's a little bit better because I was sitting for 30 minutes and then my symptoms came on and now I'm sitting for 45. So now you know that your intervention was effective because their commute increased. Right. Whereas conversely, if they say, you know what, Dave, after last time I was in my commute and I was only able to tolerate 15 minutes of sitting before my symptoms really started to act up a bit, then you know, once again, maybe it was that bigger or maybe it was that particular intervention that you did that was a little bit too much that that might have increased their symptoms a bit. So asking them how they felt with that specific goal, with their subjective asterisks that you obtained in the initial evaluation, seeing how they progressed with that. And also keeps those goals that are salient to the patient in the back of your mind that you continue to ask them in those follow up sessions. Right. So that's question number two. How are you progressing with X goal? Question number three, how often are you able to keep up with your exercises? I love asking this for a home exercise question as opposed to are you doing your home exercises? Because it's a little less judgmental. Right. If the patient didn't get to do their exercises, you're asking them from a place of curiosity as opposed to did you do your exercises? So when you ask the patient how often are they doing their exercises, it gives the patient opportunity to even tell you, you know what, Dave, I actually didn't. Wasn't able to keep up with those exercises. Don't judge them for not doing their exercises, but look at that as an opportunity to examine barriers to their adherence to their home exercise program. Right. So you can tell John, like John was up. How come you weren't able to do those banded external rotations? And they tell you, you know what, Dave, I just didn't have an opportunity to go out and buy the bands because I'm a little short on time and it did help after last time, but I just I wasn't able to go on by the band. So that way you now have the idea that the barrier was purchasing the bands. Right. So then you can change that exercise to a sidelined external rotation. We're holding a can of tomato sauce there. You're kind of taking out that barrier of buying a band. You got the stimulus that you wanted. And then you also taught John a way of creating a weight in his house using a can of tomato sauce. Right. So using that as an opportunity to identify a barrier. And then also, if your intervention was effective as far as a home exercise program. So take, for example, a patient with low back pain radiating down their leg. They say, you know, Dave, doing those prone press ups that you gave me, I felt pretty good for about an hour after you gave me that exercise. But then it kind of went back to baseline afterwards. And then you realize that you dose that out three times a day. You might consider asking John, hey, John, you know, you felt pretty good for about an hour after you did those exercises. What are your thoughts on maybe increasing that from three times a day to six times a day? You know, it might sound kind of aggressive, but in that way, you're increasing that dosage of that thing that was helping John. So now you're getting a good idea of how your home exercises are affecting your patient and then playing around with that dosage or that particular intervention. Right. So that question, once again, is how are you how often are you keeping up with those exercises? Question number four, how are you feeling today? Seems like a very basic question that we ask all of our patients. But I want you to think about why we're asking our patients that. We're asking that question to establish a baseline, how they feel right now. So that way, if we do some sort of intervention, that we know how it's changing their baseline symptoms. This is another opportunity that the patient might say, good, don't take that good as a as your answer. Tell them, like, can you unpack that for me a little bit? Tell me what what good means and then start to trace out their symptoms. See exactly where their symptoms are, how intense are their symptoms? So that way, when you establish that baseline, you feel really confident about the intervention that you did, whether or not it changed their symptoms for the better or it did. Right. Establishing that baseline. All right. So question number four, how are you feeling today? Question number five, I think, is one of the most important questions that we can ask our patients, but is often overlooked. So question number five is, is there anything you want to cover today? Talk about do that's really important to you. In that question, we're taking our hands off the steering wheel and allowing our patients to be in the driver's seat. We want our patients to feel a sense of self-efficacy in their care. And this is the best question to open that opportunity to know what's really important to them. Right. Maybe our patients will say, you know what, Dave, whatever you want to do today, I'm game for, which is fine. And then you continue on with that plan that you had. But your patients might surprise you and say something on the lines of, you know, Dave, I was actually thinking about it the other day that I don't really know how to get off the ground if I were to fall. And that's kind of in the back of my mind for a while. In that the patients opening up to being vulnerable and saying, hey, this thing is really important to me. What you don't want to do is ignore that and be like, well, sorry, John, you know, I had this other plan and I just want to proceed with it. We'll cover that in the next session. You want to cover the thing that's most important to your patient because it's going to help take that kind of fear, that concern out of the back of their mind. And then in addition to that, you're helping boost that therapeutic alliance by addressing that thing that's really important to them. Right. Nothing is going to tell your patient more that you're listening to them, that you're concerned about them than intervening in that thing that's really important to them that day. Right. So that question is, is there anything that you want to talk about or do today that's really important to cover in our session today? So those are the five questions I'm going to give you a quick recap. Question number one is, how did you feel after last time to know how your intervention affected their particular symptoms? Question number two is, how are you progressing with X goal? Recapping back to their subjective asterisk, making sure that you know exactly what's important to them and how that's progressing or not. Question number three is, how often are you keeping up with those exercises so that way you can identify barriers to their adherence to their exercise program in addition to knowing how effective your home exercise program actually is? Question number four is, how are you feeling today? Knowing the back of your mind that you want to establish a baseline so that way you know how your intervention is affecting the patient. And then question number five, once again, really important to ask our patient, is there anything important that you want to cover, talk about, do today that would be beneficial? Right. So give those questions a thought. Try that out. Keep in the back of your mind why you're asking these questions and then diving a little bit more. Let me know how it goes. Shoot me a message in the comments section. I love talking about this stuff. I love the conversational piece and the Therapeutic Alliance piece of patient care. If you're looking for more opportunities to jump to some courses or see some of our free resources, go to PTNICE.com. Check us out. Everyone, thanks for giving me some of your time and have a wonderful morning. 14:07 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at PT on ICE dot com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE dot com and scroll to the bottom of the page to sign up.

Jul 18, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the obturator internus muscle and its role in pelvic floor and hip conditions. She highlights the importance of understanding and addressing this muscle for effective treatment. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show. 01:29 APRIL DOMINICK Good morning PT on ICE Daily Show. Dr. April Dominick here. I am your host and I will be continuing our conversation on pain in the butt, this time with a spotlight on the obturator internus muscle. The obturator internus is a persnickety hip muscle that is housed inside the pelvis and it contributes to quite a few pelvic floor and hip conditions. So before we dive into that, I just want to give you all some updates from our ICE Pelvic Division. If you didn't catch our big news from our newsletter that we sent out last week, we week online course that is going to cover advanced pelvic health concepts and it's coming January 2024. So make sure you hop onto pdniice.com, check the resources page and get yourself signed up for our pelvic health newsletter for all things research oriented. And our next level one online cohort starts September 5th. So be sure and hop on to that course. And then you can catch us live for our two day course on the road next week and actually we will be here in Denver, Colorado. That's July 29th and 30th with Dr. Alexis Morgan and myself. We'll have a jam packed course for you. Our lecture will focus on all things pregnancy and postpartum. For the fitness athlete, labs will go over all internal external assessment of the pelvic floor with a option for video learning if that assessment does not sound like it is for you in terms of the internal piece. Other labs will cover management of C-section scar, diastasis recti, core work on and off functional barbell lifting, endurance including running, all sorts of fun fun stuff. So there are still a few seats available for that course if you want to come hang out with us and if you aren't able to make it to the Denver course we'll be in Sedona, Arizona and that's going to be September 23rd and 24th with Christina Prevot and Dr. Rachel Moore. So if you missed it two weeks ago we chatted about another kind of pain in the butt, one that was focusing on a bony structure, the tailbone. It's episode 1505 if you want to slide back and catch that. But today we're going to focus on the soft tissue muscle or cause of the pain in the butt, specifically the obturator internus or I love abbreviations so I may call it the OI during today's episode. So if you, the listener or if you have a client who has some sort of hip pain that seems difficult to pinpoint, they're having trouble telling you where it's at maybe because of where it's at they may be kind of pointing in the nether regions or they might be headed up near the and you're like, oh I don't deal with that stuff or they may point just at the ischial tuberosa and you're like, oh thank goodness, hamstring strains, I can deal with that for sure. But maybe you throw everything you have at it, your hip mobility exercises, your strengthening exercises and it's just not getting any better. Well I encourage you to consider my friend the mysterious obturator internus muscle as that may be influencing some of that hip pain that you or the client has. So we'll chat about the obturator internus' unique anatomy, its functions, other competing soft tissue contributors as well as certain conditions or maybe client reports to be on the lookout for that may be influenced by this muscle. I love history so the word obturator actually originates from the Latin word obturo which means to stop or block up. This lines up given that the obturator muscle actually covers the opening of the obturator for Raymond. So this, the location of the obturator, it's a big old hunk of hip muscle that lives on the front and side of the hip. So for those listening, I'm holding up my pelvic model, we're looking at the pubic bone and going just lateral to it and there's a, I like to think of it like they're two skull eyeballs, but anyways, there's a big old hunk of muscle that's in red here and that is the belly of the obturator internus. And then it has this really cool tail that actually whips out and takes a 90 degree turn to then connect onto the top of the femur or the top of the leg. Due to this unique deep parking spot within the pelvis, it can affect both the function of the pelvis and, or pelvic floor and the hips. So in terms of function, we'll go over three major functions of the obturator internus. Number one is it can externally rotate the hip when the hip is extended. So like when you're standing, it can abduct the hip when the hip is flexed or when your leg is raised up like you're marching. And then it also has a key role in stabilization of the femoral head or the leg into the acetabulum. So especially during weight bearing and propulsion. Based on a study in 2017 that looked at female cadavers, the, they, I love the phrase that they used in this article, they called it the architectural design of the obturator internus is affected by aging. In that, in their study, they found after the age of 60, both the force generation capacity and the fibrotic nature of the OI muscle is reduced. That's so interesting. And what they suggested in that article was maybe we should be focusing a little bit more on functional upright movements that have the leg and weight bearing as that tends to be when the obturator internus is more in a shortened position. So maybe we can generate some greater functional capacity and strength in that position versus our typical non-weight bearing exercises like maybe a clam. In terms of impairments, the OI will often step up to the plate and compensate to stabilize the pelvis when other muscles like the glutes or abdominals are a little on the weak side. You can also develop just like any other muscle, any sort of muscle banding, knots, and it rare if it's rarely lengthening or relaxing. And so all of that is definitely going to result also in some reduced range of motion and then reduce blood flow to this muscle, to this area and its surrounding nerves will definitely contribute to a cranky OI, which then may lead or lend towards hypersensitivity when that OI muscle is palpated. And we can palpate it externally near the ischial tuberosity as the obturator internus actually lies just on top of the ischial tuberosity, similarly to how the subscapularis lies on the underside of the scapula. So it has that similar kind of bony muscle contact. Or you can palpate this muscle intra-vaginally or interactively. And there are so many times during my sessions, if I'm doing a pelvic floor assessment and I roll over to the obturator internus that the shock and maybe relief of the person on the table is paramount. They're like, oh my goodness, that's the pain that I have during deep penetration. Or that actually just brought on some urgency for me, some urinary urgency. That's the feeling that I get randomly. Or that's the pain that I have when I'm sitting and it's been hard for me to describe it to you. So it's super powerful being able to palpate this muscle and just help bring some validation to your client who's like, I just don't know where this pain is coming from. And then due to its many functions and that unique anatomical location, the OI is capable of referring to lots of areas. So sometimes it'll kind of act like a chameleon. One day, you know, it's referring pain to the hip. Maybe one pain is referring pain if someone's pregnant to the round ligaments. So other soft tissue areas that you should be screening if you're looking at the obturator internus muscle would be the hamstrings like we talked about, the adductors, big, big relationship between obturator internus dysfunction and then the pelvic floor, specifically the levator anion muscle group, as well as the coccygeus. And then not to mention just muscle structures, but another nerve structure that would be super helpful to have on your hypothesis list that may be affected if the OI is cranky is one of its best mates, the pudendal nerve. So the pudendal nerves is going to support sensation in your urethral and anal sphincter function. So along its path, the pudendal nerve is actually surrounded by some obturator internus fascia. And that goes along alcox canal, which is on the border of the obturator internus. And it provides a really large opportunity for entrapment of that pudendal nerve, which then could lead to some possible pain and dysfunction. So the obturator internus, I like to think about it like a nosy aunt who has her nose in everybody's business and the family, all the hot goss. So because of that, it is involved in so many different conditions. And these are a few things that you may hear from your clients in terms of aggravating factors. So they may talk about, hey, I just have this ton of discomfort when I sit for a long time. Or I just got my peloton and I actually have a lot more discomfort now because I've been cycling quite a bit. And we're saying this, but maybe you will have already screened out the tailbone. deep penetration or sexual play like I chatted about. And painful or tight hips, urinary urgency, frequency leakage, SI joint tenderness, difficulty or difficulty with description or pinpointing some sort of pain or pressure that's deep within the pelvis, deep within the vagina. Or sometimes people will often say, I have pain that is, it just feels like I have a golf ball in my rectum. So these are all things that I want you to keep in your mind when maybe thinking about could this be the obturator internus muscle. From a trauma standpoint, the OI can be injured in posterior hip dislocations, again, just because of where it's at with from an anatomy standpoint. It can also be involved in acute or overuse strains from sports like kicking, tackling or falling. Falling, usually this is in young males. And then sometimes the obturator internus can be strained in conjunction with adductor longus strains. So in summary, if you have clients that are coming to you that are describing some pain up in that region where you may not be used to screening or palpating for in the nether regions and they point towards this yield tuberosity and you're like, just stay there, don't go higher. I want you to think about thinking outside of the hamstring adductor strain box and be sure to include the obturator internus in your hypothesis list. Due to its unique anatomy of living inside the pelvic bowl, but shooting a little leg out to the side or a little tail out to the side to attach to the femoral head, the obturator internus muscle is sneaky. It's involved in so many different pelvic and pelvic floor and hip conditions. We talked about pain with intimacy, prolonged sitting, bladder urgency, frequency, just to name a few. And if this is describing your hip pain or if you're dealing with a client who isn't responding to traditional PT, consider reaching out to your local pelvic health PT to help screen for pelvic floor dysfunction. I actually have a really close relationship with a lot of the ortho-PTs in my area who don't have an interest in treating the OI, but they've learned how to screen for it from me and they now refer out to me and nine times out of 10, they are spot on with calling that obturator internus as being a contributor to their client's pain. And then better yet, for the PTs out there, come on out to our live course so that you can learn how to palpate and master and learn techniques for external and internal palpation and treatment of the muscle. So learning how to screen for this muscle will be such a game changer for successfully your clients with this hip and pelvic pain without you needing to refer out. Thank you all so much for being here. We appreciate you. Hopefully you don't have any pain in the butts on the schedule, but if you do, at least you're armed now with which other sneaky muscle that could be contributing. Happy Monday and I'll see you next time. 17:02 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 14, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com https://pubmed.ncbi.nlm.nih.gov/34852731/ https://pubmed.ncbi.nlm.nih.gov/33630675/ https://pubmed.ncbi.nlm.nih.gov/32023545/ https://pubmed.ncbi.nlm.nih.gov/34770213/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493260/ https://pubmed.ncbi.nlm.nih.gov/31869820/ In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines heat-based recovery including hot tubs, whirlpools, and saunas. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show. 01:32 ALAN FREDENDALL All right. Good morning, team. Welcome to the PT on ICE Daily Show. Happy Friday morning. Hope your Friday's off to a great start live here on YouTube and Instagram, everywhere you get your podcasts. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and a lead faculty in our fitness athlete division here on Fitness Athlete Friday. We consider it the best start day of the week. We talk all things CrossFit, Power Lifting, Olympic Weightlifting, endurance athletes, running, swimming, cycling, all that sort of thing. So if you're interested in working with the recreationally active patient or client, Fridays are for you. We're going to talk all things heat based recovery today. We spent two weeks ago talking about cold based recovery. So it'll be a nice change of pace on the opposite side of the spectrum. Before we get started today, first of all, I want to say big thanks to our friends at FIRE, Foraging Youth Resilience for having Jeff, our CEO, and myself out this week to their annual camp outside of Boulder, Colorado. Huge fun getting to know a lot of the kids, the campers, as well as a great network of coaches, games athletes, all sorts of wonderful people from the CrossFit space coming together to help support FIRE. It was great to meet everybody out there. If you want to learn more about FIRE, you can read more on their website. We're big supporters of FIRE here at ICE. So you'll continue to see us have more opportunities to help get involved with FIRE and support FIRE as time goes on. Some courses coming your way from us in the fitness athlete division. If you're looking to catch us out on the road for clinical management in the fitness athlete live, that's our two day live seminar. Your next chance will be September 9th and 10th. That's going to be out in Bismarck, North Dakota with Mitch Babcock. And then you can catch the same month at the end of September, September 30th and October 1st out on the west coast. Zach Long, aka The Barbell Physio, will be out in Newark, California. That's in the Bay Area of California. And then online, our clinical management fitness athlete essential foundations, our eight week online entry level course into the clinical management fitness athlete curriculum. That will start September 11th. That's taught by myself, Mitch Babcock, Kelly Benfee and Guillermo Contreras. And then the next week after our level two online course, clinical management fitness athlete advanced concepts start September 17th. So you can learn all about that at ptenice.com. That's where everything lives that you want to know about ice. So today's topic, heat based recovery. We have talked about cold based recovery, specifically two weeks ago here on fitness athlete Friday. We talked everything regarding cold plunges and cold based recovery. We're going to go to the opposite side of the spectrum now and talk about heat based recovery. So the big summary from if you didn't catch us two weeks ago, the big summary from cold plunging is that we really want to avoid it after exercise. It seems to really have an effect on that post exercise inflammation effect that we want to build strength, build hypertrophy. It does have some benefits, but we mainly want to avoid it after exercise. You're going to see a recurring theme here with heat based recovery. But I do want to start by first of all, defining what is heat based recovery, talking about the differences between things like hot tub or whirlpool. Differences between you may have questions about infrared versus traditional sauna. And then I want to talk about some of the research supporting the use of heat based recovery, but also the application of it both in the clinic. And when you're discussing these topics in the clinic or the gym with your patients or athletes. So let's start first by defining it. What is heat based recovery? We have a couple different types. The first is what we'll call hot water immersion. This is basically the opposite of cold water immersion or cold plunging. This is where you get in a hot tub or a hot bath or a whirlpool machine, some sort of hot water immersion. Now defining temperatures here is really important. We did that two weeks ago with cold water immersion. Really important to note that at least from the research, we have specific temperature ranges that we're discussing with all of these modalities. And we're also assuming that you have your whole body immersed in something like a sauna. Or that if you're in hot water, for example, a hot tub or a hot bath, you're immersed at least up to the level of your neck. A lot of what we're going to talk about doesn't apply to you if you're somebody that just sticks your your foot in the hot tub. Or doesn't otherwise get fully immersed in whatever modality you're using. So two different types of hot water immersion, hot tub or hot bath. When we're at home and we run a bath, when we look at what is the temperature of what the average human being might consider quote-unquote hot. A hot bath is right around 100 degrees Fahrenheit. And that your average hot tub is not too different. A hot tub that you might get into is going to be somewhere between 100 to 110 degrees Fahrenheit. But now when we look at this from a research perspective, it's usually tightly controlled and it's usually tightly controlled a little bit hotter. So when they look at hot tub whirlpool type immersion in the research, they're looking specifically at a temperature range of about 110 to about 120 degrees Fahrenheit. So if you're somebody that really hates a hot bath, if you run a hot bath and you wait for it to cool down a lot, then just know this is going to be on the upper end of your temperature comfort. Why this matters is that when we add that that circulating bubble component to a whirlpool, to a hot tub, it seems with the water continuously moving that it makes that hot water immersion just a little bit more tolerable and therefore they bump the temperature up a little bit. Again, 110 to 120 degrees Fahrenheit. And again, immersion in a hot tub whirlpool up to the level of the neck. Now duration is really important. We talked about that with cold plunging. That if you're somebody that gets in for a minute, you probably don't have to worry about the positive or the negative effects because you're really not doing it. The same is true here. When we look at hot water immersion, when we talked two weeks ago, we talked about humans have a really great tolerance for heat at rest. We can sit outside 70, 80, 90, maybe even 100 degrees, especially if we're in some shade and we can be okay. We don't have a great tolerance for cold at rest. And we see this carry over into hot water immersion that because we're so much more tolerant to heat, we see duration for hot water immersion a lot higher. We often see duration 15 to 30 minutes in a whirlpool in a hot tub. Maybe you've been at a hotel or a resort or something. You've seen that sign. We've all seen that sign on the hot tub. You know, don't stay in here too long. Max time 20 minutes, 30 minutes. That tends to be our tolerance for hot water immersion. So somewhere between 15 to 30 minutes, but definitely longer than what we're used to seeing with cold water exposure where the general recommendation usually never exceeds 10 minutes. Now getting into sauna, temperatures are going to go up. We're no longer actually sitting in water. We're usually sitting in a room that is either steam heated or dry heated. Those also have different temperature parameters when we look specifically at how they're studied in the research. Traditional sauna, whether it's dry or a steam sauna, is a lot hotter. 150 to up to 220 degrees Fahrenheit. Infrared sauna is going to be lower, 120 to 140 degrees Fahrenheit. And again, the duration for sauna is going to be higher, a lot like hot water immersion. Somewhere between 30, maybe even to a 90 minute dose, and that's going to be mostly for infrared sauna. That would be really tough to do in a traditional sauna. So that's how we define hot water immersion and also what we would call just sauna, sauna protocol, traditional or infrared. Now the research. I want to share a couple of different papers with you as we get into talking about what does the research support? What does it not support? Talking back to hot water immersion. So again, our hot tub or our whirlpool protocols. A great paper from 2022, the Journal of Sports Science. More and more Gamino and colleagues, pardon me butchering that, looking at hot water immersion. They took folks and they had them sit in a whirlpool for 15 minutes at 110 degrees Fahrenheit. They also had another group sit in a cold plunge at 50 degrees Fahrenheit and they compared outcomes on the quadriceps muscle. They wanted to look at specifically the contractile properties of the muscle itself and found that the group sitting in the hot water after exercise had increased contract properties of the quadricep muscle compared to the folks who did cold water immersion and compared to the folks who did nothing, who sat at a room temperature room. So the the effects of hot water immersion appear to have a more beneficial effect on our muscle and we'll get more into that as we get more into the research. My next paper, really old. I love some of these old papers that just show how long we've been studying this stuff. Francisco and colleagues back from 1985, so before I was even alive, Journal of Applied Physiology. Looking at the use of hot water immersion and comparing it to basically an active recovery protocol. So two groups of subjects, one group exercising at 60% of their VO2 max. So essentially an active recovery spin on a cycle or a really really really low slow jog, something like that. To a group that did an hour in a whirlpool at 105 to 110 degrees Fahrenheit. And then they did a crossover here. So they took both groups and then flipped them a couple of days later and had them repeat the same thing. What they found in the group who sat in the hot tub for 60 minutes is they had an almost identical cardiovascular change. So they had an increase in their cardiovascular output and their mean arterial pressure, which just kind of tells us that there is a cardiovascular demand on the body when you are exposed to heat that mimics low-level active aerobic recovery type exercise. So what does that tell us? That tells us that first of all if we are looking for a recovery day that a longer hot water immersion or maybe a sauna can be a viable option in place of a recovery workout that we're going to get some increased cardiac output. Our heart rate is going to elevate. We know being exposed to heat we're definitely going to sweat. That's going to come on board no matter what. But we're going to see blood pressure changes as well. That tells us we're kind of getting a flushing pumping effect when we're exposed to heat specifically in this study hot water immersion compared to if we went to the gym and just spun on our bike or went for maybe a really long walk or a really slow jog or just some sort of active recovery exercise that they appear about equal. Which is great if that's what we want. If we're trying to limit cardiovascular load, if we're trying to limit volume on our body then we need to be mindful that a longer duration hot water experience can have that effect on us. So it appears to be about an equal effect, which is nice. The next study here, Borg and colleagues from 2020, the International Journal of Sports Physiology and Performance, looked at hot water immersion versus cold water immersion versus control. Specifically they had these folks do these modalities after cycling in what they called hot weather, 75 degrees Fahrenheit. So they went for a long bike ride in the heat and they came back. They threw one group in cold water immersion in the cold plunge. They threw one group in hot water immersion, a whirlpool, and one group just sat at room temperature. And they found that those exposed to the hot water immersion were more likely to report that the session they had just performed, the cycling session in the heat, was easier. And they also had a lower cardiovascular response to those who had a cold water immersion. So it seems like when we're cooling down we want to choose heat as it's easier on our body, easier on a cardiovascular system than finishing a hot workout in the heat. It sounds great. We've all had those workouts. I just had one two weeks ago where we literally want to stick our head in the sink, which is exactly what I just did, and just cool down our head. That seems like what we want to do, but we know that can have sort of a shocking effect on the body compared to if we ease ourselves out of the heat with maybe not exactly what we just did in the heat, but we choose something that's going to feel temperature neutral compared to what we just did, which was a really tough workout in the heat. Heat exposure after exercise, especially in the heat, seems to have a beneficial effect as we're trying to cool back down to baseline. Now switching gears and looking at the sauna research. So this is just as popular as everybody wants to know about cold plunges. Everybody wants to know about sauna protocols. If you listen to anything about Andrew Huberman, you have been blasted with more information than maybe you've ever wanted to know about the sauna. But I want to pick just a couple papers here looking at sauna exposure, specifically after exercise. So Bezoglav and colleagues 2021 International Journal of Environmental Research and Public Health. This is a great study. This doesn't actually research anything on sauna protocols itself. I love this study. This is basically a patient expectation, an athlete expectation of what athletes expect will help them recover and what they actually choose when they are performing their recovery. And it's just really important to know this paper in the back of your head. That 97% of athletes surveyed use sauna as their number one choice for recovery. So that's really important for us to know. We have to be able to speak intelligently about good, bad pros, cons about sauna with our athletes knowing that 97% of them are thinking I'm not feeling great. I'm feeling banged up. I am going to choose sauna as my number one recovery protocol. And we know this from physical therapy research. Massage is also popular. Not surprising. It's popular with athletes. 87% of athletes choose massage as their secondary recovery protocol. And then 80% choose taking a nap, third. So in that order, sauna, massage, and napping. So that's a really important paper to know. Miro and colleagues from 2015 in Springer Plus. This is an online open access journal. Looked at comparing folks doing infrared sauna, traditional sauna, after performing either hypertrophy focused resistance training for 60 minutes or endurance training. So they basically wanted to create a bunch of muscular damage and then have folks either get in an infrared sauna or traditional sauna. This study also had a crossover design. So the objective outcome here was a counter movement jump test and then also effects on the cardiovascular system. So that traditional sauna was performed at 122 degrees Fahrenheit for 30 minutes. The traditional sauna was performed at 70 degrees Fahrenheit for 30 minutes. And again, both groups exercise really hard for an hour. The traditional sauna group saw a reduction in performance on the counter movement jump after sauna protocol compared to the group using the infrared sauna. The traditional sauna group also had a significant spike in their heart rate. About 30 to 40 more beats per minute resting while sitting in the traditional sauna than the group sitting in the infrared sauna. So again, like we talked about a couple papers ago with environmental exposure, it seems like using sauna, specifically a really hot traditional sauna after exercise, seems to have a negative impact on our system. Of it's just too much heat load, it's too much cardiovascular load. It can lead to both negative performance outcomes, but also negative physiological outcomes. Supporting that, Skorsky and colleagues from 2019 International Journal of Sports Physiology and Performance. This group was looking specifically at performance. They had swimmers perform 4x50 meter sprints. I don't know anything about swimming. I assume that's a tough thing to do to do 4x50 sprints. Afterwards, the swimmers were either put in a group where they sat passively at room temperature. For 25 minutes or they did three eight minute rounds in the sauna, a traditional sauna at 185 degrees Fahrenheit. And then they had those athletes come in the next day and repeat the 4x50 swim performance. All of the subjects who used the traditional sauna after the sauna reported a stressful experience, both physically and mentally. And then the next day all of them had impaired performance when they went to repeat the 4x50 swims compared to the group that sat at control. They obviously did not report sitting at room temperature as a stressful experience. And they all performed better at the 4x50 than the sauna group. So it appears that longer duration, hotter traditional sauna seems to have a more negative impact on recovery. So what does this tell us? What does all this research tell us? How can we apply this with our patients, with our athletes, when they're asking questions about sauna? Maybe they're already using a sauna protocol. So as we talked about two weeks ago, cold water immersion, cold plunging appears to have a really negative impact on performance and recovery when used directly after exercise. Compared to hot water immersion, whirlpool, hot tub used after exercise. And it also really seems to affect our ability to adapt to the heat. So the takeaway here is that if we're just finishing exercise, maybe traditional sauna, especially for a longer duration, especially for a higher heat duration, is maybe not the modality of choice. Just like a cold plunge is maybe not the modality of choice. Which is not to say we can't use heat as recovery modality. But if we're thinking we just finished training, we should look towards that hot tub. We should look towards that whirlpool. We should maybe look towards that active recovery. And we should save a really long, hot traditional sauna or a cold plunge for maybe before training earlier in the day. Or what we don't have research on yet is what is that window? How much time difference between training and using a really hot sauna or using a cold plunge is still going to allow us to feel better recovery wise but not have those negative effects on performance. We don't know that yet. But for now what we can recommend is stay away from that cold plunge. Stay away from that really hot, long duration traditional sauna about right after training. Give yourself a gap. Again, we don't know how long. Or do it earlier in the day sometime before you actually start your exercise protocol. We do know that both hot water immersion and infrared sauna offer cardiovascular effects that are similar to active recovery. So if we really are not feeling like exercising today, if we're really feeling like we need a day off, we can still have some positive health benefits from going and getting in the sauna. Especially something like an infrared sauna or sitting in a hot tub for maybe 10 to 30 minutes. But we really need to consider avoiding that long duration traditional sauna. It appears to have a big effect on our cardiovascular system. It's adding a training load. It's adding a heat load to our body that's going to cause our body to need to adapt to that stress. So big term takeaways. There's no shortcut, right? What we're seeing in the research with both cold water immersion and hot water immersion, there's no shortcut here. We need to allow the body's natural inflammatory response to the exercise that we just did occur if we want to reap the benefits of that occurring. Yes, these things can help us feel less sore. Yes, they can help us feel less fatigued. But if we use them too much, they do seem to have a long-term detrimental effect on our performance. Which kind of defeats the purpose of going in and doing a hard workout, a long run, a long bike, a long CrossFit session, a long weightlifting session, whatever you're doing. If we chronically use these things, yes, we might feel better. But we need to be concerned that maybe we're leaving something on the table as far as strength, as far as hypertrophy when we use these kind of extreme temperature modalities, cold plunging, really really hot sauna. I could imagine that one study that showed a really detrimental effect was only 185 degrees. Some traditional sauna protocols in the 200s. I know Jeff Moore does the sauna at 205 degrees, I think for 15 minutes, which is even more of a heat load than 185 degrees. So just be aware of that and understand how to speak about these things with your patients and athletes because they're going to have questions about it. Remember that paper? 97% of people look to sauna is the first choice for a recovery modality and then massage and then taking a nap. So 97% of people could use probably more education on sauna because we know they're thinking about using it. So I hope this was helpful. We have an entire week in clinical management fitness athlete essential foundations dedicated to this now. We talk all things nutrition, sleep, we talk cold water immersion, hot water immersion. We also talk about compression therapy. So things like massage, massage guns, cupping, all that sort of thing. We discuss all of that research that your athletes, your patients want to know about when they come into the clinic and ask about recovering from exercise. So I hope you have a wonderful Friday. I hope you have a fantastic weekend. Thank you for joining us. Have a good day. Bye everybody. 22:33 OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 13, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses that the decision to innovate or imitate is a career-defining choice with long-term implications. The host emphasizes that while collaboration and sharing of ideas are common in any field, blatant imitation is detrimental to one's career. The host distinguishes between collaboration and imitation, stating that imitation involves repeatedly hijacking other people's logos, sayings, or content. The episode provides three reasons why being an imitator ensures a mediocre and short-lived career. Firstly, the process of creation, coming up with something new and contributing in a unique way, is described as the most invigorating aspect of any career. The host emphasizes the satisfaction and impact that comes from thinking differently and having others benefit from one's novel ideas or techniques. Secondly, the episode highlights the importance of authenticity in career success. The host suggests that imitators may experience imposter syndrome because their success levels do not match their actual contribution. They are described as grabbing ideas from others, recognizing what will resonate with their audience, and building their business without truly creating or going through the challenges that lead to breakthroughs. The more their success grows without a true contribution, the greater the asymmetry and imposter syndrome. Lastly, the episode emphasizes the value of continuous creation and innovation for a long-lived and energetic career. The host encourages listeners to keep creating and strive for novelty and harmony in their careers. It is emphasized that the decision to innovate or imitate is a defining one, and individuals should aim to put forth their authentic selves rather than copying someone else's. Overall, the episode argues that choosing to imitate instead of innovate can lead to a mediocre and short-lived career. On the other hand, embracing innovation and creating something new is described as invigorating, authentic, and essential for long-term success and fulfillment. Take a listen to today's episode. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 JEFF MOORE Alright team, what's up? Happy Thursday, welcome to the PT on ICE Daily Show. I am Dr. Jeff Moore, thrilled to be your host, currently serving in the role of CEO here at ICE. It is Thursday, which means it's Leadership Thursday, but it also means it's Gut Check Thursday. Let's talk about the workout. This is going to be familiar to a bunch of you. So this is the workout from the CMFA Essential Foundations Course 21-15-9 Deadlifts Bar Facing Burpees. Quick, painful. Go get some of that. Post your time, post ICE Physio, hashtag ICE Train, hashtag Gut Check Thursday. It's a classic workout, we've done it a lot. It's a really nice benchmark one to challenge yourself in that kind of middle distance, high intensity space to keep coming back to every year and see how your fitness is evolving. So give that a shot. 21-15-9 Deadlifts and Bar Facing Burpees. Upcoming courses, I want to highlight Modern Management of the Older Adult Live because we've got a ton of options. So if you're trying to become the fitness for provider for your older adults in your community, you've got to hit the MMOA Live course. This weekend, they are in Watertown, Connecticut. Next weekend, July 29th, 30th, they are in both, Waukonson's, Georgia and Meridian, Idaho. That'll be the first, that's in Boise. That'll be the first course, I believe, at Onward Boise. So go get some of that. And then August 5th, 6th, they are at Onward Physio in Frederick, Maryland. Important to note, August 12th, 13th, they are in Lexington, Kentucky, and that is at Stronger Life, and that is the MMOA Summit. So if you want to meet all the MMOA faculty, they're going to be at that one course, August 12th, 13th, and that's at Stronger Life. So if you want to see the Stronger Life operation that Dustin and Jeff and the crew have been building out in Lexington, that is a really, really cool opportunity to kind of see behind the curtain and meet a ton of faculty. So go check out those courses. That's Older Adult Live on the road everywhere. So go get some of that action. Innovation or imitation, the career-defining decision. That's what I'm calling this episode. And I am not saying that lightly. I think if you really zoom out, and if we're talking leadership here on Thursday and thinking about looking long, long term at your career, if you decide to innovate or if you decide to imitate is probably the great decider. I mean, let me tell you the three biggest reasons why. But let me first note that we're not talking about sharing ideas, building off of each other, sharing techniques. There is a very reasonable amount of collaboration that is not copying an imitation. We're talking about blatant imitation, right? Where you know who you are, that you're hijacking other people's logos or sayings or content on the regular, right? Over and over again. I mean, if you scroll your feed, it's like you're obviously doing this. You've probably been reached out to. And then on the other hand, many of you probably have your own imitators, right? Where you look and you're like, gosh, that person's always taking my stuff and trying to put a very lame or benign twist on it. But it's pretty obvious what's going on. That's what we're talking about. Being that person, being in a position where you've got that person tailing you, we're going to unpack both sides of it. There's only one line on being imitated, many lines on being the imitator. So three reasons why being an imitator ensures a mediocre and short lived career. Number one, creation. Coming up with something new. Feeling like you really contributed because you saw something a different way or said something a different way and other people legitimately benefited that would not have if you didn't create that process is the single most invigorating thing in any career. That process of thinking differently, of contributing something novel, of having somebody come up to you and say, Hey, because you said it that way, things have really gotten better for me. I hadn't heard it like that. I hadn't thought about it like that. I have not used that technique. And now because you did that, things are better off in my sphere. That process of creation is the single most rejuvenating thing in any area of business. When you look at entrepreneurs, you look at people who are constantly high energy, are constantly seem to be thriving. It is largely because they're tapping into that creation energy on the regular and it gives back three times what you give it. That process of doing things novel and useful is what extends careers. It's what makes careers exciting. It would make it so it makes you get up in the morning and be absolutely beside yourself to dive into that next project. It's what builds anticipation for the next year of business. It is all of the things that constantly give you energy back that make burnout sound like a ridiculous idea because you couldn't imagine ever wanting to stop riding that train of creation. Creation is invigorating. And if you're copying, you're not creating. So you're never getting that energy back. And there is simply a timeline for how long you can go without it. Number two, this is the one that people don't see when they feel like taking other people's ideas is a viable way to continue their business. It's not. And this is why you can't build on a foundation you didn't pour. I'm not saying you can't go take the idea and put it on your platform and get a few likes. You can do that. You can get a short term bump in your business. There'll be plenty of people who didn't know you did it. Like you can do that, but you can't build on it. One breakthrough and by breakthrough, I mean the process of the breakthrough. When you were thinking about a certain idea and you realize in the moment, hold on, there's a better way to do this. There's a better way to say this. There's a better way to build this. That process, that breakthrough, having that moment changes you. Like it really changes you because not only will everybody that you told think a little bit differently or be able to use it novelty, but you changed because your mind saw a different pathway. That change is what's required to make you different, to see the next thing. When you're going through the hard work of trying to make something better and having that breakthrough, that process of when it happens is what allows you to see the next one because you're now different for having had that breakthrough. If you're just hijacking ideas all the time that sound good or look good or think might get you some business, you're not actually changing. You're not developing. You're not going through those breakthroughs. So you're not going to have the next one or the next one. So pretty soon your only option is imitation because you're not doing the work of creation. You can't build on a foundation you didn't pour. Other people's ideas being on your platform does not make them yours from the sense of you are not different for having come to them. So there is no way now that you're going to be able to go from there because you didn't even really get there. So think about how hijacking that process prevents your ability to look even further. The final one, and I don't speak all that much on this topic because it kind of annoys me, but it's important to acknowledge this is where imposter syndrome I think actually comes from. The worst cases of what you would call imposter syndrome, a complete lack of authenticity in an individual in a certain position that maybe didn't earn it, you can kind of feel that, that case of imposter syndrome, the worst cases are when somebody's, and I'm those listening on the podcast, when somebody's success levels don't match their actual contribution, and this is the case of the imitator, right? So somebody who's grabbing ideas from other people and they're catchy ideas, right? They're good at recognizing what's going to resonate with their audience, grabbing ideas from other people, putting them out on their platform, never really creating, never really never going through kind of the trough of challenge that leads up to a breakthrough, never experiencing that, just hijacking ideas and quote unquote building their business. The more their success grows in the absence of a true contribution, the greater that asymmetry, the greater the imposter syndrome. And the problem is the momentum only goes in one direction because like I said, once you start imitating, you're no longer changing, so you can't make the next step forward, so you're never going to. So all you're going to wind up doing is put yourself in a position where people think that you know a lot of stuff or have done a lot of the work when you know you haven't. And the more quote unquote successful you get, a lot of people knowing of your work and maybe even financially benefiting from it, but the more deep down you know you haven't really done any of it, the greater that asymmetry, the more fragile your steadiness in that space because of the absence of authenticity. You know deep down you haven't earned that success and the more that asymmetry grows, the more other people can feel it. The phonier it feels, the more it lacks authenticity. And team, as we talked about over and over again on Leadership Thursday, authenticity realness is at the end of the day, what people really resonate with long term. And you will have less and less and less of that every year, the asymmetry of what it looks like, you know, and what you've actually contributed grows. That is an exhausting place to be. Nobody likes that feeling of I'm going to be exposed. Nobody likes that feeling when it's getting worse and worse and worse and worse every year. It will eventually overwhelm that person. And that's what brings me to the last point of this podcast. For those of you out there who are doing the hard work of creation, who feel like you're often being imitated by that person in town, by that person online, whatever, right? You feel like gosh, I really thought that, you know, I put a lot of effort into that and it kind of got hijacked, right? And you're feeling that chronically. You're not. Because those individuals always succumb to the above. They can't have longevity because creation isn't filling their cup. They can't jump from a foundation they haven't built. And every time they do that to you, their imposter syndrome grows. They know it was your work. They know they didn't and couldn't have thought of it. But they also know other people think they did. And the more that asymmetry grows, it has a breaking point. They never have longevity in the space. So stay in your lane and drive fast. We know how frustrating it can be, right? We know how exhausting it can seem at times. But understand that because of the above, every single one of those people's careers will be short lived and fizzled because all of the above are fixed equations. There's no getting out of that stuff. It's the wellspring of what a long lived energetic career can be. In the absence of those things, it simply can't be. So for those of you who feel like your work is being ripped off, let that be kind of a statement of confidence that I promise you because of all of the statements above, that will be a temporary discomfort for you. Keep creating. Team, innovation or imitation, it is the career defining decision. Do the work to try to come up with novel things that excite you, that excite others, that bring harmony into your career because you're actually putting forth your authentic self, not somebody else's authentic self. Do it right. You only get one shot at it. Cheers, team. I hope that helps on Leadership Thursday. I will see you over here next week. PT on ICE.com. It's where all the goods live. Have an awesome Thursday. 13:18 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at PT on ICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE.com and scroll to the bottom of the page to sign up.

Jul 13, 2023

Christina Prevett // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Christina Prevett discusses the significance of research in the field of physical therapy is along with the importance of translating that research into evidence-informed practice. She acknowledges the substantial nature of their research and highlights the necessity for clinicians on the front line to have access to this valuable information. Staying up to date with available evidence and combining it with clinical expertise and patients' experiences and desires is emphasized as crucial for clinicians. The episode also addresses several gaps in research that need attention, including the need for rehab research for individuals in sitting positions, outcome measures for wheelchair users, and managing conditions in neurological populations. The host expresses frustration at the lack of clinically relevant outcome measures for wheelchair users and emphasizes the need for research to support the role of rehab in enhancing quality of life and managing various conditions. Overall, the episode underscores the importance of research in informing and improving physical therapy practice. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT omn ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody.Enjoy today's show. 01:33 CHRISTINA PREVETT Hello everyone and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty in our geriatrics curriculum. So in our geriatrics curriculum, we have three courses in CertMMOA. We have our online eight-week essential foundations course, our online eight-week advanced concepts course and then we have our live course. We are on the road in the summer and into the end of 2023. So our books are closed for 2023. So we have all of the courses that are going to be on the 2023 calendar on the calendar. And so if you are looking to get into one of our courses, know that there isn't going to be an option for something closer until we're kind of booking for 2024. So this weekend, Julie is going to be in Watertown, Connecticut. And then the next weekend, 29th, I guess it will be two weekends, 29th, 30th, I'm in Watkinsville, Georgia. There's still some room in those courses. And so if you guys are interested, just let us know and come hang out with us for all of our geriatric research and all of our geriatric course material. Okay. In today's content, on Monday, I talked about gaps in pelvic health research. So I'm on our pelvic faculty as well. And so today I'm going to take the exact same approach and talk about gaps we see in the geriatric research. I am obviously in full blown research prep mode. I am defending my PhD on resistance training in older adults, at risk older adults at the end of July. So you're going to see me full blown in the research space. And so hence the topic of these podcast episodes. When we are comparing different areas of literature, and we're talking about geriatric rehab in particular, one of the things that I want to start out with is that the state of our research in geriatrics is actually pretty good. You know, we are pretty far ahead when it comes to comparing to other areas. Like when I compare to pelvic health research, there is no comparison. I can off the top of my head bring out 10 studies that have never actually even been done before in our pelvic health research, but I cannot say the same thing in geriatrics. I had to really, pardon me, I had to really think about where I thought our gaps were. And obviously I'm thinking about this around my contribution to the literature with respect to my PhD. So the first thing that I wanted to talk about is the fact that our research is pretty good. You know, we have a lot more in this space and now we're kind of going into the nuance of our rehab and how to translate the research that we do have so that clinicians who are on the front line have access to that research and can really truly embrace evidence informed practice where they are up to date with the evidence that is available. They're taking their clinical expertise, they're taking their patients experience and desires and kind of combining them together. So that's the first thing. So I'm going to be talking about four, three or four different gaps in the research that we have so far and what this means when we are making recommendations or we are thinking about them with respect to our plan of care for our older adults. So the first thing, and I'm on, this is my bias because this is where my PhD was, was we have very few studies that have looked at high load, low repetition weight schemas for resistance training with older adults. We have one that I can think of maybe two studies and the second study is kind of an ish because it had a descending rep scheme where they use less than five repetitions and higher loads. My PhD tried to change that. I did two pilot studies that looked at the safety and feasibility of a three sets of three to five repetition schema at an intensity of seven to eight out of 10. So that high vigorous intensity, high load, low repetition resistance training. And so it's important for us to know this, right? We don't have this research. And when it comes to the way that we work in geriatric literature is that we see what works in our younger or middle aged individuals. Then we push into our healthy older adults and then we push into pathology. Right. This is the story that we saw with high intensity interval training, for example. Right. We saw that it worked in athletic populations. We started pushing the intensity into HIIT training in middle age, healthy older adults. And now the state of the literature, we cannot even deny it because we have evidence for HIIT training in a variety of different pathologies, multimorbidity, obesity, different age groups, et cetera, which is great. We don't have that yet when it comes to geriatric literature in this high load schema. What we see from a muscle physiology perspective is that the magnitude of strength increase tends to bias heavily towards heavier weights. See the one that I did there versus lower weights, higher repetitions. When it comes to individuals who are doing nothing and they start doing something, of course, we're going to see improvements in strength at any set reps. But the magnitude of those differences tends to bias when our loads are heavier. Because we don't have anything in the under five repetition schema, we see this reflected in our exercise guidelines. Right. Why are our exercise guidelines the way they are? Right. Two to three sets, eight to twelve repetitions, 60. Now we're kind of pushing into that 70 to 79 percent of a person's one repetition maximum is the standard exercise prescription that we're seeing out of the American College of Sports Medicine. We saw it in the International Conference for Frality and Sarcopenia Research consensus statement. And this is because that is where the vast majority of the literature goes. And this is where this momentum can build around two to three sets of 10. Right. Because we've always done it this way. There's a good chunk of literature that's there and we don't have anything on the flanks. Right. We don't have anything in under five. We don't have a ton in the 20 plus. And when we get into the higher repetition ranges, now we have this interference that can happen between cardiovascular fitness and neuromuscular fatigue. And which one is the one that's breaking down first or is the limiting factor? All of this to say. When we don't have those discrepancies, we have to be mindful, one, about the strength of our recommendations, but number two, we have to be pushing towards trying to get studies that evaluate this type of loading schema so that we can take a big picture view and then really start to look at dose response data. So that's number one is that we don't really have a ton of studies that look at repetitions less than five and kind of my one B is that this influences things like our exercise guidelines and not in a good or bad way, just a we have to use what's available. And that's why things are the way that they are. The second one is going to kind of be a blend of pelvic health because we in advanced concepts, we go through in week five urinary incontinence and pelvic health issues and geriatrics. And I've talked about this a bunch on the podcast before. But we have very little evidence that's looking at conservative management of pelvic floor dysfunction for individuals over the age of 65. And we have almost nothing when we look at individuals over 75 or 80. Urinary incontinence is one of the leading causes of institutionalization. So where individuals need a higher level of care, end up in assisted living, end up in institutionalized setting is because of issues with urinary incontinence. That should be justification enough that that we need studies in this area and kind of this one B or two B to C type of step down is we don't really have a ton on pelvic floor muscle training in older adults. We have some. It's not a ton. Oftentimes, our older adults are giving are given medications that influence their urine flow rate, whether that's directly with medications being given to work towards helping with kidney function or things that are given as a consequence of having urinary incontinence that change urinary flow and urinary output. A big example that has nothing to do with either of those things, but is actually a side effect because this is the second classification is individuals are given a medication for one issue and side effects relate to urinary incontinence or other pelvic floor dysfunctions is Lasix or diuretics. Individuals who are on diuretics can have horrible, horrible problems with urinary urgency and urinary incontinence or both. And it has a huge impact on their quality of life. And right now, the only research we have is that it negatively impacts their quality of life. And the next step is to try and figure out what to do about it or what can we do about it conservatively? Can we change medication timing? Can we work on different things? Can we work on urge suppression techniques? Is that going to be relevant because urine outflow is higher because of the water pill? There are so many questions, but we have nothing like we have zero studies that have looked at how to help our clients with urinary urgency or urinary incontinence as a consequence of their medication regimens. This is important because the thing that happens is that people stop taking their meds because they literally cannot go out of their house or cannot be too far from a bathroom without not taking their pill. Because if they're on their pill, they're going to the bathroom all of the time for the five to six hours post taking their medication. And so this can essentially make a person homebound. That is important, right? In PT, that's a super big thing. In OT, it's a super big thing. In rehab in general, we are trying to discharge homebound status. And this is a big influence of that. Kind of in this urinary incontinence vein for the elderly, for our older adults, you know, we have conservative management in general. We have men management in combination with conservative management when there is a medical side effect because of the medication a person is on. And then the third one is some of the issues that we see post catheterization. So individuals who are placed with an indwelling catheter and then are removed from that get into this situation where they are in bed, they go to the bathroom whenever they need to because the catheter is there. And then once the catheter has been removed, sometimes there can be a disruption of pelvic floor musculature. There can potentially be damage to the urethral structures. And then you also have to try and work on those urge suppression techniques so that now you're not just going to the bathroom whenever you get the slightest urge to go to the bathroom, but you're holding it in order to go to the bathroom when it's convenient for your schedule or when you have the block of time within your day that you can go to the bathroom. We are now also seeing different types of catheters like periwicks, which are external catheters. And what do those do? All of these things that we're seeing hugely in acute care, we're seeing it in, you know, individuals going into home health. This kind of goes into neurological populations who may be doing self catheterization. All of these things and the role of rehab in managing these conditions to improve a person's function and quality of life really has been understudied and a big low hanging fruit that we could potentially be having huge impacts and potentially preventing transitions to institutionalized care is by being able to tackle some of these problems. But we need the research to back us up first. So that's number two and two A and two B. And then the third one that we're going to talk about, and I think this one is a frustration point for a lot of our clinicians, is clinically relevant outcome measures for our wheelchair users. So we have a ton of outcome measures in the geriatric space. One of the things that I think is actually really cool is that in our rehab space, our geriatric outcome measures are very strong. We have we have several options. We have good cutoff scores. We have reliability and validity data. We have minimally clinically important differences. All of these things. We have standardized protocols. We have different MCIDs, different reliability and validity data across different settings, which makes sense because our older adult population is extremely heterogeneous. All of that is good. You know, that is great. We touch on that a lot in MMOA about how we want to be leveraging our outcome measures and not just for the sake of doing outcome measures, but in order to guide our clinical reasoning and create risk stratification, which is what they're intended for. The problem becomes when we have a client who spends a good portion of their day in sitting. When it comes to our outcome measures, we have this Goldilocks type of scenario that we need to be mindful of. We are going to have a cohort of individuals who are going to experience a floor effect and a person who is a wheelchair user on a 30 second sit to stand test is a very good example of that. They are going to get zero and they are probably always going to get zero. And therefore using a 30 second sit to stand test for a person who spends the majority of their day in a wheelchair is not helpful. We also see that we're going to have some older adults who are going to have this ceiling effect where they are going to knock it out of the park and we're not getting any information. When I was working predominantly in outpatient, one of the first things that I would ask my older adults who walked in independently into my clinic was can you stand on one leg? I was not going to be wasting 15 minutes of my time doing a Berg on those individuals because it's a waste of their time. It's a waste of my time and it doesn't tell me anything. And so we have to kind of figure out we want this composite, we want these tools in our toolbox that we can pull and leverage based on our clinical impression after a person's subjective. But when we have individuals who are sitting, we have very, very few outcome measures. We have the function in sitting test, we have stuff like the FIM. We can maybe start using the Berg and look at some of their transfers, but our pool to try and fit this Goldilocks scenario is quite limited. And so we really do need to think about clinically relevant outcome measures for things like transfers or bed mobility or things that are relevant for them. And these things are starting to come out. We have some pilot research on different outcome measures. But what we try and leverage now with an MMOA is trying to get objective data for things like transfers. And what that can look like is instead of giving MinMondax assist, which is important, we're going to do that based on our clinical judgment, but also put a timer on it. And so if we can put a timer on it, then we can see the first time we did this sitting at the edge of the bed transfer, it took us five minutes from start to finish. And now it's taking you 30 seconds. Like that's a huge improvement or it's taking three minutes. That changes the flow of a person's day. It helps the caregiver a ton. It makes individuals feel more capable who are trying to help their caregivers with their care. And so we also need the research to back us up with that. And we need help to try and figure out how we can justify our rehab for individuals in sitting. If we can't use the outcome measures that are so commonly prescribed in different settings to try and see improvements over time. And we can make huge improvements in a person's function and a person's capacity who may not have the potential to get into standing and do more standing tasks, but still has an infinite amount of potential to improve their quality of life and the things that they're doing throughout their day. So those are kind of my big three areas in geriatric practice that I think we need to be focusing on that rep dose response data in resistance training, where we're looking at load under five repetitions and seeing, does that have any improvements or the magnitude of that improvement in strength with, with a direct influence on a person's physical function? When it comes to pelvic floor in the older adult space, we have a lot of work to do when it comes to just conservative management in general in our individuals over 75, anything with response to medication management, symptoms, side effect profiles of medications and their influence on the pelvic floor. And then post catheterization work, whether that's indwelling or external catheterization and what that does to things like urgent continents. And then our third is helping our individuals who are spending most of their day in sitting. How do we help our wheelchair users so that we can justify our care, have normative data and reliability and validity data of outcome measures to be able to speak to our insurance providers who are, you know, a lot of times we're trying to justify our treatment interventions and then make sure that we know when we're making clinically relevant changes in their quality of life, when the goal of getting them in standing is not the one that we're looking at. All right. I hope you found that helpful. If you have any other questions, just let me know. I'm going to be in the research space a lot in the next couple of weeks. I might be sick of it by the time I get to the end of the month with my defense. But let me know what your thoughts are. If you have any other questions, if you are not signed up for MMOA digest, that is our every two week newsletter where we bring all of that research to your inbox. So if we see any studies that are coming out that are filling in some of the gaps that we were talking about, you're going to know about it first. If you're signed up for MMOA digest, just head to ptnice.com slash resources. If you're looking for research in general, make sure you are following hump day hustling. All right. Have a great day everyone. And we'll talk soon. 20:07 OUTRO Hey, thanks for tuning into the PT on ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at pt on ice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to pt on ice.com and scroll to the bottom of the page to sign up.

Jul 11, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the importance of including lumbar flexion in a robust rehabilitation program. Take a listen or check out the episode transcription below. If you're looking to learn more about our Lumbar Spine Management course or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 ZAC MORGAN, PT Good morning PT on Ice. I am Dr. Zac Morgan. I am with our spine faculty, so I lead the spine division teaching lumbar and cervical spine courses. And this morning's episode is going to be a little bit on that topic of spine pain and specifically why low backs must flex. So we'll get to that, but before we do, let me just point you in the direction of a few courses that we have coming across the country over the next few months for both lumbar and cervical. So over in Richmond area, lumbar, the next offering will be September 23rd. We actually have several courses going, lumbar that weekend. So if you're anywhere in the country and you want to catch lumbar spine, September 23rd is a good one to have marked down. So it will be outside of Richmond, in Baton Rouge, and over in Parker, Colorado, right outside of Denver. So several good offerings spread all around the country. If you're looking for cervical management, we've got a few coming up as well. We've got Brookfield, Wisconsin, that's July 22nd, that weekend. And then August 26th and 27th will be over in Charlotte, North Carolina, and then September 9th over near Atlanta in Roswell, Georgia. So several good open offerings. If you're looking for one of those spine management courses, we'd love to see you out on the road. We'll have a bunch more throughout the year. So watch the website, watch the podcast, and you will know when we're going to be in your area. This idea for this episode came into my head this morning about, or not this morning, this idea came into my head over the last few weeks as I've seen more and more posts from, we'll just say Instagram influencers, people that are in this space of Instagram and perhaps are physical therapists and treating a lot. And I see a lot of vilifying of lumbar flexion, specifically a lot of pointing towards anatomy and the reasons why people shouldn't flex based on their anatomy. And the most common reason that you're going to see people vilify flexion in the low back is due to concerns of disc herniation. And we all know that there's some older studies that have pointed towards lumbar flexion, putting an increased pressure on the posterior annulus of the disc, and thereby making a lot of therapists for a long time very concerned about having their patients move into flexion because of the fear of every flexion weakens the posterior annulus of the disc. And with each flexion, you're actually weakening that tissue, eventually causing a problem. But I want to push back on that narrative a little bit. Now understand that at ICE, we think of back and neck pain in patterns. So there are some patterns of back pain where I will withhold flexion on my clients. I'll tell my client, hey, please, I need you to stop flexing. Sometimes I'll even utilize tape so that that way they're able to feel when their low back is moving into flexion. But that pattern is fairly obvious. And that one is what you classically think of as more of your lumbar radiculopathy or derangement presentation. And typically in that client's objective exam, when you ask that person to move into flexion, they're going to worsen. So each time you have them flex, they'll either lose range of motion in deflection, meaning their fingertips won't slide as far down their thighs as they did prior, and or they'll peripheralize. Their symptoms will exit the low back or maybe intensify in the low back and start to spread down the limb if they have some sort of sciatic related complaints as well. So if you're seeing a loss of forward flexion and or peripheralization of symptoms, that is the client where I would withhold flexion and not forever. I would tell that client on day one, Bill, right now, when you've been forward, your symptoms are getting worse. For the next couple of weeks, I need us to be really judicious and careful with forward bending. But understand that is a normal, healthy movement for your low back to make. And one day we're going to get back to it. So make sure you always prep them with that because we want that client to know we're coming back to flexion no matter what. Flexion is a normal part of the range of motion of the lumbar spine. It's really challenging to move through the world without flexing your low back. If you don't believe me, go ahead and throw some tape or have one of your coworkers throw some tape on your back and see how often you're pulling that tape top. Every time you put your shoes and socks on, when you sit on the toilet, putting your pants on, loads of things make your back into reflection. People recognize this when they hurt their back and they're flexion sensitive. All of a sudden they're like, wow, I didn't realize how much I use my back. What they're usually complaining about is that flexion. I didn't realize how often I flex my back. So let's get into it. There's a time and a place to withhold flexion, but it's certainly not everybody because for most people they need to be able to move. So one pattern in particular that pops into my head of people that really need to flex is the dysfunction patient. And if you're McKinsey trained, you've probably thought of this in terms of like, if a derangement doesn't clear up their end range flexion, they will become a dysfunction. But I like to think of that pattern as more all encompassing. Essentially a dysfunction patient is someone with soft tissue extensibility dysfunction across the posterior side of their spine. Meaning they don't have the elasticity in their muscles, in their paraspinals, and all the structures on the posterior side of their spine. They don't have the elasticity to move into flexion. And you'll hear this person say things in the subjective exam like, Zach, it's so tight. It feels very tight. It feels like I need to stretch. My back is always tight. When I wake up in the morning, my back is tight. If I've been standing for a long time, my back will get tight. If I have to sit for a while, my back will get tight. You'll hear them complain of things like tightness. And one thing that always stands out in this person's objective exam is you'll ask them to forward bend and they'll turn to the side and go to forward bend. And you'll see that they only access hip flexion. They actually don't reverse their lumbar curve at all. So you'll see that low back just stay flat as they move their fingertips down their thighs and their hip flexion will eat up all that motion. Often this person will have adapted pretty decent hip flexion. And sometimes I'll even see them put their palms on the floor. But if you look at their lumbar spine, there's no motion coming from them. So when we see that pattern, often flexion is part of the solution. Getting that person's low back to accept load and deflection can be part of what helps them solve this problem. So I always want to be really careful when it comes to vilifying any motion, because for some people that motion's the solution. While for other people that motion may really bother their symptoms. And this is the big overarching point is one solution is never going to work for all of back pain. If there was one solution, if the solution was to not flex, or if the solution was to only extend or spinal manipulation or dry needling or anything, we wouldn't see back and neck pain be this multi tens of billions of dollar problem year over year. If we had it figured out that well, this problem would be much easier to solve. So it seems clear that some people need it and other people's don't. And that's how back pain works. That's why you listening to this episode as the provider need to be confident in this space and understand that not one prescription works for all of back pain. So let's talk about why flection works a bit. And some of the things to think about moving forward, just to help push back again on that narrative of vilifying flection. First things first, with a lot of these people, they feel very tight and they feel very compressed. I don't have perfect proof for this, but if you think about the attachment site of the pair of spinals, I mean, from the base of the skull all the way down to sacrum, those big ropey muscles run parallel to one another on either side of the spine. If that person's tense, if they truly are tight, if their nervous system is just really heightened in the region, often that tone in those pair of spinals goes up. And what you see is a compressive type feel when they have it in the neck, they'll feel like somebody's got their hands on their head, just pushing down in the low back. They just hate sitting or hate compressive load. And one person that tends to do really well with flection based exercise is this one. So often, if you have that person start to put some length into that system by repetitively challenging flection, those muscles will relax a bit and the tone will drop some. And as that tone drops, the person will report a better feeling in their back. Hey, it feels like it's stretched out. That really feels like a good stretch, Zach. I love moving in that direction. Yeah. Now that I've done that, I feel better. Reminder the derangement patient who doesn't need to flex. They're going to feel worse each time that they do this. The dysfunction patient may feel bad while they're flexing, but they feel better after. So that's one of the key differences. And part of that is cause I think we're reducing some of the compressive load. That's just sort of statically sitting on this person's spine by getting them to move those muscles. So one thing that's nice is we get a reduction in that compressive load. This kind of goes hand in hand, but that subjective report that your patients give you of, man, my, my back feels so tight. It's so tight. I need a stretch. This addresses that feeling for whatever reason, their nervous system feels as if they're tight in that region. Sometimes people are, they truly have muscle extensibility dysfunction. Other times people are just tense and they have a hard time relaxing those muscles. Either way, repetitive flexion in my practice has been a really good way to sort of give those muscles some input or give them some actual stretch that allows them to lengthen out and allows that person to move with more, uh, fearless, thoughtless movement that allows them to kind of move about their day without feeling like a robot quite so much. So often getting rid of some of that tightness feel involves doing some stretching. And I realize I'm kind of going counterculture here because I feel like the pendulum is swung very far away from sweat stretching. But the most common question I get asked in the clinic is, can you show me a stretch for this? And I know a few of you are laughing and thinking, gosh, yes, people always think that's all we do is show stretches, but people see value in stretching. And if we believe in, in, um, patient expectations, then we should match those expectations to some degree. I'm not saying we're not going to load as well. We're off. We're going to do that. If the patient's impartial, my preference is certainly eccentric exercise because you get the added benefit of tissue durability alongside lengthening. But if we're just trying to get the person to buy in, I'm all for stretching and often stretching those pair of spinal makes this person's back feel way, way better. The next piece is just motion is lotion, right? Like our, our body is built to move. It is not built to be static. It has been adapted over years and years for movement, not for desk sitting, not for being really still. And so part of this is just motion is lotion, right? Like when we get a fluid exchange through those structures of the spine, through those muscles, the person's back feels significantly better. And there's no reason to run from that. We want that fluid exchange. We want that person moving around. And then the last piece team that I want to emphasize is why we should flex is that function is huge here. So if we were unable to flex our back, things like putting on our socks are completely a disaster. If you don't, if you've never experienced a derangement, I hope you never do, but spoken from someone who has that morning, you wake up and you can't flex. Everything's harder. You're considering asking your wife to help you get your pants on because it's so hard for you to move forward. We have to be able to flex. If we can't flex, all of those activities get way harder. And if we put forward the message that you need to be fearful of flexion because of your disc health, people are going to stop doing it. They're going to see those videos and they're going to say, you know what, that person's an expert. Let's be really careful with flexion. We don't want people being careful with flexion. Now I would never coach someone to lift a heavy load, a maximal deadlift with their back flexed. And that's partially due to, I do think end ranges are probably not the best for lifting, but a lot of it's performance, like straight lines or strong lines. I love when Mitch Babcock says that when we get the back flat, you can utilize your hips so much better and you can move more load. So from a performance standpoint, it makes sense to me to keep the back flat at heavy loads. When we're talking about putting our shoes and socks on, when we're talking about grabbing something off the floor, when we're talking about even doing things like ski, Yerg, GHD sit-ups, rowing, our backs are going to enter flexion. And if they don't, that will start to feel like movement dysfunction for the person. And if they try to stay perfectly flat through all of those things, it often drives this dysfunction pattern. So team, I really just kind of wanted to hit the high levels here of why our backs have to flex. And like I said, I see it over and over where there are different influencers who are vilifying lumbar flexion. And I think it's something that we as a PT community need to stand against. And it's not that we need to vilify those influencers. They are putting forth great information as well, but I do think it's a bit of an outdated narrative, outdated narrative for us to stop flexing the low back. Are there people who need to transiently limit their lumbar flexion? Absolutely. I see them all the time in the clinic. It is not rare for me to say, Hey, I need you to hold back on that motion for the short term. That said, do we need to drive a bunch of content towards making people fearful of that motion? No, much like knee flexion. We don't want people afraid of knee flexion. Same deal with the low back. It's just like everything else. It's a bunch of joints with a bunch of muscles surrounding it and a bunch of nerves giving it input and output from that region. That area needs to move. So let's not vilify it. The next time I'm on here, what I'm going to do is show you on a technique Tuesday. So we'll bring back technique Tuesday and I want to show you some mobilizations that I love to improve lumbar flexion in this person that we've been talking about. So that's all I've got for you today. Hope you have an awesome Tuesday and we will be back tomorrow morning. Same time. Thanks team. 14:56 OUTRO Hey, thanks for tuning into the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 10, 2023

Christina Prevett // #ICEPelvic // www.ptonice.com Christina Prevett // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Christina Prevett discusses current gaps in pelvic floor physical therapy research. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's PT on ICE Daily Show. 01:27 CHRISTINA PREVETT, PT Hello, everyone, and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. I'm so excited to be on the podcast. I feel like it's been a hot minute since I have been on here because our other faculty have been doing such an amazing job sharing content with you. If you're looking to get started and join us within the pelvic health division, we have our eight week online course starting today. So eight weeks going from preconception all the way to postpartum return to sport. We're going to spend a ton of time going through different concepts, research, all that fun stuff and then you get to hang out with us for the next eight weeks. So if you're interested, make sure you go to PT on ICE.com and you should sign up while you're there for our pelvic newsletter. So we're going to be talking about research today. That is where we send out new research articles that the faculty sees and we have a pretty big announcement coming into the newsletter. So if you are not on the pelvic newsletter, you should go to the resources page on PT on ICE.com and join because there's fun stuff happening over there. All right. So today we're going to be talking about gaps in pelvic health research. We have done an incredible job over the last several years of starting to fill in gaps in our knowledge. And part of the reason why we do not have as much research in some of these areas is because the rise in popularity of some of these movements or these exercise trends has really changed over the last five to 10 years. And research takes time. It's important for us to know where the state of the research is so that we know how much confidence we can give to our recommendations and assessments. When it comes to evidence informed care, it is three pronged, right? We have our evidence base, what research says. We have our clinical expertise and we have our patients or clients lived experiences and their hopes and desires. And when we don't have the evidence base, we rely on the other two. However, there is bias that gets introduced there. There's bias that gets introduced in research as well. But I think it's important for us to know what we can confidently say from a research perspective and what we can't. So today I'm going to go through five big gaps that I have seen in the pelvic health research. If you are interested in doing a PhD from somebody who is about to defend their PhD at the end of the month, here's great topic areas because our research base is really small or completely non-existent. And the completely non-existent one that I'm going to start at the very beginning because it actually blows my mind is on C-section scar massage. Scar massage after a C-section is the gold standard for helping with the rehab process. It creates more movement and motility. It allows us to get into more stretched positions. Some individuals have seen potentially some association between adherence and scar tissue and low back pain. Alexis did a podcast episode on a case study with that. But we have no research in any type that has looked at C-section scar massage. And that blows my mind because we are so confidently talk about using C-section scar massage. And it's because clinically and with our patients right there lived experience, we see such a huge benefit. Because we don't have any research, why? We can't even say is this effective or not. But the second thing is that we have no idea around dosage. Do you need to start at six weeks? Can you start at six months? Is it the same effectiveness? Should you be doing two minutes or five minutes? We don't have any research that is looking at what is the most effective dosage or does this work at all or is it a placebo because we're starting to desensitize our body to that surgical site. We don't really know. And so it's really neat to see and really important for us to recognize that there is a huge gap there that should be getting filled. All right. The second one that we see a complete lack of research in and this became really relevant with some of our athletes is around coning during pregnancy and its impact postpartum. Really confidently people say online that you should avoid doming and coning during pregnancy within our pelvic health division. We do not create fear around doming or coning. We try to minimize it as much as possible by getting recruitment from other core muscles because we think that is going to keep the pregnant core stronger, not because we are trying to mitigate damage, not because we are trying not to ruin anything, not because we are trying to prevent diastasis recti postpartum. But we know, pardon me, that when we reduce that coning that usually that also means that individuals are stronger. Unfortunately the prevailing messaging online is that if you cone during your pregnancy, you're going to have diastasis recti postpartum. And we don't have research either way about that narrative despite how confident people are saying that. What we do have research for is that individuals with postpartum diastasis recti are weaker than those that aren't. And so by scaring individuals around avoiding coning during pregnancy, we may be unknowingly or unintentionally deconditioning that pregnant person and their core. And so we need to be doing research on this about, you know, what if we don't do any modifications to their core training? What is that going to do for them postpartum? You know, when I think about a late term pregnancy, that stretching of the linea alba, when a rectus contracts, it comes together and there's going to be almost like an air pocket that occurs because of that lengthening of that tissue. In my mind, like that, especially a little bit of that is not something that I see as quote unquote bad. But I know that I am not not everybody agrees with that narrative. So we just need to be sure that we're doing more research on this. So that's number two. Number one, C-section scar massage. Number two, avoiding coning during pregnancy and its influence on postpartum outcomes. Number three is any postpartum protocols for return to activity. We have maybe the beginning of research in the running space. And largely in the running space, it's helpful because a lot of people enjoy the sport of running. It's an easy barrier. There's no barrier to entry in terms of just putting on running shoes and going on to the pavement or onto the trail. And so we're starting to see more and more research. But when we're trying to look at things like risk factors for issues with postpartum return to running, we're seeing a huge amount of variability. And that is where us and the pelvic PT space and us in the PT space in general are like well done because everyone is going to have different experiences, different support systems. All of those other factors are going to influence. And so we see some people are waiting a full 12 weeks before they go back to running. We have other individuals like our elite level athletes who are starting with four to six weeks and are back to 80 percent of their running volume by 14 weeks plus or minus 11 weeks at standard deviation. So a huge swing in terms of how long they are going back or how long they are waiting before going back. And so we need to try and look at some of this early return to activity and try to figure out different protocols to try and minimize risk for not only pelvic health concerns, but we're seeing also a larger risk for musculoskeletal injuries. And so we're seeing individuals returning to postpartum impact, which is running and are having lower extremity issues. So we have so much work to do. And then when it comes to the resistance training space, oh my goodness, we have literally nothing. In the cross-sectional study that I designed with our collaborators, we tried to give some descriptive data of when individuals are returning. But again, that is just scratching the surface of what is possible or what we may be seeing in this space. So number three is any postpartum protocols for return to activity. Anything that people are utilizing now is based on physiology theory and clinical experience. We don't really have anything in the research right now to identify those things. All right. Number four is information on pelvic outcomes with interpregnancy windows. And this may seem a little bit off to right field from me, but hear me out. So when we think about family planning, individuals kind of have often an idea of how close together they want their pregnancies to be, what sometimes these pregnancies are a surprise. Sometimes there are things outside of our control that leads to when individuals are having pregnancies. What we do tend to see in the literature where we do have research is on fetal outcomes. And we always kind of start on fetal outcomes where risks to baby increase when a person has a subsequent pregnancy less than six months after delivery versus those that wait 18 months. What we see clinically is that sometimes rates of pelvic floor issues and diastasis recti can follow that same trend where when individuals get pregnant really close together, they didn't have that window of time where they were able to recover their pelvic floor and their core strength back. And therefore they have potentially a harder time recovering after a subsequent pregnancy. Some of these fetal outcomes like increased risk for miscarriage and stillborn birth that can happen in those close interpregnancy windows may be a result of things like pelvic floor insufficiency or just not getting the strength back in those structures in the pelvis between pregnancies. And so we don't have any research on this, but as a faculty, we are super interested to see is it the interpregnancy window or is it the amount of time it takes individuals to get back at least close to baseline with respect to core strength and pelvic floor strength after baby. And so information around interpregnancy windows with respect to mom's outcomes, I think are super important. So number one, C-section scar massage. Number two, postpartum or coding during pregnancy. Three postpartum return activity and four information on interpregnancy windows. My last one and I left it for last because this is like where my research brain is right now is on lifting during pregnancy and appropriately dose resistance training. So if you guys have been following the podcast or you follow me online, you know that I was projects that looked at cross-sectional data on individuals who lifted heavy during pregnancy, over 80% of their one rep max at least at some point. And we tried to describe individuals experiences, what their labor and delivery looked like and what some postpartum issues or complications may have been. Now right now I am working on a project that is a systematic review on what we know from resistance training and pregnancy literature. So I am doing a complete scour on the research that is looking at what the dosage, what outcomes individuals are looking at and trying to make some, see some gaps in the research and make some informed decisions. Y'all, what we have so far is all exercises in sitting one to two kilos max weights. So five pounds max, we have fair band exercises and these are what we are using to make decisions. Overwhelmingly the outcomes are related to the fetus, right? So we are looking at and that is super important. Do not get me wrong. That is super important. But I think at this point we can say especially under dose resistance training is not going to be bad for baby. That is where the gross majority of our research exists. We have nothing that is heavier really than a person's purse that they use to walk in here and it gave me an unbelievable understanding of where our conservative under dose recommendations come from because all of our research was on therapy and exercises, stuff done in sitting, pelvic tilt and abdominal breathing was a protocol for resistance training. When is breathing resistance training? But that's the state of our research right now. And so we get upset about the fact that these are recommendations and yet there's this huge gap that we are seeing in the literature that does not have anything. And so because pregnancy is such a protected time, we don't want to make recommendations that we don't really have anything to base off of. And so we have so much work to do. And so here are my five, right? We have C-section scar massage, coning during pregnancy and postpartum diastasis outcomes, any type of postpartum protocol for return to activity, especially in the lifting high intensity space, information on pelvic floor outcomes and core outcomes for interpregnancy windows and the influence on pelvic floor dysfunction. And then my personal, like one that I am spending a lot of time on is around lifting and appropriately dosed RT during pregnancy. Like you all know that I am in the geriatric faculty as well and it's like just as bad, if not a little bit worse with respect to some of the RT dosage that I'm seeing in this space based on, or as compared to systematic reviews that I've done in community dwelling older adults that are struggling with mobility. And so that is saying something. And it just shows that we have so much work to do. And so I want to kind of finish off this podcast. I'm going a little bit long winded and I knew that I would talk to you about research is that we have work to do, right? We need to one show that these are things that individuals are interested in. We need to try and help inform practice. And then we need to be patient. You know, there are researchers that are working on this. I was at female athlete conference in Boston and I saw and got to connect with so many PT PhDs and other medical providers who were doing research that were trying to bridge some of these gaps for individuals who love exercise at any capacity, at any stage, at any level. It just it takes time. You know, where I'm getting ready to hopefully ramp up for perspective data, which means that I'm going to follow people through their pregnancy. But a pregnancy is 10 months and it takes time to recruit people and it takes time to go through ethics. And then we got to do all the analysis and then we have to write the research paper up and then it has to go through peer review. And that takes time as well. And so we are getting there. This is my I am so excited. If you want to do a PhD and jump into this army of trying to create research, I am here for it. And hopefully we are going to continue to see individuals pushing into this space and we're going to be able to close some of these gaps. All right. That's all I got for you today. If you are interested in learning more or you want to talk about PhDs and all those types of things and doing research, make sure you reach out. I did an entire thread in our ICE students group. So if you have taken an ICE course and you were in that Facebook group, I talked about doing research and I hope you all have a wonderful Monday and I will actually see you on Wednesday for the geriatric podcast. All right. I will talk to you all soon. Have a great day. 19:00 OUTRO Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at PTonICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTonICE.com and scroll to the bottom of the page to sign up.

Jul 6, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com

Jul 5, 2023

Dr. Jeff Musgrave // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discussed several strategies that can be employed to achieve intensity, which is crucial for cognitive changes. These strategies, including increasing load, decreasing rest, and increasing work time or volume, are part of physical training and can drive metabolic adaptation and enhance cognitive benefits. By challenging the muscles and cardiovascular system through increased load, individuals can experience improved cognitive function. Similarly, reducing rest periods allows for a more continuous and demanding workout, while increasing work time or volume extends the overall duration or amount of exercise performed. All of these strategies contribute to increasing the intensity of the workout, which is essential for promoting cognitive changes. Incorporating a dual motor task and cognitive layer during exercise can further enhance cognition. This can be achieved by integrating activities that require both physical movement and cognitive engagement. For instance, one way to introduce a dual motor task is by having individuals hold two cups and transfer water from one cup to the other while walking. This adds complexity to the exercise and challenges both the motor and cognitive systems. Additionally, engaging in mental tasks like answering questions or performing mental math while exercising can also enhance cognition. Starting with simple preference questions and gradually progressing to more challenging cognitive tasks can create a cognitive load while individuals focus on the physical activity, leading to cognitive changes. It is crucial to control the intensity of physical training by adjusting factors such as load, rest, work time, or volume to ensure the desired cognitive benefits are achieved. Shifting exercise sessions to a busy environment can introduce cognitive load and improve cognition. Instead of conducting sessions in a quiet one-on-one room, it can be beneficial to move to a busy clinic space, a bustling hospital hallway, or even an outdoor setting with unpredictable elements. Exposing individuals to a busier environment adds a cognitive challenge to their physical activities, such as skating or walking. This cognitive load stimulates cognitive changes and enhances the cognitive benefits of training. It effectively adds a cognitive layer to the exercise session and promotes neuroplasticity. Furthermore, incorporating a dual motor task, such as moving water back and forth, and asking cognitive questions like preference inquiries or mental math can further amplify the cognitive benefits of the exercise session. Overall, integrating a busy environment and cognitive tasks into exercise sessions can be a valuable strategy for improving cognition. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're sure to use the code ICEPT1MO when you sign up, that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:33 DR. JEFF MUSGRAVE, PT, DPT All right. PT on the ICE Daily Show. Welcome. This is Wednesday. This means it is Geri on ICE talking about all things, topics to help make your care for your older adults as good as possible to really set yourself apart as an expert with older adults. What we're going to be talking about today is exercise that improves cognition. There are a couple different types of exercise training that is really superior for improving cognition for older adults and we're going to talk about what those are and then how to incorporate them into your care. Before we get to that, just a quick rundown of what we've got going on in the older adult division. If you were hoping to catch the next cohort of Essential Foundations, that'll be starting in August, August 9th. If you're looking to get your advanced concepts, if you've already taken Essential Foundations looking for that next step, that'll be October 12th. Next opportunity to see us live, you've got three opportunities in July. We're going to be in Connecticut, Georgia, and Idaho this month. If you have been itching to see us on the road, get to do some of these fun labs and things that you've probably seen on social media, book your seat, come see us. We're going to be all over the place as we do 2023. Many of our older adults are worried about their cognition. They may already be experiencing cognitive changes. Maybe they've got just mild cognitive impairment. They don't have an official diagnosis. Maybe they've got early stages of cognitive change all the way to advanced dementia. It's not uncommon for us to be treating community dwelling older adults or older adults in an institutional setting that have experienced some cognitive changes. When we're thinking about our exercise interventions and how to prioritize, making physical change while keeping in mind we know there's a cognitive component. Sometimes a cognitive component ends up being more critical than the physical component for some of our older adults. We're talking about safety. We're talking about independence and their ability to manage their home environment, for example. This can be huge. The reality is a lot of us don't know where to start when we're thinking about how do I do both get the physical training piece and keep in mind they've got some big cognitive impairments on board that I'm concerned about. There was a 2019 article titled, Preferred Type of Exercise for Cognition Enhancement in Older Adults. It did just this. It broke down what types of exercise we should be focused on. Once you get through this article, and I'll share it in the caption as well if you want to look it up yourself, but there were two types of exercise that we're going to cover. The third thing we're going to do is just talk about the practicality of how to get those cognitive changes for our older adults in our sessions. The first type of training that was most beneficial for driving cognitive enhancement was a category called physical training. If you're familiar with CrossFit or not, I'm going to describe a workout to you that would be very squarely in this component of physical training. So MERF, very common Memorial Day workout done to honor a fallen soldier. The workout is one mile run. We've got 100 pushups. I'm sorry, 100 pullups, 200 pushups, 300 air squats. So that would very much squarely fit into the grunt workout. You're grinding. It's a long workout with high metabolic demand. So the first category was physical training that was intense. High intensity physical training was the number one thing that they found was beneficial for enhancing cognition for older adults. So many of our patients are not going to be doing MERF. So the question is, what's this look like clinically? So any workout that's using compound functional movements and you're moving at high intensity where you've controlled the work rest ratio, you've controlled the number of repetitions or the volume, and you've controlled the pace, you can modulate to get up to high intensity. But high intensity training is superior for cognitive enhancement. So for a patient that may be doing a remom, every minute we're doing different activities. We've controlled the amount of work and rest time. The patient is going to pace that themselves. So say minute one, we're doing 10 sit to stands. Then the next minute we're going to do carries over and back across the room with the weight that's challenging. So there's maybe 10, 15 seconds of rest. And on the third minute, maybe we're going to be doing some supported jumping. So grunt work type movements. There's not a whole lot of thought involved. Hold this walk, stand up, sit down, put your hands here, jump. Very simple, basic activities, but their nature of them being compound functional movements where we've controlled rest, we're going to drive intensity and we're going to drive metabolic adaptation, which was key for enhancing cognitive benefits in training. So that's what we want to be thinking about. Category one, physical training. They found that the change happened because of changes in the metabolic system and hitting intensity was key. So high intensity grunt work style training improves cognition. That's good news. That follows right in line often with what we're trying to do with our older adults because we know most of them are sedentary and need physical training. They need to be stronger. They need higher cardiovascular capacities to really keep themselves on a healthy trajectory as they age. So the second type of training that was beneficial for enhancing cognition was a category they just called motor training. So a good example of this would be a Turkish getup. So maybe you've never done a Turkish getup, but if you can imagine yourself laying on your back, you've got one arm pointed at the sky with the weight in your hand. You're going to move from lying on your back all the way up to standing with the weight overhead. You're going to be balancing the weight the entire time and then going all the way back down to lying on your back. That would be an example of motor training. It's a complex task. There's actually 14 steps in a Turkish getup for just one side. A lot to think about, lots of positions to hit, complex movement, a novel task for a lot of people in general, but especially older adults getting up and down off the floor without using an arm, but also adding load and having to balance that weight makes it complex from a motor training standpoint. So maybe our older adults are not doing Turkish getups. Some definitely can. There are research articles that have shown that older adults can do Turkish getups and it's beneficial for them, but maybe a more practical example for a lot of us would be working on floor transfers. Many of our patients need to work on getting up and down off the floor, doing that where we're working around a cranky joint, a knee, a shoulder, maybe a hip that is super stiff or doing this at a novel environment. Maybe we take them outside on the grass where maybe they don't have furniture or they've got limited furniture where we've just created a complex, novel task. It's motor training that's complex and that's what's going to drive cognitive adaptation. This motor control category, the driving factor was complexity and it was direct neuroplasticity. So directly impacting neuroplasticity when we do complex motor tasks. So getting up and down from the ground in a different environment would be a great way to drive neuroplasticity directly. So we've got these two categories. We've got high intensity physical training and then we've got high complexity motor training. Those are the two different avenues we can use with exercise to improve cognition for older adults. So the question is, well, what do we do? Which one is most important? And if you've been around the ICE community very long, you've probably heard this before. Or if you're new to following along with the journey here on what we're doing with our clinical approach, you're going to know the answer to this. And that is and not or. We want to do both. So we want to be greedy when it comes to our patients. We want to give them the maximal benefit, the maximal value out of every single session. And we can do that by driving intensity while driving complexity of task. And the easiest way to do that is a strategy we call layering. So a good example of this would be, say we want to drive intensity with gait training. Lots of great ways to do this. We can put a gait belt on our patient and hang on to it and add some resistance that way. We can do the same thing with a resistance band. We can throw a weighted vest. We can have them hold weights. Gait training just got much more intense at whatever resistance is appropriate to challenge our patient by just adding resistance to that walking. So we've already achieved intensity there. So how do we add this motor training piece? How do we add complexity to also enhance cognition at the same time? Lots of different ways to do this. You could do a weighted vest and maybe we've got someone with two cups in their hand and they're transitioning water from one to the other while they're walking. Man, we've just layered on a dual motor task while we're hitting intensity with a vest. Another great example, we can ask simple preference questions. That's usually an easy way to ease in on the cognitive load. Just ask them some random questions that sound like conversation. You may already be doing this, adding a cognitive layer and not realize it, but asking them questions while they're concentrating adds a cognitive component. We can scale that up. We can ask for mental math while someone is doing intense gait training. That can be super beneficial. We can ask, what's your favorite color? We can ask them to subtract three from 74 out loud while they're walking under intensity. We can move them to novel environment. There are lots of different ways we can add that in. You want to control the two things you've got to do to put these things together. For physical training, you've got to control intensity. You can increase load, you can decrease rest, you can increase work time or volume. All those things will help you reach intensity, which is crucial for cognitive changes. The second piece is adding a dual motor task like we talked about the water back and forth. You can add the cognitive layer by asking questions, preference questions, mental math, those type of things. Moving them into a busy environment. Maybe you have your sessions in a quiet one-on-one room. Maybe you move out into busy clinic space or into busy hospital hallway, or maybe you're in home health and you can take someone outside or into busier environment where there's unpredictable things and there's some cognitive load on just skating and keeping yourself safe. That's another great way to add cognition. That's what I've got for you, team. You want to hit intensity through physical training. You want to add complexity with motor training. The third thing is you want to add layers. You want to layer up your intensity and cognitive difficulty as much as possible to get the most bang for your buck, especially when there are cognitive deficits on board. If anyone's got any cool strategies, layering tips, tricks, things they've done that they found fun and beneficial, or you've just got questions or comments, drop them. I'd love to see those and interact with you. I hope that was helpful for someone out there. Have a great rest of your Wednesday, team. See you later. 14:52 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 5, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey discusses how to empower patients with osteoarthritis by shifting their mindset and behaviors. She emphasizes the importance of treating patients with MEDS (mindfulness, exercise, diet, and sleep) to combat systemic inflammation. Take a listen or check out the episode transcription below. If you're looking to learn more about our Extremity Management courses , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 DR. LINDSEY HUGHEY, PT, DPT Good morning, PT on Ice Daily Show. How's it going? Welcome to the PT on Ice clinical podcast. Today is clinical Tuesday. I am so pumped to be with you all. I'm Dr. Lindsay Huey. I guess that would help if I actually introduced myself. Today, I am going to chat with you about how we let freedom reign in our patients with osteoarthritis. Last clinical Tuesday, I hopped on here and I wrapped on the underlying battle of systemic inflammation that we are fighting with these folks with hip and knee away and the importance of treating them with MEDS, which stands for mindfulness, exercise, diet and sleep. Check in for more information there from last week on what MEDS and how we can unpack that and prescribe it for our patients. This week, this clinical Tuesday, we're going to dive a little deeper into the trenches of battle by really discussing how we can impact our folks with osteoarthritis. Whether it's the shoulder, hip, knee, hip and knee are more common things we'll treat from an extremity management perspective. But this battle involves a lot more than manual therapy and exercise. It actually involves less. Today, I will discuss how shifting our patient's mindset and behaviors really helps fight that underlying systemic inflammation battle that our patients have. But before I tell you and dive in a little bit about that, I'd love to share with you some courses extremity management has coming up. So our next upcoming course is July 15th, 16th. So in a couple of weeks, we'll be in Holmes Beach, Florida. I've hopped on a couple Tuesdays and just let you all know what beautiful beach that is. It still ranks the top beach I've been to so far. Crystal blue water, I'll be with Melissa Reed out there. There's lots of spots left. So join us if you want to do some summer extremity management learning. And then July 26, 23, I'll be in Simi Valley, that course is now to 15. There's probably only three to five spots left. So if you're on the fence, definitely sign up for that course. And then onward Madison is July 29th and 30th. So lots of opportunities to hop in in July. And then in August, we are going to be in Rochester Hills, Michigan, and then the 12th and 13th. And then August 19th, 20th, we will be in Fremont, Nebraska. So be on the lookout if you're on the fence for signing in just because these courses are starting to fill up. And then other courses in the beginning of fall in September and October. We hope to see you out there. All right, let's dive into the topic at hand. So last week, we really last Tuesday established that hip and knee osteoarthritis is becoming one of the leading causes of global disability. So worldwide, this is affecting our society. And there are so many challenging aspects of treating these folks. The battle is not just in modulating their pain. It's not just an increasing range of motion and addressing strength deficits, you know, in their hip and in their knee. And it's not just about prescribing meds. And I really made a solid case for that last week. That mindfulness, exercise, diet and sleep. It's really about confronting the uncomfortable conversations. It's about challenging and changing thoughts and beliefs with these folks and some of their daily living behaviors. I think this is our hardest job as physical therapists, whether you're in outpatient or home care, even acute care. But it's our hardest job and our greatest opportunity with these folks to really address how they think about their body and then just daily behaviors. These conversations that I'm going to bring up, they are really uncomfortable. Addressing harmful thoughts and beliefs, behaviors, we know humans, we are kind of entrenched in our beliefs and our behaviors and it is really hard if we can reflect on our own challenges. It can be so uncomfortable. And so I acknowledge that this is very uncomfortable, not only as the provider, but for the patient. So some thoughts that we really need to start addressing. And I alluded to this last week a little bit, but the patient that thinks and says to you that first visit, I have bad knees, my dad had bad knees, my great grandfather had bad knees or I have bad hips, right? My great grandmother had bad hips. So it's just inevitable, right? That I'm going to have bad hips. You are not your ailment or your pain is one of the first things that we have to establish and break down with our patients. The thoughts of this is just inevitable, this is my path, right? To be in pain, which leads to disability and dysfunction. These thoughts take a human's mindset captive. It takes captive their whole way of living and being. If you think about some of these patients and they don't just often just have osteoarthritis, diabetes, hyperlipidemia, they might even have heart disease or history of MI, stroke, these are unhealthy systems. Every thought and decision and behavior starts to be planned around their pain experience. Going out with family or friends is planned around pain. How long does it take me to get to the front door if we're thinking about going out to eat or going to the movies? Can I actually make that distance? Or will I be in too much pain to even enjoy the dinner or the movie? Or I cannot do this because it hurts. Or I can't go to that family gathering because it hurts. Or because my knees or my hips are bad. Pain, OA, osteoarthritis starts to become the patient's identity. How they do everything in life is surrounded by this. This is all super uncomfortable and enslaving for your patient. If we're honest and we even think deeper about this, it starts to become the normal. So this discomfort, right? This pain starts to actually become the patient's comfort. It's how they do life. It starts to become their identity. I need you to start as clinicians and this charges to myself as well to start thinking about how we can help our patients do less harmful mindset. Do less thoughts about how much they're in pain and how much their knees are bad. How can we help shift their mindset to be healthier? To be more productive? Can we shift and say my knees have an opportunity to be stronger? Or yes, my knees hurt but I'm on the path to recovery. Yes, my hip hurts and it's limiting how I can walk right now. But I know with doing my program from Alex Drumano, our MMOA faculty, I know I'm going to be able to walk a little bit longer every day. Helping patients shift how they think right away is a must. If we cannot shift how they frame their pain experience, how they frame their range of motion deficits, how it impacts their life and amount of walking, we will never make an impact here, right? We can have the best manual therapy, the best exercise dosage prescription and it won't make an impact if they don't believe it can help. If they are telling themselves every morning they wake up, my knees suck, I don't want to get out of bed, my hip hurts, I don't want to do this today, they're not going to be successful. And so we have to give them little phrases to help them keep going, right? Yeah, it hurts right now but here's what I can do to help that, right? And it seems small but if we're not addressing this at all, we're really doing harm. We're not doing enough and so we need to implore less harmful thought patterns in our patients to help make an impact, to help really make our exercise and manual therapy be worthwhile. So I just want you to pause and think about what are some things or reframes I can start giving my patient in their mindset. Doesn't just stop though with our mindset shifts, right? It's not just thinking that influences our beliefs about our body. We also have to shift some of our daily behaviors and here's where it gets really tough. Folks with OA have a lot of comfortable behaviors that are quite destructive. And addressing these conversations by the way are nuanced and we have to do it in a loving way and of course we first have to build rapport with our patients before we start diving in to behavior shifts. And so it won't be our first conversation with our patient but it has to be a conversation that happens in our bout of care and it has to be ongoing. And it's behaviors regarding eating and exercise habits. They have to be addressed. It becomes really comfortable that person that's in pain, right? That's coming to see you maybe three days a week, right? They worked out with you for an hour. It's a lot more comfortable to sit around and watch shows. It's all day. It's a lot more comfortable after a big meal, after dinner, to turn on Netflix and binge watch Netflix, right? Two or three episodes. If you're a big Ted Lasso fan it's really hard not to just watch the whole season in one bout. It's really hard if it's in your process and family process to have dessert after every meal that you have, especially dinner, right? And then compound that with Netflix and sitting. Extra calorie consumption kind of goes under the radar with these folks. The eating piece and our behaviors around eating have to be addressed. And you know, the Netflix, the eating, this might not be your patient specific thing that they need to worry about doing less of, but I'll tell you in a lot of our folks with me and HIPAA, there is some very familiar trends surrounding our eating and our extra calorie consumption. Things that bring us comfort like Netflix, like that extra helping of food or dessert. We have to acknowledge that this is so complex and hard. These things are often tied to family, right? They're tied to connection and community and identity, especially if that's the time where you all kind of get together, right? You share a meal, you share dessert, and then you go watch your shows. Let's all come together and rewrite some of the ways we gather and do our meal time together or handle stress, right? Some of us are stress eaters. Sub that extra helping or that extra Netflix episode with taking a walk after dinner with your family. Or maybe instead of that dessert, right? You're already feeling full, but somehow you think there's a little bit more room for that dessert. Go for a walk with your family, right? Or go for a bike ride, right? These kind of behaviors help get that food moving and processed better, and then it subs those extra calories or it subs that extra sedentary time where you're just sitting. How about some of our folks with HIPAA and NEOA that are retired, right? Where they're watching their shows throughout the day, right? They love watching Price is Right. Yes, Bob Barker is better, but Drew Carey is doing his best, right? But these kind of behaviors, maybe it's a midday walk, right? Or suggesting they walk their dog midday. I know these HIPAA close to home, folks, and I'm going to tell you a lot of the behaviors I'm listing hit close to my direct family. I am sprinting away from metabolic disease. It runs on books, both my mom and my dad's side. Diabetes, heart disease, cancer, hyperlipidemia, myocardial infarction, stroke. Whatever list that you've probably seen on your patient list, my family has it. And so I totally, I am listing out behaviors that I know my family and myself has taken part in. I've witnessed them firsthand, but I also know they can be changed gradually, and I also know the change is uncomfortable. I want to fight this battle of OA because it hits so close. It hits for me, it hits for my children and my surrounding aunts, uncles, grandmothers, right, that have passed because of this. So I don't take the battle lightly bringing up this shift in beliefs and behavior. Think about this. And I know I touched on some hard ones, right? Everyone loves a little extra Netflix episode, dessert sometimes, that extra helping of food. It is comfortable. But no one says, I wish I hadn't taken that walk last night after dinner. I wish I had had that second helping, second and third helping. I wish I had had that extra slice of apple pie. I wish I had stayed up till 1 a.m. watching Netflix. I wish I had binged, watched all my shows all day and sat in a chair for three hours. I wish I had had that another beer. No, people don't really reflect and say that, right? They're usually the next morning, oh, I wish I would have had that earlier. I wish I wouldn't have had that extra helping. I didn't really sleep well. I wish maybe I would have gone on a walk or that bike ride when my kid or grandkid asked me to do it. Instead, I just sat here and I watched these shows. No one says they wish they didn't do that uncomfortable behavior. Uncomfortable shifts in mindset and behavior, they are always uncomfortable, especially when you're making the decision, especially when you're actually doing the thing, right? When you don't really feel like taking a walk after a meal or going for a bike ride. But there is nothing more ironic, more peaceful than doing the thing that's uncomfortable. While it may not feel great during you, if you can think about some uncomfortable decisions you've made and your patients, they will feel better after. They will be thankful after when they made these shifts in their mindset or in their behavior. There is so much reward in the discomfort. Of course, it's delayed and that's what's hard about human nature, right? Our psychology wants comfort, especially when we're in pain. But just think each day, the compound reward of making one to two uncomfortable decisions surrounding our mindset and surrounding our behavior around food and our eating behaviors. One less thought of my knees suck, I don't want to get out of bed. One less helping of dessert or Netflix binge. Imagine that compounds day after day, 365 days and that becomes a year and then you do it again, right? 365 times two, right? And it patients start to see the healthy reward of these shifts in mindset and behavior. Let's stop the acceleration of OA as one of the leading causes of disability worldwide. Let's help our patients handle and battle this low grade systemic inflammation by leaning into the hard belief and behavior shifting conversation. We have to fight for our patients, our loved ones and ourselves to have these conversations because we're not doing enough. It's still going up the levels of disability, right? Lifespan is increasing, right? But our health span, the quality of life is not. These are hard and uncomfortable conversations, right? But discomfort tends to birth opportunity and change and really only always for the better. If you can think about most of the uncomfortable decisions that you've done in your life, if you can think about the yield, the reward, we can and we must start to battle beliefs and behaviors if we want to impact this space. One little mind shift and behavior shift at a time. Freedom comes in the form of less for our folks with hip and knee OA. Yes, our primary drug of choice is exercise for our folks with hip, knee, shoulder OA. But if we want to have the greatest impact, we need to deal environmental modulators to manage symptoms, to maximize fitness. We need to deal mindset and behavior shifts that change lives. It will be hard, it will be uncomfortable for both parties, clinician and patient. But along the way, we also deal encouragement. We deal hope. We deal laughter, right? We laugh in PT and we are a partnership and alliance as the patient negotiates these new mindsets and behaviors We're there every step of the way when it's hard. Free your patience. There is freedom in choosing less harmful mindsets and less harmful behaviors. New beliefs and behaviors are for sure uncomfortable. But help your patients think about their hip or their knees more positively or help them walk instead of that extra episode of Netflix. Show your patience there is freedom in discomfort. Show your patience there is freedom in the reframe in their mindset. Let freedom and independence reign for your patients through introducing them to healthier mindsets and behaviors. Help them indulge less in destructive thinking and behaviors. There is so much untapped potential in this space. I'm hitting the 20 minute mark I need to shut up. But I want to say a final thank you to our military and our vets who have fought and continue to fight for our nation's independence. Happy Fourth of July. I'll thank you for letting me rap on something I'm super passionate about. Happy Clinical Tuesday. 19:30 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 3, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses when and how the tailbone/coccyx may be a contributor to a patient's symptom behavior, as well as how to begin to assess & treat the region if appropriate. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show. 01:27 DR. APRIL DOMINICK, PT, DPT What is up PT on ICE fam? Dr. April Dominic here. Today we are starting our two-part series on pain in the butt. And today you will learn how you as a clinician can screen for tailbone pain, some general assessment and treatment strategies, as well as in part two, next in two weeks we'll cover soft tissue structures that may contribute to pain in the butt. Before we dive into tailbone pain today, let's talk about some course offerings from the ICE Pelvic Division. So we have our eight-week online cohort that starts July 10th and we still have some spots left. So please hop on in and join us for all of that fun. And then we have our live course and this course is going to give folks the ability to learn pelvic floor basics and about the pregnancy and postpartum changes of the body. We'll definitely dive into the internal exam in supine and standing with an option to learn another way if an internal exam is not for you. Then in day two, we are in the gym and we're applying what we learned day one into all activity types such as impact work, rig work, barbell and more. And we learn how to coach and come alongside and offer modifications for this population and keep them in the gym during pregnancy if that's what they desire, as well as help them feel confident returning back to the gym during postpartum. So our next course is actually going to be with myself and Dr. Alexis Morgan. It'll be here in Denver, Colorado. That's going to be July 29th and 30th. And then you can hop into our next course offering, which is in September 23rd and 24th, I believe, and that's going to be in Scottsdale, Arizona. So tailbone pain. We've got people with pain in the butt and we're thinking, hey, it may be coming from the tailbone. So what do we know about tailbone pain right now? Well, true to the pelvic health research world form, we are still learning and growing. We don't know a lot about incidence rates for tailbone pain. It is under reported. It is multifactorial in nature. There are a lot of psychological and physiologic factors that are involved in tailbone pain. So with that, it is just a trickier diagnosis to treat. But I wanted to share about all of the things that you can do from a general assessment and treatment strategy today. So one study did find that comparing female to males, females tend to be affected by tailbone pain about five times more than male counterparts. We also know that typically speaking, tailbone pain can resolve within weeks or months with time. However, we do know that conservative treatment strategies are welcome and definitely help reduce that duration for some. So what is the tailbone? Or I'll sometimes call it the coccyx. The word coccyx actually originates from the Greek word for the beak of a cuckoo bird. So like a tailbone, the beak and the tailbone have a triangular shape. The tailbone is three to five fused bones that articulate to the bottom of the sacrum. So everyone listening right now, let's go ahead and orient ourselves to where the tailbone actually is. With your fingertips, I want you to try right now, locate the edges of your sacrum, which is going to be that bone that kind of sits inside of the center of the buttock. And I want you to head inferiorly or towards the toes and towards midline. You're going to follow that bone until it ends. You'll bump into a small bone and that is the coccyx. You might be like, whoa, April, I'm like right near the anus. Well, then you're in the right spot because the coccyx is just superior to that anal opening. So the coccyx may be tiny, but it is mighty and it is not insignificant. I like to think about the coccyx as a leg of a tripod. And that tripod is going to consist of a sit bone on one side, a sit bone on the other, and then the tailbone in the center. It is the anchor for the posterior pelvic floor muscles. So there are all kinds of muscles that attach to the coccyx itself all around. Specifically, the coccygeus muscle is going to attach on either side of the coccyx. But wait, there are more. So what is really important and why I wanted to come on here today to talk about tailbone is that there are other structures that are not actually pelvic floor specific that are attaching directly to the tailbone. Those are the glute max. So we have hip insertions as well as the sacro tuberous and sacrospina ligaments. So if you've got someone coming in for tailbone pain, it is important to assess above the joint and below, of course, but assessing above the joint, like at the hip and the low back due to these attachments. Functionally speaking, the tailbone is dynamic. It's going to move as we move throughout our day doing our activities of daily living. So when the pelvic floor contracts, the tailbone is going to draw in and come forward or come anteriorly. So let's chat about actual functions that the coccyx is involved in. More specifically, the coccyx is involved in sitting, bowel health, so it helps to keep poop in or get out of the way to get poop out. It is involved in childbirth, sexual play, and transfers such as sit to stands. So let's put ourselves in the subjective exam. You've got someone that came in and they've got some kind of hip pain or tailbone pain. So what are we going to hear from a traumatic mechanism of injury or a non-traumatic mechanism of injury? I'm also going to talk about aggravating factors here. So what are some things that you might hear during your subjective or things that you might want to dive deeper into in order to maybe put coccidemia or tailbone pain onto your hypothesis list? So from a traumatic mechanism of injury standpoint, we most commonly hear of tailbone injuries during labor and delivery. The tailbone should move out of the way to allow for the fetus to slide on down the birth canal as if it was that easy, right? And simple. But sometimes that birth doesn't go according to plan and someone may need to have an instrument assisted delivery with the use of forceps or a vacuum. And that is going to put someone at a higher risk for a tailbone injury. Another traumatic mechanism of injury would be a fall. And that can be a fall during your sport, during an activity, or from a horse, which we hear often. So now I'm going to dive into eight common non-traumatic aggravating factors or contributors to tailbone pain. We have pregnancy. So during pregnancy, things are a-growing and that's going to put a lot more force down into the sacrum, onto the tailbone. So some of those folks may start to say, hey, I've actually got a lot more pain when I sit during pregnancy. But you don't have to be pregnant to have pain with sitting. So one of the biggest, biggest complaints of, or aggravating factors for tailbone pain is going to be pain with sitting. So especially for a prolonged time. The tailbone assists with weight-bearing support, especially in sitting. So let's bring it to real life. In real life, we're thinking truck drivers or maybe people who have jobs who you are sitting without any brakes or with minimal brakes. So just constant pressure and force down onto that tailbone. And then I also want us to take a minute and think about the social implications of someone who has pain, severe pain with sitting. So what is that going to prevent us from doing? Hey, maybe going on a dinner date, right? Or comfortably going to a movie with your grandkids or any sort of event at work or your job duties itself. So people who have tailbone pain and it is severe, just have some grace for them because we do a lot of sitting in our daily lives. Think about like even transportation, we're sitting in a car, right? Not everybody has subways in their region of the United States. So just extend some grace to these folks because they, this is definitely interrupting their life quite a bit. Other reasons, or contributors to tailbone pain, rapid weight loss, increased stress might increase some overactivity of the pelvic floor muscles that surround the coccyx. We also have some sometimes tailbone pain after spinal injury. If someone has hypermobility, that is going to play into the mechanics of ligaments and of the tailbone, as well as oftentimes people will complain of pain in the tailbone with sexual play due to certain positions causing a little bit more force down into the tailbone. And then finally, exercise. You know, you've got those folks who are like, oh, it's summertime, I'm going to get my hot girl summer on or whatever kind of summer they're wanting. And they are recently starting some sort of exercise routine, whether that is doing a lot of orange theory or 45 where they have or CrossFit where they have a lot of biking or cycling or rowing that they didn't used to have. And that's a little bit more pressure on the tailbone or maybe the Pilates person who is doing like a hundred boat poses, right? So exercise can play a big role in a new onset of tailbone pain. And then from a medical perspective, bone spurs, infections and cysts can also contribute. So what are some easing factors? What are these people are going to say that may lead you to be like, oh, maybe if this is what's relieving their pain, maybe I should be considering tailbone pain. They are going to say, you know, if I change positions or they might report being on their belly or standing or sideline, those are the positions of comfort. And that's because we are not weight bearing onto the tailbone. So from an objective standpoint, let's run through what are some bony structures we should be looking at. So hip and low back. Hopefully I've made that clear to you that those need to be screened out. Pelvic specific structures. We're looking at the sacroiliac joint as well as the tailbone itself. And in our live courses for our pelvic class, we dive deep into assessment and treatment and help you just dial in those skills. So hop on into our live course for that. I'll walk us through verbally how we would palpate the tailbone itself. So first, first, first, first, make sure it is actually the tailbone. I had a patient one time who is a health care provider and they were all through other subjective exam. They're saying, yeah, you know, tailbone this, tailbone that, blah, blah, blah. I get to the objective exam. I'm doing my P.A. mobs on the spine. I get down to L3 through five. Boom. That is their pain. Tenderness. Ah, that's it. That's it. And so I'm like, OK, noting for later. And then we continue on into some tailbone palpation and nothing. Any sort of tailbone pressing or mobilizations does not reproduce the pain that they came in for. So just make sure that we're all on the same page about what the tailbone is. Now, let's just call it what it is. Palpating the tailbone is awkward. It can be uncomfortable for the client, but to quote Finding Nemo, just touch the butt. OK, touch the tailbone. You wouldn't avoid palpation or assessment of the hip if someone came in with hip pain. Right. So we shouldn't think any different about externally palpating the tailbone. So let me give you some options for how to do that. When we are palpating the tailbone, we are looking for reproduction of pain. And sometimes after you get a feel for a few tailbones, you can appreciate that some positions, some tailbone positions are a little more flexed or some are a little more vertical. And that usually comes with a little time after palpating a bunch of them. But the tailbone palpation, we've got three recommendations. So number one is externally, you can palpate as a clinician, you can palpate the client's tailbone in prone, side lying or sitting. And in prone or side lying, it's going to be the same way that I just walked us through how to palpate your own tailbone, except you'll have as a clinician, a pincers grasp on that tailbone and you'll be able to do some mobilizations and manipulations there. So these do make it difficult for getting a solid grasp on the bone. And then in sitting, I love this because this is a little more functional for the person. So you can have your fingertips on their tailbone in sitting and ask them to sit upright and then also slump. And that's going to give you a good appreciation of the movement of the coccyx itself. And then another way to palpate the tailbone is they may be like, uh-uh, you are not getting anywhere near my tailbone. That is my tailbone. So that is okay. You can come alongside them and you can just walk them through how to palpate their own tailbone again in sitting or side lying. And you can ask them some subjective questions about what it is that they're feeling and make sure they're in the right spot. And then the final way to palpate the tailbone would be internally or interactively. And those with pelvic floor specialty, especially trained in inter rectal examinations, will be able to do that. So from a general conservative treatment strategy standpoint, let's talk through some of those things. You've got someone that came in, you're like, yes, they definitely have tailbone pain. Now what do you do? We'll talk through manual therapy, exercise and education. So from a manual therapy side of things, you can do some direct coccyx mobilizations, whether that's externally or interactively. So you've got your pins or grass and you are applying some mobilizations to that structure. You can also do it indirectly where your pins or grass stays on that tailbone. And then you ask them, maybe they're in side lying, hey, can you do some posterior pelvic tilts, anterior pelvic tilts of the hips or can you move your hips while we are stabilizing the tailbone? That is obviously a more active way to get some manual mobilizations in there. We can also supplement with dry needling, cupping, e-stim. We definitely want to hit the glute max, the lumbar spine. And if you're trained in it, the pelvic floor as well, especially those coccidius muscles that attach nearby, that touch directly to the coccyx. And then from an exercise standpoint, I'll talk through some stretches, strengthening and aerobic activity. So my three favorite stretches for promoting down regulation of the nervous system for the tailbone pain is going to be throwing some diaphragmatic breathing in with these three exercises. So the first, I like my clients to be on hands and knees doing some rock backs. The second is happy baby. You can be in happy baby, maybe do some lateral movement side to side, but I love a good modified happy baby where the feet are actually on the wall that frees the client's hands to actually spread the cheeks. It is okay to touch your butt. It's your own butt, right? So spreading those cheeks is actually going to put a stretch onto the tailbone itself and for some people relieve some of that pain. And then a deep supported squat against the wall is going to be wonderful for those pelvic floor muscles that may be, again, a little overactive and pulling on that coccyx bone. Of course, in the long term, we'll want to do some general loading, whatever that patient can tolerate and especially if hyper mobility is on board, loading of the hips and back and pelvic floor can be wonderful for these humans. And then finally, let's blast them with some high intensity interval training of whatever they can tolerate. So bike and rower are probably going to be out the window, but they may be able to do some standing, arm bike intervals, brisk walking, treadmill incline, pull walking, anything to really hit the system to address that increased inflammatory state and promote some blood flow and healing. And then finally, education. Education is huge for these humans. So we're going to talk about positioning, positioning in sitting. Let's encourage a neutral or anterior pelvic tilt because that's going to put a lot less pressure down onto the sacrum and the tailbone. Let's identify the threshold that the patient is able to tolerate in sitting. So if they're like during the subjective, they say, yeah, you know, around 30 minutes is when I start to feel my tailbone pain. Great. We've identified a threshold. below that and say, if you wouldn't mind, let's do some, some standing breaks or movement snacks around 20, 25 minutes of sitting just so that we don't keep hitting that threshold of pain and continuing that ripping the bandaid off cycle of I sit for hours and hours and I have pain and then it starts all over again. So let's do something about it. And then cushions. I love recommending a lumbar support cushion like a half McKinsey slimline roll. They can tuck that below the low back and that's going to give them a little more anterior pelvic tilt and then also tailbone for the cushions for the tailbone itself. So some of my favorite models are the cushion your assets, tailbone support, the kabootie or a donut. And then during intimacy. So using pillows for support or maybe opting for positions with decreased tailbone compression like hands and knees or legs up or side laying. Those may feel better for that human. And then it wouldn't be an ice podcast without talking about lifestyle factors. We want you to be talking with them about nutrition, reducing processed sugar intake, and especially for this population, stress management, increased stress with job, family, whatever can be a huge factor for keeping this tailbone pain around. So we want to make sure that we get them hooked up with someone or using some sort of stress management techniques to address that part of this diagnosis. And then finally, remind these people that it takes time. Tailbone bruises, tailbone pain, all of that. It just takes a really long time. And so it will get better, especially if they can implement some of these strategies. But unfortunately, they are going to have to be a little patient. So let's review what it is that we talked about. Tailbone pain is tricky. It's tricky to treat. It's understudied and it's underreported. But it is involved in so many life functions, including weight bearing support, especially pain sitting, bowel sexual function, labor and delivery. Due to the attachment sites to the tailbone, it should be part of your hypothesis list for folks coming in with back and hip pain. Actually touch the butt, but really touch the tailbone. Make sure that it is the tailbone that is possibly a structure that is involved. If you feel that the tailbone is involved, give it some manual therapy with some mobilizations, soft tissue love, and then supplement that with whatever kind of modalities you prefer. Cupping, dry needling, some supportive stretches like happy baby, quadruped rocking, getting some gentle loading in, and then offering some cushions for solutions for positioning. And finally, refer to a pelvic floor PT in your area or get yourself to one of our live courses because we dive deep into pelvic pain assessment and dialing in those skills so that you feel confident when you have someone like this in front of you. So happy Monday, everyone. Happy Fourth of July. And I will see you all in two weeks to discuss the soft tissue structures that may contribute 24:37 SPEAKER_02 to some pains in the butt. Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on ice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Jun 30, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes. If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:25 ALAN FREDENDALL Alright, good morning PT on ICE Daily Show, happy Friday morning. Hope your morning is off to a great start. My name is Alan, I'm happy to be your host today. Currently, I have the pleasure of serving as a faculty member here in our fitness athlete division and the chief operating officer here at ICE. Fridays, our fitness athlete Fridays, we talk everything related to the recreational athlete, whether that's somebody in the gym doing CrossFit, powerlifting, Olympic weightlifting, bodybuilding, out on the track, the road, running, biking, swimming, whatever, that person who is getting after it. Four to six days per week is the focus here on fitness athlete Friday. We're biased, but we would argue it's the best darn day of the week. Courses coming your way from the fitness athlete division. Taking the summer off, we have some live courses coming up in September. You can catch Mitch Babcock out in Bismarck, North Dakota. That will be the weekend of September 9th and 10th, so the first September of the fall. And then you can catch Zach Long, aka the Barbell Physio out in Newark, California. That's the Bay Area. That's going to be the weekend of September 30th and October 1st. Online courses from us, our Essential Foundations, our eight week entry level online course starts back up September 11th. We're currently halfway through the current cohort. And then our Advanced Concepts course, our level two course that requires Essential Foundations, that drills down deep into things like Olympic weightlifting, gymnastics, programming, both for CrossFit and strength, injured athletes, all that sort of fun stuff. That starts September 17th. So you can find out more about our courses at ptenice.com. So today's topic, let's talk about cold plunging. You can't trip over a rock in public these days without finding somebody trying to get neck deep in some cold water somehow. Everybody's doing it. They're posting about it. There are probably a million ads you've seen on social media for this tub. This thing that looks like a bourbon barrel. This thing that looks like a fancy bathtub. All these different ways to essentially cool down your body. So I want to attack this topic from three different angles. I want to talk about defining a cold plunge and how probably most of the people cold plunging currently or certainly what we see happen on the Internet is not true cold plunging. I want to talk about the research supporting, not supporting the use of cold plunging. And I want to talk about the practical application of what we can recommend to our patients and athletes when they come into the clinic or the gym and ask us what we know about cold plunging. What's the best way to cold plunging and all that sort of thing. So let's start from the beginning. What is a cold plunge? We need to start at the top and understand that humans have a really large tolerance for heat at rest and a very poor tolerance for cold at rest. You can imagine it's much better to sit outside on a 90 degree day than a 30 degree day. So our perception of temperature is a little bit different. It's skewed based on if we're active or if we're resting. It flips entirely when we are active. You can imagine how terrible it would be to run on a 100 degree day versus running on maybe a 50 degree day. We would all probably much choose the 50 degree day because our bodies lose heat tolerance as our activity level increases, which is all that to say of we have a really poor tolerance for cold at rest, which means when we define the parameters of what's used for cold plunging in research, we'll quickly recognize that most of us, most of the people we see aren't doing it cold enough. They aren't doing it long enough and they aren't exposing as much of their body as they need to to the cold plunge. So a cold plunge is defined by the research is going to be exposure up to your neck or possibly your entire body for 10 minutes at 40 to 50 degrees Fahrenheit. That's a large portion of our body. That's a really long duration of cold exposure for a human being at rest. And that is relatively cold. Again, we have a really poor tolerance to cold at rest. Now, imagine we've we've all taken a bath. Imagine you you take a hot bath or sit in a bathtub and then you get that feeling of, oh, I'm getting really cold. Like this water has cooled down significantly. Again, our perception of temperature is really skewed. When we decide it's time to get out of the bath because the bath water has become too cold, we've probably started in bath water of maybe one hundred and five to one hundred and ten degrees. And it has only cooled down to maybe 90 to 95 to the point where we say this is cold, quote unquote, cold. I'm going to get out of the bathtub now. But really, 90 to 95 degree water is remarkably warm compared to what we define as cold plunge in the literature. So most folks are probably simply not getting their water cold enough to even define cold plunging. Again, the duration of support in the research is cold plunging of 10 minutes. So if you are doing it for 30 seconds or one minute, just know you are not anywhere close to reaping the effects or the positive or negative that we've seen in the research. If you're only dipping your toe in for a few minutes or jumping in up to your knees or your waist and hopping back out again in the research, exposure would define itself as being exposed up to the neck, at least. So many folks just putting their legs in a cold plunge, just going up to the level of maybe the knee, going up to maybe the level of the waist or maybe belly button mid chest or something. Again, if you're doing that to slowly gain tolerance, that's OK. But if that's what you're calling normal cold plunging, just know you're probably not reaping as much of the effect. Again, positive or negative that we'll talk about here in a second as you could be. So cold plunging 40 to 50 degrees up to your neck, duration of about 10 minutes. So all that to say, most people are probably not actually cold plunging when we do it ourselves or we watch others do it. Excuse me. Simply not cold enough, not enough for their body to get in effect and not enough for a long duration. I do want to give a special shout out to ICE faculty members Dustin Jones and Jeff Musgrave. They are unashamedly posting their cold plunges every day on social media and they really get after it. You can see that they have a bunch of ICE in their backyard cold plunges and they're sometimes exposing their whole body to the cold plunges. So they are doing it right. That's the way to do it. So let's switch gears and talk about what does the research say. The research in this field is becoming overwhelming of just looking at the trend and volume of research. Eight hundred and seventy articles published on what the research would call cold water immersion since 2008. So an exponential growth in the people studying, the amount of people studying and the volume of research studying this particular area of what we might call athletic recovery. I want to talk about just two journals today, two journal articles. There are literally like we talked about hundreds and hundreds and hundreds and hundreds. But I really want to talk about two. What I like about these two articles I want to share is that they are 30 years apart and they essentially say the same thing. So first, I want to go way back. 1985, I wasn't even alive yet. Journal of Applied Physiology, Peterson and colleagues talking about cold plunging exposure after exercise. These folks did three sessions a week of what the again the research calls cold water immersion or cold plunging. They did do it at 50 degrees Fahrenheit. They did it for 15 minutes instead of 10. So they went up to their neck. They did it for 15 minutes and they did it cold enough. 50 degrees Fahrenheit. They did this three times a week after resistance training. Evaluation here looked at a lot of different things. One rep max leg press, one rep max bench press and some ballistic things, counter movement, jump, squat, jump, ballistic push up. And this article really wanted to focus on what happens to muscular hypertrophy. This journal article, 1985, now 38 years ago, said you can expect to have less muscular hypertrophy if you expose yourself to a cold plunge after resistance exercise as compared to control. Control in this group was people who just sat at room temperature like you might sit on the boxes at CrossFit class or on the curb after a really long hard run. They just sat and kind of cooled down for 15 minutes compared to the cold plunge group. Fast forward 30 years, 2015, Journal of Physiology, Peking Colleagues, very similar parameters. That's why I picked these two papers. They are perfectly 30 years apart. They use almost exactly the same parameters and they found pretty much the same thing. Peking Colleagues in 2015, very similar parameters, twice a week of cold plunge exposure, 10 minutes at a time, also 50 degrees Fahrenheit. They followed folks a little bit longer. Peter Peterson in 1985 followed those athletes for seven weeks. Peak in 2015 followed them for 12 weeks. Almost same exact parameters, though. They looked at almost exactly the same stuff. They looked at leg press strength, knee extension strength, knee flexion strength, both one rep max and eight rep max. So they're looking at maximal strength and they're also beginning to look at kind of what is your ability to produce force over time. So what we call maybe endurance, which really is indicative of hypertrophy. This team also did some muscle biopsies and what they found with the group exposing themselves to the cold plunge after resistance training compared to the control group, in this case, a group doing active recovery. So not even resting, just doing active recovery for 10 minutes after the resistance training session. The control group, who continued to exercise at a low level, had a 17% improvement in hypertrophy, a 19% improvement in isokinetic strength and a 26% improvement in myonuclei per muscle fiber. So the control group blew the cold plunge group out of the water. Now, that is not to say that the cold plunge group got weaker or smaller. They did not get as strong and big as the control group. And it's led to believe because they were the cold water immersion group, that it's the cold plunge, that something about that cold exposure seems to blunt the body's natural response for healing to encourage hypertrophy gains and strength gains. The big takeaway from this study is the myonuclei per muscle fiber. We can think of myonuclei as if one myonuclei per muscle fiber is great, but more is better. It's almost like having a personal assistant for everything in your life. Your life would be a lot easier if you woke up in the morning and someone was there who had your clothes ready for you. If someone was there who had already prepped your shower for you, if someone was there who already made your breakfast for you, right? The more people you have assisting you in your life, the more efficient you will be at running your life because they're doing everything for you. That's a lot of the role of the myonuclei in our muscles. The more the better. The interesting thing about myonuclei is they stick around even during a period of training, whether it's injury, whether we get busy with life, whether we switch training modalities, maybe we start prioritizing endurance training to train for a marathon or something. Those myonuclei stay around and that's kind of what creates that strength across life of that person who comes into the gym who says, I haven't worked out in 10 years and then deadlifts 400 pounds. You're like, where did that come from? That took me years to build to that strength. This person just naturally has it. Yes, they may naturally have some genetic strength, but what they probably had in the past from training was myonuclei that are now living in their body. And so losing those myonuclei or rather not gaining them through cold plunge exposure not only affects strength and hypertrophy in the short term, but affects really long term fitness gains over time. So very interesting study from PEEK and colleagues showing that cold water immersion after resistance training seems to really have a negative effect on strength and hypertrophy. So it doesn't seem to help. It maybe seems to have a negative benefit, at least after resistance training. Most people aren't doing it correctly. What is the actual practical application? What can we recommend to patients and athletes who ask us about cold plunging? The first thing is to make sure that they understand what it actually is and that they're doing it correctly. Of, hey, if you're going to do this, you should have a way to expose yourself up to the neck, your whole body up to your neck. You should build up your tolerance to do it in sessions of 10 minutes at a time. And the water should be really uncomfortably cold, 40 to 50 degrees Fahrenheit. We don't like to see colder than that. That can be a little bit dangerous, but we also don't like to see warmer than that. Right. Remember, cold bath water is technically hot, 90 degrees Fahrenheit. So we need to see somewhere between 40 to 50 degrees Fahrenheit. We need to talk about timing of cold plunging. The research would really suggest we should never do it after training, especially if we're just training once a day. We're training for life. We're training to be strong and be training for life. And we're not training to be competitive athletes. We're not training multiple times per day. If you're somebody that just exercises once a day, you should not finish that exercise session with a cold plunge. Maybe you start your day with a cold plunge or maybe you cold plunge before you exercise to get the effects that cold plunging can have aside from apparently blunting our strength and hypertrophy gains. And then there's a little bit of a caveat there for competitive athletes, folks who are, you know, let's think of a CrossFit Games athlete. Let's think of somebody running multiple races, an Ironman, a long cycle race. Maybe between events is the time for a cold plunge. We need to recognize those events are already really destructive to the body. Nobody goes to the CrossFit Games and comes away fitter. They come away significantly beat up with probably weeks or maybe even months of repair time needed to recover from an event like that. So at that event, we're not as concerned about not gaining as much strength and hypertrophy as possible because of the short duration. It's only a couple of days or maybe even a one day competition is only a couple of hours. So maybe that is the time between events to use cold plunging. But after regular training, we should not use it. We need to recognize the point of exercise is to create a micro injury that your body will repair and heal from. Your tissues get stronger from a tensile strength perspective and your brain more effectively learns how to use those muscles so that we get stronger and bigger over time. We become more adapted to the stress. We have an increase in tensile strength. We have an increase in myonuclide per muscle fiber. And that's what really creates robust lifelong strength. I love the quote from Pique and colleagues. Remember that anything intended to mitigate and improve the body's natural ability to improve resilience to physiological stress with exercise may actually be counterproductive to muscular adaptation. Cold plunging, NSAIDs, antioxidants, anything that can slow the chemical reactions, the natural chemical reactions in our body to respond to that micro injury is going to affect our ability to recover and be more resilient to that stressor in the future. So a lot like discouraging folks from taking a bunch of maybe ibuprofen or injectable steroids, we should say, hey, if you're going to cold plunge, make sure you start your day with it. Make sure you do it before training. You should really try to avoid finishing that workout and jumping right out into that maybe that cold plunge in the in the gym parking lot, because this research is really so profound of you're leaving maybe 20% improvement in strength and hypertrophy on the table when you cold plunge after training if you don't. So cold plunging, what is it? How does it work? Does it have a negative effect? Yes, it seems to. But also, that doesn't mean that we should say just don't do it. If you enjoy it, if it helps you start your day, if it helps you feel less sore, by all means, cold plunge. But let's rearrange when you cold plunge in your day to make sure that we're not doing it after training. And let's make sure we're doing it correctly up to our neck in the water, cold water, 40 to 50 degrees Fahrenheit. And duration should be at least 10 minutes, right? If you're just up to your knees in 60 degree water for two minutes, you're not actually cold plunging. You should feel good. You're probably not going to get a negative effect from that because you're not doing it correctly. But you're also leaving a lot on the table by not doing it correctly. So cold plunging. Hope this was helpful. We just revamped week five of our Central Foundations course to include a whole bunch of different training modalities like cold plunging. We talk about hot tubs now. We talk about saunas, both infrared and traditional saunas. We talk about compression therapy, massage, pneumatic boots, massage guns, everything folks have a question about. So if you've already taken the Central Foundations, head on over, check out week five for that update. If you haven't taken it yet, remember, September 11th is your next chance. So have a fantastic weekend. I hope you all have a lovely long four day weekend for 4th of July. We'll see everybody next time. Bye everybody. 18:00 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

Jun 29, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea of letting an audience grow around the passion you have for a particular area of practice versus continually trying to change your approach in the clinic or with marketing to attempt to reach an infinite number of potential audiences. Take a listen to today's episode. If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 DR. JEFF MOORE, PT, DPT, OCS, FAAOMPT Alright team what's up? Happy Thursday, happy Leadership Thursday. Welcome back to the PT on ICE. Wherever you're taking this show in thank you so much whether it is here live on Instagram or YouTube or whether it's on the recording we love having you all with us. It's Leadership Thursday but if it's Leadership Thursday it's Gut Check Thursday. So let's talk about the workout. It is a doozy. So it is the last workout in the I Got Your Six. The Warrior Water. Friends over at Warrior Water have their virtual competition going on so our Gut Check Thursday has been mirroring that. So we've been loving the videos of all of you in groups of two nailing these workouts. This is the last one so it's going to be it's gonna have a time cap of I think it was 23 minutes in teams of two and you've got to do 10. So athlete one will do 10, 8, 6, 4, 2 box jumps. Only one athlete working at a time. Athlete two has to bang out 10, 20, 30, 40, 50 double unders. Then you both accumulate only one athlete working at a time a hundred deadlifts, 225, 155. Then you switch athlete rolls to finish up the box jumps and the double unders. So if you want to see that workout I know it's a bit more complex. It's over on the Ice Physio Instagram as always and please if you do it throw a hyperlapse on there. Grab a pic. Ice Train. Ice Physio. We love seeing that stuff pour in on Instagram. So cheers to Warrior Water. Hope the virtual competition went awesome. I hope that you were able to as always raise some funds for for veterans who are being helped by getting that fitness and nutrition stimulus as opposed to maybe more aggressive medications to help out with all things psychologically and quality of life. So cheers to the Warrior WAD crew. If you aren't following them get on that they're doing great things. Okay team let's jump in. So Gandhi once said that happiness is when what you think say and do are all in harmony. When what you think say and do are all in harmony. When what you're thinking is what comes out of your mouth. When what you say is backed up by action that proves that you believed in what you said. When all of these axes are in perfect alignment that is when you are truly profoundly at peace happy. Now in today's society it's hard to get that right in some level we are always trying to adapt to our environment. It's really hard. You come off as a bit of an oddball. If you had those perfectly executed all the time it'd be really challenging to fit in. So there's some level of kind of massaging those or working with malalignment which is probably why there's some level of disharmony in most people. Right you can't have this perfect pure energy flow between what you think say and do and still be functional in modern society. But the closer you can get to that undeniably the better because we are at our best. We are our most energetic. We are our most uniquely valuable. When we are sharing, when we are doing, when we are serving what we absolutely must. Right when those things are all in perfect alignment with our beliefs we are undeniably at our most uniquely valuable. So the first charge and I think if you look back at all of my episodes up to date this is probably the thing that falls out of solution most commonly. But our first charge is always to figure out what is that? Like what does line all of those things up for me and how do I figure that out? Well you figure it out by reflecting in real time on when you're in your flow state. Right when after doing anything you are more energized than you were before you did those are the moments of reflection when you've got to say whoa whatever I just did first of all felt effortless and second of all I think I have more energy now than before I did the activity. Those are your things team and a simple awareness of what are the activities that put you into that flow state. A great tip off can be when other people say boy you made that look easy and you think to yourself well it was easy but clearly to them it wouldn't have been. So when people start helping you identify these asymmetries when you're making something look effortless that to most people is not these are your activities whatever you're sharing right now whatever you're talking about whatever you just did those are your things that are aligning all of those axes and if you can identify what those things are and spend more time in that lane and drive fast you're gonna be not only more successful but significantly more energized and excited and useful in those activities that you're participating in. That classic quote the riches is in the niches which nobody in sales denies the reality of that right specialists win when it comes to business but a lot of people think that's totally explained by market dynamics and I do agree that if you can market a really specialized niche you can get the attention of people who need you but there's a whole other half to that when you're doing a really niche activity that you're particularly great at where you're spending a lot of time in flow state because you've drilled down to realize oh this is my thing a big part of why long term the riches are in the niches is because you're doing what you're in harmony while doing and that gives you unbelievable longevity it allows you to bring incredible enthusiasm to the plate so it is a combination of market dynamics in the fact that you're doing an activity where those axes are all lined up and in that space you are going to be unstoppable which brings me to today's message you gotta stop trying to please your audience and I mean this across all sorts of domains and I'll unpack that a bit in a second but you gotta stop trying to please your audience you gotta do you and let the audience be formed by those who resonate with it I'm gonna say that one more time you gotta stop trying to please who you think is your existing audience you gotta just do you and let your audience be formed by the people that resonate with that where I see a huge obvious sign of deviation from this is when we say things to our audience is like what do you want me to talk about that is one way to ensure that whatever you wind up talking about is not in perfect alignment because what are the odds right what are the odds that the answers are things that are absolutely in perfect alignment for you that line up what you deeply believe in that where you believe it you're the most useful to add value where you believe the greatest need exists what are the odds that what somebody else answers to that lines up perfectly with your needs now team this is not to say that the occasional call for topics or the occasional Q&A does not have great value because you can pick through what comes back and try to identify which things are in line but in general be a little bit wary of that method certainly is a primary component of your business be wary of that it is ultimately professional people pleasing right hey tell me what you want me to do and I'll dance right like this idea takes you out of alignment it doesn't put you into it the reframe to this is I'm going to talk about X because I have to right if you feel like that message might serve you please tune in or if you feel like this message might serve somebody that you know well please tune in but I don't have a choice right this is what's in alignment I have to talk about this I really hope for some of you that it resonates I tell ice faculty this all the after classes because oftentimes when we're recapping if I go to a live course and I'm and I'm trying to give some notes to see if we can't make the content even sharper a lot of times our faculty will say well I really feel like I need to talk about this and immediately my response is you don't need to talk about anything besides what you deeply feel you want to talk about what is real and organic and honest for you that's what you talk about this is a big part of the reason whole other conversation but it's a big part of the reason why ice since day one has never had close partners or accreditation or tied into other groups because I always want our faculty to feel at any given moment when something doesn't feel authentic to them they can drop it with no thought and change and say this is what I really need to talk about I have to say perfect that's our content whatever follows I have to say this that's our content it goes for ice faculty but it goes for all of you it goes for who you market to it goes for where you do workshops it goes to the topic of those workshops it goes to what population you want to treat you know who you need and want to treat you know who you are uniquely valuable for you know who after you engage with them you feel energized team 100% of your effort goes to that niche identify that and just stay in that lane you don't need to do what people want you to do what you need to do is what you have to do what is in harmony with what you're always thinking about with the words that you're always saying with your actions in your own personal life those things need to line up with whatever direction you choose in that direction doesn't have a whole lot of options right so it's like look this is me I've got to do this and I hope that some folks resonate with it I hope that some folks respond well to that treatment paradigm I need to be in this space it is what it is we got to stop asking our audience what they want we got to start doing us and let the audience or the patient base or the customer solidify around that now how do you know if you're doing it right how do you know if you're staying in your lane in driving fast the answer is a little bit uncomfortable but it's that your audience should be unstable you should be dropping people and gaining people if you're not trying to please everybody that's an inevitability but what you're gonna notice is that a core group in your audience solidifies and becomes unshakable team if you aren't losing people regularly especially early you're being inauthentic because authenticity should always offend people this isn't wrong it's just that people who have drastically different beliefs when you present yours in an undecorated fashion it should be moderately offensive and people should be like oh that's not my tribe great right that's the whole point of the drill right that's why your audience should be relatively unstable early on but you're gonna see that what people want is an authentic person delivering value in their area of need and they're gonna feel that match so while your audience is gonna be unstable on the outskirts you're gonna see that this tribe is crystallizing out of solution in the middle because people that do need to hear what you have to say that you need to say they need to hear it you need to say it when that match happens when those ends plug in together your true tribe crystallizes out of solution that's the only way that great cultures are created the person delivering it is being raw inorganic inauthentic and even though that offends some people the people who need to hear that message who belong in that tribe gravitate towards it and that match is made as soon as we start trying to please everybody nobody can actually connect because nothing real is actually happening and this is what happens with what can I say for you today as opposed to here's what I need to say and I hope it lands for some of you generally speaking in your marketing in your outreach as you're trying to build followers be real suffer the consequence of an unstable early audience and what you're gonna see is underlying that your true tribe is developing all along stop trying to give your audience what what they want say what you need to say and let your audience form as a result of that hope it hits team we'll see you next week PT on ice calm all the courses are on there tons of online courses starting up in July we had a little bit of a hiatus there in between our first q1 and q2 online courses they're starting to drop right now by the way we have finished our live calendar so if you're waiting for a new live course to show up in 2023 it's probably not gonna happen because all of our division divisions are done booking so if you've got your eye on a live course a new a new one that's more convenient probably isn't gonna show up this year so grab the one you're thinking about alright team have a wonderful week we'll see you next week 13:09 SPEAKER_00 on leadership Thursday hey thanks for tuning in to the PT on ice daily show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home check out our virtual ice online mentorship program at PT on ice calm while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to PT on ice calm and scroll to the bottom of the page to sign up

Jun 28, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the effects of terzepatide on older adult patients. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show. 01:43 Dr. Julie Brauer, PT, DPT Good morning, Instagram. Happy Wednesday. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. My name is Julie Brauer, member of the older adult division. We are going to jump right into our topic this morning. It's Wednesday, so all Wednesdays we talk all things older adults. This morning, we are going to talk about terzepatide and the older adults. And this is going to be a case study type discussion. So what is terzepatide? You probably have heard it all over the news by its brand name, Mount Jaro. So terzepatide is a FDA approved drug for glycemic control in individuals with type 2 diabetes. The problem is that many folks, including my 72 year old patient who does not have type 2 diabetes, these folks are getting their hands on it for weight loss. And many of these folks, including my clients, is not considered overweight. So this morning we are going to talk about what this drug is, what we know from the clinical trials, how it works, what are the side effects. We will briefly touch on that. And then I am going to tell you the story of my client Martha, who experienced some pretty negative side effects and consequences from taking this drug. And we will talk about how to navigate this challenging situation where your client is doing something that you know is probably not good for them. You don't necessarily support the decision, but you need to support your client in general, through this decision. We will talk about how you have to be a master of scale and adjust your exercise interventions to keep an individual safe as they are going through something like this. And then we will talk about the scary and unfortunate event that occurred for Martha to finally decide that was the nail in the coffin and she was going to go off of this drug. Okay, so Mount Jero Terzapatide has gotten a lot of attention in the media about how it potentially can be more effective as a glucose lowering therapy over other glucose lowering therapy drugs like Ozempic and Wigobi, or others that you have probably heard about. Those are just the brand names for the drug Semiglutide. What are these drugs and what is the difference here? Semiglutide is a single receptor agonist. Mount Jero or Terzapatide is considered a dual receptor agonist. What you will see in the literature is that it is a dual GIP GLP-1 agonist. What those are are hormones. These are hormones that are released from the gut that regulate insulin response to a meal. What they do is they increase insulin secretions, increase insulin synthesis, they decrease gastric emptying, which in turn promotes this feeling of feeling really full. And then it promotes a decrease in appetite. So individuals are just not hungry. They're not eating as much. And so why this drug is getting so much attention is that because it's a dual receptor agonist, it's having this synergistic effect of having an even more potent dose on decreasing glucose as well as weight loss than the more commonly known drugs of Ozampic and Wigoby. So that's the basis there. Now let's talk side effects because that's really important to know that what are the side effects that come along with this drug. So many of the side effects are primarily having to do with GI discomfort. And now there are so many, like nine plus clinical trials, they are called the Surpass and Sermout trials that are going on, looking at the safety and efficacy of turzapetide. And they're looking at the safety and efficacy of individuals who are on glucose lowering therapies already. And then they're looking at it in individuals who are not on glucose lowering therapies. They're looking at individuals who are also doing intensive lifestyle and exercise interventions. I think those studies would be really interesting to actually see what those exercise interventions are. They're even looking at the cardiovascular benefits and then just the benefits in individuals who are considered obese and looking at the benefits for weight loss for individuals who are not even living with type 2 diabetes. Okay. So what they have found in terms of side effects, those GI side effects. So you're going to see individuals who are going to have really extreme nausea, diarrhea, vomiting, constipation, and you see this dose dependent response. So the higher dose that people are taking of turzapetide, and this is a once weekly subcutaneous injection, you're seeing those side effects increase with the higher doses that people take. And so some of the clinical trials, even up to 66% of individuals were experiencing GI distress. And so many individuals who start taking this drug actually stop taking this drug because of those adverse GI effects. They just feel like crap, literally. Okay. So that is an overview of the drug. I will post a article link to the Surpass and Surmount clinical trials. If you guys want to get into a little bit more detail about these specific drugs. Okay, let's talk about Martha, my client. So she is someone who started working with me. She has severe arthritis in her knees, very, very weak. She's a yoga gal, never lifted any weights. She could barely do a sit to stand from a workout bench without using her hands. It caused a lot of pain. We have been working together for months and got her to a point where she is lifting. She's doing goblet squats, 35 pound dumbbell for 12. We've been working together for months. She is doing high intensity interval training. She is repping out burpees and slam balls. I mean, she's absolutely crushing it. Like we were building her reserve and resiliency, her arthritis in her knees. That pain was starting to decrease. She's starting to feel really, really good. She is so on board. It's been this beautiful, beautiful journey. And then one day, Martha hits me with, so I'm going to start this weight loss drug, Mongero. And it took everything for me to not automatically question that and show on my face that I was upset about this decision. And so I want to emphasize to you all how to go about this, how to react, how not to react. I know that we're going to have some regression here. I know that we're going to have some challenges. The important thing to remember is that we need to be the guide and not the hero. Be the guide, not the hero. That doesn't sound or look like this when Martha drops that bomb. You do not say, Martha, wait, huh? Why? Why would you do that? You don't need to do that. We're crushing it. You're doing so well. You're going to lose weight by exercise and lifestyle intervention and nutrition. What are you doing? That's going to make you feel like crap. Don't do it. Don't do it. We do not want to do that. Even in our head, if that's kind of what we're feeling, we do not show that. We do not say that. That is not being the guide. It does sound like this. Being the guide sounds like this. Got it. Martha, I'm so curious. This is totally new to me. Tell me a little bit more. Why have you decided to go on this? Hey, Martha, we may experience some challenges here. There may be some side effects. We may have to switch some stuff up with our exercise approach, but we will get through it together. That is what being the guide sounds like. We have to remember that older adults are allowed to assume their own risk and they're allowed to make their own decisions. For some reason, when it comes to older adults, and this is based in ageism, this is based in ableism, it's like we believe that they're little children who don't have fully developed frontal lobes. We assume because they're old, they need us to make decisions for them. That's not the case with many older adults. They are fully, fully capable of making their own medical decisions. We have to remember that this is not our life to live. This is not our journey. It is a journey for us to come alongside our clients, not to decide what that looks like. We want to gently try to get them back on track into our fitness forward lane, right? It's not a time to drop them from our care because they're not following along with our philosophy. I remember a very specific day. I was in the gym. I was on the GHD. Why I was looking at my phone, I don't know, but Martha texted me. She had been on this job for a few weeks now. She's like, I have such low energy. I feel awful. I just can't do the intensity that you're putting me through in these workouts anymore while I'm going through this weight loss period. I just can't do it. That was so upsetting, right? Because it felt like a failure. It felt like we were going to go backwards so many steps. My gosh, what had we worked so hard to get to? I was glad I'm at the gym, right? Because then I was like, you know what? I'm just going to go lift some heavy weights and I'm going to feel better. Obviously, 10 out of 10 times, you always feel better when you're stressed out and you lift some weights. I started to think about it and I was like, okay, I can't drop her. Even though it felt like, well, what skill am I bringing if I'm not appropriately dosing her? What else can I do here? I had to reflect and be like, no, I'm with her. Martha, I'm with you regardless of what you decide to do and how this looks like throughout this journey. And why is this important? Because when we spend so much time getting someone into a fitness forward lane, we're doing this because we want to build this long lasting relationship with them. Martha is going to get to a point where she's crushing it again. And I probably back off and I don't see her anymore for a while. But what do I want for our relationship? I want that if anything else comes up with Martha, right? She has an injury, she has pain, she's hearing some, you know, maybe some things are discouraging from her doctor. I want me to be the first person she thinks of. I want her to think, I want to run this by Julie or you know what? I know Julie could help me. We went through a lot together so far. I trust her. She's with me. I'm going to make sure to contact her. That's what we want guys. Like we want to develop that long term trusting relationship so that when something else comes up, we can get her right back into our fitness forward lane and we can keep her there. Okay. So that's number one. We have to remind ourselves that we are the guide, not the hero. All right. Now, how did I have to adjust for these regressions? How did I adjust our exercise interventions? So number one, she's right. I had to decrease the intensity of these exercises. I had to cut out a lot of the high intensity interval training. She had zero energy. She was feeling a little bit uncomfortable, a little dizzy. I mean, vitals and everything were fine, but she just felt like crap. And I would see her, you know, get a little wobbly when we were exercising. So I'm like, all right, we got to switch this up. So decreasing the cardiovascular intensity, I stopped having her do exercises that were high intensity with a lot of positional changes. So burpees and mountain climbers, supermans, hollow holds, thrusters, all of that took that out. And I just kept her on the bike. I just went back to getting her on the bike and just pedaling and maybe taking that RPE from an eight or nine down to a four to a five, right? She's sitting, she's safe on the bike, but I can still get a little bit of intensity there. Next, what I did is increase the amount of just raw strength training that we were doing. So taking away the high intensity interval, the full body functional movements, and I went more towards isolation and really just tried to focus on strength, right? Heavy, low amount of reps to where she's not getting a cardiovascular stimulant. It's more just muscular fatigue. So we started just going really heavy and really slow. And we became, I put her closer to the ground with all these positions. So instead of doing a standing press, I had her do a sitting press. We did a lot of supine, like hamstring, sliders, many times at tempo, right? That was another way to increase intensity without driving cardiovascular stimulus up. Supine chest press in a bridge position, sitting tricep extensions. Instead of bent over rows, that could get her a little bit dizzy. I had her do some standing banded rows, right? So I'm just changing things a little bit. I'm being a master of scale. I'm meeting her where she's at, prioritizing that raw strength training over intensity intervals. Next, I had to remind myself that something is better than nothing. When Martha texted me to say, I just don't think I can do anything. Like, I don't think I can do much. Should we still get together? Should we still meet? And part of my brain was like, again, it was like, well, what's the point? But then I'm like, you know what? Yes, something is always better than nothing. And 10 out of 10, Martha's been doing nothing. Her joints are becoming more achy. Her energy is getting lower because she's not moving. I know that if I help her just move her body and give her things to do that don't exhaust her, but make her feel good, that is going to make her emotionally feel better, physically feel better. It can be a gateway to opening up a little bit more activity because she had become so sedentary. And so that's exactly what we did. I modified everything for her. I gave her a workout specifically that was called, when Martha feels like crap, like, here you go. Here are the things you can do that make you feel good. And at the end of that session, she was so thankful. And she said, you know, I am so glad we met. I feel so much better that I did a little bit of something. So something is always better than nothing. Next, we have to talk about the nutritional aspect here because she got to where she was only eating a smoothie in the morning. And then she would eat like a spoonful of cottage cheese and maybe some crackers for the rest of the day. And she was telling me she was having these weird cravings for like hemp hearts and artichokes. Very strange. And she said, I can't really eat solids a lot. Like, I'm too full to eat solid food, but I really like my smoothie. So I was like, cool, let's make that smoothie as calorically dense and packed full of protein as humanly possible. We know that malnutrition is so, so detrimental to older adults. We know how that can lead to clinical geriatric syndromes like frailty and sarcopenia. So I wanted to try and make sure that I was making the food that she could eat as nutritionally dense as possible. So packing that smoothie with chia seeds and flax seeds and peanut butter and making sure it's high protein, full fat Greek yogurt, all of that. Really trying to make that one smoothie as nutritious as possible. So remembering when folks are, they don't feel like they can eat their calories, can they drink those calories and tolerate that a little bit better? Lastly here, the most important thing to remember is that you want to be thinking about maximizing reserve and resiliency, even when things are going really well. Like even when you're crushing it with your clients, your older adult clients, the job is not done. All right, I think about Kobe Bryant and the 2009 NBA Finals. They were 2-0 over the Magic and the reporter at the end of the game was like, you don't look happy. Like what's wrong? And he's like, what's there to be happy about? The game's not finished yet, right? The job's not finished yet. That is the attitude that we have to have, is that even when you have built reserve and resiliency and things are going well, you do not want to take your foot off the gas pedal. You want to continue to instill this person becoming robust and resilient because something's going to come along, right? It could be that they decide to go on this darn weight loss drug and they lose a lot of their strength and their resiliency or they get sick or they have a family member who passes away and they become emotionally depressed and they become, they socially withdrawal, right? All of the complexities that can happen in our lives. Like we want to be building reserve and resiliency and do not take your foot off that gas pedal, right? The job is not done yet, okay? All right, so what happened to Martha? What is this scary ending that happened? So Martha has a partner and her partner was also taking Mongero. He was outside working in the yard, something that he loves to do. He had lost 20 pounds over a period of six weeks, whereas Martha didn't lose any more than just a few pounds, but her partner really experienced significant weight loss. He wasn't eating, he wasn't hydrating, he was trying to maintain his normal level of activity. He was outside in the yard, it was really, really hot and he passed out and like fell down an embankment, rolled a bunch of times, bruises all over the place. I mean, went to the emergency room, bruised a bunch of ribs, got a bunch of x-rays, he's okay, but Martha said to me, he's like, Julie, if that would have been me, I don't know what would have happened. I mean, he's a big strong guy. I could have gotten seriously hurt and even more so, I mean, if I hadn't built the strength that I had working with you over the past however many months, I don't even know. Maybe I would have died. Maybe I would have died if that happened to me. So she's seeing something really awful happen to the person that she loves. She's thinking if it had been her and she's saying to me, you know what, I just, I love being active, right? I miss how strong I felt. This sucks. I don't like this, right? And she wasn't even someone, she didn't have negative GI effects. She wasn't having nausea, vomiting, all of that stuff. She simply wanted to feel good again and full of energy. She was sick of feeling like crap, you know, and obviously saw something really awful happen to someone that she loves. So she has discontinued this medication just recently and we are going to be seeing each other again next week and we're going to just have to rebuild, you know? But she was able to come to her own conclusion. I didn't have to tell her not to do this. She decided to get off this drug on her own because she had built up this belief in this fitness forward philosophy. She knows how good it feels to work hard, to do her high intensity intervals, to lift those heavy weights. She wants to get back to that. And so this was a beautiful example of how we have to let people make their own mistakes and come to their own conclusions. All right. That was a long one. That is all I have for you all. So some things to think about. I hope this helps if any of your clients are taking this drug or you're just trying to navigate a situation where maybe they are doing something in a way that you don't fully support and how do you continue to support them on their journey and maintain a good relationship? I will end things here by telling you guys a little bit about our courses that are coming up in the older adult division. In July, we are in Connecticut, Idaho, and Georgia. In August, we are in Maryland, Kentucky, Minnesota, and Texas. And our next eight week online course, Essential Foundations, starts August 9th. So PTI Nice is where all of that information lives. Feel free to reach out if you have any questions. Have a wonderful rest of your Wednesday.

Jun 27, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey highlights the four pillars of healthy living behaviors: mindfulness, exercise, diet, and sleep. These pillars are essential for improving overall health and wellness. Mindfulness involves helping patients become more aware of their beliefs and mindset towards their body, and providing them with strategies to think about their body in a healthier way. For patients with hip and knee issues, mindfulness should also involve reframing their mindset to view their bodies as having opportunities for improvement through strength and flexibility. Exercise is crucial for meeting physical activity guidelines, which recommend 150 to 300 minutes of physical activity per week. The WHO recommends aiming for 300 minutes as it is more beneficial. However, prescribing physical activity for patients in pain can be challenging. The episode suggests starting where the patient is at and finding ways to infuse physical activity, such as starting with five-minute bouts. Therapeutic exercise is also helpful but may only result in small to moderate size effects on pain and disability due to variability in patient response. Diet involves adding healthy foods to a patient's diet, rather than taking away harmful foods. This is especially important for those who have received negative messages about their body. Sleep is also crucial for tissue healing, and strategies such as sleeping in a cool, dark room and going to bed at the same time daily can help improve sleep quality. Overall, addressing these four pillars may be challenging, but they are essential for improving brain tissue and making the body more resilient. The goal of mindfulness is to help patients become more mindful of their bodies and to frame their mindset in a more positive and proactive way. Meeting physical activity guidelines is a must, and therapeutic exercise can be helpful but may only result in small to moderate size effects on pain and disability. Adding healthy foods to a patient's diet and improving sleep quality are also crucial for overall health and wellness. If you're looking to learn more about our Extremity Management courses , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 Dr. Lindsey Hughey, PT, DPT, OCS, FAAOMPT Good morning PT on Ice Daily Show, how are you? I am Dr. Lindsay Hughey, one of our lead faculty from our extreme management team coming to you live from Grass Valley, California. Kind of an atypical place to see you all, but I'm just finishing up teaching a course here with body logic. What a weekend and about to take off to Delaware a day of travel, but I'm so happy to be with you all this morning. Today I'm going to chat with you about hip and neo-a and really the unspoken battle we have with these folks when we're treating them. But before I dive into the topic at hand, I would love to review just briefly some courses that Mark and I and our extreme management team have coming up this summer. So our next offering is July 15th, 16th, we will be in Holmes Beach, Florida. And then July 22nd, 23rd, we will be in California again, but now we'll be in the southern part, almost the most northern part. So we'll be in Sydney Valley, California, and there are still spots in both of those courses. So we'd be delighted to have you with me. And then July 29th and 30th, we're going to be at Onward Madison. I think there's only one or two spots, maybe zero. Check it out though, because we are filling up because that's right before the CrossFit Games. And one of our faculty, Kelly Bempi, is competing in the CrossFit Games. So I'm going to teach that weekend and then stay the whole week and cheer her on. I couldn't be more pumped and a lot of ICE faculty would be there. So think about that as one of your weekends if you're wanting to go to the CrossFit Games as well and kind of make a week out of it. And then check us out on ptlnice.com in our extreme management division because we also have courses in August and then early September. But I'd love to unspoken battle. So in this episode, I want to briefly review what we know helps hip and knee away, which we in the last couple of years keep seeing studies that really just confirm exercise is the way. It's not injections. It's not surgery. It is exercise medicine. And just recently, a 2023 systematic review and meta-analysis on hip and knee away just came out out of the Lancet Rheumatology Journal reiterating this. The exercise is superior to no exercise. And kind of the challenge and this study in particular, its title was Moderators of the Effect of Therapeutic Exercise for Knee and Hip Osteoarthritis, a Systematic Review and Individual Participant Meta-Analysis. This involved 91 RCTs and they compared exercise versus non-exercise strategies and they included both knee or hip or included studies that actually looked at both or looked at each individually. And really the outcome measure is pain and disability, right? The number one things patients are coming to us for. And then the study just really reiterated the importance of therapeutic exercise. What we often just say exercise, but what this article defined therapeutic exercise to be was it involves participation in physical activity that is planned, that is structured, repetitive, and purposeful for the improvement or maintenance of a specific health condition such as osteoarthritis, right? So this has to be purposefully planned and it has is multimodal and in nature. This article not only reiterated that therapeutic exercise, in fact, that combination of multimodal treatment is helpful, but it also further demonstrated that we always see small to like moderate size effects or effect sizes as it relates to pain and disability. Meaning not really huge shifts and necessarily changing that patient's world and then implying it to the broad population because there's a lot of variability in patient response. We are just still missing the target here is what that's telling me, right? We're missing the target in this patient population because we're not even though we know exercise is the way, we're not reaching everyone. People are still going on to getting knee replacement. They're still going on to having pain and disability. And I believe it's because our focus is really misdirected and what the underlying battle here is. And it's not just about strength, range of motion, access. It is a much bigger underlying systemic issue because we're not even reaching the target. Because what is happening under the surface with hip and knee away is a really complex process. And while it's complex, I'm going to just unpack it for you in like a minute. But when we see folks that are inactive, not moving, and whether it's because they first started having pain and then they stopped moving or because of being sedentary, they started kind of developing osteoarthritis. What came first, the chicken here, but what we do know is there's this cyclic cycle where when you stop moving and you have underlying osteoarthritis, sarcopenia starts to happen, right? We start to see muscle wasting. With this inactivity in this sarcopenia in our tissues, we start seeing accumulation of visceral fat. And then macrophage infiltration throughout our body, hanging out, low grade. We see links to osteoarthritis and then this cycle where this leads to Alzheimer's disease. Our brain cells, our brain tissue starts to become unhealthy because of this low grade systemic inflammation. This starts to affect these immune cells are hanging out in our blood tissue. We have unhealthy blood. So we get atherosclerosis, right? We get buildup along our arterial walls. This starts to lead to insulin resistance and glucose just hanging out in our blood because it's not being uptaked as much as readily as it needs to because again, the blood is unhealthy and this leads to type two diabetes. We see cyclical links and then guess what? Then our blood no longer is oxygen rich. We see links to then anemia and osteoarthritis and this cycle of low grade chronic inflammation continues leading to other major diseases that affect our whole ecosystem. We know this, right? This is a like this cycle I'm describing came out in 2018 from school at L&T and JOSPT just talking about the importance of if we don't get our patients moving and physically active, this low grade inflammation, it's just going to hang out there. And if we pair that with what we know is happening in our society at large, I don't just mean the United States, but globally, when we look to the WHO, right? The World Health Organization and you look at the top 10 causes of death, right? Guess what just got added to that top 10 list recently? Diabetes, diabetes, diaphragm, diabetes, right? And we have our folks with hip and knee osteoarthritis, not in pain, so they're not moving. And then this low grade systemic inflammation cycle, which leads to diabetes and things like Alzheimer's, which is also on our list of top 10 issues are things leading to death. We are dealing with metabolic disease with hip and knee away. We have to address the hard conversations around metabolic disease if we really want to impact our humans, our patients lives with hip and knee away. Think about most of your folks that have it. Most of those folks have diabetes on their past medical chart, right? We have an opportunity to not just impact joint health, right? But we have an opportunity to impact their blood, how their blood takes up sugar, right? And uses it for their body. We have an opportunity to ward off risk against developing Alzheimer's. We have an opportunity to work against leading towards anemia and sarcopenia. Our job is pretty huge here. So we have to do better. And I'll tell you, these conversations are so hard, right? But our society, we are, yes, living longer from a longevity perspective and lifespan, yet we're getting sicker. And you can look to the Who for data about that. I'll tell you at ICE, any faculty member, it doesn't matter what specialty division. Mine is in particular extremity management. We have pelvic health, we have CMFA, we have modern marriage with older adults, spine health, right? If you really ask each one of our faculty what we're really fighting against, what is ICE really doing? We are fighting against metabolic disease. We are championing and fighting for healthy living behaviors because we see this sickness in our society that we are getting more unhealthy, even though we're living longer. And it's because of sedentary behaviors. And we have to have these hard conversations surrounding how do we change these unhealthy living behaviors? How do we get these patients moving? Because again, it's not just about symptom management of their hip and knee pain. And it's not just about via exercise. It's really about infusing fitness into their life, into their tissue health. And when you think about that cyclical cycle I just described and that School.L article in 2018 gives a great visual. But this includes, when we think about fitness forward, we think about healthy living behaviors that help improve brain tissue, that help improve your blood, making your blood healthier. And we do that via cardiovascular physical activity. We want the ecosystems of our humans to be more healthy and more resilient. And really the best and most efficient way to think about how do we do this in the clinic, right? Because I mentioned this is a hard, hard conversation when we think about how we change patient lifestyles, how they eat, how they sleep, and how they move. The best way to think about this is through meds. Thinking about the four pillars. And med stands for mindfulness, exercise, diet, and sleep. When we think mindfulness for these folks that come in with hip and knee, or think about any patient you've ever had, what is our greatest responsibility here in mindfulness? When we think about mindfulness, I think we typically think about breathing strategies, taking a walk in nature, maybe journaling, some physiologic sighing, meditation. And yes, when your patients are stressed, yes, we want to give them this and give them those tools. And for our folks with hip and knee, this is fair game. But I'll tell you with these folks, when I say mindfulness, I'm thinking about how you frame their mindset, how you help these folks be more aware about what they believe, right? The folks that say, I had bad knees, my mom had bad knees, my great grandmother had bad knees, my great great grandmother had bad knees. They're the people that sit back, open up that hip angle, and you know you're about to get a long story that first visit, right? About this history. And this is deep ingrained beliefs, right? About their knee health. And we have to also acknowledge that this is probably deep ingrained lifestyle behaviors, right? When it comes to our food choices, our sleep choices. So there's some really entrenched shifts that we have to make. But we have to let them know, no matter what, like really let them tell us those beliefs, and then allow a reframe, a mind shift that these are knees that aren't bad, right? Please stop saying your knees are bad, Betty. Your knees have an opportunity, your hips have an opportunity, your hips have an opportunity to blank, right? To be stronger, to be more flexible. Your body has an opportunity to move more. Yes, we can help them manage stress with some of those techniques that I mentioned earlier, but it's really more about helping them be more mindful of how to think about their body in a healthier way, and giving them strategies to do so, right? So they're no longer a victim, but a victor. Exercise is that next, so we did mindfulness, and then exercise is that next pillar we have to address with these folks. Meeting physical activity guidelines. 50, 150 to 300 minutes, right? Of physical activity is a must. And the WHO acknowledges that 150 is on the low end, right? That we want more towards 30, which means 300, excuse me, which means 30 minutes at minimum, but probably 30 to 60 minutes of physical activity five days a week. If they're doing higher intensity exercise, right, 75 minutes is fair game. But this is so tough, right? Because these patients are coming to us in tons of pain. So what do we do? How do we get them moving? And this is the hard part, right? If Betty can only walk three to five minutes, and it's painful for her to just make it into your clinic, and she needs a rest break, it's hard to prescribe, okay, 30 to 60 minutes of activity a day. And so we have to start where they're at and figure out ways to infuse physical activity. Maybe initially that's that five minute six bouts, right? And some of you are like, Lindsay, you're freaking crazy. My patient, Betty's never doing that, right? Maybe we start off small at 50%. Maybe the first goal is just five minutes, three times a day, right? We have that dose, and we see her response to movement. The real key part is we figure it out. It doesn't matter. It doesn't have to be walking. It could be dancing to music, right? It could be calling, Betty could be calling her grandson and going for a little walk so she's a little bit distracted. It could be marching in place. It could be an exercise video. It could be linking them to their community. It doesn't matter what it is. You have to figure it out. And it is hard, but you have to partner with that patient and figure out a way to get them moving. And then that's not enough. It's not just the physical activity piece. It's then adding in strength, flexibility, endurance, neuromuscularity, right? Kind of the things in our wheelhouse and figuring out what really helps their tissues feel better. That also respects irritability. In extremity management, we talk a lot about the rehab dose, which is an irritability respecting dose. And that part is really key in these folks because you need that initial buy-in, right? Our CEO, Jeff Moore, says we manage symptoms to maximize fitness. If you don't first get that modulating buy-in window of opportunity by dosing exercise well to show patients that actually exercise, right? You do about an exercise and then you retest some maybe knee flexion, knee extension, hip flexion, or maybe how fast they're walking and show them, right? Oh, wow, you're now moving faster. Oh, wow, you now have more motion, Betty. That's awesome. You have to give them that show me moment. So our test retest strategies have to illustrate that exercise is medicine. Exercise is the thing making tissues feel better, right? Not just our manual therapy. So that's a big thing that we can do to help with this exercise pillar. And then diet, right? This is probably the hardest one and these folks have been told they're obese and they need to lose weight and that's not the answer, right? Please don't say that to those folks, right? They've heard that time and time again. They've heard it from providers that haven't even looked up from their chart or from their computer to look them in the eye. What I want you to do is a weight neutral strategy where we add resistance training. We add things that increase basal metabolic rate and then start chatting about things they can add like half their body weight in ounces of water, right, for a diet and then maybe adding a little bit more protein, right, for tissue healing and to help as they continue to increase their exercise activity level, right? So it supports their activity level. Talking to them when they're open to it, eating more plants, right, more colorful, diverse diets. That's kind of where we go with our diet discussion. It's not right away take away the soda, take away the bowl of ice cream because you're going to lose buy in with those folks, right? And we know the harmful inflammatory effects of sugar but with these folks that have been told a harmful message about their body already, let's add to these folks with hip and knee away before taking away. Sleep is our final pillar so we've talked mindfulness, exercise, diet, sleep and I'm pushing my time limits a little bit here. Sleep, we need to help our folks work on sleeping better, right, in a cool dark room that's 60 to 65 degrees. Use blackout curtains, go to bed at the same time daily. Those are just a few of our strategies that we really love to help with quality of sleep, right? While seven to nine hours is ideal and I would love sleep quantity on board for tissue healing, work on sleep quality before quantity first with these folks. And again, yes, these pillars, addressing these pillars are hard and no, we can't address them all at once, right? We'll dose our education just like we dose exercise. But we have to have the hard conversations with these folks. Behavior and lifestyle change, I mentioned earlier, they are hard but they have to occur to make our society healthier. Diabetes was just added to the top ten killers of our world, not just the United States. That's a big deal and most of our folks with hip and knee away have diabetes so don't miss that link, right? Fitness forward is not just about lifting heavy shit with your friends. Although barbell medicine is a key part of it, right, because it brings on intensity for our tissues and that pumping effect for good healthy blood, right, and it tends to make a patient feel pretty bad ass when they start getting heavy. But we are here to wage war on metabolic disease with our hip and knee away. It is plaguing our system, it's plaguing our country and our world. Hip and knee away is associated with diseases like diabetes and Alzheimer's. It will not go away without engaging the hard, it will not go away without engaging the hard conversations and the hard behavior change. We have to wage war here and we as physical therapists that have that experience, as our patients, probably have the greatest opportunity to wage war on the underlying tissue inflammation that is there in these folks, the sedentary lifestyle that's associated with that pain and the poor mindset of I have bad knees. Take this opportunity with your folks this week to address one of the pillars, mindfulness, exercise, diet, sleep. I suggest starting with the M and getting some buy-in with the E. Thank you for your time this morning everyone. Joining me in Grass Valley in an atypical spot here. It's been a pleasure. Have a great, happy Tuesday. 19:32 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at PTOnICE.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnICE.com and scroll to the bottom of the page to sign up.

Jun 26, 2023

Dr. Rachel Moore // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how physical therapists don't need to be the masters of movements in order to teach them to others, or help others begin their progression towards achieving them. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's PT on ICE Daily Show. 01:27 DR. RACHEL MOORE, PT, DPT All right. Good morning, PT on ICE Daily Show. Welcome to our 1500th episode of PT on ICE. We are incredibly honored that you guys tune in and listen to our crew rap about everything from pregnancy and postpartum to fitness athlete management, from pushing the envelope on Geri Care to evidence based orthopedic care, whether that's from our spine division or our extremity crew and the latest and greatest about dry needling and then gaining some leadership insights. We are so honored that you guys choose us to listen to for all of the information. ICE wouldn't be what it is without you guys. So thank you so much for hanging with us on Instagram, on YouTube, on your podcast apps and in our courses. We love connecting with you all and working together to push our profession towards PT 2.0. Today, I want to ring in our 1500th episode with a topic that honestly might seem a bit random, but don't worry, I'm going to explain where it came from. Today, we're going to be talking about lessons we can all learn from the man, Ted Lasso himself, both as physical therapist and honestly, just in life too. Before we do that, I'm going to dive into our upcoming courses in the Ice Pelvic Division. Our next online cohort starts July 10th. This is our eight week course where we dive into everything from preconception and relative energy deficiency in sport to pregnancy, making modifications for pregnant athletes. We talk about birth, we talk about the fourth trimester, we talk about postpartum, we go over how to get athletes back to the barbell, back to the gymnastics rig. It is a lot of really great information and that cohort starts July 10th is when our next one kicks off. Our next in-person courses, we've got three coming up in the next few months. July 29th and 30th, we've got a team going out to Parker, Colorado. That's going to be with Alexis Morgan and April Dominic. September 23rd and 24th in Scottsdale, Arizona. That'll be with Alexis Morgan and myself. And then September 30th and October 1st, Christina Prevot is going to be hanging out in Ontario. So if you've been looking for a course north of the border for the pelvic division, check that one out. Head to the website, sign up for those courses. While you're there, head to the resources tab, sign up for our newsletter to stay up to date on all of the latest pelvic and pregnancy and postpartum information and research. All right, guys, here we go. We're kicking it off. Why are my here on Pelvic Monday talking about Ted Lasso? In our online cohort, we cover a lot of different topics like I just said. In week six, we talk about gymnastics and we are talking about helping our patients get back to the pull-up bar, working on pull-ups and chest to bars and bar muscle ups and ring muscle ups and all of these like advanced gymnastics skills that we learn how to do in CrossFit that are all super fun. We always ask the crew in the class kind of towards the end of our meetup, what is the biggest barrier that you perceive in helping patients get back to these skills? In every single cohort, we always get the same answer across the board and it's that I can't do this skill so I don't feel like I can teach it. I'm not confident in the ability to be able to teach it. While we do encourage people to be about it and we want them to get themselves into whatever area of fitness they love and we always encourage them towards the CrossFit side in particular, we also always have a conversation that you don't have to be able to teach things in order to be able to do things in order to teach them. So in past cohorts, I always make the reference of like a coach and a sport team. I admittedly do not watch sports at all so I'm always trying to like pull a random name out and it never really works out very well. I'm like, oh yeah, like you know the football coach on the sidelines, he's probably like scrawny but then the football players are over there. And last cohort, in the middle of trying to explain this with my very poor background in sports, it hit me that Ted Lasso is the perfect example of this. This leads us beautifully into lesson number one. And don't worry, I went through all of these examples with a fine tooth comb to make sure that I don't spoil it if you are still finishing up Ted Lasso or maybe you haven't watched it. So lesson number one, you don't have to be able to do the thing in order to coach it. We all know this is a prime example from Ted Lasso because he has never played soccer and has never coached soccer and he moves to London to coach a soccer team after having a background working with college football, athletics. So that kind of resonates with me personally, I coach CrossFit and I've never done a ring muscle up for example. However, I understand the component pieces of a ring muscle up. I know what the points of performance are. I can record somebody doing a ring muscle up and I can break down where in the movement maybe we need to tweak something or the mechanics are changing. Being able to take a step back and watch a movement and help an athlete clean up the pieces of the movement matters. Being able to jump up on the rings and do it yourself doesn't. Your patients are seeing you for a reason. They're not there to watch you just bang out a bunch of reps. They're there to get your expertise in the physical therapy realm and help connect to the dots of fitness and rehab. And again, we absolutely want you guys being about it and pushing yourselves in your own fitness domains. So spending the time to learn these movements both by like watching videos of people doing these things, pulling up YouTube, following athletes on Instagram, getting comfortable with seeing movement variability and what some of those common faults are, but also by working on them yourself. You don't have to be the best athlete out there. We actually had a whole conversation in that most recent cohort about how sometimes the best athletes do not make the best coaches because they can just jump up and do the thing. They don't really understand how to break down those component pieces. They're like, yeah, you just do it like this. So sometimes it can make you an even better coach if you don't know how to do the movement or you're not proficient in it, but you've taken the time to kind of break that down and work on it in and of yourself. Put the time in to work through it yourself and that's going to help you troubleshoot what you're going to be eventually teaching. You want to get to know the things your patient's wanting to do, understand them well, and then understand how to break that down to the key points of performance. If that is in the fitness realm or realistically the functional movement realm, we really encourage you guys to hop into our CMFA courses to learn what those points of performance are with a physical therapist kind of scope on them or hop into a CrossFit level one course or take a CrossFit specialty course. If you know you want to hone in on your gymnastics coaching specifically or maybe your weightlifting specifically, there's specialty courses that break that down seeking out the knowledge along the way, but that doesn't have to be a barrier to getting into the thing. You can start it. You can learn it. We want to make sure that we understand the component pieces, but you don't have to be able to be a master of it on your own physically in order to be able to teach it. We're going to head into lesson two. This is my favorite lesson. Be unashamedly enthusiastic in celebrating your patient's victories. Within the very first few minutes of the first episode of Ted Lasso, there is a video of Ted dancing in the locker room with a college football team that he led to victory in his first year of coaching after they won the division two national title. This is what Ted is known for before he becomes the coach for AFC Richmond and moves to London. This is his reputation. If that's not what I hope every single one of us is doing in clinic when our patients tell us some positive progress, I don't know what it is. Maybe we're not busting out fully into a dance, but we need to be enthusiastically celebrating the wins with our patients. Vision this. You have a patient named Sally. She's coming in to see you. You're chatting with her. You're catching up on your asterisk signs. You ask her how things have been since the last visit, asking how her leakage has been because that was her worst symptom at your first visit. She tells you, like, yeah, things are okay, I guess. I'm still leaking when I work out though. So naturally, you follow this up by asking her more details. What was the workout? What movements were in the workout? When did the leakage happen within that workout? She tells you it was in her third round of a METCON that had 200 meters running and 50 double unders. And you're looking at her chart and you're scrolling through and you look at her last asterisk sign and you see that previously she was leaking at 10 double unders, but she just made it all the way to the third round of a workout that had running and double unders in it. You're going to freak out, maybe not freak out, but you're going to tell her, girl, that is amazing. You're doing fantastic. Look at all of this volume that you just did. We used to be here and this was our buoy. And now your buoys all the way up here. What we're doing is increasing your functional capacity. It's increasing the amount of work that you can do before your symptoms kick on. And that is fantastic. You are crushing it. That is what we want to be doing. We want to be celebrating our patients. Another example, maybe you have Lucy on your schedule and Lucy used to have three out of 10 pain with her sit to stands every single time when she was getting off the couch with her newborn. And the other day she sent you a text message because she back squatted 70% of her one rep max pain free at three months postpartum. And she wants you to know maybe you're not seeing her in the clinic. Maybe she's just excited to tell you in between sessions. We are going to respond to that text message with all of the party emojis. We're going to tell her great job. You are crushing it. You are doing so awesome. We want to pump her up and make sure that she knows that she is doing fantastic. We can take this concept and we can apply it across so many different realms in the physical therapy world, not just in the pelvic space. Our job is to guide our patients. Our job, particularly in the PT 2.0 realm, is to load our patients and make them stronger and more resilient humans. And dang it, our job is to celebrate with them when they are crushing it. And if they are struggling to find those victories, our job is to help point them out and again, celebrate all of these victories with them. This leads us into our third lesson of the day. Our final lesson of the day from Ted Lasso is to not be afraid to pivot. If plan A isn't working, plan B is there. This is another topic we talk about a lot in the pelvic space because there's kind of a dichotomy between high tone versus low tone and how you address the presentation. This is another topic that does come up a lot in our online cohort. We typically ask students, like, if you're new to pelvic, what are you worried about or what is a barrier? What kind of things are you nervous about with getting into this space? And a lot of times people say that they're nervous about doing the wrong thing or giving the patients the wrong exercises. So for example, if there's somebody that the therapist sees and they're like, we're going to do down regulation and really work on calming that tone down and you see the patient the next time and nothing has changed, it's okay to pivot. It's okay to say, okay, great, we tried to downtrain, we did that and that was fantastic, but that wasn't really exactly what landed for us. So now we're going to switch gears and we're going to focus on loading. The downtraining stuff is okay and we can still continue it, but now I want to see what happens when we introduce some load to the system. As PTs, our job is to test, treat and retest within session is great, but also between sessions, right? So if we give a patient intervention and they take that home, they work on it for homework and it doesn't quite do exactly what we were hoping, it's okay to change gears and do something different at your next session. It doesn't make you a bad therapist, it makes you somebody who is consistently creating hypotheses, testing them, retesting them and pivoting for the best interest of your patient. So there we have it, lessons from Ted Lasso. I hope you guys enjoyed this topic. If you haven't watched Ted Lasso, I highly recommend adding it to your list. If you have watched Ted Lasso, feel free to drop a comment of your favorite Ted Lasso in the comments below and you guys get out there and crush your Monday. Bye! 14:16 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning Check out our virtual Ice Online Mentorship Program at PTOnIce.com. While you're there, sign up for our Hump Day Hustling Newsletter for a free email every Wednesday morning with our top 5 research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

Jun 23, 2023

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Fitness Athlete instructor Guillermo Contreras breaks down the difference between the different types of training shoes for the functional fitness athlete that are currently available on the market. Take a listen to learn how to recommend the best shoe for your patient or athlete (or yourself!) If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 01:33 – Dr. Guillermo Contreras, PT, DPT, CF-L2, Cert-CMFA, Cert-ICE All right, welcome to the PT on ICE Daily Show Gang. Welcome to the best day of the week, Fitness Athlete Friday. I am here with you, Guillermo Contreras, physical therapist and faculty, or on the team under Fitness Athlete Division of the Institute of Clinical Excellence. Excited to be on this morning to talk all things near and dear to my heart, fitness footwear or shoewear as far as it goes with the fitness athlete. Before we dive into the extensive topic at hand, where you can catch us next, most, next, I can't even talk today, for Fitness Athlete Central Foundations, if you're looking to take the online course and learn all things squat, deadlift, press, pull-up, and even medcon and remod start some introductory programming, the next cohort of Central Foundations kicks off on September 11th, so you have about a month and a half before we start that one up. That course, as well as our Advanced Concepts courses, tend to always sell out before the course begins. So if you've been looking at taking it, you're considering taking that course, make sure to sign up early, especially Advanced Concept, because that course has less seats in it and it's a lot bigger, like heavier, denser material, so make sure you're jumping on that as soon as you can. Speaking of Advanced Concepts, that starts up on September 17th, so again, about another month and a half before that one kicks off. If you're looking to catch us out on the road, we have a handful of courses throughout the fall, and then the summer is a little bit quieter. The only course right now we have going on this summer is June 24th, 25th in Loveland, Ohio. That's where we leave with Zach Long down at Onward at downtown in Ohio, and then we move on to September, so starting in the fall, a lot of courses going through until the winter ends. Bismarck North Dakota on September 9th and 10th, Newark, California on September 30th and October 1st, Linwood, Washington October 7th and 8th, a double course weekend on November 4th and 5th in either San Antonio, Texas or Birmingham, Alabama. November 17th and 18th, we are in Holmes Beach, Florida. I'm not sure where that is. I believe it's up near the Sarasota area, and then a double weekend again on December 9th and 10th in Louisiana as well as Colorado Springs, Colorado. So if you've been looking to take those courses, if any of those courses are in your area, if they're nearby, you can drive to them, quick flight, pop over, right? Hope to see you there on the road in the next couple months. Again, my name is Guillermo Contreras. I'm on the staff of the Whitney Fitness Athlete Division, Help Out With Essential Foundations. It's one of a lot of courses, and if you've taken Essential Foundations in the past, you know that I'm commonly like jokingly referred to as the shoe guy. I've met people who have way more shoes than I do. They collect them, they put them in boxes and store them and things like that. That's not my style. I buy them, I wear them, I train in them, I circulate depending on what I feel like wearing that day, what my outfit is going to be, like weird things like that, things that aren't really necessary as far as training goes, but it's important for everybody here. And what I'm doing here is I'm basically going through all the shoe options that we have now available to us in the fitness athlete realm. The most common question we get around shoes is not like, oh, what material do you recommend? What's the heel drop? It's usually, hey, gearmo or hey, gang, if I have someone who's just starting CrossFit, what shoe do you recommend they start out? Or, hey, I'm into this CrossFit thing now, I think I really enjoy it and I want to keep doing it. What shoe would you recommend I start out with? What shoe would you recommend I buy? What shoe should I purchase and use? Those are the questions we kind of get. So that's what I'm going to go over. I'm going to do my best to keep this in a short format because this is something I could probably go on a long tangent about. I enjoyed doing my write-ups for this and getting all my research listed out for me so I can kind of really make sure I hit all the points. And by all means, if anyone ever wants me to do a long version of this in like a vice lecture, as long as the crew is okay with it, please let me know. Happy to do slides and everything as well. So we're going to start with the most commonly known brands, most commonly known shoe that people are aware of that's out there and maybe basically go down to the least known. And at the end, I'll give my recommendation for my favorite shoe, like the thing I wear the most for training, as well as probably the most common shoe we see in and out of the CrossFit sphere. So starting off with the shoe that kind of started it all, I would say, well, technically, it doesn't matter, the Reebok Nano, right? So Reebok Nano, this is the Nano X2. They now have the X3. The X3, from what I've heard, actually delivered a little bit better with this shoe, a little bit more flexibility, more bounce, more comfortable with running. The Nano X3 has a seven millimeter heel drop. So from heel to toe, seven millimeter heel drop. So more comfortable for lifting, gives you a nice base. The back here is nice and firm and stiff. It has this cage thing here, which helps with support. And then this weird line thing is supposed to be some sort of weird spring bounce. So that's some of the little features. It's got a lift run chassis is what it says it's called. But it's an overall solid training shoe for interval training, for high intensity training, for CrossFit. It's got a solid base for lifting. And I would argue it's got a, it's a decent shoe, especially the X3, where it's a little bit more comfortable, a little bit more cushioned, especially through the forefoot, midfoot. It's a little more comfortable for runs. Would I recommend training for a marathon, doing long duration, long distance running in it? No, I would honestly probably limit this shoe to somewhere around the 800 meter, maybe no more than a mile. If you've gotten used to it, you're comfortable with it. You don't mind a slightly heavier shoe. This is what I would recommend for you if you're comfortable with it. So if you are looking for a very, very good running Nano from the CEO of himself, Alan, he recommends the Nano X1 Adventure. So that one came out two series ago. I think you can probably get those for like 70 bucks now on sale for everything that we're seeing there on the Reebok website. Only thing else I have with this is, again, slightly heavy and the cost is around 150. It used to be 130. They've jacked up the price. I'm not sure why, but the Nano is about $150 now to buy on brand new. But sometimes you find pretty good sales as far as like family, friends sales or previous versions. The X2 is pretty good if you want to go with that. Number two, again, this is not the newest version because I left my pair at the gym, but this is Neki Metcon. So Neki Metcon came out shortly after the Nano. It was kind of like the biggest competitor as far as a CrossFit shoe. The Metcon is stylish, right? It's got a lot of durability to it because it has like this really big rope guard is what they call it for rope climbs and such. The newest one, the Nano, I believe, or sorry, the Metcon, I think they're on eight now. The eight is more built, right? It is made to be the quintessential fitness shoe. It's functional. It's 100% about function. It looks kind of sleek, but I'm not a huge fan of the look of it than you are one. But again, it's a very functional shoe. This has a four millimeter hill drop. The older ones have a four millimeter and they came with like a lift thing you could slide into it. This is a Metcon 5, I believe. But then the Metcon 6, 7, 8 come with like it's already in there. So it's a thick TPU heel. This one isn't as stiff as the newer ones, but they have a really stiff heel and that I would say is the biggest con about this shoe. It's very good for lifting. It's good for wall balls and such because it's a nice, stiff heel. You can elevate the back a little bit. It's flexible, which is very nice. It's got an advantage for hands and pushups because it's got this like weird TPU plastic heel clip thing that's supposed to slide up the wall a little more easily. But again, it's a very blocky shoe when you think about the heel. So if you're someone who is a heel striker, the Metcon is actually one of the worst shoes for running at any distance more than maybe a 200, 400. So sprints probably fine. 400, 600, 800 in a workout is probably fine. But if you're doing a 5K day, if you're doing Merve, the Metcon is probably not the shoe you want to go with for that there. So this is the Nike Metcon. These run, I think 130 is what they run. And you can get customs for 160. So if you ever want to customize a shoe, 160 is not bad and a good option for most people there. A lot of people wear these. So those are the most common shoes you probably see in the gym because they're the most well-known brands. The next, what am I going through? Five, six here are less known or just less worn more than more is probably the better thought here. And the first one is right here. This is the Innovate, which people probably know Innovate for their old school barefoot minimalist kind of shoe wear. This is the Innovate F-Lite G300. In my opinion, this is the best crossfit shoe that Innovate makes. They make a couple other people. I believe the F235 is another option that people really like. And I believe there's another one that I can't recall all the letters and numbers, but Innovate makes these pretty good shoes. This one here has a six millimeter heel drop. So a higher heel height than the other shoes they have. It's definitely not a minimalist in that it doesn't have that heel drop there. It has what they call a booty style here. So there's no tongue. It's just you slip your foot in and you're over it again once you're in it. I never untie or tie the laces and it's pretty snug for me on my foot. It has a wider toe box, but not super wide. So if you like that, like the ability to display your toes, this is kind of nice here. It's lightweight. It's flexible, right? So you can bend it, you can turn it, you can go both ways. That's not as flexible as I thought it was, but I feel it's pretty flexible. It's got a stable heel, but it's not so stiff that you can't run in these either. These are actually very comfortable to run in, in my opinion. One con or con that this one has is you can kind of see this plastic cage on it there. And for those who are watching, just listening on the podcast, there's like a plastic cage around like the midfoot. That plastic cage, quote unquote cage, provides some more stability in that midfoot, in that midsole, but it also can be a con in some people who do not like, or who have slightly wider feet, because it's going to restrict that midfoot a little bit more and it's not the most comfortable thing. So if you're someone with more wide feet, not so narrow midfoot area, this shoe is probably not going to be the most comfortable because of this plastic cage, but overall it's a nice solid shoe. My biggest qualms with it, again, are the cage, if you're not into it. If you're not into that boot style, kind of slip on shoe, this is probably not going to be for you because you like to cinch up those laces and cut blood flow off to your feet. And honestly, they claim that the durability is very good on these because of this plastic cage. But if you look here, this fiber here, which is meant to be breathable and really flexible and nice, is actually one of the downfalls. That is not as durable. So I have a couple of friends who own these who have like little holes in them. And despite this being a rather expensive shoe, it can run anywhere from, I think, let's see, you can get them on sale for like $75, but they run up to like $155. I think these were like $150. For something that cost $150, you would expect it to last and do pretty well with road climbs and everything crossfit. And then customer service is not ideal. So little things that we don't need to dive into here. But again, good shoe, 6-millimeter heel height. So keep that in mind for your athletes. Next up, we have the Rad 1 Trainer. This one came into the market, I think, two years ago. It started off not so hot because it came out and it was extremely narrow, really sized poorly. So everyone was buying them and they needed to go with a full size. But they've actually fixed a lot of their sizing issues at this point. The Rad 1 Trainer has, again, another 6-millimeter heel drop. It has what they call a multi-directional outsole. So you can do a lot of different agility type things. It's good for jumping. It's good. It's really, really solid and stable for lifting. Cushion for plyometrics. It's actually fairly comfortable for running. Again, I wouldn't do a 5K or anything like that. But again, it's comfortable for your shorter runs, maybe max of a mile, mile and a half. So Merck would probably be really comfortable in these. High density, they have something called a Surge Energy Foam Midsole. So it's a very comfortable shoe. I personally actually really enjoy wearing these for working out, for crossfit workouts. I like them for lifting. So I kind of recommend them. They're a smaller brand too. So if you're into that whole helping smaller businesses and not just the mega ones like Nike and Reebok, this is a cool brand to get into. Price point, again, a little bit high, $150 when you're looking at them. It's aesthetically pleasing, which is always nice. Something that kind of looks kind of good, looks kind of cool and good options there. And the one thing they do have is similar to, if you're familiar with Noble, is that they'll have different colorways come out. But unlike Noble, I think they do re-releases. With Rad, when they run out of a colorway, that's it. They don't remake them, at least at this point they have. They're probably still early on enough where they're not going to, but they might in the future. But they start off with a colorway, they release it, and that's pretty much it. When they sell out, they sell out, they're done. So again, really solid shoe, really good for weightlifting, really good for crossfit, HIIT style workouts. Again, aesthetically, it looks nice for some people because of all the different colorways. Some colorways I think are hideous and I don't understand, but again, to each their own when it comes to what they wear on their feet for that. So this here, again, is the Rad One Trainer. Next, we have probably the newest brand out there that we've seen in the crossfit sphere. Athletes like Pat Velner, who else are wearing these? Pat Velner goes to mind right away. There's a bunch of like mayhem athletes who have it. I think Guillermo Maieros, shout out to the Guillermo's of the world. This is the Tier CT One Trainer, and it is CXT One Trainer, whatever. Again, this runs about 129, so about average for most crossfit style shoes. This one has a big old heel height. So this is a nine millimeter heel height. So this is fantastic for anyone who has stiff ankles looking to have that little bit of a jump in height to be able to squat a little deeper. To not have to worry about the stiff ankle, not have to worry about inserts or something that's in between like a weightlifting shoe and a training shoe while still having like flexibility, which is it's a very flexible shoe. It's actually really comfortable too. It's got a good cushion to it. I made a mistake when I said the Energy Foam Midsole that's in this shoe, not in the Rad One Trainer, but the Rad One Trainer is still comfortable. So it's got there. So it's responsive for like jumping, plyometrics, everything like that. It's breathable. This is like, it looks dense, but it's actually very breathable through the fabric on the top there. And it's just a good quality shoe. My cons with this one is I don't know if you can tell. Let's see if we can compare it to like the Nano. If you look at the difference, it is significantly more narrow, especially through the forefoot down into the toes. So I personally like wearing these for short lifting sessions. I don't do them for a lot of plyometric workouts. I have a slightly wider foot. My toes splay pretty nicely. So I don't like having my pinky toe kind of crushed into here. I could go up a size 12 and a half, but I also like to wear my laces loose and therefore it slips off my foot. So for me, this one's out. If you have narrow feet, if you have a narrow toe box and you don't have like big toes and like the splay and spread out, this one's actually probably a solid shoe. And I would say it's a very good, very comfortable training shoe for most individuals. Breathable, comfortable, really good for lifting. Again, sprinting short runs, but because of that high heel height, stiff heel, probably not the best for like really long runs if you're someone who's doing longer runs. And then some people on the internet say like durability because the fabric is soft, because it's breathable, durability might not be the best. But again, quite a narrow toe box. So keep that in mind for your athletes who like that wider toe box. Also a caveat, but surprisingly they have such a narrow toe box on these when their lifters are basically publicized as like the best natural minimalist wide toe box lifting shoe there is. So surprising there, but again, very comfortable, good to go there. Last ones we have, I'm going to say is, or not the last one we have, the next one we have is not the actual trainer itself, but it's one of the pairs I have from the same company. And that is the Strike Movement Haze Trainer. This is not the Haze Trainer, this is the, what is this, Strike Movement, I don't remember, Transit Trainer, I'm sorry, it's the Transit Trainer. But the Haze Trainer is the same company, so that's the brand, Strike Movement. I would probably say I use this shoe to train in more than any other shoe I have. I have them at my clinic at the gym, so I work out there a lot with those. This one has a four millimeter heel drop. It is known as the, some claim it to be the most underrated shoe on the market as far as CrossFit or fitness athlete training shoes. A really cool little feature that which I love, because I, for some reason, I have this thing where I don't like my laces over the top of the shoe. It's got this little shoe pocket where you can, or shoelace pocket, where you can tuck your laces into it and hide them. So you just see that logo and it just looks really clean and fresh. These shoes are that minimalist feel. So it's got a minimalist feel in that it's not super heavy, it's not super dense, it's very flexible throughout the shoe, while still somehow maintaining a really solid heel cup and stable heel for weightlifting, for squatting, for deadlifting, for pretty much all of your heavy lifts. Oops, sorry about that. There's a slightly wider toe box on all of their shoes, so they have enough space for your toes to really spread out. It's a little wider through the mid-foot, which gives really nice kind of plushy, really nice kind of splay and play for your feet throughout all your lifts and your workouts and everything like that. And it's actually pretty good for distances anywhere from 100 meters to a 5K, just because of the comfort of the shoe, the flexibility of it. Good for daily wear, because it's a good looking shoe too. Lots of colorways coming out now. They have a lot going on. They just released their, what is it, their Bomb Pop packs. So there's a red shoe, a blue shoe, and a white shoe in case you're interested in that kind of thing. They do run a little pricey. They are $150 and they come from Canada, so the shipping is a little slow, but it does get to you and it's totally worth it. They're a lighter shoe. And again, the biggest cons with these are, one, the price. They're a little pricey. Two, the durability. Because they're a lighter shoe, a very breathable shoe, a very comfortable shoe, they might have a little durability issue if you're pretty rough with them. But again, I've had mine for probably almost six months and a year, and I've had these for at least three and a half years. And you can see that there's nothing wrong with them. I did an entire open with them. I work out with them. I go to work with them. They're just a good shoe to wear. I travel with them and everything like that. So they're pretty good. And some people say that if you need a custom orthotic in the shoe, it's probably not the best shoe for that. Just the way that the shoe is built, the orthotic fitting in there. So keep that in mind if you're someone who wears custom orthotics every time they work out. And that's that there. Okay. So those are the shoes I have in my possession. The two that I do not own that I want to mention quick are the Goruck Ballistic Trainer. That one is a very good shoe. It has an eight millimeter heel drop. So again, a fantastic shoe for weightlifting for someone with stiff ankles or limited ankle mobility. It's a very durable shoe. It is bare bones construction. It has, I believe it's like the fabric is like a cordura. So something like you would see in the military. And it's going to last forever. It's very comfortable for daily wear. It's very comfortable for working out. It's comfortable for weightlifting. It's very stable. It's a solid, solid quality shoe. The best, the only cons we see in that one are that it's not the best looking shoe for some people. Like some people think it looks, because it's so bare bones, like it's very minimal. They're not trying to be flashy. They're trying to just be functional. So it's not the best looking shoe. And I've also heard that it's a little bit hot and sweaty. So if you wear it for all day, your feet get really warm in it because of the fabric of it. And it's not the most breathable thing, even though I think they claim it's very breathable. And it does take a little bit of a longer break in period to kind of get the shoe loosened up and to feel like it's best, but it does get there and it's worth it once you get to that point. So the shoe can also be a little heavy at times, which people are not a big fan of. And lastly, the only other shoe that I no longer own that people still wear occasionally are your Noble trainers and the Noble Now Trainer Plus. These have a four millimeter heel drop, whether you're going with a Noble Trainer or the Trainer Plus. They have abrasion resistance. Kind of the fabric on the outside is like that ripstop fabric or I can't remember what it's called. And they have tons of colorways. So there's so many options in black and whites and polka dots and flowers, pretty much anything that you want, they probably make both in the short and the thicker sold Trainer and Trainer Plus. The pros for me are it's a good looking shoe for someone looking for that shoe that can do fitness as well as go out, hang out all day for wear with jeans, things like that. There's so many options that it's a durable shoe, a good material. Some people, if you have perfect ankle mobility, everything like that and strong feet, it's a comfortable shoe to wear to work out. The cons for the Noble Trainer is that it's a very narrow shoe. Our COO Alan, he's a very tall, tall shoe. Our COO Alan, when he wore his, he would basically flood out the sides of it. He's got very wide feet, good solid arch, so he's not like this over pronated or flat feet thing. It's just a very wide foot that just cannot be contained by the material of the Noble Trainer and especially their runners, which don't have any real material support there. So if you're someone with flat feet or a lot of pronation, probably not the best shoe there. These are terrible to run in. I've heard people, like immediately they get them and they hate them for running, so they take them off and put other shoes on for running, even like 200 and 400, so not the best there. Not ideal for a lot of high volume plyometrics too, because again, there's not a lot to the shoe. It's a very, I would say, minimalistic shoe with a hefty price tag for a shoe that hasn't really changed in style since its inception in 2014, 2013. And if you go with the Trainer Plus, which came out recently in the last year or so, it's got a much thicker entire sole and it actually makes the shoe about 20% heavier. So it's a heavy dense shoe if you go with the Trainer Plus. What I will say though is people do seem to love these shoes. It's going to depend on the person. I personally used to wear these a lot. Then I started wearing other shoes and I'm like, man, I really don't like these. I sold them all. No longer wear them. Don't really recommend them to most people unless they have like really skinny feet and they want to go with more of a stylistic shoe versus like a very good functional shoe they can work out in. But if you're going to go for the Noble, the Trainer Plus is going to be more of your comfort and spring. So more plyos, running, jumping, things like that. If you're looking for a more stable trainer, go with the regular trainer. Honorable mentions, I want to make sure I mention here that Alan told me to say the Ultra Lone Peak. So if you've heard of Ultra, it's a minimalist footwear company. They make something called the Ultra Lone Peak. It's a fantastic shoe for running, hiking, everything like that. Wouldn't do rope climbs in it, but it has its nice wide base. It's not a CrossFit shoe. It's not a fitness shoe, but it's still a shoe that you can use in fitness if you're looking for that realm. Yes, it definitely is a cult. I was a big part of that cult for a while there, Audra. Narrow feet, narrow feet. There you go. So that's it. So my recommendations here, gang, I'm going to finish off because I've been going for quite a while here. The biggest things I want to say is if you have someone that has really stiff ankles, limited ankles, go back to the episode, which ones did I recommend? Right? The Reebok Nano has your nice heel height. It's got the seven millimeter heel height. The Go-Rek has an eight millimeter heel height and the Innovate here has a six millimeter heel height or heel drop. I'm sorry. Those are going to be the ones that are going to be great for the ankle. And then number one overall home is going to be the tier one, right? So if you have someone with narrow feet who's comfortable with that, who needs all that ankle extraness there, nine millimeter height, the tier one is going to be your best weightlifting shoe. The shoe I would recommend the least to people I already mentioned is the Noble, but again, some people love Noble. It's very cultish. They look good. So again, if someone has narrow feet, they like that style. It's worth trying to see how it works for them. And then my number one shoe, the one shoe that I love, that I wear more than anything else, is going to be the Strike Move and Haze Trainer. That is my favorite shoe to train in, to treat in the clinic, to do short runs in, whether it's weightlifting. I've PR'd my snatch in those. I PR'd my deadlift in those. I hit a heavy squat in those. The Strike Move and Haze Trainer, even though it's got a little bit of a price tag, it's worth it. It's one of the best shoes out there. I think it's less known in the fitness community because you don't see it very often and it's kind of a smaller brand. They do a lot of cool things with even like parkour athletes, which is kind of a unique thing. But a great shoe there. And if you want to go with like a comparable second place with me, I would probably say my second is going to be somewhere between the Innovate FF G-Lite, or GF Lite 300, whatever, and the Radwin Trainer. It's a very good shoe. They're both quality stuff. You got to play around with it, but feel free. If you want me to do some sort of like write up with all these details, I'm happy to share it in like a comment or on the iStudents page. Again, I've gone way over on time. I can go on for a very long time about this stuff. So thank you, gang, for tuning in. Again, we hope to see you on the road. Hope to see you on an online course soon. If you have any questions, feel free to reach out and have a wonderful Friday and have a great weekend, everybody. Thanks. 27:30 OUTRO Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 22, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Brick by Brick lead faculty & ICE COO Alan Fredendall discusses tips & tricks for working with Medicare including the ins & outs of documentation/billing. Take a listen to learn how to make more money billing Medicare while spending less time on notes. If you're looking to learn more about live courses designed to start your own practice whether you are considering accepting insurance or not, check out our Brick by Brick practice management course or our online physical therapy courses , check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 – Alan Fredendall, PT, DPT All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your morning's off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our Fitness Athlete Division. We're here on Thursdays, Leadership Thursdays, All Things Small Business Management, Ownership, Clinic Practice, all topics related to that. Today we're continuing our series on getting more familiar with Medicare, whether you are not a clinic owner, whether you want to become a clinic owner, whether you just want to get more polished at the Medicare patients and documentation you're already working with, or whether you are a future clinic practice owner who is considering taking Medicare or not learning the ins and outs. So if you go back, we've already done three parts on this series. Every two weeks back, part one, part two, part three, we talked about what is it, how to take it, what it pays, is it worth it to you? And today we're going to kind of have a cornucopia of things to talk about related to documentation, expectations, that sort of thing. Before we get too deep into the episode, some announcements coming your way. It's Leadership Thursday. That means it's Gut Check Thursday. We're continuing with workout number two from the I Got Your Six virtual competition held by the WarriorWOD, which is a nonprofit group that looks to give six months of functional fitness gym memberships, nutrition coaching, and peer mentorship for our combat veterans. So we're big supporters of WarriorWOD here at ICE. We supported them last year with our ICE Foundation dollars, and we're supporting them in this virtual competition. It is a series of partner workouts. If you were here last week, Jeff explained the first workout completely incorrectly, so hopefully you actually read the caption or you went to WarriorWOD and read the actual workout instructions and you did not approach that as a solo workout. These are all intended to be partner workouts where you are sharing some of the workload between you and your partner. This week's workout, we had the quote unquote pleasure of doing last week. It is a couple of rounds of bike calories. So the workout is going to start. Partner one is going to do 90 seconds on a fan bike, eco bike, a soft bike, whatever you have. Switch. And then you're going to repeat that. Partner one does another 90 seconds. Partner two does another 90 seconds. So you're each going to do two rounds of 90 seconds on the bike. You're really trying to find an aggressive, moderate pace that's not going to redline you there because your score for the first part of the workout is going to be all the calories you get on that bike. Then you're going to transition. Partner one is going to go their own way. Partner two is going to go their own way. Partner one is going to have three minutes to find a max load of a complex of one snatch, one hang snatch, and three overhead squats. Yes, those snatches can be power. While partner two is working their way through an AMRAP of eight toes to bar, 12 wall balls and 16 alternating dumbbell hang clean and jerks. And then at the three minute beeper, partner one and partner two switch. The person finding the complex is now doing the AMRAP and the person doing the AMRAP is now maxing that complex. That fatigue from the bike adds up. If you're doing the AMRAP first, the fatigue adds up when you go to max your complex. You will find that that complex feels significantly more heavy than when you're warming up. Be kind to yourself. Put up a number that you know for sure you can hit and then maybe have some extra time to go a little bit heavier. That is workout number two for this week and we'll release and participate in workout three next week. All your scores are due by June 30th. If you do want to participate, you and your partner can sign up. Go to warriorwad.org and sign up through the competition dashboard. It's $100 for you and your partner. You both get some swag and all of the money goes to support WarriorWOD. That is Gut Check Thursday. The course is coming your way. We have so many to mention. We have a very busy summer and fall. Hundreds of courses coming your way live and online. Head over to ptownice.com and click on courses to see what's coming your way. Today's topic, okay, I've decided to take Medicare. Whether it's a participating provider, is a non-participating provider, now what? This is basically a bunch of different questions that you all in the community ask that we're going to answer in a way that addresses a lot of the hot button issues around Medicare, particularly documentation and what you can bill and not bill for. Just so you know, before we get started, everything I'm referencing is from a document called CMS Pub 100-02. This is the Medicare policy manual. This tells you everything you need to know about taking Medicare, billing Medicare, documentation, expectations. This is straight from Medicare to us as healthcare providers. In this policy manual, it's 951 pages. In this policy manual are sections related to inpatient, outpatient physical therapy, home health, skilled nursing, all the different settings that you can work in as a physical therapist and how to interact with Medicare based on your setting. I've gone through this manual many, many times now and I've pulled out answers to your questions and also just general information that I think you all would like to know if you have decided, hey, you know what? I think I am going to start working with this population and I want to know better how to more efficient with our documentation. What's nice about this is that all other insurance companies, if you're an insurance based clinic, anchor their expectations off what Medicare puts out. Medicare is considered the gold standard. So if you follow this standard, your documentation will be clean and for any other insurance that you take. So this is the gold standard. If you adhere to this, you'll never run into problems. Quote unquote, your documentation will become bulletproof. So let's start from the beginning. So you should know, I've heard this, I've experienced this myself as a staff clinician that you cannot bill for both evaluation and treatment on the first visit with a patient using Medicare. That is completely untrue. This is from section six, subsection C, sections 220.1.2, part A. So go ahead and peruse yourself to that section. And I quote, the evaluation and any treatment may occur and are both billable on the same day. It is appropriate that treatment begins as a plan of care is established. So yes, you can build a patient for evaluation. You can also build timed codes, manual therapy, therapeutic exercise, gait, balance, neuromuscular read, whatever you're doing, you can build all of that on the first visit. Now what if you see patients in their home and you do a home visit, but you're not a home health clinician? This is still a part B visit. This is still an outpatient visit. What's the difference? Home health is generally covered under Medicare part A, and it allows a little bit more money from Medicare to a lot for your travel to that patient. If you are an outpatient clinic that offers home visits, you should just know you're not going to be as profitable if you drive to somebody's house because the money that you receive does not include any extra money for gas, for wear and tear on a personal vehicle, a company vehicle, anything like that. So yes, you can see patients in their home as an outpatient clinician operating under Part B, but you should know it's just not as profitable. But all the other rules apply as if that person was in your clinic as far as you seeing them, billing them, working with them for physical therapy. Now let's talk about caps. People have questions about caps. Jess Garcia sent this question in. What about caps and payments? So as of a couple of years ago, there are no more caps, kind of. We have a modifier that goes into your documentation called KX. This allows you to go above the current cap of $2,150 per year. Now there is technically no more cap. You can see a patient as long as it's medically necessary. That being said, you should know when you cross $3,000 of billable, reimbursable time with a patient, you go on a list where your visits might become subject to medical review. Now this is not the same as an audit, just that somebody working at Medicare might want to look at your notes and make sure that the treatment that you're rendering above and beyond this $3,000 soft ceiling is medically necessary. Related to billing, you should know about something called MPPR, multiple procedure payment reduction. Many of you are familiar with this, but you're not sure why you do it or the how and why behind why you do it. This is basically a rule that reduces the amount of money you receive per billable code the more you bill that same code. So multiple charges of the same code. For example, if you bill four units of Therax, you will get paid less for every subsequent charge of therapeutic exercise. So for example, if you would normally have been paid $40, the second, third, and fourth charge will only be paid at half or $20. So you will get $100 total for that visit versus for example, if you had done one code of manual therapy, therapy of exercise, therapy of activity, neuromuscular re-ed, and you got 40 for each of them, you would have made $160 for that visit. So we're kind of familiar with this. Maybe our manager told us this or we heard it in school or from a friend or something of vary your treatment codes. This is the reason why that when you do the same thing over and over again, you get paid less. This is essentially a system in place to punish low quality clinics. Of Doris comes in, she writes the new step for 20 minutes, she walks for 20 minutes and she does some bandit exercises or some knee extension for 20 minutes and then she goes home and she gets billed four units of Therax. This is punishing that clinic saying, hey, you need to actually do something more productive with your time. You need to vary up your treatment and it should be skilled one-on-one treatment that is progressing that patient towards their goals. So you should know that you should vary up your codes. If not, you should know that you will make less money the more charges of the same code you use each visit. Now there's another billing problem, quote unquote problem called sequestration. This is essentially a reduction in payments across the board from Medicare to healthcare providers. The amount for physical therapy is an overall 2% reduction in your payment. So if you're clear on the MPPR and you bill out $100, for example, you should know that you will get 2% less, $2 less sequestration. This is budget management. This is coming down from Medicare. This is balance the budget type legislation that takes place in Congress. Overall it's really not that much money. As long as you are following the MPPR guidelines and billing a diverse code set. So that's a little bit nitty gritty behind the scenes with billing. Mainly relevant for those of you who are going to open your own clinic, running your own clinic, already operating your own clinic and you want to know a little bit more about the billing. Now what about referrals and prescriptions? Can I see a Medicare patient direct access? Yes. The answer is yes, provided it's allowed within your state practice act. Every state allows for direct access. Some states are more liberal about this than others. Some of you, you can only see a patient for the evaluation. Some of you can see a patient indefinitely and most of us are in the middle. You can see a patient for a certain number of time and or visits and then you need to get a signed plan of care or a referral. You do not need that to begin your first visit in any state as an outpatient physical therapist practitioner. A signed plan of care after you complete the evaluation that you get over to the doctor, email, fax, whatever, as long as they sign that and say, I agree to your plan of care, that counts as your referral or prescription. As long as that's done usually in 30 days. So when Betsy calls and says, I don't have a prescription for my doctor, can I still come see you? The short answer is yes, you can come see me. We'll need to do some paperwork on the back end, but you don't need to go have a doctor's visit before you come see me with physical therapy. And as long as they have a primary care physician or specialist, whoever they're working with that knows them that will sign that, then you're in the clear. This comes from section six, subsection B, section 220, part A. So there's your reference if you're looking to see that reference in the Medicare manual. Now this is a question from Megan Long. This is a question about documentation requirements. This is probably the number one question that most physical therapists have, regardless of taking insurance, taking cash, Medicare or not, what do I actually have to write down? It seems like I'm doing notes forever. I've had positions where I was told I needed to write a paragraph for every section on my EMR and I submitted novels every day for notes. I spent three or four hours after work every day doing documentation. I will tell you your daily note, regardless of what type of insurance your patient is using or not, if you're a cash-based practitioner, should be about two minutes. Your evaluation, regardless of the types of insurance you accept or not, if you're a cash-based practitioner, should be about eight minutes. We'll talk about what you need to put in there and why the vast majority of you are over-documenting for no reason. Again, these requirements come straight down from Medicare, from the Medicare policy manual. I'm going to quote what needs to be in your evaluation. A separately payable comprehensive service provided by a clinician as defined above, that requires professional medical skills to make professional clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of both patient performance and their function. Evaluations are warranted for a new diagnosis or if a condition is being treated in a new setting. How we teach it in our lumbar and cervical spine management courses when we talk about the symptom behavior model, what are the subjective and objective asterisks for your patient? What are they reporting to you subjectively that they're having trouble doing functionally? I can't go up the stairs. I can only go up 10 stairs before I get too weak to continue or I have too much pain. I can go upstairs but not downstairs. Any of those subjective reports of what's limiting function in their daily life. And then our objective asterisk signs. Things that you can measure clinically. Knee flexion range of motion, five times sit to stand speed, max reps of sit to stand in 30 seconds. Your objective measurements are going to go on your objective asterisk signs. You really don't need to say more than that. You don't need to report on the patient's attitude. You don't need to tell us what the patient had for breakfast that day or their overall constitution. Right? When we read a lot of notes, when people ask us, hey, what does this note look like? It looks like a bunch of nothing. Right? Doris presented to the clinic today. She had one egg McMuffin for breakfast and she's feeling kind of fatigued. Nobody cares. What are her progress or non-progress towards subjective and objective asterisk signs since the last time that she was in the clinic? That's really all you need to say there. On top of your evaluation, you do need to do a progress report with Medicare patients. Again, straight from the Medicare policy manual, I quote, you need to provide justification for continued medical necessity of treatment. That's it. You need to do this every 10 visits or every 30 calendar days, whichever comes first. You can do this more frequently and this can be done by someone other than yourself. It can be done by another therapist if you're not there and it can be done by a physical therapy or occupational therapy assistant. This is a quote, description of patients, subjective statements and objective measurements of changes in functional status. It's literally what has changed since you measured this stuff at evaluation. Again, it does not have to be this long novel about how their grandson moved away and they're very sad. Only stuff that's relevant to their lack of progress or the progress that they are actually making towards those goals and those subjective and objective asterisk signs that you've already measured or that you've introduced since their evaluation. Quote unquote assessment of improvements made or lack thereof towards their goals. Keep it simple and then your plan for continuing treatment. We're going to keep doing what we're doing. We're going to keep progressive overload. We're going to keep progressing Doris's deadlift. We're going to keep progressing her aerobic capacity as measured on the six minute walk test, whatever. And then any changes you may have made to the plan of care since the last time you did an evaluation or progress. No, again, evaluation progress. No, it should not be a 30 minute thing. Should not be a 60 minute thing. It should maybe be a 10 minute thing. What has changed since the last time we tested all this and how has it changed? And if it hasn't changed, what complications might have been this patient had covid and did not come to physical therapy for a month. Okay, that's relevant to put in the note. They went on vacation and they didn't come to physical therapy for a month. Okay, relevant to put in the note to justify why they're not making the progress you would expect them to make. But again, keep it simple. Stick to that symptom behavior model. Keep your notes short and sweet and just state the subjective and objective data that's relevant to that patient and that you want to see them make progress in the clinic. Re-evaluation. What about this? We have questions about reevaluation, very similar to evaluation and progress note quote provides additional objective information, not include another documentation. It's separately payable periodically indicated during episode of care when the professional assessment of clinician indicates a significant improvement or a significant decline in the patient's condition or functional status that was not anticipated. Maybe the patient was hospitalized for a period of time. Maybe they're making such great progress that you need to basically rewrite their entire plan of care. You wrote a goal for them to deadlift nine pounds and walk 100 feet on the six minute walk test and they blew that out of the water early on and you're updating goals, updating goals. So sit down and have a reevaluation. Gather what you think is relevant to the patient. Ask the patient what they think is now relevant to their goals. Now that they've met their goals, you've already established reestablish new goals and then continue with your care. What should go in the plan of care section? Your diagnosis, right? What's wrong with them? Don't say signs and symptoms indicative of 10,000 different things. Keep it simple. Keep it ICD 10 based. This patient presents like they have right knee pain. I've ruled out their back. I'm convinced their knee pain is actually knee pain. Boom, done, right? Your physical therapy diagnosis, your goals, specifically only your long term treatment goals. You only need long term goals. You do not need short term treatment goals. Again, straight from the Medicare policy manual. Write out goals, six, eight, 10, 12 weeks and measure your progress against those goals. If they meet them, great. Once they've met most or all of them, again, going back, that's time when you maybe sit down and do a reevaluation. Hey, Betty, you've met all your goals. What are the goals you have? Let's write some more. Let's take this to another level. So long term treatment goals and then how often you think the patient needs to be in the clinic. You know what? You're doing really well. I think we can drop to once a week for the next six, eight, 10, 12 weeks. You know what? You're not making the progress you want to, but you've only been here once a week for the past six, eight, 10, 12 weeks. Let's bump that up. Let's write and see if two or maybe three times a week will really bump up the frequency, and get the change that we both want to see for you. So that's our plan of care. Now evaluations done, progress notes done, reevaluations done, whatever you've done. And now in between those benchmarks, you're doing just a daily note. This again, this is relevant for every physical therapist, regardless of if you never say plan to take Medicare, if you're completely cash based of what needs to be in a note just to basically cover your own butt. And again, all of this from the Medicare policy manual quote, the purpose of these notes is to simply, and it's bolded in the policy manual, simply create a record of treatment and intervention provided and to record the time of these services to justify your billing. Medicare is telling you, you just need to tell us enough to cover your own butt. Please don't tell us anymore. No one is probably ever going to read this in your life. So keep it simple. It's bolded, simply bolded. Quote, treatment notes are not required to document the medical necessary appropriateness of continued physical therapy service. You do not need to write a paragraph every time you do a note about why that patient needs to come back to physical therapy. If they're in physical therapy, it's assumed that your evaluation, your reevaluation, your progress note is going to justify why they're there. And the physician signing off on that is going to be kind of the double stamp that between you and them, the medical system has decided that this patient needs to be in physical therapy. You do not need to explain to anybody or yourself every note, why they need to keep coming to physical therapy. If they don't need to keep coming to physical therapy, then that's, you know, when we consider maybe a discharge note instead. But you don't have to write a paragraph about why physical therapy and how physical therapy can help this person. It's already implied by them being on your caseload and you measuring goals, visit over visit, note over note, progress note over progress note. Specifics in a daily note such as the specific number of repetitions or sets of an exercise or other fine details already included in your initial plan of care are not needed to be repeated in treatment notes. Again, Medicare is saying stop writing so much junk in your notes. It's worthless and time wasting for everybody. Stop quote mandatory elements of a daily treatment note include the date of the treatment, the identification of a specific intervention or modality provided. We did dry needling. We did spinal manipulation. We did active exercise. We did aerobic capacity training. We did gait training. Whatever specific thing you did, you should list that, but you don't need to itemize it. You should have the total time in coded treatment minutes put on your note. That's it. Hey, we did 20 minutes of exercise. We did some dead lifts and biking. We did 10 minutes of balance training. We did some clock yourself. You don't need to itemize and be that specific. And then you need to have the signature of a qualified professional in the note. So that's it. That's how you get yourself to a two minute daily note. You stop writing dumb stuff that nobody's going to read. You write literally what they tell you you need to write that they're looking for if they happen to audit you and want to see your notes. Okay. Kind of segueing from documentation into more nuanced things about treatment. What about treating somebody for more than one condition simultaneously? What about maintenance therapy, those sorts of things? Let's talk about treating more than one condition. If you're like me in school and your early career, you learned that somebody needs to go all the way through a plan of care for one condition. Then you need to do an evaluation for the second condition and then see them all the way through there. This is mainly a scheme to get more money out of people. Medicare, again, from the policy manual, section six, subsection B, part A. You can see somebody for more than one condition simultaneously and bill for both at once in the daily note. You don't need to do two notes for two different diagnoses. You don't need to see somebody for 12 weeks for knee pain and then see them for 12 weeks for elbow pain. You can do knee and elbow pain at once. I quote, during an episode of care, the beneficiary may be treated for more than one condition, onset that happened after the current episode has already begun. For example, a beneficiary receiving physical therapy for a hip fracture who, after the initial evaluation, develops symptoms of low back pain could also be treated under the same PT plan of care. Now for rehabilitation of their low back pain, you can treat the whole person. They're telling you it's okay. So do it. Treat the whole person at once, please. What about maintenance therapy? We have in our mindset as physical therapists that once somebody says, you know what, I don't have any pain anymore, we freak out. Oh my gosh, get off my caseload before the government comes in here and puts me in prison. Get out of here. Medicare pays for maintenance therapy. Let's talk about it. I quote, Medicare claims and coverage cannot be denied based on the absence of the potential for improvement or restoration beyond what skilled physical therapy service provides. to improve a patient's condition or if it's necessary to maintain the current condition or prevent slow deterioration of current condition. If your patient would get worse leaving your care, then they can be seen for maintenance therapy. If they would regress in function without coming to see you, then maintenance is needed and justified. Especially we know those patients, sometimes they're upfront about it. Sometimes they're not of, hey, I'm not going to do this at home. Like, I should come here two to three times a week, right? We see this with patients of all backgrounds and populations of people who are just not self motivated, who need to come and basically get their butt kicked at physical therapy. That is okay. You can continue to treat that person. This is a settlement agreement from January 2013 that covers maintenance therapy in skilled nursing and home health and in outpatient physical therapy. So that's almost all of you listening right now. You can see patients for maintenance if you are convinced and you can justify that this patient would get worse or regress to where they were before they started physical therapy if they did not continue to see you for physical therapy. How long can we keep that going? For the patient's entire life? Maybe quote, as long as all of the coverage criteria are met, maintaining the patient's current condition or the prevention or slowing of further deterioration are covered under skilled nursing facility, home health and outpatient physical therapy benefits. As long as you are setting goals, meeting goals, reestablishing goals, writing progress notes and obtaining that recertification from the primary care physician, then you are good to go. You should not be scared that just because Doris is coming twice a week and she's doing an upper body split on Tuesday and a lower body split on Thursday and you're working some balance as accessory work or some cardio or something, you should not be worried that a SWAT team is going to bust down your front door and take you to jail. It's not going to happen. If it's justified, if it's truly justified and you know that you can justify it, you are good to go. How do I frame this to the patient? How do I frame this to other healthcare providers? How would I frame this to you all if you came up to me and asked? I would have you look at the cost of physical therapy versus the cost of pretty much anything else in the healthcare system. Medicare is looking for, I quote, the greatest possible improvement for the most efficient plan of care. They want to know what's the biggest bang for the taxpayer dollar, for the government's dollar. Let's look at some common surgery costs. A heart valve replacement is $170,000. A triple bypass is $150,000. A spinal fusion is $100,000. A hip replacement, $40,000. Knee replacement, a little bit cheaper, $35,000. Angioplasty, $30,000. And just a debridement of the hip or knee, $30,000. So look at the costs of those surgeries and ask yourself, would my patients stay away from that if they came to see me twice a week and they paid about, Medicare paid me about $250 a week, about $1,000 a month, about $12,000 a year? The answer overwhelmingly is yes. Physical therapy, getting strong, staying mobile, staying active, working with a physical therapist, a high quality physical therapist, overwhelmingly is the greatest possible improvement for the most efficient plan of care, the best bang for the government's dollar. Medicare spends about 33% of its overall budget, about $1 trillion per year on inpatient hospital stays. The average person who goes to the hospital spends $13,000. That's more than coming to physical therapy twice a week, every week of the year. Just think about the cost savings of that. If you're thinking, how do I justify this to myself, to my patients, maybe to the manager, the owner of my clinic, to other healthcare providers of why this person should come see me once or twice a week, maybe forever, because it is the most efficient way. Exercise is the most efficient medicine for almost everybody. So that's the justification for maintenance therapy. So a lot to wrap up here. Documentation, if you're doing too much, do less, right? Do what Medicare tells you to do, which is not as much as probably most of you are doing. A daily note should maybe take you two minutes. An eval or reval or progress note should maybe take you 10 minutes. Make sure you understand the justification of why we're billing multiple treatment codes so that you make more money if you are providing high quality physical therapy to that patient. You don't need a referral prescription to see somebody on their first visit anywhere you live in the United States. You just need to get that plan of care signed at some point and that's going to vary based on your direct access laws. Again, you're documenting too much. Document less. Better. Make sure that you understand that maintenance therapy is supported and that you can treat more than one condition at a time and that is supported, justified, billable as well. In summary, you're doing too much documentation that's taking away from your time with the patient and you're probably kicking patients out the door a little bit too early over an unnecessary fear of getting in trouble for things that Medicare says that you are allowed to do. So understand some of these rules. If somebody asks you for your proof, CMS Pub 100-02, 951 pages. Get after it, boss man. Let me know your questions, right? So I've gone through this a lot. It's pretty cut and dry. It's pretty straightforward. It's a government manual, right? There's no fluff about it. It's pretty in the clear what we're allowed and what not to do and I would say in general, we over document under bill and we don't see our patients long enough and see them through actual long-term functional change when they're in our clinic. So let's start changing that. So that wraps up our Medicare series. Thanks to everybody over the past couple months who sent in questions. It's been a great series. It's been really helpful for you all, I hope, and we'd love to do something like this again. So have a great Thursday. Any questions related to stuff like this, throw them on Instagram, email us, throw them the ICE students Facebook page. We love to get podcast episodes out to you all that are based on the things that you want to hear and see about. So have a great Thursday. Have a great weekend. You're going to be on an ICE Live course this weekend. Have fun and if you're going to hit up Gut Check Thursday, have fun, quote unquote fun. Bye everyone.

Jun 20, 2023

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, our dry needling division leader, Paul Killoren, talks about how and why patients may faint during a dry needling session as well as the approach to take if this happens in your session. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live upper body dry needling courses , our live lower body dry needling courses , or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 0:00 – Dr. Paul Killoren, PT, DPT Morning team, welcome back to the PT on Ice Daily Show. I'm your host for the day, Paul Killoren. It is clinical Tuesday. If we've never met, I'm the head of the dry needling division. So today we'll talk some dry needling. Very excited to discuss fainting during dry needling today. Not a topic many people want to talk about until an event occurs. And actually, what kind of prompted the topic this morning was one of the techniques that we teach, one of the go-to techniques that we teach on our upper dry needling course, is a seated position. And I think it'll be a topic for another day, the advantages of this position, allowing access to post here and anterior, honestly getting a more supported, more comfortable position for the shoulder. But what that post, the expected response from certain camps out there, the expected response was, aren't you afraid that your patients are going to faint? And I 100% know if any of you were trained out there by other organizations, honestly, up to current day, but anytime in the past decade or so, you were probably told, we always needle prone or supine on the first visit. That's how I was trained. That's how I taught for a long time. But I'm going to challenge that today. Before we get deep into the positions for dry needling, the topic for today will just be fainting from dry needling. We'll talk about some of the numbers. We'll talk about if there's some things we can do to avoid it. But let's talk about fainting. And first of all, to qualify, what is a fainting event from dry needling? It's vasovagal sympathy, syncope, not sympathy. We are sympathetic to their syncope. But it is a hypotensive, it's an autonomic nervous system, hypotensive. Basically, your heart rate drops, bradycardia, and your blood pressure drops at the same time, which causes a very brief loss of blood flow cerebrally. So I mean, if we say fainting, it's not just feeling dizzy or feeling faint or nauseous, it is a loss of consciousness, which can occur. But I think we have to immediately qualify how likely is it to occur. First of all, my own sample size. I personally have had two of my patients faint in the past decade. I've been dry needling since 2011. I mean, you can do some napkin math there. I've been teaching dry needling courses since 2014. And I've probably seen a handful more, maybe five to seven people, actually lose consciousness. So quick napkin math, we're getting upwards of maybe 10,000 people that I've seen being needled. And I have less than 10 that have fainted. So first of all, we can't say that it's impossible. But I think we have to immediately qualify, what is the risk? People can faint. Some more data, there are 12 billion injections done throughout the world every year, we're talking injections. And honestly, most of our needle phobic or needle related vasovagal events, our blood draws, there is something slightly more autonomic to our vessels and some of our nerves like our median nerve, tibial nerve. So we can immediately say, if we have a large needle like a hypodermic, and we're intentionally puncturing a vein, the risk of an autonomic nervous system or a vasovagal event is probably slightly higher. People faint when they give blood. Most people are aware of that, if that's them. First of all, let's qualify that we use a smaller needle and we're doing our best to avoid vessels. So immediately just the mechanisms of a vasovagal event, we should assume would be slightly less with our dry-neeling procedure. But we also have to say there is a large psychosomatic, psychological aspect to this. Rough numbers, I went off on a tangent and just looked at all these vasovagal fainting events, but just needle related phobia and needle related events research. So broad strokes, there's about 10% of us, of people in the general public, who have a needle related phobia. And honestly, if you've been dry-needling long enough, or it doesn't take very long, you probably know this. Whether we're actually screening them or not with our words or with our intake questionnaires, I'd say one in 10 people probably do say like, all right, I hear you're the dry-needle guy, I really don't like needles, but I'm here to give it a shot. I think that kind of fits. I think one in 10 makes sense. But let me dive into some more, I won't even say dry-needling because some of it's acupuncture, but some more monofilament data as far as feeling faint or actually fainting from dry-needling. First of all, McPherson in 2001, this is acupuncture, but it's European acupuncture, which includes some physical therapists, 0.22% feeling faint out of 34,000, not actually fainting. I say that because Boice 2020, which is American dry-needling, American physical therapists, over 20,000 treatment sessions, 0.78% of patients, which categorically they said was a minor adverse event, 0.78% felt faint. Only four people out of those 20,000 sessions, so 0.02, actually slightly less, actually fainted. So again, I think we need to acknowledge this can occur, but I'm immediately going to say that is a very rare risk. And again, what I'm trying to get to is should this risk of fainting guide our practice patterns, should that very low percentage that I just mentioned to you mean that we should always needle prone in supine on the first visit? I'm going to say no. I'm going to say there are a handful, there is a large majority of my patients where I feel very comfortable doing a comfortable seated dry-needling procedure on the first visit. And I'll talk about that a little more as we get through this. One more publication, because I thought it was actually kind of funny. It was, again, it was acupuncture. Christensen was the author in 2017. They actually surveyed, retrospectively, over 18 months, all of these people that had acupuncture treatment, and they finally found eight people that had said they fainted from acupuncture. So over a year and a half, they finally found eight people who fainted. What's unique is they kind of tapped into duration of symptoms. Almost all of them were very transient, recovering almost spontaneously. As soon as there was a loss of consciousness, they immediately regained it. What's unique here, and what I wanted to point out, is that of those eight, three people actually said when they came to, when they regained consciousness, their primary pain complaint was improved. I think that's a great stat. I mean, I think we're going to say fainting or feeling faint, a vasovagal event, we're going to call that an adverse event for sure. That's not our goal, but I think it's also pretty amazing to say nervous system responded for sure. We're saying it's an adverse response, but it responded, and that massive adverse response actually decreased the pain experience for those patients. I just wanted to throw that in there, because we'll talk through now about how to avoid it, and what we can do clinically, but I think we always have to say that nervous system response has benefit, or we should at least screen the patient for saying that was a pretty intense response. How do you feel right now? And don't be surprised if some of those patients feel better. So first of all, this is probably going to be obvious data, but who are the patients out there fainting? Again, going through some big systematically reviewed stuff, age is a component. So younger, younger patients faint more often, and we're talking kiddos getting injections. Number of attempts was a significant correlation for venue puncture. So they're trying to draw blood. A lot of you have probably had similar experiences of like you're in the hospital, it takes the nurse three or four attempts to truly get that IV into the vein. Number of attempts was directly correlated to fainting events. And then the last one is probably the most obvious, but probably the most important, and I'll come back to this, is that if there was a history of a needle phobic or an adverse event from needling, if they had fainted previously, the risk of fainting again was significantly higher. So age, number of attempts, and history. So those are probably obvious things as far as risk factors, but I'm going to immediately parlay into that and say, are we screening our patients? And again, the challenge that the contest that I'm trying to put out against kind of the typical conservative narrative is I'm okay treating my patients first visit, first time being needled seated, if I do some screening questions of have you ever felt nauseous? Have you ever felt faint or actually fainted from a needling procedure, from giving blood, honestly, anything from a piercing to blood draw to a tattoo? And if they're like, Nope, never had an issue. I feel much more comfortable versus that person that says, Oh yeah, I mean, I'm pretty anxious to be here because yeah, every time I get my blood drawn or every time I get a vaccination, you know, I get a little dizzy and I feel like I'm going to pass out or I have passed out. Those are the patients where I think that 10 to 30 seconds screening verbal screening says, okay, that's cool. Good news is the needles we're using today are much smaller, much different. I'm also trying to avoid all of the large nerves and vessels. But you know, it's your first time let's start supine or prone. I think that simple mechanism of a screening question, you can do it written on your consent form. But basically, have you had an event or not? Or I guess to add into it, if it's a kiddo, maybe we start them supine or prone. The absence of all of that, the absence of a previous event or the admission of feeling faint from previous needle procedures, as well as age makes me feel very comfortable to needle that person seated, visit one. And again, that is challenging a narrative out there that says, we would never do that. What if your patient faints? That's why we always do it supine and prone. I don't think we have to do that. First of all, the data, the incidence rate doesn't support it. Second of all, what I just said is that if we have a simple screening process, we can pick out the people that are much higher risk of fainting. And the last thing I'll add here is that I already mentioned that the majority of this adverse event data fainting like vasovagal response needle born data is from injections and blood draws. And any of you that have had an injection or blood draw recently know how it goes. You walk in, they don't overly sensitize, honestly overly screen you. They also don't put you supine or prone. You're seated in a chair. And I mean, you depending on how compassionate your nurse is, she's probably, you know, putting the little strap on your arm saying, you ever get squeamish from needles? And then half of us are like, yeah, a little nervous and they proceed anyways. So let's just, I'd like to infuse a little bit of that. I don't even know the right words, not cavalier. It's not aggressive. I just want to apply a little bit of that mindset to our dry needling. And again, if we're picking up answers or body language that they're highly anxious about needling, then we can lay them supine or prone. But the truth is injections, vaccinations, blood draws are all done seated. And that's one of the reasons I think we should be more willing earlier on to do seated dry needling. But let's say, let's say you subscribe to anything I'm saying right now. I was like, okay, I'm going to try, or if you've taken our upper dry needling course, you know that one of those go-to setups is the seated prop position. So let me put a few barriers, buoys in the water for that initial session coming in for shoulder pain. Maybe they're post-op surgical or post-surgical shoulder pain. We're going to prop them up on a chair. And first of all, I think a few buoys worth putting in the water. I like using a stable chair, so not a wheelie stool. It's a chair with legs. It has armrests. It has a firm back. So they are more or less able to completely relax. They're putting, you know, my sarcastic script is I want you so comfortable, like you could take a nap here. Like I don't want you holding yourself up. I don't want you feeling imbalanced. I want you comfortable, stable, but honestly relaxed. You should be able to stay here for five minutes, 10 minutes, 15 minutes. So that is very helpful. Secondly, I think if we reduce the number of needles, so again, if it is their first session, we've done kind of a brief screening. We're not picking up on anything, but it's still their first session being needled. We're probably not going to put six, eight, 10 needles in that patient, in that seated position on that first visit. So maybe two needles, maybe four needles. And not that we want to think worst case scenario, but how quickly could you take those needles out if an event occurred? Again, they're in a bailout position. They're seated, but they're supported against a table in a chair with an armrest. Those shoulder needles, could you take those two to four needles out in two to three seconds? The answer is probably yes. So I think the environment, so the table, the chair, the patient position, and then the number of needles really makes us more willing to go to a seated position quicker, even in the event of fainting. One more thing I'll add is that if we said that potential vessel interaction or nerve interaction might slightly increase the chances of fainting, I'll add what I add to most discussions these days is that if we minimize the amount of mechanical needle work, if we minimize pistoning, that anxious, that sensitized, and that kind of psychological aspect of the needling will be less. If we piston less, the risk of almost every adverse event goes down, and that applies to fainting. So I think if we follow those rules, and so far I'm saying the data doesn't support us always being supiner prone, I think we can go seated quicker if we screen better. Is there a history? Is there an age or any other reason why that patient might faint? And I guess I'll add one more anecdotally. It's not from the research, but both of my NF2, both of my patients that fainted in my clinic, first of all they were early 20s, very fit Division 1 soccer guys. Both of them were either late morning, early afternoon sessions where they hadn't had breakfast. I think there might be a blood sugar component to this as well. That wasn't from the literature, but I think if we're talking about an autonomic or a nervous system response, because I think you guys, if you haven't seen it before, I mean the symptoms that are going to key you into vasovagal syncope are diaphoretic, so kind of cold, sweaty, very pale, so paler or green skin, feeling nauseous, bradycardia. If you take their heart rate it'll actually be lower and their blood pressure will be lower. So those are the symptoms that are like, you don't look so good. And again the data will say that there's going to be a few people that have that feeling faint, feeling dizzy without actually fainting. The number of people that actually faint from dry dealing acupuncture is very, very low. But let's say it happens. What do you do with the patient in the clinic if they faint, if they lost consciousness? Honestly, whether they're seated or if they're supine or prone, what do you do? This is legitimately an algorithm from a publication, and I say that because it's going to seem like such obvious stuff that we don't need to cover it, but here is the algorithm. And first of all, this was dry needling. It's international. It was actually from the Turkish Journal of PT, but they specifically said what is the algorithm and what are the positional considerations for trigger point dry needling in the context of patients fainting of vasovagal events? And first of all, they were talking upper trap needling and levator needling. They said that yeah, you can do it prone. There might be an orthostatic component to this vasovagal, this hypotensive event, but they actually said that's probably unnecessary. You can do this seated just like all the other injections and blood draws in the world. But what they said is if a patient faints, the response should, number one, create a safe environment. So again, I think that just speaks to, I guess, not the extreme opposite of doing this anywhere unsafe. Maybe that speaks to what I said of not being in a stool with wheels, but being in a chair with legs, with a back rest, and creating a safe environment. To say it another way, a bailout position. If this patient fainted right now, where are they going to go? That answer should be there. Or if they're prone or supine, there. They're in a bailout position. We're not standing. We're not, again, on, I don't know, I'm trying to, crazy clinical apparatus. We're not needling on a Swiss ball the first visit. So safe environment is number one. Number two, it says clinicians should not overreact. There is a major psychological component to this. Whether the patient faints or is near fainting, the reassurance from a clinician not overreacting to that situation or seeing the sympathetic responses actually reverses course. So if they're like, oh, how you feeling? They're like, I don't feel so good. Like, okay, take the needles out. Let's just rest here for a minute. That quick reassurance, that not overreacting, very quickly reverses course for our patients. If the patient loses consciousness, if it's convenient, you can elevate the legs. Again, we're trying to get central blood flow restored quickly, but otherwise safe position. And then depending on how long they have lost consciousness, we turn their head to a side to just help breathing, depending on the size of your patient. But again, all of that's pretty obvious stuff. That's the algorithm, those four things. This publication said that almost all of these events recover almost immediately, spontaneously. Perhaps we should take vitals in the clinic, again, being at least heart rate and blood pressure. Perhaps if there was a true loss of consciousness, there should be an observation period. Depending on your clinical setup, it's like, hey, do you mind hanging out here for a little bit, 20 minutes, 30 minutes or an hour before you drive, just to, you know, you did lose consciousness for a second. I just want to make sure you're okay before you head out. But that's it. I mean, rarely, I only have one event that really lasted more than a few seconds throughout my teaching, driveling courses for a long time. And that time we did keep, we kept monitoring, we did alert EMS and they showed up. So they did the leads and all of that, the patient was discharged immediately. So I think there's a medical diligence here, but it's a pretty obvious one that if they lose consciousness for a second or two, then they recover. First of all, you'll see that they recover pretty quickly. Maybe we can do some of the orange juice, the snack, just resting there. Again, if there does seem to be a blood sugar component, but really they recover very quickly. And really, I mean, that's all I have for today. So my challenge for you is based on the incidents of vasovagal events and fainting, how willing should we be to treat seated initially? I would say we should do it initially, as long as we screen well, which could be just a verbal, like if you ever had a reaction to needling, if you ever fainted from a blood draw injection, piercing anything else. I think we need to have a control environment. Really, that's just the chair, the setup, maybe having a table to support the arm in, reduce the number of needles and pistoning. And then I guess just knowing how to respond, but really that response should be reassuring, if anything, and then positional if needed, knees up, head to the side, that sort of thing. So I'm sure that prompts more questions. If you've ever had a patient faint, maybe it looked a little different. When we talk about nervous system responses, it could have not just been fainting, it could have been anything else from voiding bladders, that sort of thing. If you have other questions, send me a message and that can be at DPT with needles or at Icephysio, it'll get funneled to me. But thanks for jumping on this morning to talk about fainting with dry needling. There will probably be a follow-up series, maybe more so as to why we'd like not just, um, avoiding adverse events from needling seated, but what are the benefits. I think the benefits far outweigh the risks that we discussed this morning. So thanks for tuning in, and I'll see you down the road. 23:02 SPEAKER_00 Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram, at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jun 19, 2023

Dr. Jessica Gingerich // #ICEPelvic // www.ptonice.com In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses how to return to loading the core during the first 12 weeks of the postpartum period. Take a listen to learn how to better serve this population of patients & athletes. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses , check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION 00:00 INTRO What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show. 01:27 DR. JESSICA GINGERICH, PT, DPT Good morning PT on ICE Daily Show. It is rainy and humid here in South Carolina, so I am already sweating this morning. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division here at ICE. Dr. Alexis Morgan and Dr. Ellison Melrose and myself are coming off a fun webinar with the CrossFit Affiliate Southeast team where we were talking about coaching the pregnant and postpartum athlete, trying to keep those athletes in the gym as long as we can throughout their pregnancy and get them back in the gym as early as we can in that postpartum timeframe. I wanted to take this opportunity to continue the conversation more specifically around the benefits of training the core during the first 12 weeks postpartum. As always, we want to just highlight some wonderful opportunities to learn. We are coming your way. Go ahead and head over to ptonice.com to see when we are close to you for our two day live course. That is where we take the internal exam and we bridge it with return to sport, return to endurance training, return to strength, gymnastics and so much more. We also have an eight week online course. That is wonderful. We have an online course for eight weeks. So if that is something that you want to hop on, if that's easier for you to get to, head over to PT on ICE.com to snag your spot. So we are in a really exciting time within that pregnant community. We are starting to see women push boundaries and challenge the norms around exercise. However, the question always continues about returning postpartum. When to do it? We often hear what is safe and unsafe. Here at ICE we like to not use those words because it is more so about what you are ready for and what you are able to do in that snapshot of time. So we know that every pregnancy, birth, prior fitness level and so many other factors vary per person. However, we also know that returning to exercise postpartum has massive mental and physical health benefits. So what I want to do is I want to define that fourth trimester. So this is the time period between zero and 12 weeks postpartum where those physical, mental and emotional changes are huge. They're huge in so many ways and exercise can be such a massive benefit to mom. And so we want to make sure that we're doing them justice. So as we make recommendations for core training, we need to respect certain factors. So that's going to be tissue healing timeframes, pain levels, the amount of help someone has at home, maybe sleep, how much sleep they're getting, how they're eating, what they're eating, are they trying to get their breakfast in as soon as baby starts to cry and they're getting their lunch in as soon as baby cries and moms are really good at putting themselves first, right? But most importantly, we have to respect function. As hard as we fight for maternity rights, for example, longer maternity leave, mom still has a job at home. She's caring for a newborn, potentially other children are at home and likely has physical demands of a job waiting for her eight to 12 weeks later, which means she needs to strengthen her core and she really needs it now. Too often the recommendation is taking that six to eight weeks off after birth, which encourages a significant amount of deconditioning, making motherhood, return to work and a whole lot of other things a lot harder. So here at ICE, we love encouraging physical therapy to begin at two weeks postpartum. With this recommendation comes some exceptions, like how is mom adjusting to motherhood or adjusting to adding another baby to the family? Does it give her anxiety to leave the house, which virtual sessions are great for that? Does she need sleep when her appointment time is? You know, that's a big deal. We want to encourage sleep. Or are the baby's appointments just adding up and it's making it hard for her to add this appointment on top of that? So during the first visit, we addressed several things, but core is absolutely one of them. That is looking at diastasis, that is looking at her ability to sit up, a full sit up. We're going to talk through three planes of motion acting on the spine. You all probably know these from school, but we have the frontal plane, transverse plane, and the sagittal plane. There are a lot of exercises to be utilized in these planes of motion that are important throughout the plan of care for improving strength and function. But where do we start? We love teaching a transverse abdominal contraction along with the pelvic floor contraction, but it never stops there and it usually is something that we move on from fairly quickly. So we do those in supine, we do them in standing, we do them in hanging quadruped, we do them in a trunk extended position, but then we add all of those wonderful layers. So our top three exercises to begin and to start with are the Paloff Press, the Supported Sit Up. This is such a great movement, right? It encourages that full range of motion. Mom is having to sit up out of bed multiple times in the night to feed. And then the Unilateral Farmhouse Carry. I always get a kick out of moms coming into the clinic holding the carrier. That thing is heavy. I've carried it out for a couple of moms just to kind of get an idea of how much it weighs with baby inside. It's heavy and they are having to carry that immediately postpartum to appointments because they can't leave baby at home. So here we had all three planes of motion with an isometric type of load aside from the Supported Sit Up. There's plenty of room to progress range, length, load, and then time under tension. As well as these movements mimic those physical demands of life. So again, holding the carrier, rolling out of bed, sitting up for feedings. We often get asked the question, but what about diastasis? So we are assessing that in that first visit. But the goal around diastasis is to coach points of performance. So if you are seeing coning or doming in the midline with a certain movement, can we take a step back, coach those points of performance, and then modify if your client is unable to maintain those points of performance. If they are unable to, you adjust. We need to get the core stronger. And if they have a diastasis, we have to get the core stronger. And we have research on this. So first of all, 57% of people have a gap greater than 2 centimeters. And this is not just in the pregnant or postpartum population. Therefore, we really don't even have an accurate definition of what constitutes a diastasis. Furthermore, Hills et al. found that diastasis recti was associated with decreased sit up strength and decreased torque generating capacity. A literal weakness issue. So to recap, the fourth trimester is defined as weeks 0 to 12 postpartum. Early core intervention can and should begin at two weeks postpartum per the mom in front of you. Begin with isometrics, then build range, length, and load. As always, we monitor symptoms of leakage, heaviness, pressure, bulging in the vagina, pain, and an increase in bleeding. So with that, I hope you guys have a great Monday and I will see you next time. 10:27 OUTRO Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

Jun 16, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com Research discussed: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9331349/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314602/ https://journals.lww.com/nsca-jscr/fulltext/2020/08000/a_comparison_of_bilateral_vs__unilateral_biased.1.aspx https://pubmed.ncbi.nlm.nih.gov/37123275/

Jun 15, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com

Jun 14, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com

Jun 13, 2023

Dr. Lindsey Hughey // #ClinicalTuesday // www.ptonice.com

Jun 12, 2023

Dr. April Dominick // #ICEPelvic // www.ptonice.com

Jun 9, 2023

Dr. Joe Hanisko // #LeadershipThursday // www.ptonice.com

Jun 8, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com

Jun 7, 2023

Christina Prevett // #GeriOnICE // www.ptonice.com

Jun 6, 2023

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com

Jun 5, 2023

Dr. Alexis Morgan // #ICEPelvic // www.ptonice.com

Jun 2, 2023

Dr. Jason Lunden // #FitnessAthleteFriday // www.ptonice.com

Jun 1, 2023

Dr. Megan Daley // #LeadershipThursday // www.ptonice.com

May 31, 2023

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

May 30, 2023

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com

May 29, 2023

Christina Prevett // #PPPonICE // www.ptonice.com

May 26, 2023

Dr. Rachel Selina // #FitnessAthleteFriday // www.ptonice.com

May 25, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com

May 24, 2023

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com

May 23, 2023

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com

May 22, 2023

Dr. Jess Gingerich // #PPPonICE // www.ptonice.com

May 19, 2023

Alan Fredendall // #FitnessAthleteFriday // www.ptonice.com

May 18, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com

May 16, 2023

Dr. Eric Chaconas // #ClinicalTuesday // www.ptonice.com

May 15, 2023

Dr. Rachel Moore // #PPPonICE // www.ptonice.com

May 12, 2023

Dr. Megan Daley // #FitnessAthleteFriday // www.ptonice.com

May 11, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com

May 10, 2023

Dr. Dustin Jones // #GeriOnICE // www.ptonice.com

May 9, 2023

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com

May 8, 2023

Christina Prevett // #PPPonICE // www.ptonice.com

May 5, 2023

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com

May 4, 2023

Dr. Jeff Moore // #LeadershipThursday // www.ptonice.com

May 4, 2023

Dr. Ellen Csepe & Alan Fredendall

May 4, 2023

Dr. Ellen Csepe & Alan Fredendall // www.ptonice.com

May 4, 2023

Dr. Ellen Csepe & Alan Fredendall // www.ptonice.com

May 3, 2023

Christina Prevett // #GeriOnICE // www.ptonice.com

May 3, 2023

Dr. Ellen Csepe & Alan Fredendall // www.ptonice.com

May 3, 2023

Dr. Ellen Csepe & Alan Fredendall // www.ptonice.com

May 2, 2023

Dr. Zac Morgan // #ClinicalTuesday // www.ptonice.com

May 1, 2023

Dr. April Dominick // #PPPonICE // www.ptonice.com

Apr 28, 2023

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com

Apr 27, 2023

Alan Fredendall // #LeadershipThursday // www.ptonice.com

Apr 26, 2023

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