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 FREDENDALL
Good 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.

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 MOORE
All 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.

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 MELROSE
All 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.

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 DOMINICK
Good 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.

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 CONTRERAS
Here 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.

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 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, 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.

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 JONES
Good 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.

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 GINGERICH
All 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.

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.

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 SELINA
Alright, 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.

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 HUGHEY
Good 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.

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 PREVETT
Hello 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.

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 MELROSE
Good 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.

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 MOORE
Alright 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.

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 LUNDEN
Hey, 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 MECHANICS
And 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.

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 BERRY
All 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.

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 MUSGRAVE
Welcome 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.

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 MORGAN
Good 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.

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 PREVETT
Hello 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.

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

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EPISODE TRANSCRIPTION

ALAN FREDENDALL
Welcome 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.