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

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance (or not!) of ground reaction force as it relates to running related injuries. Megan discusses research evaluating the association between ground reaction forces & running related injuries, noting that these forces do not seem to be directly linked to the onset of injuries. Furthermore, Megan shares that footwear that decreases ground reaction forces does not also seem to have an effect on the development of running related injuries. Megan cautions listeners to not worry too much about the manipulation of ground reaction forces in training or in rehab as the link to injury prediction seems to be poor.

Take a listen to the episode or read the episode transcription below.

If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app.payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app/physicaltherapy. Thanks, everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 MEGAN PEACH

So what I want to talk about today is ground reaction force and how it relates to running related injuries. And we need to be a little bit cautious, I think, when we're talking about ground reaction force and how it relates to those injuries, because I think the popular opinion is that ground reaction force really is kind of the cause of running related injuries, or we need to address ground reaction forces when we're addressing running related injuries, or we need to reduce it And what the literature actually says is that it's not really the case. And so I'm going to give you a couple of examples from current literature that may tell a different story from popular opinion. So we'll start with a 2016 article. And this was actually a systematic review meta-analysis. So it pooled a lot of different studies. And what it looked at was the association of a ground reaction force with running-related injuries. What they found was that when they pooled all of the injuries together, loading metrics, so loading variables like ground reaction force or loading rate, were not necessarily related to running-related injuries when all of the injuries were pooled together. It was a bit of a different story when they individually looked at separate injuries. where they took out patellofemoral pain, they took out bone source injuries, they took out Achilles tendinopathy, for example. And what they found was that the vertical loading rate was associated with subjects or was related to the injury in subjects with tibial stress fractures. And so different outcomes there when we pool the running related injuries versus when we look at them individually. Another more recent study, so 2020 now. looked at about 125 injured runners, and they compared these runners to healthy controls. And what they found in this study was, contrary to the previous study, was that when they assessed the whole entire group of injured runners as a whole, so all of the injured running injuries together, what they found was that the impact variables, so vertical loading rate, ground reaction force. They were associated with running-related injuries when all of the subjects were pooled together. Different results when then they separated out the running injuries and looked at them individually.

03:59 IMPACT VARIABLES

And so when they took groups of running-related injuries, groups of patellofemoral pain, groups of IT band syndrome, groups of Achilles tendinopathy, et cetera, what they found was that some injuries were associated with impact variables and some were not. And so the injuries associated with impact variables were our patellofemoral pain, our plantar fasciitis, And the injuries that were not associated with impact variables were tibial bone stress injuries, Achilles tendinopathy, and iliotibial band syndrome. So when we take a step back out of that space and think about our injured runner on the treadmill looking at their gait mechanics, when we have a injured runner with patellofemoral pain or plantar fasciitis, and they're on the treadmill, what we would expect to see in terms of faulty gait mechanics are faulty gait mechanics in the sagittal plane. So looking at that runner from the side, very typically or commonly we'll see clinical patterns of an overstride, we'll see a lack of knee flexion at initial contact, and we'll see an increased angle of inclination, so increased dorsiflexion at all at initial contact. in the runners with patella femoral pain and plantar fasciitis. So very common, not always. And it's not like that clinical pattern can't be seen in other injuries as well. It's just very common in those two injuries. And that makes a lot of sense because that clinical pattern is very much associated with increased ground reaction forces as well. So it would make sense that within this study, when we separate out all of the injuries and pull them as separate injuries and look at them, that those two specific injuries would be related to ground reaction force. When we also look at the other injuries, so IT band syndrome and Achilles tendinopathy, and we get those runners on the treadmill, we see different clinical patterns. So more likely in those runners, are we going to see movement faults from a different angle? We're likely to see um, faulty movement in more of the frontal plane and, and maybe kind of surrogate transverse plane movement faults as well. So we would likely see, um, increased femoral adduction, maybe internal rotation of the lower extremity, uh, potentially this crossover sign or a narrow, um, foot to center a mass, maybe over pronation. Those are very, very common mechanical faults that we might see with, um, your IT band syndrome and your Achilles tendinopathies. And so when we think about those movement patterns, those are much more associated with range of motion deficits. Maybe they have too much, maybe they have too little. Neuromotor control of that range of motion, maybe strength deficits in that frontal plane, but much less associated with the impact variables like ground reaction force and loading rate. So it makes sense from this study that those specific injuries, the IT band syndrome and the Achilles tendinopathy from like a clinical standpoint would be less related to ground reaction force than the other already previously mentioned injuries. So then when we take tibial bone stress injuries and we look at that, it's kind of in a group all of its own because when we look at bone stress injuries, and I'm talking more specifically to tibial because we just don't have enough information on the other common bone stress injuries like metatarsal or femoral. Most of the research right now is on tibial bone stress injuries in terms of biomechanics. And so when we consider a tibial bone stress injury and whether or not it's related to ground reaction forces. We have to look at the forces on that bone. And so ground reaction force is just one component of the force, the total force on that bone. And it's the external load. When we look at the internal load, it comes from muscles. And so when we're talking about the tibia specifically, we're generally talking about the soleus because it's directly attached to that tibia. And when the soleus contracts, it imparts this internal load directly onto that bone. So it's considered an internal load. When we look at the differences between the external load and the internal load, the external load during running activity or the ground reaction force is generally about two and a half to three times body weight of that runner. But when we look at the internal load, it's upwards of eight times body weight for that specific runner compared to the two and a half times for external load. So you can see how the internal load in a tibial bone stress injury is going to play a much greater role in the development of that bone stress injury than the actual external load coming from that ground reaction force. So again, the results from this study suggest that ground reaction force doesn't really play a big role in, um, tibial bone stress injuries. And that is consistent with the rest of the literature as well. Um, there was a systematic review about a decade ago, looking at ground reaction forces in, um, bone stress injuries, tibial and metatarsal and their conclusions were, um, supportive of this result as well, where they found that ground reaction force is really not related to the development of, um, bone stress injuries in runners, as well as more recent literature has basically corroborated that and their results are very, very similar. Now, a more recent study, so one published just last year actually, looked at 800 runners Um, now that's, that's insane for our running study that those are huge, huge numbers. And so initially I was thinking, okay, this was a survey study. Like they sent out a survey to a bunch of runners and they got it back and they figured out some results from the study, but no. they actually got 800 runners and put them on a treadmill, did their motion capture, and then evaluated it all for ground reaction force and biomechanics. And so that's a tremendous amount of work, a tremendous amount of data, and really interesting results as well. And so really, the big purpose of this more recent study was to look at um, risk factors, uh, for running related injuries in two different shot conditions. And so one shoe was a, uh, like a hard cushions shoe and one shoe was a softer cushion shoe. And so they're looking at the differences in risk factors between those two different shoes and, um, interesting results. So while they did find, uh, different risk factors based on the different shoe condition, what they didn't find was any of the loading variables, so there were numerous in this study, but the big ones are ground reaction force and loading rates. And they did not find any association with the loading variables and in either of the shoe conditions and risk for injury. So basically, what they're saying here is that regardless of the type of shoe that that runner is wearing, or those 800 runners are wearing,

10:41 GROUND REACTION FORCE & RUNNING RELATED INJURIES

Ground reaction force did not play a role in the development of that injury, which is super, super interesting because I think often we associate different shoes with different ground reaction forces as well, but that's not necessarily the case. And that's not what the literature is telling us. And so. all of this literature combined. And certainly this is not all the literature. It's not all encompassing. And these are, these are just four different studies. Um, so take that with a grain of salt, but I think there's, there's this popular belief out there that, um, ground reaction force is very closely related to the development of bone stress or not, sorry, not bone stress, but running related injuries, regardless of the type of running related injury. And I think we can look at studies two different ways. And so In one way, we can look at the study as a whole and take all of the running-related injuries and pool them together, and then look at the results from there. But those results tend to be very, very different from when we separate out running-related injuries and say, okay, what do the patellofemoral pain injuries look like, and what are the mechanics for Achilles tendinopathy, and how are they different from IT band syndrome? And when we do that, we actually get very different results, not only for the biomechanics, but for the ground reaction force as well. And so, you know, contrary to popular belief, I don't think impact variables like ground reaction force are a very good predictor for running related injury, nor may they be. And again, this is different per injury. So they may be something to address in injuries that are definitely related to ground reaction forces like patellofemoral pain, plantar fasciitis, plantar fasciosis. But ground reaction force may not be the best thing to try to address with other types of injuries like bone stress injuries or Achilles tendinopathy or IT band syndrome. And I think the main goal here is just to get the point across that it's not the only metric, and quite often we don't actually have access to that information anyways in a clinical setting. It's more in a lab based setting, but we need to look at that whole runner. So we need to not only address if we are addressing ground reaction force, but address the range of motion, address other running biomechanics, address the strength, address the neuromotor control, so that we can basically address that runner as a whole. Okay, that's all I have for you today. I hope that was helpful. I hope you have a wonderful Friday and a wonderful weekend. Don't forget, if you want to sign up for Rehab of the Injured Runner online, our last cohort of 2023, make sure you get in there. Go ahead and sign up today. All right, have a good one. Until next time.

14:39 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the concept of excessive humility and being overly open-minded, discussing how it can hinder individuals from taking action and being useful. While acknowledging the importance and benefits of open-mindedness in considering different perspectives and possibilities, Jeff also points out that excessive open-mindedness can render one unable to take stances or make decisions, rendering it useless.

Jeff emphasizes the need to strike a balance between open-mindedness and the ability to take a stance. He cautions against being so open-minded that one loses their ability to make decisions and take action. Excessive open-mindedness, according to Jeff, can lead to a lack of direction and clarity, making it difficult to make progress or contribute effectively.

Similarly, Jeff addresses the issue of excessive humility, particularly in relation to feeling inadequate to take action due to a lack of knowledge. While it is important to acknowledge and respect the limits of one’s knowledge, Jeff argues that excessive humility can be detrimental. Constantly waiting for more information or certainty before taking action, they assert, can result in paralysis by analysis and prevent individuals from being useful in their professional careers.

Jeff encourages individuals to have a level of humility that allows them to act even in the presence of uncertainty. Jeff highlights the importance of being willing to make choices and decisions, even if they may not always be perfect. By embracing the imperfection of action and remaining focused, individuals can gather data and fill the gaps in their knowledge. This approach allows for continuous improvement and growth while avoiding the pitfall of doing nothing.

Take a listen to the podcast episode or read the full transcription below.

If you’re looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

Okay, team, what’s up? Welcome to Thursday. Welcome back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always thrilled to be here on Leadership Thursday. I cannot wait to jump into this topic about choice and the need to make one. Before we do, it’s Gut Check Thursday. Let’s not ignore the workout. Let’s talk about it. Let’s take it on head on. It’s a doozy. We’ve got five rounds for time, okay? We’ve got 12 handstand pushups, nine toes-to-bar in six squat cleans. Okay, it’s gonna be at 155, 105, so a little bit heavier than we usually encounter our cleans in Gut Check Thursday, but the volume’s a little bit lower there on that set. Five rounds of that for time, bang that out, you’re probably gonna have some rest on the handstand push-ups and the heavier squat cleans. Try to keep moving steady, make sure you tag Ice Physio, hashtag Ice Train, we love tracking those videos. Get it in, it’s Thursday, get the work done. All right, upcoming courses, I want to highlight CMFA Live this week. We’ve got Newark, California coming up. I think there’s only two spots left in that course. That’s with Zach Long and crew. It’s going to be September 30th, October 1st, so in a couple of weeks over in California. We’ve got Linwood, Washington coming up October 7th, 8th, and then down in Hoover, Alabama, November 4th, 5th. So if you want to get out on the road, learn all things barbell movements, get into some basic gymnastics, talk about programming, demystify a lot of things around resistance training. That is the course you need to be in. It is, of course, part of our CMFA certification, which includes Essential Foundations, Advanced Concepts, also known as Level 1 and Level 2 on the fitness athlete side. And, of course, during that live course, you get testing in person if you want to obtain that certification. So hit that up. PTonICE.com is where all that good stuff lives.

02:16 YOU HAVE TO CHOOSE

Let’s talk about the topic. You have to choose. Team, it has always driven me nuts. From the very, very first entrance into my professional career, this comment or idea of more research is needed has always driven me crazy. Now, I don’t mean from the actual research side. Like, I get the idea of why that statement is made, at the end of papers, like, hey, to get to a certain level of statistical significance or confidence, we have to have more data, right? Totally understand where that comes from in the research world. But the ridiculous incorporation or discussion of that into patient care has always blown my mind, right? So you see so many folks saying that, we don’t know, we don’t know, we don’t know, as though we can’t do anything. This is absurd from a patient care perspective. Like, I always imagine these people, like, are you really sitting in front of your 8 a.m. and saying, hey Lynn, I know your shoulder’s really bugging you. Problem is, the jury’s still a little bit out on the best rehab for this until we know, we’re gonna pause here, I’m gonna have you come back. Like, are you really doing this all day, every day, every 30 minutes with a new patient? Of course not, it’s absurd. To be of any use, we must decide and act in the presence of uncertainty. This is true literally everywhere in our lives. It is obviously true in patient care, right? We’ve got to do something for Lynn, right? We know it’s not gonna be perfect, but we’ve gotta act with the knowledge we have and do our best. We have got to decide and act in the presence of uncertainty. And this goes so far beyond patient care. This is true in every aspect of our professional journeys and lives. We’ve gotta be willing to say, we’ve gotta be willing to choose to say, From what I’ve learned and experienced thus far, I currently believe X. I don’t care what domain you’re talking about. I don’t care if you’re talking about business, sports, hobbies, patient care, nothing moves forward with waiting. I was thinking about this last weekend. So for those of you who haven’t followed my recent journey, I’m getting into enduro motorcycling, right? So I’m signing up for some races next year and I’m terrible at it. So this weekend I’m up in the mountains and I’m flying down this trail, moderately out of control per usual, and having to choose lines in real time, right? So you’re coming up on obstacles, going relatively fast, thinking I’ve got to do something in real time in this moment. I have to choose. Now, knowing full well in that moment that if I was to go back to that same trail two years from now, I have no doubt that I would choose a different and by different I mean better line because I’ll be better at the activity. But that does not mean right now I don’t have to choose. I just have to choose, thinking with the experience that I have, what is the best way to move forward, knowing full well it isn’t going to be perfect. In a couple years when I come back, I’ll choose something different. This is the process. Just because you know down the road, you will know more and do better, doesn’t mean right now you do nothing. not in patient care, not in business, not in sport. Yet, people are always trying to remain neutral and I want to discuss a few of the reasons why they do this and I want to challenge them a little bit. So, number one, people are often proud of themselves for being open-minded. What I would say is excessively open-minded. Being open-minded is great. Always remaining vigilant that better options are out there and keeping an eye open that you’re not missing them because you’re so tunnel-visioned, that’s great. But being excessively open-minded to the point where You say, yeah, I’m open to that, I’m open to that, I’m open to that, I’m open to that, I’m open to everything.

06:23 “AT SOME POINT, BEING SO OPEN-MINDED IS HAVING NO MIND AT ALL”

Well, at some point, being that open-minded is having no mind at all. And having no mind at all isn’t useful to anybody. Being open-minded is great. Being excessively open-minded to the point where you can’t take any stances is useless. And you’ve gotta be careful of which side of that line you’re on. Number two is excessive humility about what we don’t know yet. People love to say, yeah, but we aren’t sure yet. We will never be sure. That’s the nature of the game. So while, again, some of that humility is useful, so you’re not excessively betting on something that you truly don’t have the requisite data for yet, understanding that we are never gonna hit a point where we say, we are absolutely certain about this, Knowing that and owning that will allow you to act even in the presence of some level of uncertainty. So this excessive humility of, we never know enough to do anything, again, simply isn’t useful. Number three. People don’t wanna be seen as falling into a guru camp, and there’s some good reasons for that. Looking back historically, and again, speaking to physical therapy, it’s the area I know the best, there have certainly been plenty of extremists in guru camps that have led the collective astray, no doubt, but don’t be one of those. You don’t have to be an extremist in a camp to go in and say, hey, I think most of what’s going on here is pretty useful. There’s no reason you can’t go into it with that frame of mind. But people are so afraid of being labeled, of being in this camp, or that camp, or that camp, that they stay, again, doing nothing. And unfortunately, doing nothing doesn’t serve anybody. Number four, they don’t want to step on toes. Once you say, hey, I believe this, you are naturally going to rub some people the wrong way because now you’ve committed a bit. You’ve said, I kind of looked at everything that I could and I’m going to go this direction. I think this makes the most sense. Well, other people that made other commitments are going to be rubbed the wrong way by that. If that is not happening, you are not doing anything of merit. If you are never rubbing anybody the wrong way, I can promise you, you aren’t moving anything forward in a relevant fashion. So reflection point number one of this episode is are you doing that? In the past couple years, have you rubbed some folks the wrong way? I mean, give this some serious thought. Like really think, have your stances, have your actions bothered some folks? If that answer is no, you’re not standing for anything. And if you’re not standing for anything, you’re not being useful. So just give yourself a little pause today and really think, like, am I committing enough that people who have made contrary decisions are a bit bothered by that? That should be a constant in your life. As you’re working through decisions and emerging and making choices, some people aren’t gonna love those, and if you aren’t feeling some of that pushback, I think you’re holding yourself back and trusting yourself and making commitments that actually allow you to decide and move things forward. But the number one reason is I look at folks who are forever trying to stay in this kind of neutral ground that I really feel this static posture doesn’t get anybody anywhere is because they don’t want to be wrong. They don’t want to be wrong. They don’t want to look back in two years and know the line they took on that motorcycle trail was the worst one they could have chosen. They don’t want to be wrong. They’re perfectionists. Team action is always imperfect. Action is always imperfect, especially in hindsight. There is not a single action you are ever gonna take that you’re gonna look back with five more years of data and say that was perfect across every domain. That’s never going to happen. So if you can’t embrace that you’re gonna be wrong, at least in some percentage, every single time you make a choice, You are forever going to be paralyzed. It will be paralysis by analysis for the rest of your professional, business, patient care career. You’ve got to get over that. You’ve got to embrace that every single action will always be looked back as imperfect, and that is a beautiful part of the process. That’s what allows you, as you recognize that, to alter it, shape it, and make it better. This is the process.

10:55 “IF YOU CAN’T CHOOSE IMPERFECT ACTION, YOU CAN’T CHOOSE ACTION. PERIOD.”

But if you can’t choose imperfect action, you can’t choose action, period. And that’s a problem if you’re trying to be useful as you’re moving forward. Bottom line is this, the people that I’ve observed who have been the most useful, and of course, the most useful meaning the most successful, because these two things tend to go together. You provide a lot of value, you’re useful, success follows, are always those who took really deep dives. They said, I think this makes a bunch of sense, I’m going all in. Like I’m gonna learn as much about this as I can, I’m gonna try to replicate it, I’m gonna try to leverage it, I’m gonna try to use it. But as they’re doing that, they’re aware and okay with acknowledging the shortcomings of that model. So that they can in real time be seeking out solutions to fill those gaps. They’re learning through action, which necessarily followed decisions, choosing. You have to do anything besides nothing. You have to do anything besides nothing, because if you don’t get out there and go, you can’t evaluate the shortcomings, because you aren’t doing anything. The people that I see that act with the most, again, it’s not arrogance, it’s not even confidence, it’s out of necessity to act. They know they have to say, I know this isn’t perfect, but I have to go anyways. Those people that are willing to be in that space, first of all, provide the most value, and absolutely learn and refine at the highest rate of speed, simply because the data’s now coming back at them because they’re out there. And because they’re out there, it’s a bit vulnerable and emotional, and you tend to learn a ton in those phases. Now, all of that being said, Your decisions should always change. This is a critical part of this conversation, right? Your decisions should always change with emerging data. If they aren’t, you’re just being arrogant. And now you’re falling into the other side of the problem, which is not having one eye open. If your decisions aren’t changing consistently, if that’s not just a part of your growth and process, where you look back and say, ooh, shoot, should’ve done, now that I know better, I’m definitely gonna do better because that was imperfect. If you are not regularly doing that, you are also going about this process wrong, but on the other side, right? Remaining blind and over-trusting your actions. So reflection point number two of the episode is have they? In the past couple years, Have you reversed course on a couple of key philosophies, beliefs, decisions, directions? If not, I think you’re erring on the other side, where you’re not keeping one eye open. You think your action’s perfect. You aren’t aware of the imperfection and looking for the gaps. You’re going in blind. This is every bit as errant, maybe even more dangerously, than the former. In this case, not only are you probably not being as useful as possible, but you’re probably leading folks excessively astray by not being aware of what’s emerging. So reflection point number two is are you every couple years realizing something you believe strongly had some pretty significant flaws and are you willing to incorporate emerging data to change them? Team. If you aren’t willing to embrace that action’s always imperfect, you’re never gonna choose, decide, and move forward. If you don’t do that, you can never get the data that fills the gaps of what we don’t know that you’re so concerned about, it’s holding you back from action to begin with. Trust that your intentions are good. Remain focused. Humble in the face of everything emerging, so you’re not totally just tunnel visioned in one direction. Allow that to shape your actions, but make sure that you’re actually playing the game. So when you get information, you can modulate in real time, forever become better, but always stay away from the pitfall of doing nothing.

14:49 “PARALYSIS BY ANALYSIS IS THE ONLY WAY TO ENSURE YOU’RE USELESS YOUR ENTIRE PROFESSIONAL CAREER.”

Paralysis by analysis is the only way to ensure you’re useless your entire professional career. Do anything besides nothing, stay humble, be ever evolving, but be willing to choose. You’ll be wrong. I guarantee it. Me too. Let’s be wrong bravely and let’s adapt in real time. You have to choose. I hope it makes sense. Hit me up with questions, comments. Thanks for being here on Leadership Thursday. PTOnIce.com where everything lives. We’ll see you next week. Cheers, team.

15:28 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the book "Radical Candor" by Kim Scott as a valuable resource for improving patient care and leadership skills. Jeff highlights the book's teachings on radical candor, including its definition, common pitfalls, and practical application in patient care. Jeff emphasizes the significance of caring personally for patients and challenging them directly. Caring personally entails demonstrating genuine concern for the patient's life and goals, while challenging directly involves establishing and upholding standards and expectations that contribute to the patient's success. Jeff believes that this book is relevant to patient care and can assist clinicians in becoming better leaders for their patients.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up, everybody? Welcome back to the PT on Ice Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a wait list, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app.physicaltherapy.com. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code IcePT1MO. When you sign up is that gives you a one month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:43 JEFF MUSGRAVE

Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave. I'm one of the faculty with the Institute of Clinical Excellence in the Geriatrics Division. We call modern management of the older adult. Super excited to talk to you about a book that I recently read called Radical Candor, written by Kim Scott. This is a great leadership book, but it has some direct correlation to ways that you can improve your patient care, okay? So super excited to talk about radically candid patient care with you this morning. But before we get into that, just a couple things going on in the MMOA division. If you're looking to continue on to get your MMOA cert, Our next cohort of Essential Foundations is going to be on October 4th. If you've already had Essential Foundations, you're looking to get into Advanced Concepts, you're going to want to hop in the cohort October 10th, and if you want to see us on the road, there's still some spots in Oklahoma City for this weekend.

02:55 RADICAL CANDOR IN PATIENT CARE

So, this book, Radical Candor by Kim Scott, what does it have to teach us? The things we're going to cover is what is radical candor. We're going to talk about some of the ways we sometimes miss a mark. This is going to hit home for me because one of these downfalls is something that I have succumbed to time over time and have been working to improve. And then how to apply this well in patient care and some things to consider. So, what is being radically candid? What does that mean? So, Kim Scott defines this in the book as two factors. Two factors to being radically candid. You've got to care personally. You've got to care personally. I think oftentimes, if you're listening to this podcast, you're someone who cares personally, because you're trying to get better. You're trying to level up. The second piece of this, where I think oftentimes we miss a mark as clinicians, is to challenge directly. to challenge directly. And for me personally, this was something really difficult to learn is how to challenge our patients directly to hold the line. We've got to hold the standard. We've got to say, this is what it takes. and we're going to hold the line until we get there. Or we're gonna make referrals to other people, we're gonna bring in whatever parts of the medical team it takes to get you to this standard, because this is what it takes to reach your actual meaningful goal, the thing that you really want to do. So that's what radical candor is. You've got to care personally and challenge directly. Some of the ways we see this go wrong, the first bucket is the one I fell into over and over and over again, and that was ruinous empathy. So ruinous empathy is defined as you care personally, but you don't challenge directly. You care about your patients, they know you care about them, but you don't challenge them directly. They may give you a really bad rep or any effort and you just say, that's so great, that's amazing, that's exactly what I wanted. And you know in your heart of hearts, that wasn't it. You didn't hit the mark. That's not anything like what I told you to do, and we did not coach them up. We want to be really effective coaches, really effective coaches, set people up for success, and we challenge them directly. We give some room for them to struggle. So ruinous empathy is the first bucket if you miss being radically candid. That is, you care personally, but you don't challenge directly. We're congratulating every attempt, whether it's actually a progression or not. Now that being said, I will tell you one of the factors that we use, one of the principles we use when we're working with older adults is we do intentionally underdose. We do make things a little bit easier so we can hit success. So we make the challenge a little bit easier so that we can get some successful reps early on, and that is important. But over time, we ramp up that challenge pretty quickly because we don't have time to waste, particularly with older adults. If we're not getting them strong, we're going to see them decline very quickly.

04:05 RADICAL CANDOR & FEEDBACK

So to circumvent that, to make sure that they can be successful and we can be honest when we're giving them that feedback, we make sure the challenge is appropriate. And sometimes we'll make it just a little bit easy at the beginning, but we very quickly ramp up so that we are directly challenging our patients because that is where they're gonna get better. So maybe you're not being ruinously empathetic, Maybe you've fallen into this other category that Kim references as obnoxious aggression. And that could represent the burned out clinician here. I've had periods in my career before I found my passion where I was doing work, too much work, not saying no, and found myself completely overwhelmed with work. where you don't care personally about this patient, you've not connected on a deep level to be empathetic to what their experience has been, but you do challenge directly. So that could look like you being obnoxiously aggressive in your feedback. Like, nope, that's not it. Nope, nope, nope, nope. Instead of just being quiet, letting those improper reps happen, we like to have people start some of these new movements that we're teaching in such a way that they're not gonna get hurt if some ugly reps happen. We can let those ugly reps happen, and then once we see a good one, we'll be like, yes, that's it. that can help you circumvent if you tend to be obnoxiously aggressive in your feedback. So that is when you don't care personally, but you do challenge directly, and there's a mismatch there. And that can do a lot of damage when we're trying to build a relationship with our patients so that they trust us. If they don't think we care about them, then they're probably not going to come very long, they're not going to take our instruction well, probably not going to be very beneficial of a therapeutic relationship with that client. So that's the basics of radical candor and how we can miss a mark by being ruinously empathetic or obnoxiously aggressive. What I want to do now is just lean into what it looks like to truly care personally for our patients. So I truly believe that you cannot give world-class care, you cannot give the best care if you don't care about your patient. If you don't know enough about your patient to know how their problem is impacting their life, you just can't do it. If you don't know how it's impacting their life, you're never gonna dig deep enough to even get a good goal. And if you don't get a good goal, you don't really know what movement to work on. To give you an example of this, say someone is having knee pain. You've got an older adult coming to you for knee pain, and you just take that at surface level. Okay, I'm just gonna figure out why your knee hurts, and I'm gonna give you exercises for your knee. But maybe you've not dug deep enough to find out why the knee hurting, why that even matters. Why does that matter to this patient in their world? What impact is this having? If that knee pain is keeping them from taking care of maybe their favorite pet. We like to talk about Fluffy a lot. A lot of our older adults have pets. And we say, okay, why does it matter that you have to get in the ground, get on the ground to take care of Fluffy? Or maybe they need to kneel down to clean the kitty litter. It's like, well, I live alone. I have no help whatsoever. And Fluffy is my only emotional connection. Fluffy's the only person in my world. I'm completely socially isolated, and if I can't take care of Fluffy, I'm gonna have to get Fluffy away. And my fear is that my only social connection, my only being that I can connect with is going to leave me, just like maybe family members that have passed away.

10:53 CARING PERSONALLY FOR PATIENTS

Man, if we have dug that deep into our patient's goals to know why it's important that they get their knee better, First of all, we're going to set a better goal because their knee may feel good and they may have better manual muscle testing. But if we don't ever bridge the gap back to them being able to get in the floor or take care of Fluffy, we've not really done our job. We've not dug deep enough to even get a good goal to care for them. And if they don't know how important this is, they're not going to trust us. like they would if we dig deep enough to know that we really genuinely care. And that trust is going to allow us to do the second part very well, which is to challenge them directly. We've got to challenge them directly. So what we've got to do is set very clear expectations of what success, what it's going to take to get to success. This client may have been dealing with this problem for decades. And if we tell them, oh yeah, I can get you better, in three weeks, even though we know this problem has been coming on for decades and decades and decades. When the reality may be that we are in more of an acute setting, someone just had a fall, they're in an acute or subacute setting, and the reality is to get back to getting into and out of the floor or getting their own groceries, it may be a year-long process. And if we just tell them, oh yeah, you know, I'm gonna give you a few exercises to do and if you do those for a week or two, you're probably gonna be better. That's not it. That's not truly challenging directly. That's being ruinously empathetic.

12:01 SETTING REALISTIC EXPECTATIONS

We care, but we're not setting realistic expectations. We're not challenging directly. That patient needs to know this journey is gonna take you a long time, but you can get there. The tools, the resources are out there. I'm gonna get you started on your journey. I'm gonna plant the seeds of the fitness that you actually need. to hit these big goals and I'm going to make a referral to someone who can take care of you. So if you're in a more acute setting your job is going to be planting some seeds and you're going to send them to a fitness forward clinician on the next step down the line so they can hit those big goals after you've uncovered them. So This may take one referral, maybe you're an outpatient, it may take several referrals. Maybe their medications are off, maybe they need different shoe wear, maybe they need to go to a podiatrist or an optometrist. If we dig deep enough, we do a really good job on the front end and get this information, we need to set realistic expectations of all the people that may be involved and how long it's really gonna take. Our older adults know when we're not shooting them straight. They know. When you hear, I've not been active for 40 years, and I've got a goal that requires a lot of activity and strength I've not had for 40 years, they know immediately if the goal is not realistic, and they've already lost trust with you. They may show up and get what they can, but they're not going to open themselves up to the challenge that they're really gonna need to reach their goals. So that's what I've got for you team. I think that this book by Kim Scott was very beneficial. It is a leadership book, but is very relevant in our ability to be leaders to our patients. And the two main goals here is we have got to care personally for our patients. It's got to be clear to them that we actually care about their life, that we've dug deep enough on that first visit to find out what their true meaningful goal is. And then our second job is to challenge them directly. We've got to set and maintain the standard. We've got to set realistic expectations that's actually going to lead to their success. If you've read this book, if you've got questions, comments, concerns about what I outlaid out here, I would love to discuss it. Leave me some comments. Otherwise team, have a wonderful Wednesday. We'll catch you soon.

14:29 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses treatment progressions for lateral knee pain/"IT band" pain. Mark encouraged beginning with open chain exercises as a starting point for individuals with high irritability. These exercises can help decrease force on tissues while still providing a stimulus for the body to adapt. Additionally, open chain exercises stimulate the release of endorphins, which can have a positive effect on pain and mood.

Mark mentions several open chain exercises that are beneficial for individuals with high irritability, including hip abduction, hip extension, and hip rotation. These exercises can be performed in different positions, such as bent over hip extension against a table or in a quadruped position with significant bracing of the anterior trunk.

It is important to note that the intensity and volume of open chain exercises should be adjusted based on the individual's irritability level. For individuals with high irritability, the podcast recommends starting with a high volume of open chain exercises, such as two to three sets of 20 repetitions with a low load intensity. The goal is to challenge the individual and provide a stimulus to the nervous system.

Overall, open chain exercises can be a beneficial starting point for individuals with high irritability as they help decrease force on tissues while still providing a stimulus for adaptation. It is important to adjust the intensity and volume of these exercises based on the individual's irritability level.

As symptoms decrease and heavy, slow resistance training is introduced, closed chain exercises such as the hip thruster and Bulgarian split squat are recommended. These exercises effectively strengthen the hip and quad muscles while improving stability and control in the lower extremities. The hip thruster involves thrusting the hips upward while keeping the feet planted on the ground, targeting the glutes and hamstrings. On the other hand, the Bulgarian split squat is a single-leg exercise that requires the back foot to be elevated on a bench or step, improving balance, stability, and leg strength.

In addition to closed chain exercises, proprioceptive training or reactive neuromuscular training can be incorporated. This involves using loop bands around the knees to provide feedback and improve body awareness. Proprioceptive training enhances control and stability during movements, reducing the risk of injury.

Once individuals can handle both heavy slow resistance training and reactive neuromuscular training, they can progress to plyometric training. Plyometric exercises involve explosive movements like jumping and hopping to develop power and improve muscular endurance. The recommended goal is three sets of 20 repetitions or three sets lasting a minute for endurance, and 10 sets of three to six repetitions for power. Plyometric training enhances both endurance and power, important for athletic performance and overall functional fitness.

Mark finishes this episode by offering a number of different options to reintroduce running, if it's part of that patient's goals.

Take a listen or check out the episode transcription below.

If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

All right, what's up PT on Ice daily crew. Dr. Mark Gallant here, lead faculty with the extremity management division alongside Lindsey Hughey and Eric Chaconas. Coming at you here Tuesday morning, Clinical Tuesday. Before we dive in, a few upcoming courses that we want to announce. I'm going to be in Cincinnati, Ohio this weekend with Onward Cincinnati. So if you've all been looking to check the extremity management course and haven't had that opportunity yet, definitely sign up today. Get on the list for Onward Cincinnati. There's still seats left. If that's not available, Cody will be in Rochester, Minnesota first weekend of October. So that'll be your next opportunity to check the extremity management crew out.

1:01 LATERAL KNEE PAIN

So I was on here a few weeks ago and we talked about the myths of iliotibial band pain, where we came from, from the research in the 70s, and now how we've adapted with newer research and things we now know. Mainly being that this is no longer believed to be a friction mechanism of the lateral knee because we know the IT band is firmly attached to the lateral femoral condyle, the patella, the tibia, and that this is more of a magnitude or a volume of load with a potential lack of frontal plane control or simply too much volume to the lateral knee. So what are we gonna do if that person comes in? Tim's been running on the treadmill for most of the year, he decides that he wants to get out and do some trail runs, start working some downhill in. Brittany has been relatively unfit for most of her life and decides, you know what, this fall, it's the time that I'm gonna run that half marathon. And then they start to develop some lateral knee pain. Well, how are we gonna treat those folks out? And what we're really gonna look at, that's gonna depend on where their irritability is. So we have four or five steps that we're gonna go through and that individual can jump onto that highway wherever they're at on this progression. So if that person comes in and they're highly irritable, they tell you that they've got eight out of 10 lateral knee pain, it hurts when they're going downstairs, when it's the trail leg that's walking, they begin to have some discomfort, they're certainly having trouble getting out and doing any of their runs, and it's really a quite uncomfortable pain for them. Well, when that person comes in, like we talked about last time, we'll do the dry needling, the myofascial decompression, the soft tissue to help modulate their pain. How do we work the exercises in and how do we specifically dose those exercises? So if the person has that 8 out of 10 or above or even 7 out of 10 irritability, oftentimes a good place to start with our exercises is open chain exercises. they're really going to decrease the amount or magnitude of force going into those tissues while giving them a nice stimulus so that the body knows it has to adapt, we get some good endorphins going. We specifically like open chain abduction of the hip, open chain extension of the hip, and if you want to get some open chain rotation of the hip, that works as well. So we like either a bent over hip extension so that person is leaning against the table so they can really contract their abs so that we know they're not getting any back arching there. Or if they go into a quadruped position, really brace the anterior trunk significantly, and then do their hip extensions. For the open chain abduction, we'd like to get them against a wall, starting them so where their hip is in neutral, so their hip is either, their leg's propped up on a ball or a bench, heels against the wall, slightly internally rotated so we know we're really hitting those glutes and working our hip abduction that way.

04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS

For our hip rotation in open chain, the traditional clamshell has come under fire quite a bit in the last handful of years. What we like to do is a pseudo open chain clamshell where their feet, their bare feet are gonna be against the wall. So they have to keep that flat foot against the wall and then go into their clamshell. How are we going to dose this? Well, if you've been to the course, you know, we talk about the rehab dose, eight to 20 repetitions, 30 to 80% of their one rep max basing that that volume and intensity on their irritability. Well, these folks are higher on the irritability, so we're going to go higher volume. We're going to hit two to three sets of 20 repetitions with a really low load intensity. It's hard to get a high intensity load an open chain without volume anyway. So that's really going to lend itself to this to begin with. So our hip extension, our abduction, our pseudo clamshell, we're going to hit those two to three sets of 20 reps where they feel challenged when they approach that 20. It's getting a lot of stimulus to that nervous system. It's letting the tissues know that we want you to be active, but it's not giving them a magnitude of load that's going to be threatening to the tissue. Once the person says, you know what, I went downstairs last night and my pain was only a 3 out of 10 or my symptoms were only a 3 out of 10 or less, or that person comes in and says, you know what, now when I'm walking, when that leg's the trail leg, really doesn't seem to bother me that much. Maybe a 2 out of 10 at best. That's when we really want to make sure we're progressing to a more closed chain activity. What we love for our closed chain exercises, again, working into that hip extension, getting the quad stronger. We like a hip thrust, so a barbell hip thrust that we can really load up a lot of weight. If we see a big side-to-side discrepancy in strength, we can go single leg landmine hip thruster to make sure we can load that up. We also like a Bulgarian split squat. For our IT band folks, we're gonna modify this split squat a bit Instead of having all the weight on the front leg, you're gonna have a majority of your weight on the leg that's slightly elevated so that we can get a big eccentric load into that posterior leg. How do we like to dose this one? Three sets of eight to 12 repetitions at a weight where they feel like they've only got two or three left in the tank by the time they get to that eight out of 12. You'll notice that three sets of 10 fits beautifully into that eight to 12 repetitions. A lot of clinicians out there like to bash the three sets of 10 calling other clinicians lazy. Three sets of 10 is a wonderful stimulus as long as you're dosing it out appropriately, as long as they're approaching failure. We're not saying they have to get to failure, but can they get in the ballpark of that failure? So again, three sets, of eight to 12 reps. We really love three sets of 10. It's easy for us, it's easy for the patient, and making sure they've only got two to three reps left in the tank, specifically with the barbell hip thruster, the Bulgarian split squat with the weight shifted posteriorly. You can also add, if you want to continue to work on those hip abductors, we really like a kettlebell-weighted hip hike to get a closed-chain version of that hip abduction. At the same time you're doing your heavy, slow resistance training with your Bulgarian split squats, your hip thrusters, with your hip hikes, we also want to get that person to start being able to feel where they can control that lower extremity in space. So we really like reactive neuromuscular training, often used the acronym RNT for short, where they're going to have a band around their knees, so a small loop band that's going to pull their knees into valgus. with a flat foot, they're going to drive their knees outward. We're going to do this at a high volume. So either two to three sets of 20 or setting a timer and saying, I'm going to have you rock this three sets for a minute each. Again, we're really trying to get that nervous system to feel where that limb is and is in space to gain more control. So we want that volume to be a bit higher. You can also do this single leg where you have a meter loop band attached to a rig or a door frame. It's going to pull them into that, that valgus force with a flat foot. They have to drive that out again, high volume, three sets, 20 reps, three sets for a minute. You can progress this into having them do step downs, lunges or squats with that band on. So they have to feel their lower extremity limb where it's at in space while going through a movement. So, Just to rehash where we're at right now, high irritability, we're going open chain exercises at a high volume, lower intensity. Once they can tolerate that with mild pain, we're going to go into our closed chain exercises, increasing the intensity, making it really challenging for that three sets of eight to 12. At the same time, doing our closed chain proprioceptive work or our reactive neuromuscular training.

09:28 PLYOMETRIC TRAINING

From there, when they say they're starting to tolerate that really well, then we wanna start working into our plyometric training. We talked about last week, we know that iliotibial band has a lot of similar properties to tendons. We wanna make sure that it has the ability to transfer force and absorb force quite well. We need to do this from both an endurance perspective and a power perspective. So can that tendon or that iliotibial band Absorb a lot of force and generate a lot of force and can it absorb and generate a high volume of force? So we like to do Lateral skater hops for a high volume to really get that endurance. So they're gonna be jumping side to side To get that that that volume for the endurance piece of three sets of 20 or three sets of a minute We also like pogo hops, where they're having to hop on one leg. Again, three sets of 20 or three sets of a minute. And then we really want to work on the power component. How high can they jump? How long can they jump? And can they go laterally against resistance? A couple of exercises that we really like for this, box jumps are great. Our long jump, just the traditional long jump. And then again, strapping either a band around the hips or a strap that's attached to an anchor cable column, and then we have them go three sets of three to six repetitions. So we're gonna have them go relatively low. If you've got the time in clinic, what we really prefer is 10 sets of three to six repetitions, because it's really gonna train that power very specific to how like our Olympic lifters would train. So again, if time is short in clinic, get the job done, get it in. What we really like is that 10 sets of three to six repetitions for our power. Another thing you can do for power is your rebound jumping. So they come off of a small step and they immediately have to jump to a higher box. That's going to train that lower extremity to both absorb force and immediately generate force overall.

12:01 RUNNING PROGRESSIONS FOR IT BAND PAIN

As they're tolerating those plyometrics better, both from an endurance perspective and from a power output perspective, then we're going to really look at how we're able to get them running more effectively. So what this is going to look like is early on for running to get them out of symptoms, we're often going to have them run on a treadmill with a fairly steep incline. This typically will reduce symptoms for a lot of our iliotibial band folks. Then we're going to lower the treadmill. have them make sure that they can run with relatively low symptoms at a normal treadmill where it's a very controlled environment. Once they can run on a regular treadmill at that very controlled environment, then we're going to have them outdoor run. Once they can outdoor run on something like a track, a blacktop, or a sidewalk where it's relatively controlled, then we'll progress them to their trail running when they can handle a relatively flat trail then we'll progress them back to their downhills and then get them back out there on the circuit, hitting their runs. So again, these folks can enter this anywhere along that progression, depending on their irritability. If they're highly irritable, start them out open chain, high volume exercise. As their symptoms decrease, get them into that heavy, slow resistance with closed chain exercises. We like the hip thruster and the Bulgarian split squat. As you're doing the heavy slow resistance, also getting them into some proprioceptive training or reactive neuromuscular training with loop bands around the knees so that they can feel where those knees are in space. Once they can handle both the heavy slow resistance and the reactive neuromuscular training, we're gonna get them into their plyometric training. We want them to have both endurance and a lot of power. So three sets of 20 or three sets of a minute for the endurance piece. 10 sets of three to six reps for their power piece. And then, of course, whatever their functional activity is that was initially their aggravator, the thing that they love to do that they wanna get back to, making sure we're incorporating that. Starting out incline treadmill, go to a neutral treadmill, get them on the outdoor, on a blacktop, pavement, or a track, then progress them to a trail, and then progress them to the downhill running. Hope this helped as far as the plan for IT band pain goes. Hope to see you all out on the road next week in Cincinnati. If not, catch Cody in Rochester. Hope you all have a great Tuesday in clinic. Thanks for your time. Have a great day.

14:14 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick  kicks off part 1 of a series on postpartum depression. In this episode, she discusses the differences between postpartum depression and other PP mood disorders. She then highlights the prevalence of and risk factors for developing postpartum depression.

In her next episode, she will focus on screening for and how to communicate with folks who may have postpartum depression.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app.com. Use the code icePT1MO at sign up to receive a one month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on Ice daily show.

01:26 APRIL DOMINICK

Good morning, everyone. Dr. April Dominick here from the Ice Pelvic Division, and today we're gonna talk about postpartum depression. This is a series, so in part one, we will define it, we'll talk about its prevalence, and we'll go through some risk factors for developing this condition. But before we dive in, we have some exciting updates from our division. Drum roll, please, or Harp glissando. So if you didn't catch our big news that dropped on Thursday of last week in our pelvic newsletter, we now have an eight week online level two course that will drop in spring 2024. We are so excited for this course. It is loaded with fun material. So we'll talk about pelvic pain syndromes. We'll go through post-op rehab for the pelvic and abdominal surgery that someone may get. We'll go through some birth prep and talk about all things fertility and infertility. So hop into that course when it becomes available. If the virtual option is not for you or your cup of tea, then I invite you to join us on the road live where we teach all things pelvic health rehab, bridging the gap between the fitness athlete and pelvic health. We're doing internal exams, external exams. We are talking about core rehab, going through labs that go over diastasis recti, return to the barbell, hopping on the rig, endurance, impact. It is so much fun as well. So when can you catch us live? We have some courses coming up September 23rd and 24th in Scottsdale, Arizona, and October 13th and 14th in Milwaukee, Wisconsin. Those classes will be with Dr. Alexis Morgan and Dr. Rachel Moore. Or you can find Dr. Christina Previtt. That's right, I said doctor. She just earned her PhD and we couldn't be more proud of her. So Christina and I will be out in the Pacific Northwest in Corvallis, Oregon on October 21st and 22nd. Tons of opportunities for you all to learn with us head over to PTOnIce.com and check out more.

06:34 POSTPARTUM DEPRESSION

All right, postpartum depression, the topic of the day. Let's just cut to the chase. We'll call a spade a spade, pregnancy and parenthood. That is a transformative time. It's filled to the brim with new challenges when it comes to emotional, physical, mental, and lifestyle changes. We'll talk about pregnancy, I mean, that's approximately nine months of physical body alterations that support and nurture the baby. Then we have labor and delivery. That's an incredible feat. It's remarkable in the mental and physical strength that is required to get the baby to come out into the world. And then we have postpartum. Voila, the baby has arrived. Now what? So even though the baby may be all that the birthing person has ever dreamed of, it's gonna come with a lot of emotions, anticipation, joy, maybe even fear. Not to mention the added responsibility of caring for a baby while the birthing individual is functioning on minimal sleep, who knows what's happening with nutrition, and then there's an emotional rollercoaster going on. What up, hormones? and all the while that person is trying to heal and recover themselves. All of that can put a person at risk for postpartum mood disorders. We'll focus on postpartum depression or PPD, but I am going to share other conditions that may look like PPD. There's a side note here. A lot of the research that I did is on the postpartum parent who identifies as pronouns she, her, hers, or mother. So I'll be using that terminology for this podcast just based off of the research that I found. So here are three different postpartum mood disorders to include in a differential diagnosis if someone is coming to you postpartum. Number one, we have baby blues. This is gonna be the mild, most mild form of a depressive mood disorder. Then we have postpartum depression. And then our third type is postpartum psychosis, and that's gonna be the most severe form of depression for postpartum. So let's unpack baby blues. Due to the hormonal changes that happen immediately postpartum, About 50% of new mothers get the baby blues. That's a lot. By definition, the baby blues are mood changes that are mild, transient, and self-limited. And that means it'll resolve on its own and there is minimal medical retreatment required. Someone experiencing baby blues may exhibit signs of tearfulness, sadness, exhaustion, They may be irritable, they may have decreased concentration, mooniness, and decreased sleep. But all of those changes don't affect the person's ability to care for the baby or their own daily function. So from a time standpoint for baby blues, the onset and conclusion is like a bell curve. The symptoms come on within two to five days after childbirth, they peak, and then they generally resolve within two weeks of onset. One of the most common complications though of baby blues is the development of postpartum depression. So what is postpartum depression defined as? The DSM-5 defines it as a moderate to severe depressive episode that starts around four weeks post delivery. And this is typically going to require medical intervention. Compared to the baby blues, The big difference is that with postpartum depression, or PPD, symptoms persist for a longer period of time, so they aren't transient.

09:06 EFFECTS OF POSTPARTUM DEPRESSION

If we zoom out, a person with postpartum depression can have changes in feelings, changes in everyday life, and they may even change how they think about their baby. Common symptoms for someone who is experiencing PPD They may have chronic feelings of guilt, feelings of failure as a mother, loss of interest in activities that used to bring them joy, feelings of despair that do interfere with their ADLs, and self-care. They'll also have unreasonable worries about the child's health and possibly infanticide or suicidal thoughts. So I wanted to talk about the effects of postpartum depression on the members in the family. So it's going to put the mother at greater risk for developing depressive episodes in the future. It can also affect the mother and infant bonding, and this has some potential implications if, say, the person is wanting to breastfeed, that may interrupt the success with that just due to the bonding issue. Beyond that, it's gonna affect the co-parent or the spouse and overall family dynamics. And there is some research showing the effects of postpartum depression and how that may negatively affect the behavioral and emotional development of the child. All right, so we went over baby blues, we went over postpartum depression, I can't leave this conversation without talking about postpartum psychosis. This is a psychiatric medical emergency. It's associated with increased suicide and infanticidal risk. It's rare. The global prevalence of it is about one to two and a half in every 1,000 women. It's going to emerge during the first few days or weeks of childbirth. And folks with postpartum psychosis will demonstrate rapid shifts in mood swings that are similar to bipolar tendencies. They'll have a loss of sense of reality. They may experience hallucinations, lack of sleep for several nights, agitation, delusions, and attempts to hurt themselves or the baby. So when you're meeting with a client, two keys for differentiating between baby blues and postpartum depression is the time since childbirth and severity of symptoms. So with baby blues, symptoms are usually present and gone within the first two weeks. Whereas those symptoms that persist beyond the first few weeks are more in the PPD camp. And then with baby blues, the symptoms are more mild and they don't affect the daily function of the individual. Whereas with PPD, it is more moderate in symptom nature and it will affect their daily life. So what is the prevalence of postpartum depression? It is one of the most common complications for someone after they give birth. PPD occurs in 15% or one in seven postpartum women. One in seven. These numbers are just representative of those who actually report it. So according to a study done in 2006 by Beck and colleagues, as many as half of PPD in new mothers goes undiagnosed because the individual is not wanting to share this with their family members or to share it with a research study. They wanna protect their own privacy. There are some effects of race as well in terms of prevalence, at least in when postpartum depression hits folks. So African-American and Hispanic mothers reported the onset of PPD within two weeks of delivery versus white mothers who tended to report the onset of PPD later. Region also matters. So geographical region. The prevalence of PPD varies by country. And what we know is that folks from developing countries have a higher prevalence of postpartum depression. Okay, what are the risk factors for postpartum depression? Y'all, there are so many. There were so many that I'm only gonna highlight the ones that came up over and over again that had the greatest impact in the research. So a 2022 literature review of risk factors of PPD identified the following as those that had the most powerful impact on development of PPD. Previous history of depression or psychiatric illness, depressive symptoms during pregnancy, and decreased social and spousal support. So there has been some research done that suggests, hey, if someone has healthy and supportive relationships, that is going to act as a protective mechanism during the prenatal period, specifically for the development of depression as well. There were some other factors, risk factors for PPD. Low socioeconomic status, stressful life events, and obstetrical specific factors like gestational diabetes, negative birth experiences, preterm deliveries, and low birth weight infants. All of these have a profound effect on the development of PPD. There was another systematic review from 2021 that they identified six major risk factors, which some of those we've gone over. But there were two in their list that I thought were interesting. One was that a risk factor if you were a pregnant woman who gave birth to boys, and then if you had an epidural anesthesia during childbirth. So I felt like those two were interesting, just side effects or side notes, and they were from a systemic review as well.

15:06 THE ROLE OF THE HPA AXIS

Another area of emerging evidence looks at the role of the hypothalamus pituitary adrenal axis, or HPA. So we're about to get a little nerdy, but I love the brain, I love neuroscience, and I'm a psychology major, so let's talk about the brain and the endocrine system. So the HPA, or that hypothalamic pituitary adrenal axis, is a known responder during stress because it regulates physiologic processes such as the immune system and the autonomic nervous system. The HPA releases cortisol in trauma and stress. So if the HPA is not functioning correctly, there's a poor stress response. I think we can all agree that pregnancy itself and labor and delivery are some pretty extreme stressful and sometimes traumatic events. So during pregnancy, there are higher levels of estrogen and progesterone. Then during the delivery of the placenta, there's a dramatic fluctuation and drop of estrogen and progesterone. This rapid drop in hormone levels during that immediate postpartum period is a potential stressor and thought to contribute to the onset of depression. There was a 2017 systematic review that found seven out of 21 studies evaluating postpartum blues, and then 15 out of 28 studies evaluating PPD found abnormalities in the HBA axis. And from previous literature, we know that the dysregulation of the HBA axis is present in those with mental illness. So from all that, this is what I want us to think about. A healthy management of stress during pregnancy and postpartum should be a priority. We as rehab providers and medical professionals can have a tremendous impact in offering solutions for stress management like exercise, nutrition, sleep, proper medications. All right, let's recap.

18:39 IDENTIFYING POSTPARTUM DEPRESSION

When working with the postpartum population, one of the most common complications is postpartum depression. It affects 15% of women giving birth. It's imperative that we're aware of the different mood disorders that can happen postpartum and the differences between them. We have postpartum blues, very common, affects about 50% of new mothers. It's mild, it's transient, doesn't usually need medical intervention, but we do need to provide some validation and compassion for those individuals. It's usually resolved by week two from childbirth. Then we have postpartum depression. It's moderate and severe in symptom nature. It can arise around four weeks post childbirth. It is going to affect daily functions and be present for up to a year postpartum. It will usually require medical intervention. Then we have postpartum psychosis. This is going to be a medical emergency. It's rare. but the person will present with rapid shifts in emotions, maybe have hallucinations, and the lives of the birthing person and infant are at risk. We as PTs play a tremendous role in identifying postpartum depression and other mood disorders. We can refer them to their physician, their mental health providers, and this can be helpful for someone if we think it's a medical emergency and we're suspecting postpartum psychosis. Understanding risk factors for PBD can be impactful when it comes to managing and treating it. Some of those major risk factors we can ID during pregnancy as well. So, hey, we're treating someone who is pregnant and we notice, oh, they have a lack of social or spousal support. They've told you they have a previous history or are having some depressive episodes during pregnancy. They have a lower SES or increased stressful life events besides pregnancy and delivery. Or they may say, hey, I was diagnosed with gestational diabetes. What I want to point out, these risk factors are modifiable. So in my upcoming podcast in this postpartum depression series, we'll discuss screening for PPD in the clinic, ways to communicate with a client who may be suffering from PPD, Then our final episode will cover resources, support, and the effects of exercise in treating PPD. Cheers, y'all.

19:53 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the role of carbohydrates, the relationship between carbohydrates & performance, carbohydrate loading, and carbohydrate consumption timing.

Take a listen to the episode or read the episode transcription below.

If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

02:14 ALAN FREDENDALL

Good morning everybody. Welcome to the PT on ICE Daily Show. Glad to be back again. Hope your day is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and elite faculty in our fitness athlete division. It is fitness athlete Friday. We would say it's the best darn day of the week here on Friday, live on Instagram, live up here on YouTube, and wherever you get your podcasts. Thank you for joining us. Some announcements really quick. If you're looking to join us in the fitness athlete division, we have a couple chances online and about a dozen chances live before the end of the year to catch us out on the road. Our online courses, fitness athlete essential foundations, that's our eight week entry level online course. All things relevant to treating the recreational athlete, the cross fitter, the Olympic weight lifter, the power lifter, the orange theory athlete, the boot camper, so on and so forth. That is the course for you. That starts this coming Monday, September 11th. We still have room in that class. And our advanced concepts course, also eight weeks online. Pre-requisite for that class is essential foundations, our entry level course. Advanced concepts is only taught twice per year. It is taught spring and fall. So this is your last chance to catch it this year. That will kick off the week after September 17th. That class has just two seats remaining. So if you're looking to round out your fitness athlete certification, make sure that you get into fitness athlete advanced concepts this fall. Live courses coming your way between now and the end of the year. Your next chance will be September 30th on October 1st. That will be out on the West Coast in the Bay Area with Zach Long. Also on the West Coast, October 7th and 8th, you can catch Mitch up in Linwood, Washington. That's outside of the Seattle area. Also on the West Coast, October 21st and 22nd, Zach will be on the road again, this time up in Vancouver, British Columbia. You have two chances the weekend of November 4th and 5th. You can either catch Mitch down in San Antonio, Texas, or Zach will be down in Birmingham, Alabama. Mitch will again be on the road in November, November 18th and 19th. He'll be in Holmes Beach, Florida. That's right outside of the Tampa area on Anna Maria Island. You can catch Joe Hanisco in New Orleans. That'll be December 9th and 10th. And then our last course of the year will be December 9th and 10th as well. That'll be out in Colorado Springs with Mitch. So that's your chance to catch us on the road in the fitness athlete division. Today's topic, let's talk about carbohydrates. Let's take a deep dive into what a carbohydrate is, how it's relevant to us here in the fitness athlete division as far as exercise, energy and performance goes. And then let's talk a little bit about when and how to kind of dose out your carbohydrates, who needs to be eating them, who maybe needs to think about eating more. And let's talk about timing of getting those in to best suits whenever we're going to be exercising to maximize and optimize our performance.

04:18 WHAT IS A CARBOHYDRATE?

So starting very basic, if you know nothing, what is a carbohydrate? It is a sugar, a starch or cellulose plant material. So commonly we know carbs traditionally are things made out of maybe table sugar, candy, soda, that sort of thing, potato chips, things that are maybe less than optimal carbohydrate choices but are overwhelmingly what is often consumed when people eat carbohydrates. We also think of fruit being fructose. We think of the sugar that's in milk, lactose. We also think of carbs as vegetables that we eat when we're primarily eating the cellulose in a vegetable, we're eating that plant matter, we're eating things like green leafy vegetables, broccoli, kale, asparagus, that sort of thing. So different ways we can consume carbohydrates. They're not all equal as far as content goes, but those are all kind of classified as carbohydrates. Why do we care about them? Well, we really care about carbohydrates because eventually they become glucose in our body, which is an energy currency, a way that we metabolize energy reactions and chemical reactions in our body, but we also store glucose as glycogen. We store glucose as glycogen both in our liver and in our muscles. At any given time, we only have about four grams of circulating glucose in our system. So we have a relatively small amount. Our body does not really like to have glucose moving around in our blood system. So when we tend to get beyond that four grams circulating throughout our body, that's when insulin is released, insulin is released, and at the end of the day converts that glucose into glycogen, either stored within our muscles or stored in our liver, or if we do have an incredible excess of glucose in our system, it can be also stored as body fat.

09:13 MUSCLE GLYCOGEN 

Aside from the four grams circulating in our body, we have about 400 grams stored inside of our muscles, and we have about another hundred grams stored in our liver. For most people, a total of about 500 grams of muscle glycogen or about 2,000 calories worth of energy. And that's kind of where, if you ever wonder where is the recommendation that I should eat 2,000 calories a day to maintain a healthy weight, where does that recommendation come from? It comes from estimations of how much muscle glycogen we are storing and throughout the day using for regular physical activity, but also for exercise. And that if we deplete that glycogen throughout the day, we will need to eat 2,000 calories of food to replenish that glycogen back into our muscles and back into our liver. We can make glucose and then store muscle glycogen on demand. This is that process you may remember back from middle school or high school biology and chemistry called gluconeogenesis, gluconeogenesis, make new glucose. This is a very, very slow energy intensive process. We can only make about 30 grams of glucose per hour. Now this typically comes from our body fat. It's synthesized, made into glucose, and then is either stored as glycogen or pushed into circulation for energy. So this is kind of where the all day energy you have of being at work, maybe working around the yard, relatively low intensity activity. The energy, the glucose that supports that energy, those metabolic reactions comes from that process of taking body fat, turning into glucose in the liver, about 30 grams per hour.

11:17 GLYCOGEN DEPLETION DURING EXERCISE

Now when intensity increases is really our concern in the relationship between carbohydrates, glucose, glycogen, and exercise. That when we start to exceed about 65% of our VO2 max, we start to use more glucose, use more glycogen than our body can produce per hour. So we start to dig into the reserves that are inside of our skeletal muscle and our liver. Now at very high intensities and very long durations, especially if heat, if temperature, is a factor as well, humans can use up to 150 grams or more per hour of that glycogen, which means at any given time, there are only about a couple hours of energy stored in our body for higher intensity activity. So above 65% of that VO2 max, what we call a low oxygen environment, we can no longer make enough glucose and glycogen to replenish what we are burning with that high intensity exercise. We are in a high oxygen environment, relatively low intensity activities. Our body can again make those carbohydrates, make those sugars from the fatty acids from our body fat, but as intensity increases, we start to dig into our reserves. Now that typically happens around the 90 to 120 minute mark. That is going to be a little bit different for every person. Bigger people, people with more muscle can store more muscle glycogen. Those who are better trained, who exercise at all, but especially those who are used to doing long endurance training, can store a little bit more muscle glycogen. And then certainly you've heard of the concept of carb loading, where if we taper our activity for two to three days and we increase our carbohydrate consumption accordingly, we can supersaturate our muscles with glycogen as well. And overall, we may have about 50% more glycogen reserves than the average person. We might have maybe 600 to 700 grams available. So maybe we can kind of flirt with having two hours of energy total for high intensity activity before we need to start thinking about eating, eating food, eating it to not only continue exercise, but feel better after, which is part of what we're going to talk about today. The relationship between carbohydrates and performance, especially if you want to be training multiple times a day or otherwise just not feel terrible the rest of the day after you finish exercise. Now it's not an all or nothing concept. It's not, I have a hundred percent of my muscle glycogen or I've used it all and I need to stop exercising and eat. We certainly know that we can consume food during long endurance activities, but also that as those reserves deplete, we feel a performance shift as we're doing different activities of we can feel maybe speed slow down on a run, maybe power slow down if we're out and we're on the assault bike or something like that. And we know we can run out. That's a concept that's called bonking of where we have depleted almost all of our muscle glycogen and our body is going to take us from that high intensity, low oxygen environment and say, Hey, you need to cool it. We need time to recover some of this energy and your body's going to stop you for you. And that's the concept of bonking of shifting you to a high oxygen environment by lowering your intensity in an uncomfortable manner, maybe even possibly losing consciousness, but definitely not feeling like exercising anymore. It's really important that we never hit that point. If we can avoid it, we've all we've all done it. I have a story of hiking in the smoky mountains of bonking at the top of a mountain, mainly because my wife ate all of our food on the way up and I had nothing to eat. So I had no choice and bonked at the top. But it's important to know that we don't want to get to that point. We never want to use all of our glycogen and hit that wall because there is a compensatory recovery point afterwards where for one to three days after we're going to feel really low energy as our body slowly recuperates and restores all of that glycogen in our body. We're not going to feel like pushing the pace. We may not feel like exercising at all. It's going to impact our training. And what you don't want to get into is kind of this weekend warrior phenomenon. Where maybe you go you go for a really hard run for two to three hours. You hit the wall and then you don't feel like exercising maybe for another week, right? Where you don't feel like you can work out again for a couple of days. That's not very productive training. So we want to avoid that.

13:58 CARBOHYDRATE CONSUMPTION

And we'll talk about that now as we talk about when should I eat my carbohydrates. So it's really cool that technically a human being does not need to eat any carbohydrates at all. You may have heard of the keto diet of being low carb, maybe no carb, under 50 grams of carbohydrates, being in a state of ketoacidosis of only utilizing your own body fat as an energy source and the fat and protein that you consume. But it's cool that we don't technically need to eat carbohydrates. Yet almost all of the metabolic and chemical reactions in our body are fueled by carbohydrates. It's very, very interesting how our body operates. So you can go without eating carbs. So again, your body can make carbs about 30 grams per hour, but we need to understand that that takes time as we talked about. And especially if we are doing longer, harder events, we're thinking about maybe training twice a day, something like that. Then we need to understand that that process is slow and we need to give the body either a lot of time or we do need to consume carbohydrates. We also need to recognize at some point that eating carbohydrates is like consuming jet fuel for a mechanical engine. Of it's a very caustic chemical reaction to our body, a lot like burning gas inside of a gasoline engine, that it does create some low grade, low grade inflammation that's kind of always present as we're eating carbs and fueling our chemical reactions with the carbs. And so kind of the longevity side of the research would say, if you want to live as long as possible, avoid that. However, that's in direct conflict with the performance research, especially if you want to be a more competitive athlete. You want to do longer, more intense activities. You want to maybe train multiple times a day. You need to understand that those are two kind of diverging thoughts of longevity versus performance. At some point, those tend to dissect and not reconverge of needing to eat carbs to fuel your activity, especially multiple activities in a day or a busy workday after you exercise or avoiding carbs. Maybe even you may have a longevity physician who recommends you take metformin prophylactically to keep as much glucose out of your system as possible because of the inflammation that's present. But nonetheless, we need to talk about that relationship between eating carbs and performance. So it's that that longevity versus performance question that we have a need to eat carbohydrates if we are a long duration endurance athlete, that when you start to run 10 miles, 15 miles marathon, ultra marathon, when you start to do long trail runs, long bike rides, long hikes, that sort of thing. Again, you are using your reserves faster than your body can make more. And you either need to know that at some point you're going to hit that wall that we talked about or you're going to need to start consuming carbohydrates as you exercise. Higher level elite endurance athletes may eat 90 grams of carbohydrates per hour in the forms of liquid carbohydrates, gels, chews, that sort of thing. Folks who maybe are doing half marathon or marathon training may be eating less, maybe about 30 grams per hour. Our fitness athletes don't necessarily need to eat carbohydrates during exercise. We think about a typical one hour CrossFit class. We're not really at the level of intensity and duration long enough to need to eat carbs during that hour. We can get away with doing that hour of fitness and then worrying about carbohydrates after. But there's also a want, a need versus want. The want for carbohydrates is understanding that performance trade off, but also understanding that your body can only make about 30 grams per hour. So what does that mean? That means if you do go to that one hour CrossFit class, you don't technically need to eat carbohydrates before or during, but that you might want to front load your consumption afterwards, especially depending on the time of day in which you do your exercise. If you're like me and you like to get up and exercise first thing in the morning and then you might be looking at, hey, I have 8, 10, 12, 14, 16 hour day ahead of me. Those subjective feelings that you may feel your patients, your athletes may feel of, I feel tired all day after exercise. I feel like I just need to go home and go to bed. I feel weak. I feel like I can't do my work tasks. I can't take care of my kids. Maybe even feeling lightheaded or some sort of impaired cognitive function. Like my mind just feels cloudy. All of those are good subjective reports to tell you that you should probably eat some more carbohydrates after that exercise session or to recommend that to your patient or athlete. And then we get in now to how to do that of our long duration endurance athletes. We've already talked about they're probably going to be or hopefully should be consuming those carbohydrates as they're exercising, especially once they cross maybe that one hour mark of again, it's not an all or nothing equation of go until I can't anymore of as those reserves of muscle glycogen get depleted, I'm going to feel worse and worse and worse than my performance. And how I get ahead of that is eating, eating those carbohydrates while I'm exercising. So the combination of me eating them and my body making some more keeps them relatively high, keeps my performance, my output higher, keeps me away from feeling kind of that onset of losing power, losing speed, losing energy throughout my workout.

22:08 CARBOHYDRATE CONSUMPTION & TIMING

How to eat those? Well, I'm still trying to figure that out. As I get more into long endurance training, I have tried chews and gels and my body doesn't really sit with those. I tend to do better with liquid nutrition like Gatorade. Every person is going to be different, but definitely those people who are going out for longer workouts, especially crossing an hour need to find a way to start to consume that as they're exercising. This is also relevant to our fitness athletes who may be doing a multi event day. Maybe they're doing a local CrossFit competition. Maybe they're a quarterfinals or a semi finals athlete where they have multiple events per day, multiple days in a row. I always laugh now when I go to a CrossFit competition and I see that person after workout eating chicken and salad, right? Just not enough carbohydrates in that meal to replenish what was used in that CrossFit workout in order to have those reserves restored and ready for the next workout, which might be two to three hours after the first one. They might have a third one two to three hours after that, right? Those are athletes who they don't necessarily need to eat carbs during the workout because it's a relatively short event, maybe 10, 20, 30 minutes. But if they have to workout again in three hours, they're definitely somebody who's going to want to eat higher carbohydrate food. That's the case. You see CrossFit Games athletes eating gummy bears and Snickers bars, just getting as much carbohydrates as they can. Again, they're trying to maybe replenish 200, 300, 400, 500 grams of carbohydrates within a two to three hour window to be ready to work out again. So understanding it's important to get those carbs back in if you're wanting to train or you have to exercise again in a relatively short amount of time. I hiked the Grand Canyon last year with Dustin Jones and Jeff Musgrave and we did it. It was about a 12 hour hike up and down about 20 miles and we did it almost exclusively on water, Gatorade and gummy bears, right? Just high carb food that's going to keep our reserves up because we're basically hiking and walking in a hot environment at moderate to high intensity for a very long period of time. I'm thinking I just ran 10, 800s this morning. I have a 12 hour day ahead of me. The first thing I did was eat three bananas, right? The first thing I did was house 100 grams of carbs to give my body that jump start on replenishing that glycogen, which was not entirely gone, but definitely mostly gone at the end of that running workout. And that's really going to determine how you recommend carbohydrate intake to that patient athlete in front of you of what does the rest of your day look like? When do you train and what does the rest of your day look like? If you work out at 5 a.m. and then you have to go to work all day and you're maybe a physical therapist, right? You have a relatively physically active job. You're getting your steps in. You have an eight to maybe 10 hour day in front of you. You'll probably feel a lot better if you eat the majority of your carbs earlier in the day to replenish those reserves. You will find yourself feeling subjectively better. If you work out early in the morning, maybe you run and you want to lift weights at lunch or go to CrossFit after work. How can we fuel our body to be able to do double sessions in a day, two a days, right? The same thing, we need to front load that carbohydrate consumption in the morning, at lunch, in the early afternoon so that by the time we are going to work out again, most of those reserves are back. They're probably not going to be 100% back where I can PR my 5K in the morning and go PR a CrossFit benchmark in the afternoon. It's probably not going to work out that way to be 100% ready to go for a second session in the same day. But you will feel better during the day subjectively and you will definitely perform better objectively in that second session if you eat a lot more carbohydrates in between. Now who is that person that maybe works out in the afternoon or evening and that's their only session of the day and then they go home and they basically watch some TV, get ready for bed and go to bed? That is maybe a person who can get away with maybe a lower carbohydrate or could maybe play with a keto diet, right? Of hey, I work out at 6 p.m. when I'm done with work, I get home around 7.30, take a shower, eat some dinner, go to bed. That is a person that they do not necessarily need to replenish as much of their glycogen as possible because of their schedule, right? They deplete their glycogen in the evening, they are going home consuming some with maybe a dinner meal and then they're going to bed. They're giving their body maybe 8 to 10 hours to replenish hundreds and hundreds and hundreds of grams of muscle glycogen overnight while they're asleep. So that is a person who maybe could get away with lower carbohydrate or no carbohydrate consumption between when they work out and when they wake up again. That's a person who's going to work out, have dinner, sleep, have breakfast and have lunch again before they work out again 24 hours later and they're in a really good position where maybe they don't need to worry about it as much. So carbohydrates, what, when and how? Understanding they're very important for performance, especially for longer duration exercisers, for long endurance athletes. They're definitely linked to performance, especially if you are wanting to train multiple times a day. You are in a competitive environment where maybe you're doing multiple events in a day and then we need to understand timing of when should I eat them. For most people, if they're working out in the morning, they're maybe doing multiple sessions in a day. They're going to work and they want to feel like they have high energy. They should probably eat a good portion of their carbohydrates earlier in the day, but there is that person who maybe trains later in the day who doesn't have a lot going on between when they train and when they're going to train again, who maybe can get away with not eating as much carbohydrates as somebody else. So understanding that food is our friend, food is fuel and understanding how your body creates, consumes and utilizes carbohydrates for energy can be a really big game changer for performance during and after exercise. We all probably have that patient who seems really active, really fit, but complains all the time of being tired, of feeling weak, of not hitting PRs. And that can be a good person, yes, to evaluate their protein consumption, to make sure that their muscles, their musculoskeletal system is recovering appropriately, but also to have a conversation of what their carbohydrate consumption looks like. If we can up our carbohydrate consumption a little bit, we'll often find that that subjective fatigue, weakness that comes after a training session, especially if we're going to train again later or we have a long day of work or whatever ahead of us, we can alleviate a lot of that just by tweaking our diet a little bit. So I hope this was helpful. If you're going to be on an ice course this weekend, I hope you have a fantastic weekend. Have a great Friday. Have a great weekend. Bye, everybody. 

24:46 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the different avenues to find out if a potential hire is right for your clinic: screening the resume, conducting a series of interviews, and getting to know the person outside of work. In addition, he reinforces to listeners the importance of utilizing employment contracts.

Take a listen to the podcast episode or read the full transcription below.

If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I'm happy to be your host today here on Leadership Thursday. We talk all things practice, management, and ownership. Leadership Thursday also means it is Gut Check Thursday. Gut Check Thursday this week is a workout called Gut Check. Kind of going back to our roots of a really kind of low skill, high work workout. We have four time, 180 calories on the fan bike, a one mile run, and then 100 bar facing burpees. So nothing complex here, just some good old fashioned grunt work. Each of those elements you're thinking is going to take you maybe 8 to 12 minutes and that you're going to get done maybe depending on your run speed, on your biking ability, on your ability to ignore the pain during the burpees. You might get done somewhere between 20 to 25 minutes. So that's a great workout to do in the garage, in the basement. Great workout in the clinic to scale and modify for patients. Very easy to modify the volume there, modify the movement, so on and so forth. So try Gut Check Thursday this week called Gut Check. Course is coming your way. I want to highlight our online courses. We have a bunch beginning related specifically to Leadership Thursday and Practice Management Brick by Brick. Our next cohort starts September 12th. That's next Tuesday with yours truly. All things related to getting your practice off the ground, all of the legal things you need to do to establish and incorporate your business, and then finishing talking a little bit of strategy depending on if you want to open a brick and mortar clinic, a mobile clinic, a dock in the box style clinic, whether you want to deal with insurance, be 100% cash, or maybe meet in the middle with a hybrid practice. Whatever your goals are for starting your practice, that is the course for you. Eight weeks online. That starts September 12th. Other online courses starting next week, Clinical Management Fitness Athlete Essential Foundations begins Monday, September 11th. Myself, Mitch Babcock, Guillermo Contreras, and Kelly Benfey. All things related to helping the recreational fitness athlete, the crossfitter, the boot camper, the orange theorist, the powerlifter, Olympic weightlifter, you name it. That class is for you. Clinical Management Fitness Athlete Advanced Concepts, the level two course of Clinical Management Fitness Athlete. That cohort begins September 17th. You need to have taken Essential Foundations first. That course is taught only twice a year, spring and fall, and it has two seats left. So if you've been thinking about rounding out your Clinical Management Fitness Athlete certification, you'll want to jump in that class this fall. Otherwise, you'll need to wait until the spring. Other online courses, Rehab of the Injured Runner online. That also begins September 12th. Modern Management Older Adult Essential Foundations kicks back off October 11th, and then Persistent Pain Management begins again October 31st. So today we're kind of building on last week's topic. If you were here last week, you know that we talked about really being intelligent and diligent and intentional about growing and scaling your practice, about how to add new practitioners to your practice, about how to do it the right way in a way that facilitates long-term growth, but also quality of the product that you're offering. So go back and listen to last week's episode if you have not yet. We used the example of McDonald's, of how they've grown and scaled to be one of the largest, most successful businesses in the world in all of history, and how they've done that. They've done that by having that shared foundation of training and a common belief system in all of their leadership and ownership to help maintain that company culture as they grow. Today we're going to build on that. As I said, we're going to talk about how to find that person. We talked about how McDonald's has Hamburg University, but how can you, maybe is the individual practitioner right now, solo practitioner, how can you find practitioner number two? How can you find maybe practitioner number one for location number two, so on and so forth.

04:15 FILTERING CANDIDATES

So we're going to talk about the different ways that you can really get to know somebody, and then we're going to talk about something that's really undervalued and not really discussed in physical therapy at all. The legalese of bringing somebody on board, of getting everything that you are promising them, everything that maybe if you're on the other side of the table, everything you're looking for in a position that you get that stuff in writing. You get it written down, everything that you are offering, everything that you are wanting to see out of the position, get that stuff in writing. So let's start first about talking, what are the three avenues where we can get to know somebody better? They are the resume, very familiar with resumes, they are the interview, most of us are very familiar with at least participating interviews, maybe not conducting interviews, and some other maybe non-traditional ways to get to know somebody else. So the thing to understand about finding that next practitioner, about maintaining that clinical culture, that standard of quality and excellence that you want to maintain, is that you can teach some of the stuff, but some of the stuff that's really important to be a physical therapist unfortunately cannot be taught. If I can teach anybody a clinical reasoning algorithm to rule in or rule out the lumbar spine if somebody comes in with low back pain, or comes in with maybe what we're suspecting to be, radicular type pain. I can teach the clinical reasoning to help that person find out if it's actually that patient's low back or if it's something else. I can teach somebody manual therapy skills, I can teach somebody spinal manipulation, I can teach somebody dry needling, I can teach somebody exercises, go-to exercises for different conditions, I can teach them about dosing for tendinopathy, I can teach them a lot of different things related to clinical practice, but what I cannot teach anybody is how to be a nice person, an interesting person, or a hard-working person. So we talk about these three different avenues of filtering people in and out of kind of sitting in what we might think of as a potential pool of candidates for a position. How do we find that stuff out? Because that's ultimately some of the most important stuff and it's stuff that you cannot teach somebody to do and you cannot make somebody good at. They have to kind of come on board with it naturally or at least show a passion at getting better in those areas.

08:30 THE RESUME

So the first way we're probably familiar with is the resume. If you have not gotten to this point yet in your clinic ownership or business ownership career, you will eventually, where you receive pretty much an endless stream of usually unsolicited resumes, of they come via fax, they come via email, sometimes they come via email and there's no message, it's just an attached resume. Sometimes people give you a long story about why they think they're the perfect fit and why you should hire them and they are a little bit forceful and they say things like, let me know when I can start. Sometimes they come in person and they drop a resume off. So we talk about a resume, you as the person evaluating a resume, what should you be really looking for? And when I look at a resume, I really just think it is a box check to get to the next step, which would be the interview of when someone gives me a resume, if I have an open position and I want to look at it, what am I looking for? I'm really looking to see is this person a licensed physical therapist because sometimes they're not and that's really important to be a physical therapist that you have successfully finished school and passed the board exam and you have a license. And then the only other thing I really care about on the resume is previous work experience besides school. My question in my brain is has this person done anything remarkable other than go to school for 25 to 30 years? Because when you look at a lot of resumes, when you evaluate new graduates who are coming out of school, what you'll find is that not everyone has experience besides going to school. And yes, I don't want to poo poo getting a doctor of physical therapy degree. Yes, work went into that. Yes, it is an advanced education. It is a remarkable achievement for that individual, but across our profession, it is not. Most of us are DPTs or we're working on our DPT or a transitional DPT. It is now the entry level of education for our profession. So just having that doesn't make somebody stand out. I'm saying, okay, this person has their DPT and their license, but what else? When I think about other things in life, hey, if you can run 10 miles in 90 minutes, that's kind of fast. You're faster than people who can't run that far, run that fast, but it's not that impressive to people who can run faster and or further, right? It's a remarkable achievement for you in the moment, but overall not remarkable. And that's how I look at the long list of education that you might see on someone's resume. Of the question in my mind is, does this person have experience outside of just going to school that would translate into being a good physical therapist? And again, those are the elements we're looking for. Is this person a nice person? Is this person interesting and are they hardworking? So when I see resume experience that maybe somebody worked in the restaurant industry or they worked in a retail position, I know, well, this person probably knows how to wake up to an alarm clock and be to work on time. I know they probably have some experience working with human beings, which is a very important part of being a physical therapist. And they're probably used to working relatively hard. So I learned a lot by looking at somebody's job experience on the resume. So that's my first filter of what else has this person done besides go to school to be a physical therapist. And in some cases, the answer is nothing. They have gone to high school, to undergraduate and to graduate school. And that's it. And that's okay. But that's not the person that I want to bring into my business. Again, the idea of having that shared foundation of training, having that common belief system of having things that I can't teach on board already. That's really going to facilitate that person getting into a good position in the business that I'm operating.

10:14 THE INTERVIEW

So that resume is just a filter for the next step, which is the interview. In the interview, I'm really trying to figure out where does this person lie with their passions and do those passions and interests line up with a position I currently have or that maybe I'm looking to provide, right? Is this person really passionate about vestibular physical therapy? That's fantastic because we don't have a vestibular physical therapist. That is an entirely new demographic of patients that we could attract and treat here at the clinic. If somebody had experience in it, maybe clinical experience in school, but also had a passion for that area. A lot of people in an interview, interviews tend to be very redundant and basically just a, a live action version of a resume of explaining what has been done. We often hear things like, I'm really passionate about physical therapy, just like a resume. Cool. You've gone to physical therapy school. What else you're passionate about physical therapy. Okay. Tell me more, right? I think many, many years ago, when I came to Jeff Moore, the CEO here at ice, when it was just the Jeff Moore road show, ice was just Jeff Moore and had taken a couple of his courses. I had not received my certificates, which I needed for school to prove I had taken the credits. And I said, Hey, I need those certificates. And he told me how long it takes. And I said, Hey, tell me your process. And his process was, as you can imagine, terrible. If you know, Jeff, not very logistically minded. And what I came to him with was a better process about a passion for logistics, about a passion of creating a system that streamlines things like issuing CU certificates. So that's kind of the same passion we're looking for in that interview. Does this person already have an idea in their mind of what they want to do? Do they want to run older adult, small group fitness classes? Do they want to treat vestibular or concussion type style presentations with their patients? That is something that in your mind, you're thinking, Ooh, that's something we don't offer, but I would love to offer. And finding more about that person's passions kind of again, checks another box of resume. Yes. Got them to an interview, interview, interesting person. It's obviously hard to learn everything you can about a person in a 30 minute or 60 minute job interview, even across maybe multiple interviews. But you're looking to uncover where does that person's passions lie? And is that something that can be put to use here at my clinic? And something that's almost never discussed in an interview is what is that person's longterm plans? I don't need to know where you see yourself in 20 years or 50 years, but I do need to know if you're planning to move out of state in a year, right? Because that's probably going to affect my decision to hire you. I'm looking to bring longterm people on board. I'm looking to train them, help them become a better clinician, but also give them a really stable, a well-paying job that really offers a lot of benefits as far as schedule flexibility and treatment, kind of freedom and how they want to almost run their own practice within a practice. So if somebody says, well, I'm thinking about moving to Colorado in six months, then again, that's in my check, check box in my head as I'm going through it thinking, well, that's probably not going to work out just as we kind of train you and bring you on board, you're going to be leaving. So that doesn't really work out. So don't forget to really kind of dig deeper of what are your longterm plans of if you see yourself settling down and having a bunch of kids and maybe leaving the workforce altogether, that's okay. But when is that again? Is that three months from now? If so, that's probably going to affect my hiring decision versus somebody who says, I do want to have a family, but I'm 24 or I'm 25 and that's maybe five to 10 years away. Okay. We can cross that bridge when we get to it. Again, that's a box check in my head.

14:52 EVALUATING SWEAT EQUITY

So the resume builds, get somebody to interview, interview, get some more boxes checked, maybe, or maybe it doesn't. But what else? How do you really start to learn those things about a person? We've talked here before on the podcast of watching that person practice in your clinic. That's great to do. If you're hiring somebody that's maybe currently or previously was a student, you can certainly go watch somebody practice. It's really kind of hard and awkward to have somebody come to your clinic and treat your patients while you watch them to get an idea. But there are other ways we can look at those characteristics of a person and get a good idea of is this person a nice person? Is this person an interesting person? And is this person a hard working person? And that's to get outside of the clinic entirely of, hey, come to my gym. Let's work out a couple of times. I can learn a lot about a person outside of the clinic. I can learn, are they punctual? If I say, hey, come to CrossFit class at 8 a.m. or meet me at 6 a.m. for a run, are they punctual? Are they reliable? Are they showing up late? Are they showing up not at all? Are they snoozing that alarm? How do they handle stress? If CrossFit is brand new to them or running is brand new to them or whatever you're doing is brand new to them, how do they handle that stress? Is that the person that trips on a couple of dumbbells and throws their jump rope out into the parking lot? Or is that a person who goes, hey, they're not in the cards today and just scales to single unders and keeps working out? How does that person handle pressure and stress? And ultimately what we're learning when we kind of use sweat equity as an interview is how is that person with being coachable and open-minded of are they open to feedback on improving their performance in the gym, running, rock climbing, whatever you all decide to go and do together, are they open or do they believe they've already learned everything and they have mastered it and they can't be taught anything? Because that is a red flag for somebody, right? Of somebody who shows up late to the whiteboard because they think they already know how to do CrossFit really well and they think they have nothing to learn from the coach. They don't listen to any sort of coaching. Those are all kind of red flags for you of if this is how this person behaves outside of the clinic, how is this person going to behave at my clinic? Are they going to be late to treat patients? Are they going to be somebody that calls in a lot? Are they somebody who believes they can't get better as far as the clinical practice goes? If their clinical reasoning is already at an expert level and they have nothing to learn? Those are all red flags for you of maybe this is not the right person for my job. This person does not seem to have our shared foundation of training and our common belief system.

18:36 GET IT IN WRITING

So moving through those three avenues, resume, interview, sweat equity call it. What if then you fall upon somebody you think this is the person that I want to hire for this position? What should you do? You should always, always, always get everything in writing of you can be the best friends with somebody. You can have known them since you were kids. It can be your brother-in-law or your sister-in-law. It doesn't matter of when we're talking about dealing with professional employment, we should have employment agreements on board. We have these here at ICE with all of the faculty who teach for us. They don't have to be this complex 50 page document. It just needs to lay out what we're offering and what we are expecting for essentially work in return. And all that stuff, no matter how small, should be listed out. Obviously pay should be described of how a person is going to be paid. Things like time off should be described. Things like payment for continued education benefits or health benefits. Anything you can possibly think of that you are giving in exchange for work should be written down. Anything that person is wanting to receive in place for their work should also be written down in that agreement. And these things do not have to be set in stone. You can set a three month, a six month, a one year, a three year expiration agreement on these agreements. You're not forcing somebody into chains, but you should have that stuff in writing. I will tell you as Jeff and I sit at the head of ICE over the years, what we see not daily, but definitely weekly are really unfortunate emails from you all who follow us at ICE, who take our courses of, Hey, I was promised this, but then this happened. I was promised X, but because Y happened, now I'm stuck with Z. And it all comes down to the question we always ask of is that in writing somewhere? And universally the answer is no, it was promised verbally. It was promised in passing. It was promised maybe at a meeting or maybe at my first job interview five years ago, eight years ago, 10 years ago. And I kind of just expected that that person would keep their word. And certainly things change with the economy or whatever excuse we want to use on the employer side, but at the end of the day, it's not in writing, which means it doesn't really count. Right. And so getting stuff in writing, it doesn't matter how you're going to be paid. If you're going to be a W-2 employee, a 1099 contractor, it doesn't matter. Get all that stuff in writing, get time off in writing, get benefits in writing, get scheduled pay increases. If you agree upon those in writing, this is just another friendly reminder that if you don't get a pay raise that matches or beats inflation every year, you have taken a pay cut. And if you don't have that in writing, you probably didn't get it. Right. So having all that stuff in writing, when you're accepting a new position, putting it in writing, when you're bringing somebody on board is later on going to save a lot of time, money, hardship, bad feelings by having that stuff in writing. And if everything related to what's expected at the job, productivity, you clean your own room, somebody cleans your room for you when you're done, whatever, no thing too small can go in that employment agreement. And once you've both read it, reviewed it and agree, sign it. And that's how you bring that person on board. We have all been in that position where maybe we were told, Hey, it's one-on-one for an hour. And maybe it became, Hey, could you see a double book this hour? And one patient per hour became two, two became four. And all of a sudden you find yourself, how am I seeing 20 or 30 patients a day? And you go back and none of that was in writing, right? It was all verbally promised in your initial interview or your onboarding training. And none of it was in writing. And ultimately at the end of the day, there's not much that can be done. So whether you're hiring, whether you're being hired, get all of that in writing. And that should be a red flag to you on either side of the table. If one party to the other does not want to put anything hard and fast into writing, that should be a big red flag in your mind that you push the chair back and you step away from that table. That should already be enough of a red flag that you shouldn't even consider bringing that person on board or being brought on board if you're the person being hired. So get it in writing, find those people, figure out that we have a shared foundation of training, a common belief system, use a filtering system of resume into interview, into maybe sweat equity interview to filter those people out, really ensure that they are the fit of the person that you see working for you at your clinic. And then get as much of that stuff in writing as you can get done. So I hope this little mini-series was helpful. Again, if you have not listened to last week's episode, listen to that one, get some context, and then maybe revisit this one. If you're going to be on a live course this weekend, I hope you have a fantastic time. We hope to see you in our online courses starting next week. Other than that, have a great Thursday, have a great weekend. Bye everybody.

20:35 OUTRO

Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses setting expectations with patients as a home health provider, learning when to "fire" patients in order to "hire" patients who are better able to utilize your time & services.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:33 JULIE BRAUER

Hello, everyone. Welcome to the Geri on ICE segment of the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Julie Brauer. I am super excited to be talking to you all this morning all about setting expectations with your patients and I'm going to focus this on the home health setting in particular. Okay, setting expectations with your patients. I think we can all agree that really successful relationships are built upon effective communication of setting expectations. Think of arguments you've had with friends or your partner, relationships you've been in. I know I've been here where when you come out on the other side, you think, man, if I just would have communicated what I wanted or if I just would have set that expectation, maybe things could have been different or you say, man, like if I knew that that's what you wanted, if I knew that that's what you expected of me, maybe things could have been a little bit different. Like I definitely can reflect on a lot of relationships I've had or arguments I've been in and that would have saved a lot of heartache if those expectations were laid out in front, if they were communicated up front. And what I think we should be doing when we are starting a plan of care with our patients is to remember that we are entering a relationship with our patients and ideally they are going to have expectations of us and we are going to have expectations of them. We should level set those expectations and we then can hold each other accountable. When we are introducing a plan of care to quote Jeff Moore from his process lecture, you are coming to a mutually agreed upon plan where you pitch optimal and then you agree on acceptable, right? Like these are ways in which that relationship can really thrive. Unfortunately, and I've been here, we get really burnt out from being in long term shitty relationships with patients. Long term shitty relationships. I know you guys have been there, right? I mean, think about it, especially in a home health situation, you get that patient on your caseload and right away you know, you're like, this patient is going to be an absolute pain. You're already thinking like, oh my God, I have to deal with this patient for eight weeks. You dread seeing them. They dread seeing you. They're not motivated. They don't follow your HEP. They don't want to be there. You don't want to be there. You kind of sandbag your treatments because this person is just sucking all of the life and joy out of you. They don't answer when you try and schedule. They cancel on you all the time. You have been so frustrated for weeks on end, but you didn't say anything to begin with. You know this relationship is going nowhere, right? You are dreading running that outcome measure at the end of your plan of care because you know that it definitely hasn't improved at all. You feel this frustration. However, we have as clinicians, we have this feeling that we don't want to upset our patients. We really prioritize just keeping the peace. We don't want our patients to fire us. We want our patients to like us so much. We want to be liked. I think a lot of times we have the pressure from our companies to show progress and we're just afraid to have those hard conversations.

07:18 ENDING RELATIONSHIPS WITH PATIENTS

We're afraid to just tell our patient that this relationship isn't working. And I want you all to reflect about, you know, how much heartache and time and effort could have been saved if we level set expectations and had those hard conversations right out of the gate? How much time could have been saved if we really discovered if this person was appropriate for therapy services to begin with in the very beginning? If we discovered if we were actually a good match for our patient and our patient was a good match for us? Instead of thinking that having those hard conversations and maybe discharging that patient early as a failure, like think about the opportunity that you can create when you discharge a patient. You end that relationship instead of dragging out a plan of care for eight weeks that is going to go nowhere. I think we have to remember that like ending a relationship with the patient, discharging them, whether it's because they're not appropriate for therapy services, they're not meeting the expectation, they're not being compliant, or maybe they're just not a good match for us in particular, right? They could be a good match for a colleague, but maybe for us in particular, it just doesn't work. We have to reflect it and realize that that's okay. That doesn't mean we don't bring value as clinicians. That just means that this relationship in particular was not a good match. And that's a good thing that you can find that out early.

09:52 STARTING RELATIONSHIPS WITH PATIENTS & SETTING EXPECTATIONS

So instead of thinking about discharging a patient early, ending that relationship as a failure, I want you to think about it as an opportunity because there are so many patients out there who need our services, who want our fitness forward services. We want to find those people and we are not going to be able to find those people if we are staying in bad relationships with other patients where this is just not a good match. We need to remember that we have a choice, right? We have a choice to have hard conversations, to level set expectations, and we have a choice to end that relationship. Every single patient now that I approach with my home health patients, I think, is this someone that I want to enter a relationship with? Is this person a good match for therapy services? Is this a good match between just my personality and their personality, right? I know, like, hey, if this person isn't willing to put in the work, I can go be like LeBron James and take my talents elsewhere to someone else who is rearing to put in the work and get on board with therapy. So that is the first thing that I want you all to be thinking of as you walk into your patients going forward today and the rest of the week. So I am going to give you a couple ideas of expectations and how to make sure that you are getting the right person to go with your patient. I am going to give you a couple ideas of expectations that I have set with my patients and things that I have said that have been really helpful in starting that relationship out on a good foot and knowing pretty clearly right away how this plan of care is going to go, if this is going to be someone I keep on my mind, I am going to give you a couple ideas of expectations that I have set for you. So first of all, I want you to know that you don't get into this situation where your week is in and it is not going anywhere and you are frustrated and you are getting burnt out, right? And the patient, too, on their part, they are getting frustrated. This isn't even anything that they wanted to begin with, right? These are some ways that I have kind of nipped that in the bud with my home health clients. Many times home health patients have no idea what home health is. So the very first thing, the very first conversation I am having with them in level setting in terms of expectations, what the heck is home health? What does it look like? What can they expect, right? So I am talking about things like frequency of visits in a week. I am talking about things like duration of a visit and intensity of a visit that there is one person coming in their door, not multiple. These are things that patients who are in acute care should already know. And for any of you acute care therapists who are out here listening, I mentioned this before in a previous podcast, for the love of God, please level out these expectations first and foremost so that when that home health, when that clinician, home health clinician goes to see the patient, they already know what to expect. But like I said, many times patients who are, patients in home health have no freaking clue what they are in for. Many times they are coming from, for example, acute care where they are used to two people coming in, maybe a clinician and a tech and they bring in the ultra move or they bring in big pieces of equipment. And we know in home health that is not realistic. So setting expectations like that, there is one clinician going to be coming in to see you. I don't have fancy equipment and I don't have the extra sets of hands. Setting the expectation that I'm at most going to be seeing you two times a week. However, you are going to be having other clinicians, most likely nursing, OT, maybe speech, who are coming into your home throughout the entire week. Right. We know that a home health client could have, my God, five visits in one week. That can be incredibly overwhelming for a patient. That's something that we want to tell them about right out the gate. So just setting those initial expectations of what they can expect from home health services in general can go a long way. Many times that first week patients are so overwhelmed because they didn't know that people were going to be calling them constantly. Multiple clinicians were going to be coming in the door. They're thinking that they're going to have, you know, extra sets of hands to stand them up if they're like a max assist. We need to level set that immediately. Okay. So you get like the bare minimums out of the way. What is home health? What is it going to look like?

13:23 PUNCTUALITY IN HOME HEALTH

Next, I am telling them what they can expect from me. And the very first thing I start with is that I tell them I am going to be here on time. Punctuality is incredibly important. If you talk to a lot of patients who are in home health, that is, and they've had other home health services before, that is one thing that bothers them a lot. Clinicians don't show up. Clinicians show up late. They want to know that they can rely on me from a punctuality standpoint. They want to know that I'm going to show up. So I put that out there right away. I am going to be here on time. You can count on me for that. If I am going to be late, I am going to call you as soon as possible. I appreciate your flexibility, but I know that you are able to cancel our session without penalty if your schedule cannot accommodate it. So right away, I am holding myself accountable. I am wanting them to feel like they can rely on me. Then I want them to feel that I am here for them. I am going to do everything in my power to show up for them in terms of helping them get to where they want to go. I want them to feel like, whew, this person gives me hope. So I am going to say something to them like, I will do everything in my power, in my capacity to advocate for you. I'm going to meet you where you're at, and we are going to work as a team to move towards a healthier, stronger, more purposeful life. Okay? I am going to tell them, I am going to hear your concerns. I am going to actively listen. If I cannot help, if I cannot solve your problem, I will do everything in my capacity to find someone who can. I right away want them to realize that I am trying to be that resource dealer. If I cannot solve the problem, I will find someone who can. And then lastly, I am holding myself accountable again. Hey, if I am not meeting these expectations I just laid out, please bring it to my attention right away. Right out the gate, right? I am setting expectations of things that they can expect from me and I am giving them the power to hold me accountable. That is so incredibly powerful when it comes to building a strong relationship with your patient. Okay, so next, I used to really lay in about what I expect from the patient in terms of bringing this fitness forward approach. They're going to have to work really hard. They're going to be sweating, da da da da da da. And I realized that that was way too much. That was coming on too hard and heavy. I saved that conversation about really expecting them to work hard and you're going to sweat and you may be sore. I saved it. Saved it for the next visit with them. When we're really getting into loading them up and putting them through an EMOM or an AMRAP or something like that. So I wouldn't, please learn from my mistake and don't throw that out at them right away. It's too much too early. What I do lay the expectation of is my visit time and scheduling compliance. And I'm very strict about this because too many clinicians in home health get the run around. They are exhausted because their patients are late or they're late. They're with patients for too much time. They're asking to be seen at crazy times. That burns clinicians out all the time. You have to set barriers and you should be doing that day one. So what has been successful for me is that I am telling my patients that they will have a 30 minute visit time. I know that's very unorthodox for acute, I'm sorry for home health because usually you're seeing patients for various times. However, I approach it as if it's outpatient. You get 30 minutes, not any more, not any less. They expect that. And how I have made that 30 minute visit work is that I am laying the expectation that I will be following up with you on with a phone call on my drive to your home. We are going to talk about what's happened this week. We're going to get a plan in place. I have a whole podcast that I talked specifically about that that I'll put in the comments here, but I'm giving them 30 minutes so they know when I walk in that door, we got to get to work because I'm only going to be there for a 30 minute time period. The next expectation I lay is that if there are more if there are three non medical cancels, we're done. I'm discharging them. If there are three non medical cancels, right, we got to give a lot of grace to these patients. They're freaking sick. Many times they go back to the hospital. They got a lot going on, but we have to hold them accountable as well. When our patient cancels, it screws up our day. We don't get paid for that patient, right? It affects all of our other patients and our scheduling. We have to hold them accountable. So I give them three strikes and then they're out and I'm discharging them. So those are the main expectations that I am saying to them they can expect from me and the things that I am saying. This is what I expect from you. Next, when we get further into conversations about goal setting, right, I am digging into their meaningful goal. If you listen to the MMOA crew, you know that we talk about make it meaningful, load it, dose it. I want to visualize exactly what they want out of this relationship. What are they trying to reach? What is that goal? What does it look like? I want to visualize it. When we are getting into that goal setting, I am asking them a very important question that helps dictate our plan of care and gives me a lot of info. I am asking them, how long do you think it will take to reach that goal? And what do you think it's going to take to get there? That is going to tell me a whole lot of information. Is this someone who is like come to me three times a week? I will do anything. I will do all my homework. I am. I am just willing to put in as much effort as I possibly can. Or is this someone who's going to be like, you are not coming into my house more than once a week. No way. And there is no way that I'm going to do any sort of therapy after that. Right? You have to approach those two people very, very differently. It's going to dictate your plan of care. What is the frequency that you start out with? What type of HEP do you start out with? Is this somebody that you have to give one very, very simple exercise to? Or can you give them a very simple exercise? You are going to get an idea of how compliant this individual is going to be right off the bat. So you're already thinking this may not be an eight week plan of care. This person is nowhere near ready to put in the work. So I'll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if they're going to be able to do that. So I'll do my due diligence and maybe see them for the first two weeks. And then we can reevaluate the plan to see if we're going to continue. Incredibly important question to answer that it really helps dictate your plan of care. Okay, that's it. That's all I've got for you guys to recap. Really realize that you are entering a relationship with your patient. And just like any other relationship, you get to break up with them if you want. Right? If you're able to fire you, you're able to fire your patient as well. It's a relationship that you can have control over. Next, a couple things to start level setting those expectations. First off, what exactly is home health services going to be like? Next, lay the expectation of what the patient can expect from you. You will be there on time. You are going to advocate for them. If you have not solved the problem, you are going to find someone who can. Then you are going to lay the expectation of scheduling. I will be there for 30 minutes. You can expect that I will be there on time. You are going to give them three chances of three non-medical cancels before you discharge them. Then you talk about your goal setting. You get an idea of where they are at. What are they to put in the work? That's really going to help you develop that plan of care and know what this relationship is going to look like. All right, y'all. I hope that was helpful. Go ahead. I would love to hear you all, what you think about this. Try some of these expectation level setting when you go into your patients today and for the rest of the week. I'd love to hear comments, questions, and thoughts that you have. I will leave you with courses that are coming up in the MMOA division. We are all over the globe. Not the globe. We are all over the US. In September and the fall, we are super, super busy. In September, we are on the road. We have a course here in Charlotte and Colorado this weekend. These are open courses. We have more, but some of them are private. Then we are also in Oklahoma for September and October. Our eight-week online Essential Foundations and Advanced Concepts is starting up. Then we are also in Virginia, California, and New Jersey in October. Plenty of chances to catch us on the road or hit up one of our online classes. All right, guys. Have a wonderful rest of your Wednesday.

23:47 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. Thanks for watching.

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Eric Chaconas discusses the benefits & risks of youth weightlifting, dispelling many common myths regarding the negative effects that lifting weights can have on children.

Take a listen or check out the episode transcription below.

If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 ERIC CHACONAS

Morning everybody, Eric Chaconas here for the PT on Ice Daily Show. I am part of our Extremity Management team along with Lindsay Huey and Mark Gallant. Extremity Management is our really basic general orthopedic course that covers so many different conditions that you see of the shoulder, elbow, wrist and hand, hip, knee, foot, ankle. So it's two days, heavy lab, lots of fun, lots of movement, tons and tons of you performing the actual current best exercises that you would utilize in the clinic for all these different injuries and pain conditions that we see. As well as some of the most modern and evidence based manual therapy techniques that are utilized for all those same conditions. So we've got a number of upcoming open courses. Mark will be in Amarillo, Texas September 9th and 10th and then in Cincinnati, Ohio September 16th. And then we also have one in Rochester, Minnesota October 7th. So if you go to our website, PTOnice.com, click on live courses, you'll see Extremity Management down there in the second row. And that's how you can find out more details about that course.

01:31 WEIGHTLIFTING & KIDS

So today we're going to get into this topic of weightlifting and kids. And so this comes from some of the experiences that I've had in coaching youth sports and in training clinically. What I did early in my career was performance based training for youth golfers. So I've had this conversation and then really just experiences I've had with my own kids and friends in the community here. I've had this conversation about kids and weightlifting with a lot of people, a lot of people over the years. And it is amazing to me how often you hear people say, I don't, I don't, it's not a good idea for a kid to lift weights because it can stunt your growth. That is like saying the earth is flat. That is one of the most outdated, inaccurate statements that can be made. What we know now is that that is absolutely false. There is no difference in risk of, and what you're talking about are growth plate injuries, right? If you say stunt your growth, you're talking about the epiphyseal plate. You're talking about a growth plate injury being more at risk or having higher prevalence in a young athlete or young individual who participates in weightlifting versus one who does not. So we're talking about pre-adolescence. We're talking about middle school age kids. We're talking about even elementary school age kids. And I don't think a lot of people are making that argument in high school age kids.

04:52 BARBELL WEIGHTLIFTING FOR YOUTH

Usually most people are pretty accepting of the idea of weightlifting in high school. But where they push back on you is in middle school and elementary school. And so I think that's totally wrong. I think that's inaccurate. Now, again, it's a case by case basis and it's based on the kid and their maturity level and their ability to, you know, pay attention and be coachable and be well behaved enough to properly, you know, be safe. But for the most part, the argument that it could stunt your growth and that there is a higher risk of growth plate injury is completely unfounded. So that came from like old wives tales. And then in the 60s, there was a few case reports that show growth plate injuries. They talk about growth plate injuries being a little bit of a higher risk in young weightlifters versus those who are not. That's been completely refuted since then. There's well over a dozen studies that show that there is no difference in the general population, pre-adolescent population versus the pre-adolescent population who participates in weightlifting. There's no difference in growth plate injury rates. So there's no more risk of lifting weights than there is playing on the playground or playing soccer or running around with your friends playing tag. There's literally no greater risk with weightlifting. So I'm specifically talking about barbell lifts because I think a lot of people, here's the other issue. People will say, because like resistance training is promoted by the American Academy of Pediatricians, like eight years old kids should start resistance training. But, you know, they're talking about body weight exercises. They're talking about a lot of different stuff. And not most of organizations, most of these people are still pushing back on the idea of barbell weightlifting. I am saying barbell weightlifting is critically important for youth development, for the young athlete. And just for general, you know, it's really tough today with kids with smartphones and year-round sports, and they're getting pushed in all these different directions. I mean, everybody's, you know, playing travel, baseball and travel soccer, and it's year-round and it's the same sport year-round. And we're not doing a good job at developing well-rounded athletes. And we're not doing a good job developing foundational strength and speed and power. And that's where weightlifting really has a strong, important role. And so that's what I'm saying. What I'm saying is we've got it all wrong in that we are pushing these kids to play sports like crazy and specialize and focus on the sport so much, and we're not spending enough time focusing on training. They need to be trained. That's really what is really important. And so what age is appropriate? I mean, that's really a key question. What age is appropriate and what exercises are appropriate? I don't think there should be a limit to the age. I think it's individualized for the kid. When my kids, when my son specifically, when he was in third grade and my daughter not that far behind him, third grade is when they started back squatting and deadlifting. So I bought a 15-pound barbell when they were really young, about a 15-pound barbell, and taught them all the foundation, most of the foundational lifts. And this is one-on-one coaching. This is a very controlled and safe environment. I have not done well in group settings. I'm not promoting this in a group setting. I think it's hard when you have multiple kids and they start messing around and they're all kind of doing different stuff. I think that can be more challenging. But in a one-on-one safe environment where you are very focused and the kid is coachable, the kid is willing to learn, the kid wants to learn, and you have to introduce it slowly. And that's the other thing too. This isn't like we're doing some periodized program where we're hitting it every single week and this and that. At a young age, it's introduced slowly and it's integrated with all the other fun stuff that we're doing as far as play and everything else goes. But yeah, I think deadlifting is important. I think back squatting is important. I think people that are pushing back on that because of injury risk have got it completely wrong. I think that if the environment is safe, I think that they're progressively loaded in a progressive way that makes sense. You're breaking things down in a way that makes sense and we're not hitting with too much at once. And the kid sees the value in it and the kid sees the importance of it. The kid sees their progression. I think that is a really, really important valuable thing. So what's the harm? I think there's so much greater harm in not weightlifting. I think there is significantly greater risk in not weightlifting. The last thing I'm worried about is a growth plate injury. You know what I'm much more worried about? Smartphone use, mental health, emotional development, confidence, the ability to work hard and to grind and to learn grit and determination. When you know you're pushing yourself and you're kind of close to your max effort, I want a kid to feel that. I want a kid to know what that feels like. I could care less about the specific skill they're developing and some specific sport.

08:45 LIFELONG LOVE FOR PHYSICAL DEVELOPMENT

I'm much more interested in the lifelong love and passion for working on your body and developing yourself physically and working hard and loving your body, loving yourself enough to devote time and effort and to invest in yourself because you want to get better. You want to be healthier and you want to approach each day as improving from the day before. I think that's really important. So I think the negative consequences of not doing that are significant. I think the negative consequences of doing that are minimal to none. And so I would encourage, I think as a clinician, I think that's an important thing for us to educate people on. So I think when you're seeing youth athletes, when you're seeing pediatric orthopedic injuries, that's a great opportunity to introduce a little bit of resistance training and to show people that it's safe and to show people that it's effective and to show them all the benefits of it. So hope that helps. Have a great day, everybody.

09:25 OUTRO

If you want to learn more about our program, check out our virtual ICE online mentorship program at PTOnICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnICE.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich  emphasizes the importance of capturing and recording ideas when creating content. She stresses the need to write down ideas because they may be forgotten later during the content creation process. Jess suggests using a notes tab on your phone to jot down thoughts and ideas. Additionally, she encourages taking inspiration from what you see and not worrying about the possibility of stealing ideas or duplicating existing content. Jess emphasizes the importance of sharing your unique perspective and ideas, as someone who follows them may not be following you. Overall, the episode highlights the significance of documenting ideas to utilize them effectively when creating content.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show. 

01:22 JESS GINGERICH

Good morning PT on ICE Daily Show. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. As always, we have some wonderful opportunities for learning coming your way. If you go check out ptonice.com to see when we are going to be close to you. We have a two-day live course that's going to bridge the internal pelvic floor assessment with return to strength training, endurance training, gymnastics, and so much more. We also have an eight-week online course that is a wonderful starting place in treating the female athlete. If this is something that's been on your list, head over there and snag your spot. I'm going to actually take a turn and instead of talking about pelvic things, I'm going to talk about social media. Social media kind of from the lens of someone who has been doing it for two and a half years, so not all that long. I don't have a degree in it, so I would consider myself somewhat of an amateur with this, but also kind of talking about it in the space of pelvic health and how scary that can be because there are already a lot of really negative things around pelvic health and putting that on social media can be really difficult.

02:17 SOCIAL MEDIA & PELVIC HEALTH

So again, I've been active on social media posting things about pelvic health, pregnancy, postpartum, and other various PT related things for about two and a half years. I was encouraged by the ICE faculty to just kind of do it, just do it, show up, post, don't think too much about it. And I remember feeling all of the things around this. I was nervous, I was scared, I was excited. I've felt things like, I just want to quit. I've also felt the things where I just want to push the gas pedal down and keep going. I've felt all of the feelings. So my nerves tend to get exacerbated when I think about, you know, what are people going to think about what I'm posting? What do I do when someone comments something mean or negative? What if I, when I share something, it's not enough? It is a topic, but there's a lot of different kind of things that you could post about it. Really the list kind of goes on. So what I want to do is I want to share some of the things that I've learned along the ways along the way, as well as breaking down some of those fears.

04:08 BREAKING DOWN CONTENT CREATION

So first, if you have an idea, write it down, because you will not remember when you come back to it and you are thinking about the time that you're, you're creating content, filming stuff, you're not going to remember. So write it down, have something in your notes tab on your phone where you can write down and jot down kind of what you were thinking. If you see something that inspires you, just do it. You can take an idea and turn it around and make it where it's going to resonate with the people following you. Does not mean you're stealing an idea or that that's already out there. Post it because someone who's following me may not be following you. If you are feeling overwhelmed, take time off, turn your app off and go on a walk, do something different. That idea that post will still be there when your mental health is better. So let's break down some of the feelings. So what will people think of the post that you're posting? First of all, everyone's going to have an opinion. Everyone has an opinion. And what if they think instead of it being negative, what if they think it's helpful? What if it drives this person who needs you to view? Obviously you will have other opinions that trickle in and when they do, just think it will increase your engagement, meaning it will reach more people. The wonderful thing about having this kind of thought is that if you are an ICE trained physical therapist, you know the importance of positive messaging around anything. So if you are posting something and it's not negative, it's not going to encourage someone to not work out to stop what they're doing. Post it. What about all the negative comments that you see on so many other reels and posts? You will inevitably get those. They will come in, but sometimes it's really hard to read the context behind text. So when you first read a comment and you aren't filled with those butterflies and unicorns, like, oh, they really love this. This is awesome. Close the app, take a breath and think about the response you want to give. This is a great time to educate someone who doesn't know. Remember you are the expert and even like validating them can be very helpful. So this kind of leads me to my next point. What about not sharing enough? So for example, what if you get a comment from what like SoccerMom87 and she says something along the lines of you didn't address this? Well, that's a perfect time to come and say that's actually something that I was going to address on my next reel. Thank you for bringing that up. So now you have something that you can create another reel on and you didn't even have to think about it. I think sometimes people forget that you have a 12 second reel that you're trying to get some kind of educational piece around. And so you can break up your reels and that way you have content over the course of however many weeks. There are so many feelings around social media and the trolls will be there, but so will the people that are in desperate need to find the right person. So if you are sitting on your post, you've got several drafts in your Instagram drafts reels, post it, just post it, reread it, make sure there's no typos. And even if there are, that's okay. Just post it. I want to encourage all of you to go to my last reel. It is about running and peeing in your pants or maybe it's my second to last reel. I was totally off beat with the music that I found or that I use for it. I even made a funny face on the reel because I realized I was off beat, but I had a patient coming in. I wanted to get that content filmed and I wanted to get it posted.

08:00 JUST POST IT

So I kind of said screw it and posted it anyways. And I've gotten a lot of love, a lot of like, hey, I love that you just kind of posted that and you recognized it. But I also have gotten some comments about the what ifs, like what you didn't post about this or what about that. And that's all I care about is that that's driving more traffic to this. I want people to know that they can run without peeing in their pants. And so the comment that was left, I just said, hey, that's a great point. I love it when this when that person can come into that visit. So if you are nervous, I want to encourage you all today's Labor Day. So I know most of you are off, but just post the reel or the carousel, whatever you have waiting in your drafts. And if you do have something that you post today and specifically one that you didn't want to post, I want you to tag me and I will love to share it and hope that it brings more people to you. So I hope you guys have a happy Monday and a wonderful Labor Day and we will see you next time.

09:33 OUTRO

Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the evolution of cycling pedals, including clipped in riding, and changes in the safety & efficiency of clipless pedals. 

Take a listen to the episode or read the episode transcription below.

If you're looking to learn professional bike fitting from our Endurance Athlete division, check out our live physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the P10i's Daily Show.

01:26 MATT KOESTER

Alright guys, welcome to another episode of the PT on ICE Daily Show. I'm Matt Koester, lead faculty in the endurance athlete division with a specific specialty in bike fit. The title of today's episode, clipped in, clipless and clueless. I want to spend a little time today diving into a topic that I think is really fun. It's also really, really confusing, especially for people who don't understand the cycling industry, the cycling world. It's a very, very basic part of terminology that I think will help you to get a little bit more credibility having conversations with cyclists when you're discussing the pain that they're experiencing. Before we dive fully in on the topics for today though, I do want to take a moment and just give a quick shout out to our last bike fit host, bike fit course of the year. That's going to be down in Knoxville, Tennessee, September 23rd and 24th. Sadly a sad thing to say, our last one of the year, but we are super pumped for it. And if you're unable to make it and join us this year, have a good look into next year. We are currently ramping up probably what's going to be the biggest year for this course we've ever had. We'll be coast to coast and all over the place in between. So we're really, really excited for that. But if you like what you hear what we're talking about today, you want to learn more, you want to dive in, you're definitely going to have an opportunity to jump in in about a month. You can also learn from us on virtual ice where I'm going to be doing some podcast, some lectures on this content in a little while as well. So those are the things that are coming up down the road.

04:07 EVOLUTION OF PEDAL TECHNOLOGY

As we shift into today's topic, as I mentioned clipped in or clipless those are some of the things that you're going to hear people talk about all the time and they can be relatively confusing and what we really mean is how is the foot interacting with the pedal? So the big part to talk about here right away is just terminology. I just want you to be able to hear somebody talk about this or bring it up yourself and actually know what the heck it is because otherwise it's really confusing. So in general, I brought some props today that I think will be helpful. If you're watching this on Instagram, it'll be really easy to keep up watching on YouTube. Same deal. If you're on the podcast, I certainly recommend you jump back onto one of these platforms so you can see if you're a visual learner because it'll help out in that sense. We're all pretty used to this style of pedal. It is just a flat pedal. Both sides look the same. Basically this is just going to go right into the crank. If you put your foot on it, they're going to go forward. That's as simple as it gets. At some point during the evolution of the sport of cycling, the idea was our feet are jumping around and we want to be more efficient on the bike. So how can we try to improve that sensation, be more connected to the bike? Well, the idea for the clipped in version of this, the original idea behind that was actually a cage or a strap that went over the foot and it had a little clip on the side that allows you to snap that thing down and it would lock your foot to the pedal. Some of them had plastic, some of them were really truly just more of a fabric cage, some of them were like a strap. Now, I don't have one of those with me today, but it is funny. My Nordstick rig mount actually is a perfect example of this. I'm going to use this for the purposes of this. Foot would slide into this space. It would be set down and then you would basically cinch and pull down on the strap on the side. What that would do for it was essentially lock the foot to the pedal. We were seeing cyclists get more efficient. The feet were mousing up the pedals. They were quicker, all kinds of good things there.

07:31 THE CLIPLESS PEDAL

The next evolution of that was the clipless pedal. Now the clipless pedal or clipless pedal shoe interface, the idea was to get rid of this strap. I'll talk more about why you really want to get rid of that in a second. Just to explain that piece, if we talk about we went from flat pedal to one that had a cage over it or a strap to now this thing that we're used to seeing all the time, which has just these little pincers on it, these little things that grab onto what's at the bottom of the shoe. What that does is it operates kind of like den settings on ski boots and the way that they interact with your skis. When you step in, they click in, you're in a spot where now you can move around and do what you need to do, but if enough force is applied to it in a sketchy situation, whether beyond the mountain or on the road, they will come out. And in fact, on the bike, they come out pretty darn easy and it's usually modifiable to do so. The reason they're called clipless pedals, even though you are clipping in, is because they don't have that toe cage on them. And the main reason to get rid of that toe cage in many ways was actually a safety thing, as well as just an improvement upon the actual interaction between the foot and the pedal. The safety side of this is if I'm falling down and I'm going to the ground and I have an option to save myself by getting my foot off the pedal, if I'm running a clipless shoe or a clipless pedal interface right now, if I twist my foot a little bit or pull, it's going to come right off and I can put that thing on the ground and I'm going to be in a really good spot to save myself or at least not be attached to the bike when it goes down. Now the other side of that is if my foot is in this cage and I have strapped my foot down and it is nice and snug, when I go to tip over, my foot's not coming out of that. That's going to be really hard to get out. You're going to see those cyclists go with the bike, get slammed down to the ground. It's safer. That's the first part of it. That's kind of nice. It does seem a little bit scary to some folks to attach their feet to the pedals, especially when they're used to going from this to what now is this shoe that feels clunky and hard to walk in but snaps in just the same. Now that right there is just the general gist of it. So flat pedals, the original clip pedals just had a cage, went over the top. We go to clipless pedals. Those things are basically the shoe attaching to the pedal itself, easy to twist and pull in case of an emergency or kind of a sketchy situation. Now why does this matter to our patients? Why would they make that shift? I'm going to be honest with you that the first one that most people are going to actually say, it just looks more professional. It looks more legit. They've been riding with a couple of friends. Everybody's been riding clipped in and they're like, dude, why are you still riding flats? Well at that point, they're ready to make that jump. They've been doing this for a while. They're thinking to themselves, everybody else is doing it. They're thinking it's going to be more stable. They're thinking it's going to make me look better. You know, that's an important piece in this whole thing. You want to fill in with your peers when you're out for your rides. On our end though, and more importantly, it's going to give that person a reference point, a starting point, especially in the bike fit world. What we are trying to do is essentially get rid of as many variables as we can or at least control the variables that we can control. That way, when we talk about making modifications to some of these bike, we're actually going to know where we started from. In the bike fit process, it starts from the floor and it works its way up. We start at the feet, we go to the seat, and then we go to the hands or back to the feet if needed. In that scenario, there's a good chance we could spend two thirds of a 90 minute appointment doing just things with the feet, getting this all set up. In the case of somebody who has, let's say knee pain, I want to kind of pose this for why this nomenclature, why this stuff matters. Someone who's in a case where they have active knee pain while riding their bike. Let's liken this to somebody who comes in and says, I have knee pain with squatting. If I say, what type of bike are you riding? And they say something about their pedals and they're like, yeah, I've been riding flat pedals. What that tells me is that they have no idea where their feet are the majority of the time. Imagine somebody coming in who has knee pain with squats and you're like, hey, show me your squat. And they step back and they spread their feet out and they do one and then they kind of bring them in and they do another one and they're like, I don't really know where I want to be at and this is actually kind of what I do every time I'm at the gym. I don't know where I want my feet to be at. It'd be pretty hard to get good information from that, to not know where you're starting from. So in the case of somebody who's dealing with a specific pain complaint, it's nice to be able to at least educate them on, hey, I'm going to make sure that you have a reference on your flat pedal for where your foot should go.

09:45 SOLID FOOT POSITION WITH FLAT PEDALS

But more importantly, if you're serious about this and you're doing it long term, we should get you a set of clipless pedals and a shoe that interacts with it appropriately. That way we can find the position that you're comfortable riding in. Because as soon as we know that we have a fixed position at the foot, we can then go adjust the seat and just other factors that are going to improve that person's knee pain. But if you don't know where their foot is relative to the pedal or relative to the crank arm and you go to adjust things on the seat, it's very unlikely you're going to get to where you want to be. If they move their foot even a half centimeter forward or back, all the angles that you used as a reference are going to be totally off. That can be a really frustrating place to start from. Now this isn't to say you can't do bike fits with somebody who is using flat pedals. We are going to talk about references. In the course a lot of times we talk about just saying that first MTP, that first knuckle, trying to get that in line with the pedal spindle, so this center piece as it attaches into the crank arm, is going to be a good reference for that person. But at the end of the day, if that person is A, riding on rough terrain like a mountain bike, every bump is going to shift their feet a little bit. Even with some of the best pedals out there where things stick well to the pins or the more pointy parts of the pedal. Shifting that person over to clipless pedals is going to allow them to stay in one spot the whole time. They may know the reference, but at least they're not going to get out of that reference position, so that's going to be really, really important for this person. Or that person, maybe they ride really consistent terrain, but they're getting better at the idea of improving their cadence. They're talking about trying to run 90 RPM for an extended period of time, which is the recommended RPM in most cases, especially on a road bike, for being the most efficient in any given gear for any given scenario, whether it's going up or down or in a good position. When you try to carry that much RPM on a road bike out in the street, it is actually pretty darn hard to keep your feet fixed in one position and staying still. That is actually a pretty big challenge. So for that individual, when they attach their foot to the pedal, all of a sudden now they can push the pace go faster because their feet aren't trying to slide off. There's less clunkiness in that pedal stroke. They're going to move a lot better at higher RPMs and be less frustrated trying to do so. More power down in those scenarios. Now the last thing for that person who is jumping into this or is curious about jumping into it, is what it does is it's going to, as I mentioned, smooth out the pedal stroke. So as somebody starts pedaling, in general we are putting the most of our power down. That is where we are most efficient. Our quads, our glutes, everything that drives down on the pedal, working with gravity, is what's going to propel us forward. However, that's not to say that it's not valuable to be able to pull through and pull up and over with the other foot. Now it's not your main power, it's not a big driver of the motion, but it does allow you to create a much more smooth and cyclical cycle stroke.

14:43 SAFETY & EFFICIENCY OF CLIPLESS PEDALS

So the idea here is if you could have your feet attached to the pedals, you could have more influence over that pedal stroke. You can pull through, you can pull that foot up and over, you can counter what's happening on the other side so that things get much smoother and much more efficient. Athletes that go to a clipless pedal, that go to being clicked into the pedal, are going to have way better engagement when they're trying to run higher RPMs, pedal smoother, and be more efficient in the long run. Now the last thing I want to talk about is that safety piece, again, just because this is one of the things that always ends up being the determining factor for somebody jumping in or not. In general, people know that it's probably a more professional thing to do, but they're kind of like, ah, I don't know if it's for me. The truth is, there is a bit of a hurdle. There's a bit of a hurdle in terms of safety. Somebody gets on, they're nervous about getting on and off the bike, they think they're going to get to a stop sign and fall over, and in all reality, it does happen. I mean, it happens like the very first time everybody rides, you get one situation where you clip your right foot out because you're going to put your right foot down, but you end up leaning left and now your left foot's stuck in and you go over. It happens. You want to try to avoid it, but this is how you actually would do that, try to avoid it. The idea would be if you're on your bike trainer or with a friend holding it still, the idea is you click in, get your foot set, maybe you stand up, sit back down, take your foot out, put it back in. The idea is just get exposure to that mechanism and how that interacts so that you can get your foot in and out easily. As I mentioned really early on, we also have this little setting on the pedal that allows us to change, I kind of like the DIN settings on your skis, but you can change how easy it is for someone to get in or out of those pedals. For the beginner, getting out really easily might feel great. They might really, really like the idea that, okay, this is super easy to get in and out, but as soon as they go to put power down, they might be a little bit irritated by the fact that their foot keeps clicking out. They may want to crank that thing up because now they understand how to get in and out, they're more confident, they want to put the power down and pedal hard. Same way, an aggressive skier, he doesn't want those DIN settings super light. In fact, some people get to that point where they'd rather die than have them come off. People want those things firm so they can do what they need to do. So a couple of things just to wrap this whole piece up. The clipless pedal is a really interesting misnomer. The idea is it gets rid of the clip that used to be on the toe cage. It gets rid of that idea that now when I go to dismount the bike, my foot is locked in so I can't get off. So clipless pedals get rid of that locked in position and give you more of a temporary lockable position so that you can be more efficient while you're pedaling on the bike. To our patients, a lot of times it's just like the next evolution in their cycling journey. They end up wanting to go that route because everybody else is doing it. They know that it's a more professional look, it's a more professional feel, they know that it's a more efficient ride. For us, we love that because if we can get that person into that type of a shoe, into that type of pedal interface, we know that when we go to fit their bike, talk about the pain they're experiencing, we have a reference point that's going to be consistent and fixed the whole time. If we don't know where we're starting, it's hard to fix the issues that pop up. If you're going to come to a bike fit course, you're going to learn that we spent a lot of our time on the pedal and this is a big reason why. Understanding where somebody starts, understanding what you can modify and understanding how that can affect somebody's symptoms are paramount in this space. Alright, that's all I got for you. Have a great Friday, y'all. Appreciate your time. Thanks for jumping on.

16:23 OUTRO

Hey, thanks for tuning in to the PT On Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning Check out our virtual ICE online mentorship program at PTOnIce.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall highlights the key principles behind growing & scaling your practice, using McDonald's as an unlikely but successful example.

Take a listen to the podcast episode or read the full transcription below.

If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Good morning, PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start so far. My name is Alan. Happy to be your host today. Currently, I have the pleasure of serving as Chief Operating Officer. I'm a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice, management, ownership, small business, leadership, that sort of thing. Leadership Thursday means it is also Gut Check Thursday. Gut Check Thursday this week is a workout I actually did this past Monday. It is 9, 15, 21 calories on a rowing machine, power snatches with a barbell, 75 pounds for gentlemen, 55 pounds for ladies, and pull ups. Ascending reps game automatically. You should proceed with caution as you get more tired. The reps go up, something we don't like to see too often. Also very redundant in this workout on pulling and grip, right? Pulling on the rower, you have grip on the barbell, and then you have grip and pulling up on the pull-up bar. So it gets redundant, gets really grippy, even with that light barbell. That barbell should be so light you could do all of those rounds unbroken if you really needed to. Maybe one break in the round of 15, maybe one or two breaks in the round of 21. Definitely should be aiming to get that workout done under or around the 10-minute mark. I did that, rested three minutes, and then did 9, 12, 15, rested three minutes, and did 6, 9, 12. I don't recommend doing the extra two rounds. Just stick with the 9, 15, 21. That's plenty of fitness for the day. Courses coming your way from us here at IEFCE. I want to highlight our Extremity Management division led by Lindsay Huey, Mark Gallant, and Cody Gingrich, the newest lead faculty to join the Extremity Management team. You can catch those three out on the road this fall. A couple of different courses coming your way. September 9th and 10th, Mark will be down in Amarillo, Texas. Lindsay will be out in Torrington, Wyoming. The next weekend, September 16th and 17th, Mark will be on the road in Cincinnati, Ohio. The weekend after that, Lindsay will be on the road September 23rd and 24th in Twin Falls, Idaho. The first weekend in October, the 7th and 8th, Lindsay will be up in Ridgefield, Connecticut, and Mark will be in Rochester, Minnesota. November 11th and 12th, Mark will be down in Woodstock, Georgia, which is north of Atlanta, kind of out in the suburbs. The weekend of November 18th and 19th, Mark will again be on the road, this time in Murfreesboro, Tennessee. That's a little bit southeast of Nashville. Cody's first weekend as a lead faculty in the division will be the weekend of December 2nd and 3rd. That'll be out in Newark, California. That's the Bay Area, the Fremont area. And then December 9th and 10th, the last chance to catch extremity management for the year will be in Fort Collins, Colorado with Lindsay. So that's what's coming your way from the extremity division.

03:21 GROWING & SCALING YOUR PRACTICE

Today we're going to be talking about hiring from the viewpoint of growing and scaling your practice. And I want to highlight the McDonald's story. So I want to talk about kind of what's always in our mind when we're thinking about growing our team, which is that little voice in the back of our head that says, geez, I hope the person that I hire is mostly like me, right? When we think about growing our team, we're often thinking about how to basically mirror or replicate ourselves. And while that's not 100% possible, that is the goal as we grow and scale. That what we're really talking about when we're bringing new people on the team, we're growing our current practice. We're thinking about maybe even a second location. We're thinking about maintaining our standards of how we run our business, of how we practice physical therapy and preserving our company's culture. So we're going to talk about the who, the what and the how. The who today is going to be McDonald's. Yes, McDonald's, the Golden Arches, the fast food company. The what is going to be talking about how they grow and scale their businesses. And the how is going to be the foundational training that every member of the team has, how that relates to your team as a physical therapist growing your practice and how shared belief systems are really important. So as a company grows, those things tend to get diluted over time. Over multiple generations of leaders and employees, teammates, whatever you want to call the folks who work with you. As we tend to get many generations deep, we noticed a subtle decline in quality and culture of when you first went to the business, when it was a single owner operator, you knew the owner. You knew how things went. You had a relationship with that person. And maybe when you come back to that business, our business in this case being physical therapy, maybe you can't see that provider before. Maybe their schedule is full and they offer to have you see another provider. As the customer is the end user, how do we know that that person is good as the first person? And how do we know that the 10th person is as good as the third person? And so on and so forth. And unfortunately, what we see happen is companies tend to grow, especially as they tend to grow to new locations and maybe even start to franchise. We see that that stuff just gets diluted over and over again until the current business that we are going to no longer resembles the initial encounter with that business. Maybe even to the point that as the customer is the end user, we decide not to give that business our money anymore. So how do we avoid that? How do we avoid the customer coming to that conclusion?

07:26 THE WHO: MCDONALD'S

Well, we need to start with the who. We need to start with McDonald's. If you're not familiar with McDonald's, we'll talk about that and we'll talk about how they grew and really the foundations that allow them to grow there. So love or hate them. Everybody has their thought immediately in their mind, their knee-jerk reaction about McDonald's, but they certainly know how to run a business. They know how to deliver a consistent product. That product, at least in my personal opinion, may be quite mediocre. But dang, when you go to McDonald's in Texas or McDonald's in Michigan or McDonald's in Seattle, it doesn't matter. McDonald's in Hong Kong, it is maybe mediocre, but it's consistently mediocre, right? A McDonald's hamburger in Texas tastes the same way as a McDonald's hamburger in New York and the fries are the same and the experience of purchasing from McDonald's is largely the same as well. So they know how to deliver a consistent product and we want to figure out how they do that. They also certainly know how to grow. McDonald's has been in business for 83 years, almost 100 years of continuous business. We've talked here on Leadership Thursday before about how many businesses don't make it to the one-year mark, to the five-year mark, that about the 10-year mark, 75% of all businesses are gone. They have gone out of business before they reach the 10-year mark. So to have been in business almost 100 years continuously is quite impressive. They are the largest restaurant business in human history. They have $24 billion a year in gross revenue. Now that is an amount of money that can be hard to conceptualize. Let me break it down for you. If you haven't heard of ATI Physical Therapy, they are the largest chain of physical therapy clinics in the world. They only grow $600 million a year in annual gross revenue. So any town that is big enough to have a McDonald's, a Walmart, probably also has an ATI Physical Therapy for reference. Nonetheless, McDonald's is almost 40 times larger. They are present in 120 of the 195 countries on the planet, and they are the fourth largest employer in human history. Of the largest employer on the planet currently is Walmart. The second is the Chinese Government Railroad. The third is the Chinese Government Police Service, and the fourth is McDonald's. So of the jobs that you could currently get, you can't go work for the Chinese Government Railroad or police service. You can't just go drop an application and start. We're talking about the second largest American-based employer on the planet. Now if you haven't seen the movie The Founder, I highly recommend you watch that movie. It's one of my most favorite movies. Every time I watch it, I take something away from it. Came out in 2016, and it's really kind of the tale of the start of McDonald's and the growth of McDonald's across the country and eventually the world.

11:27 THE WHAT: SUCCESSFUL GROWTH

So that's the what we're going to talk about today. We're going to talk about the franchising of the McDonald's Corporation. Amazing movie. Nick Offerman and John Carroll Lynch play the McDonald's brothers who formed the first McDonald's out in California many, many, many, many years ago. And Michael Keaton does a great job playing Ray Kroc, the guy who finds the McDonald's brothers and becomes the person that franchises McDonald's into the business that it is today. So the original McDonald's started out in San Bernardino, California. It was a one-location restaurant run by the McDonald's brothers. They had a very systematic way of approaching a business. They practiced and trained and redesigned the restaurant again and again and again to optimize efficiency, to basically make burgers and fries and shakes as fast as possible in the almost pre-drive-through era of you had to drive to McDonald's and walk up to the window and order your food. And they created a wonderful, flourishing business that Ray Kroc stumbled upon. He actually was selling a machine that could make six milkshakes at once. And he was hand delivering it to the McDonald's brothers out in California when he watched just how busy their restaurant was all day long and decided this, these guys are onto something. If we could take this business and multiply it, we could really make a lot of money. So those brothers practiced. They had their employees practice work, right? They trained almost military style of running and operating their business. And they did so with a systematic approach, a fundamental approach to how to cook and serve food in a high quality, yes, but also a consistent and efficient manner. And it was built upon a common foundation of training and also of shared values of we want to deliver a high quality product, but we want to do it efficiently. People don't want to sit and wait 30 minutes for a hamburger. They want to be able to walk up to this window and a couple of minutes, get their food, pay and be on their way. Right. The person that's on lunch break or grabbing a bite to eat after work or before work or whatever, walk up, grab your food, go again in the pre drive through area, definitely the pre door dash era of delivering a high quality product. Very, very fast. So Ray Kroc stumbled upon these guys and started to franchise it. Initially did not go the right way. And I think it's important to know that it did not start off in an amazing way that immediately started cheapening ingredients, started using premixed milkshakes instead of actual milk in the milkshakes and initially started with a model that had really minimal control over new locations and leaders. And early on, and you'll see this if you watch the movie, McDonald's all over the country was completely random and different as far as what you might expect. You might find a McDonald's in Illinois that sold hamburgers and french fries and milkshakes, but you might go to a McDonald's in Wisconsin and find barbecue food. You might go to a McDonald's in St. Louis and find them selling tacos. So they kind of had a rocky start that they got away from their foundations. They no longer kept that regimented training, that regimented shared value systems. But I'll tell you the tale of how they turned it around. One of the cooks that worked at one of the original McDonald's, his name was Fred Turner In 1961, he created a training system called what is now known as Hamburg University of saying, hey, this is getting crazy. Every location that the customer goes to, they might be serving completely different food. There may be a completely different experience. They might be dirty at one location, unbelievably clean at the next, a different food just all over the place with consistency and quality. We have to fix this. And that kind of evolved with Fred Turner working alongside Ray Kroc into forming now what is known as the present day McDonald's, which again, the food may not be the highest quality, it might not taste the best, but darn it, it is consistent. And that is really the values that McDonald's presents today. Consistency and simplicity and uniformity with a goal and a shared belief system of quality, service and cleanliness. So they formed this university back in the 60s, Hamburg University. They now have locations in eight countries. They started in 1961. That guy, Fred Turner, who was just a cook, worked his way up and eventually became the CEO of McDonald's for 20 years and really kind of led the global expansion of McDonald's across the planet onto every street corner in America, into 120 countries across the planet. Down to really specific stuff. He was really insistent that fries had to be cut 0.28 inches thick, that one pound of beef should make exactly 10 1.6 ounce patties, so on and so forth. Consistency, the ability to replicate that business across not only shifts at the same location, but at every location across the town, across the state, across the country and eventually across the planet. So that is the who, that is the what.

13:59 THE HOW: SHARED TRAINING & BELIEFS

Now we need to talk about how, how did they get there? Again, they had a rocky start, but how they arrived at where they're at now, again, one of the largest, most successful businesses in the history of our species. How did they get there? They get there these days by being very, very selective that each addition to their team is of similar quality to the rest of the team, that they have a shared belief system and that they all go through the same foundational training of when you are maybe a line cook or fry cook or you work the drive through McDonald's. Yes, you are just an hourly wage employee, but once you are maybe going to get promoted when the regional manager, when the owner decides your management material, you go to Hamburger University. If you are thinking about starting a McDonald's franchise, you also go to Hamburger University. They are very selective in who goes to Hamburger University. Only 1% of the people who apply get accepted. And the goal of Hamburger University is to teach managers and owners how to run a McDonald's to the McDonald's standard. Again, we have that common shared training foundation. We are hiring people with a shared common belief system. We are allowing the business to grow and scale without the end user, the customer being really able to notice any change in quality. McDonald's is doing it right. If you leave your house at 6 a.m. and you have a 12 hour road trip and you grab a coffee from McDonald's and a McMuffin at the start of your journey, if you stop at McDonald's four states away for lunch or dinner, it should feel almost exactly like the McDonald's that you stopped at at the start of your journey right by your house. It should really be no different. And even you have probably done this and if you haven't done this, you are a liar. You have gotten a drink at McDonald's in the morning on a long road trip and you have stopped maybe at multiple McDonald's along your route to get a refill of your drink. And again, if you haven't done that, you are probably lying. A lot of us have done that. So that replicated experience location over location over location. And I think we have a lot to learn from that model. And that model does not start with putting money first. It does not start with putting numbers first. It starts with making sure that we are incredibly selective of who we let join our team. And so that brings me to the how. How do we do that? We do that by being extraordinarily picky with who we let join our team. A lot of people will see your clinic, your business, whatever you are doing, being very successful and they want to invite themselves to come on board the ship. They are happy to stop by and drop off their resume and let you know that they are ready to start a position whenever you are ready to start paying them. And oftentimes we find ourselves as our business, our clinic, our practice is growing. We need people more than we care about exactly who that person is. And we have the mindset of we can train that person later. We can mentor that person later. All that matters is that I have more patients on my schedule than I can see. I have a month long wait list. I have a three month wait list. I have a six month wait list. And that's money I'm not capturing now. So I'm just going to hire that person who walked in the door and threw their resume on my desk. And we can't do that. Not if we want to replicate a really high quality experience, a consistent quality experience for our patients and our clients. Not enough businesses are picky enough at this process of making sure that person has the same beliefs that we do, making sure that we have a common shared foundation of training. Us here, we now only hire students who do a long rotation here or folks who have passed the ICE certification exam. That's where our standard is at now. That tells us that person either we have trained them in our training, our foundation as well, and we find out if they have our common belief systems or not, or we know that is on board already because they have passed such a rigorous certification as the ICE cert. But not enough of us are that picky.

17:23 WHEN GROWTH GOES WRONG

And what happens if we don't do that? What happens when growth goes wrong? I want to just share a hypothetical example, speaking of the extremity management division today. Imagine that folks just have maybe even a little bit of a difference in what they believe and what they have been trained to do as physical therapists. And we say, you know what? They're only like 20% different. It doesn't matter. It doesn't really matter at the end of the day. Let's just hire this person anyways, even if they are maybe 20% different than the rest of the folks already on the team. Let's take an example of Lindsay and Mark from our extremity management team. Let's say that Mark believes that the foot, the ankle and foot, has no orthopedic value whatsoever. When he teaches his course, he just kind of glosses over that material and maybe even ends his class early. He ends faster than he planned to, right? Maybe he just kind of flips through the slides, shows a couple techniques, maybe an exercise, and he says, you know what? The ankle is really not that important to the body. Have a great weekend. Thanks for being here. Bye. And we're done at 3.30. Now, as we take that person who is now going to train more people underneath of them, the next person Mark trains is likely going to give even less attention to the ankle and foot. They're going to pass over even more of the fine details. And you can imagine if we take that now several generations deep, three, four, five generations deep, that that next person teaching extremity management may not even teach the ankle and foot, right? They may delete it from their slides entirely. Hey, we don't teach that in this course. Which is not true at all, right? Now we have a consistency problem in the product. What about the other end of the continuum? What if Lindsay believes the opposite? What if she believes the foot is the most important structure in the human body? What if she believes that great toe extension is linked to developing Alzheimer's disease? What if she spends so much time on the ankle and foot when she teaches extremity management that now her classes run until 7 p.m. on Sunday? Again, we have for a different reason, a consistency product, a consistency problem with the product we're delivering. Now again, that same example, as we get multiple generations deep, you could imagine the next person Lindsay trains underneath her maybe believes the foot is even more important and spends even more time on the ankle and foot. And maybe three, four, five generations deep, that person spends all of Sunday talking about the ankle and foot. We don't even talk about the hip and the knee anymore. Everything's about the ankle and the foot. And eventually what we come upon is a divergent offering of the same product. That the consistency of the product is diminished or absent entirely. And we have an entirely splinter product being offered. We're now offering two separate products from the same company, even though up many layers above in the leadership position, we're trying to figure out why the inconsistency is there. And it comes from not having that shared common training foundation and that shared belief system. So who is McDonald's? What is how they have franchised across the planet into one of the most successful businesses And the how is being really particular in who you let on your team and making sure that they already arrive with similar belief systems about how to practice physical therapy in a common training foundation. So many people arrive, new students, new grads with a wide variety of beliefs depending on where they went to school, what continued education courses they may have taken after it really can lead to that divergent offering of product that really creates a consistency and a quality product for your business over time. And again, in our mind is the original owner, the leader of the business. That's something we're trying to avoid at all costs. When we think about hiring new people, we're thinking about how can I essentially copy myself as much as possible so that when people come to see this new person I've hired or this eighth new person I've hired or my new location, how can I be sure that they get the same consistent product that I initially delivered when I started the business and it comes down to that shared common training foundation and that belief system. So that's the first part of this series. I want to take you all through the who, the what and the how. Next time I want to talk about once you have actually found that person, where do we go from there into the nitty gritty of things like operating agreements, things of making sure that our training foundation stays the same as we move through our practice, as we move through time together with these members on our team. I hope this was helpful. I hope you have fun with Gut Check Thursday. I hope you have a wonderful, fantastic Thursday and a great Labor Day weekend. We'll actually see you next week for a little bit of talk on carbohydrates on Fitness Athlete Friday. Have a great Thursday. Have a great weekend. Bye everybody!

21:52 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses how encouragement and support are crucial factors in helping patients overcome challenges and develop resilience. This episode emphasizes the significance of being there for patients and showing them that a healthier and stronger version of themselves is achievable, despite the short-term suffering they may experience. Lindsey acknowledges that this aspect of patient care cannot be measured on standardized scales or assessments, but it plays a vital role in the patient's journey towards better health.

Additionally, the episode highlights the importance of providing encouragement to patients when they face setbacks or failures. It is essential to support them and let them know that it is okay to struggle. By reframing these setbacks as part of the process and emphasizing that it is better than not taking any action at all, healthcare providers can help patients maintain their motivation and continue working towards their goals.

Furthermore, the episode emphasizes that patients should not be defined by their diagnosis or label. It is crucial to help patients understand that they have the power to make choices that can improve their well-being. Healthcare providers should assist patients in reframing their experiences and show them a different way to approach suffering. This involves forging connections, offering hope, and helping patients gain a new perspective on their situation.

In addition to encouragement and support, the episode also mentions the importance of accountability. Patients may need someone to hold them accountable for their actions and help them stay on track with their goals. This can be achieved through forming new connections, such as involving family members or enlisting the support of a healthcare provider. By creating a sense of accountability, patients can stay motivated and make positive changes in their lives.

Overall, the episode emphasizes that encouragement, support, and accountability are essential components of helping patients overcome challenges and build resilience. By providing these elements of care, healthcare providers can help patients navigate their journey towards better health and well-being. Lindsey emphasizes that simply modulating pain symptoms is not enough. They want to open up opportunities for patients to maximize their fitness, both physically and psychologically.

Take a listen or check out the episode transcription below.

If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY

Good morning, PT on ICE Daily Show. How's it going? I am Dr. Lindsay Hughey, one of our lead faculty for extremity management, along with Dr. Mark Gallant and Cody Gingrich. It's nice to see you all this morning. I am coming to you from Manitou Springs, Colorado. There are some mountains peeking in the background. This Clinical Tuesday, I am going to be chatting with you all about the stimulus of suffering and how in our folks in particular with knee and HIPAA can transform their current suffering to a strength. But I'll tell you it's not by giving up suffering, it's by transforming it. So we will take on this challenging subject today and consider how the suffering stimulus produces growth and satisfaction. But before we do, I would love to tell you about some upcoming courses that Mark and Cody and I have in the extremity division because there's only a handful of courses to catch us in 2023. So coming up is we are in Amarillo, Texas, September 9th and 10th. Mark will be there, so there are still spots left. Join him. And then September 16th, 17th, we'll also be in Cincinnati, Ohio. Moving into the fall, in October, October 7th and 8th, Cody will be in Rochester, Minnesota. So that'll be his first lead course. Join him. He is going to crush that. He has been on the extremity management team and ice team for so long. He brings such a wealth of knowledge. So that is going to be a blast of a course if you are nearby. And then Ridgefield, Connecticut, I added that course about three to four months ago. I'll be there with Melissa Reed. It's a really rad CrossFit gym, CrossFit 203. Lots of spots there, so join us. And then just a couple more opportunities in November and December. So check us out on ptlonice.com. But to the topic at hand. So I've come on here the last few months really chatting a lot about Hip OA and Knee OA and kind of that underlying systemic struggle that they have. And so in particular, we're going to talk about the mental physical struggle that they go through. So those folks with Hip OA and Knee OA, they often start to really identify with that bone on bone label, right? Osteoarthritis becomes who they are. It's how they plan their day. They plan their outings, their weekends, their shopping trips. It's all planned around how long a distance to walk, their energy level, the amount of steps that might be on board, wherever they're headed, how much pain they might be in, how much medicine they might have to take to get through that, or how much they'll pay for it later. So they are considering all of these factors. And it all comes back to like that label that diagnosis of, Oh, I have osteoarthritis. And this starts to really dictate their whole life. And it starts to creating quite a bit of disability limiting their interaction socially. It monopolizes their mental and emotional capacity a bit. And they're struggling. They are suffering. And this is on top of their pain, right in their knee or hip joints and in other areas in their body, because they're walking with the intelligent gait patterns. It's not just the physical impairments, right? Range of motion and strength. They are suffering physically and psychosocially. And we have to recognize this if we want to make an impact. And what's strange is that this suffering becomes a sort of comfort for them, because it's familiar, right? This is now their identity.

04:42 WHEN SUFFERING BECOMES COMFORT

We often associate comfort in our society with happiness and well-being. But there's really this intriguing paradox that you start to become comfortable in your current suffering because it is familiar. And this happens to our folks with hip and knee OA in particular, their suffering becomes their comfort. It's what they rely on to dictate their life. Their whole identity is around the suffering. So the reason they don't go to the grocery store anymore, that they have their cousin do their shopping for them, the reason they ride the motorized car and don't walk through the store, the reason they don't take that flight to see their daughter because they can't help bear the thought of walking to that plane and the pain that will cause, or maybe the embarrassment of being pushed in a wheelchair, they're missing their bingo nights, birthday parties of family members, their church Bible studies. They're not able to mow the lawn anymore. They need their nephew or their grandson to do it. They're not doing their exercises because they hurt. They don't want to do them. They'd rather watch their shows. They're not going outside and enjoying the weather. This is suffering and it becomes this holding pattern of inactivity and excuse, which leads to what? It leads to more suffering. The familiarity of that routine to stay home, to not exercise, to eat out, maybe because it's convenient, because they no longer can stand to make a whole meal. This becomes comfortable. Folks are suffering though in another way with these choices, right? They're missing out on socializing. Their joints become more immobile the less they move. They become more painful with less activity and then plus that sequelae of untangible systemic inflammatory changes that are happening when you stop moving, right? Physically and then we can't even put a, you know, a tangible thing on the mental emotional changes that are happening internally and possibly affecting their ecosystems. They will not only stay in these patterns, think about your patients with HIP and NEOA or really anyone really suffering in any diagnosis. Folks tend to find solace in it. We are creatures of habit humans, right? And we stay in these holding patterns of suffering. Our job, we need to create a novel suffering stimulus for these folks. We have to help them see there's this opportunity challenge before them and guess what? They're going to continue to suffer, right? But in a different more productive way, right? And what I mean by that, it's doing your exercises regularly, getting 30 to 60 minutes of physical activity regularly, these things, planning a meal so you don't eat out or having someone come over, help you prepare that meal, things that are outside of comfort zone. Our job is we have to show them the dividends of adapting and learning and evolving lifestyle behaviors. They can change their activity level little by little. They can change their diet and nutrition, their fueling. They can change their hydration. This will all be hard. It will cause some suffering shifts, right? Because of the planning and the change associated with changing those behaviors, like waking up early to do exercises, right? If there's someone that works full time and they just say, I don't have any time to do my exercises for my hip and knee. It might be helping them develop a routine to take their vitamins or hydrate. It might just be asking for help, right? To have an exercise buddy in the morning to walk with. But these all take effort and it takes getting out of that comfortable routine of sitting, right? And doing less. It will definitely take failing, right? Patients, it's hard when you make lifestyle changes. Think about yourself, right? It's hard to make diet and lifestyle changes and nutrition, like eating more protein, drinking half your body weight in ounces. But if you're there, encouraging them, they'll continue to go back at it despite these failures. All of this causes some amount of suffering, right? This change out of normal routine to shift to more healthy lifestyle behaviors. It's one that involves sacrifice, but they have to be novel. It has to be something different, not their comfortable suffering.

09:17 PATIENT AUTONOMY & RESILIENCE

We have to try to challenge and force adaption and learning and evolution surrounding their ecosystem, not just in their home program. And this ultimately leads to the patient's autonomy, right? Showing them that a healthier, stronger version of themselves is more resilient despite some short-term suffering. If you can be there to encourage them, right? When they do fail, this helps produce fortitude and resilience. And this can't be measured on an MPRS or KOS. I can't tell you an MCID of encouraging someone and the dividends associated with this. But if we can be there, right, to help them get back up on the saddle, maybe they take off doing their, they're doing great for a week with their physical activity and then they hit three days in a row where they don't, and they just don't feel like it. We have to be there to encourage them. When you fail, right, patients, this causes mental suffering. So as they shift behaviors, lifestyle behaviors, and maybe fail at them, we have to let them know that that's okay and that that's normal and that you're going to be with them. But this is better than sitting on the couch, not going out with your friends, planning your life around your osteoarthritis diagnosis. Our patients are not their diagnosis. They are not their label and they have to believe that. We have to help reframe that and I've talked about that in previous episodes you can check out. But the patients, they are, the some are their choices and we have to let them know that. We have to make them make better suffering choices. It is not okay if they miss doing their exercises, right, those three days. I'm not going to tell Nancy or Marilyn, it's okay. I'm going to say we need to get back at it, Marilyn. We need to get back up on that saddle. They need someone to tell them it's not okay. Along the way to the suffering and accountability, there's healthy byproducts, right, like forming new connection as your PT, right, as their healthcare provider. Maybe it's a family member that they're eliciting to help them be accountable to eat a little bit healthier diet or to drink that extra glass of water. We all need help and accountability to get through hard things and so help them realize that this is also an opportunity for connection to change their outlook and how they even connect with others around them.

12:21 THE SUFFERING STIMULUS

The suffering stimulus creates change. Your values of the patient priority start to shift. I keep saying suffering stimulus and that's because in our course we talk a lot about dosage stimulus. In particular, we talk about it in the physical realm, right, like when we talk about strength, we say this is for functional confidence and competence or performance dominance. We work at this at five reps, five sets, greater than 80% one rep max intensity. We're working some sets, greater than 80% one rep max intensity. We're working so hard we need a three-minute rest break. We are doing this three to four days a week. In the rehab dose, it's eight to 20 reps, three to four sets, 30 to 80% intensity. This is for dysfunctional tissue issue, local issues, right, we might rest 60 to 90 seconds and then powers three reps, 10 sets, right, requiring a three-minute rest break because we're taxing the CNS to use strength quickly, right, power is force times velocity, right, these all have standard definitions and reps and set schemes and frequency. The suffering stimulus is a little bit different, right, this is an intangible dose but this is a dose that pushes a human outside of their mental and emotional comfort zone. It shifts their values and their priorities in their time choices, their nutrition choices, their exercise choices, lifestyle choices, even your friend choices. Some friends have to go, right, if they're the ones you're drinking with on the regular and that tell you to eat that extra piece of cake and those cheese fries, right, we might need to change our circle and that might even involve some family ties, right, our activity choices will change and there is a certain amount of suffering associated with that. The suffering stimulus frequency, it's a daily commitment, it's reps and sets, they are boundless but this yields in unmeasurable dividends of hope, resilience, confidence, and maybe a dash of fun if we do our job well to elicit and show them the power of doing exercise and how that changes life and how lifestyle behaviors enhances that even more. The suffering stimulus, it's a life-altering dose that we don't talk about enough. It's our job to show our patient that they can do this and support them in this journey and we do have to be honest that some folks are not going to really lean in to suffering, right, they find finding comfort in suffering. It really is a deeply personal journey, right. I want you to know this isn't about glorifying pain. I hate the saying no pain no gain, we don't say that but this is about recognizing that resilience and growth emerge from life's difficulties, from one's sufferings. We have to reframe that experience for the patient, show them a different way to suffer. It is a delicate balance. We have the privilege of serving humans on the regular, right, in their most vulnerable moments when they're in pain and they're hurting and they are suffering but let's forge connection, hope, and perspective change. Let's help them redirect to control the controllables. Let's help them find their why, paint that picture of what is most important to them, right, playing with grandkids, picking up their kids, running, it's always usually family, right, being able to keep running with their kiddos. Maybe it's running a marathon, maybe it's doing chores without restriction or mowing the lawn again, going to bingo. Let's give them the resources that hold them accountable to achieving these goals like gym access, community classes, connecting them with others with the same struggles. We know this if you've been to an ICE course and you've been part of our tribe for a while but we don't just want to change your hip or knee, shoulder pain, back pain, pelvic pain, right, we want to change your life. We want to modulate your pain symptoms to open the opportunity to maximize fitness but not just physically and not just through fitness-forward lifestyle behavior. We want to build and challenge your psychological fitness. We have to help our humans break their routine suffering for a novel suffering stimulus that challenges them not only physically but mentally to lean into hard-think mindset, lifestyle shifting behavior that yields a more healthy human.

15:47 PRODUCTIVE SUFFERING

I want you to not only think about humoring suffering with hip and knee OA patients but even consider yourself, is there some comfortable suffering that you're currently taking part in that you maybe need to shift in to more productive suffering? Maybe it's tracking your food, maybe it's getting in zone two work more, maybe it's actually taking a rest day if you're a work outaholic, right, and allowing yourself dessert once a week. Consider how you can shift your patient to a suffering stimulus that changes their life and think about in your own life as well. Thank you for joining me this clinical Tuesday and if you feel so inclined share with me some ways that you have helped invoke the suffering stimulus personally or in your patients. The suffering stimulus is always a catalyst for change if you let it be. Happy Tuesday folks.

16:20 OUTRO

Hey thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Rachel Moore discusses reintroducing exercise early to the postpartum athlete, including modified CrossFit workouts, gymnastics, core training, and impact training.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at sign up to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 RACHEL MOORE

Good morning PT on ICE Daily Show. My name is Dr. Rachel Moore. I am on faculty with the pelvic division here at ICE, and I am coming at you live from a different space than I normally am today. I was in San Antonio this weekend with Christina Prevot at a pelvic course, and it was a blast. It was so much fun. We met so many amazing people. We always love our weekends out on the road. So if you are interested in jumping into one of our upcoming live cohorts, we've got Scottsdale, Arizona coming up September 23rd and 24th. That is our live course. It'll be myself and Alexis Morgan. And then September 30th and October 1st, we actually have a course in Canada. Christina Prevot will be leading that one. So if you are north of the border and you're interested in jumping into one of our live pelvic courses, great opportunity to do that coming up. We also have our pregnancy and postpartum newsletter. If you're interested in learning about all things pelvic, staying up to date on everything pelvic, it's a great way to get resources sent directly to your inbox. And you can find that link on the website. So you might hear my baby screaming in the background because he's eating. My mother-in-law is feeding him, so just ignore the baby.

02:46 MODIFYING CROSSFIT WORKOUTS

I'm here to talk to you guys this morning about modifying workouts for the postpartum athlete, particularly in that early stage. So what I wanted to do is kind of break down one workout and talk about how somebody at four weeks, eight weeks or 12 weeks for the same athlete, maybe we would modify that workout. Modifying workouts can be confusing because there's no set standard of at this point you do this, at this point you do this. So kind of across the board, it's going to be very individualized depending on the athlete in front of you. This is something we dive into a ton in our online cohort and we have an entire assignment where we break down different types or the programming and talk about ways to modify it for a particular athlete. But just to kind of give you a little glimpse of what that looks like and just chit chat about it this morning, there are a few factors that we're going to really heavily consider when we're trying to decide what we want to do for a postpartum athlete. And before we dive into those, I want to talk about why.

04:09 GETTING ATHLETES BACK INTO THE GYM

Why do we care about getting an athlete back in the gym, maybe at that three to four week mark rather than waiting until six weeks or even later? Why are we really emphasizing and why do we promote here at ICE getting our athletes back? For a lot of women, the gym is their community and it is their mental health support system. And so postpartum in and of itself can be an incredibly lonely time, especially if you don't have a village around you and especially if you feel like you're isolated from a village that you maybe have. So if we can find ways to get these women into their boxes back at the gym, maybe bringing baby along in their car seat or stroller or if there's child care, great. But bringing baby along, finding ways to modify the stimulus appropriate for somebody that's at that three, four week postpartum mark, we feel that that is incredibly advantageous for mom from both a physical health standpoint. So what are the factors we're going to look at when we're deciding what workouts need to be modified and how to modify them? For one, we want to know what mom did before she was postpartum. So did she work out in pregnancy? What did she do prior to getting pregnant? Had she been a CrossFitter for years when she found out she was pregnant? What was her previous level of strength and did that maintain throughout pregnancy or did she take a long time off and see this big deconditioning response? Method of delivery is another thing that matters really heavily. Some issues with their anterior core wall, but we typically expect to see that somebody who's had a vaginal delivery is going to have potentially more struggles with pelvic floor dysfunction with things like heavy lifting and running and that are going to challenge that anterior core wall. Again, that's not a hard and fast rule. That's not saying it's the only way. We see that overlap, but that's kind of the things that we can expect to see based on the type of delivery. We also need to know about the type of delivery that we expect to see. Especially if they're breastfeeding, we need to make sure we're having the discussion with them about making sure that they're getting enough calories in to support their body and help that not only postpartum healing that is occurring naturally, but also that recovery from being in the gym. We also really want to think about mirroring the stimulus of the workout. So we're not going to do the same things that somebody who is not postpartum, four weeks postpartum is doing, but we want to think about what the intended stimulus of that workout is and try to find ways that we can match that intended stimulus, whether that's muscle groups that are being hit, whether it's cardiovascular versus more muscular strength or what kind of factors we're shooting for and prioritizing in that workout. We want to preserve that with our modifications. So let's break down an athlete and a workout and let's talk about how we would how I would scale this athlete at four weeks postpartum, eight weeks postpartum and 12 weeks postpartum. So our athlete, we're going to call her Suzy. Suzy is a CrossFitter. She's been doing CrossFit for seven years. She just had her first baby. She exercised during her pregnancy until 38 weeks and then she just kind of felt like she wanted to rush. She was feeling like, meh, I'm not really wanting to push fitness right now. I'm just going to kind of take it easy. Her previous lifts, her one rep max back squat was 215 pounds pre-pregnancy. Her one rep max deadlift was 275 pounds pre-pregnancy. Her strict press pre-pregnancy was 95 pounds. And from a gymnastics standpoint, she was able to do kipping pull-ups, bar muscle-ups, chest to bars, and she was able to do double-enders and workouts. So an athlete that has pretty decent experience in CrossFit. It isn't brand new to this and continued to exercise during her pregnancy, had a vaginal delivery. How would we modify a workout for her at four weeks? So we're going to take a workout. It's going to be the same throughout just for the sake of not being confusing. And it's hard to kind of conceptualize and listen. So our workout, the RX version of this workout is five rounds for time, 40 double-enders, three wall walks, 15 toes to bar, and 20 double kettlebell deadlifts. At four weeks postpartum, how are we going to modify for Suzy? So we're going to maybe keep that same stimulus of five rounds. We could also decrease that, but for this exercise, we'll keep that same stimulus of five rounds for time. Instead of 40 double-enders, four weeks postpartum is pretty dang early to start doing that impact. So instead of just doing something like calf raises that would work her calves, but maybe not tax her cardiovascular system, I'm going to have Suzy do a 30 second either bike, row or ski, whatever feels the most comfortable at a comfortable pace. So she's not going breakneck. She's not going to like an eight, nine out of 10 RPE. She's just moving and getting her heart rate up for 30 seconds. Instead of wall walks, we're going to do a 30 second, 30 second, 30 second workout. So swapping the three wall walks out for 12 elevated plank shoulder taps, really focusing on that core connection piece. So focusing on that hollow body, maintaining that core brace, making sure that she's not pushing down into the basement and doing plank shoulder taps to an elevated surface that is challenging for her, but does not feel uncomfortable in any way. Instead of toes to bar, thinking about what the components of that toes to bar are with that lap pressed down and core component piece. I'm going to have her hook a band up to the rig and face away from it. She's going to hold a isometric lap pressed down. So she's going to engage her lats. If you're watching, you can see, but facing away from the rig, hands are in the van, pressing down, standing in that hollow body position, focusing on maintaining that core brace. Focusing on maintaining that core engagement. And I'm going to have her do knee marches. So we're going to swap out those 15 toes to bar for 15 standing knee marches with isometric lap pressed down to mimic that pressing with the knee raise. We could also, if we're thinking about flipping this, preserving grip or reintroducing grip, have her hold an active hang for 30 seconds as well. Those are two options for the same athlete. And you could also alternate from round to round. So maybe one round, we're doing that lap pressed down knee raise. And then that second round, we're doing that active hang and we're alternating between those two. And then finally, instead of the 20 double kettlebell deadlifts, we can even just take bodyweight good mornings. These get sneaky on you if you haven't worked your hammies in a while. So putting hands behind the neck, nice flat neutral spine, hinging forward and coming back up. So her workout again, five rounds for time, 30 seconds on a cardio machine bike rower ski, 12 elevated plank shoulder taps focusing on maintaining that core engagement, either 15 standing marches with isometric lap press downs or 30 seconds of an active hang or whatever amount of time she was able to maintain. And then 20 bodyweight good mornings. That would be the workout for somebody who is four weeks postpartum. She's showing up to the gym. She's hitting a similar intended stimulus. She's moving. She's in class with her friends and she's getting a workout in. Let's take this same athlete, same workout and pretend we have fast forwarded for whatever reason she's now eight weeks postpartum. At eight weeks post, five rounds for time, 40 toe taps or line hops. So we are introducing impact at this point. We can absolutely have maybe began this earlier at about that six week point. So introducing that impact 45 times is a high volume. So if this was something where we wanted to work on single unders, we could maybe cut that rep scheme to 15 or 20 and then still have her do those five rounds focusing on that less volume as we're introducing impact. So two options there from that impact standpoint instead of three full wall walks, maybe we're having her do three modified wall walks. So if you've done the crossfit open and you did a scale division with the wall walk, you start out on the floor, press up on your hands, feet go on the wall and you go hand behind, hand behind, hand forward, hand forward, come all the way back down. The chest hits the floor again. to start working on that core engagement, that active shoulder and getting up on the wall. Alternatively, she can work on a wall walk as high as she can go. So two options there as well. Instead of toes to bar, we're going to say that she's been working on her hangs, she's building that grip strength, she's got that hip swing down. We're going to swap that out for hanging knee raises and maybe 15 is too high volume so we can do 10 hanging knee raises, working on that good kip swing, pressing down as she brings her knees up and really pulling through the bar to get into that arch position. And then finally for the double kettlebell deadlift, we're going to let her send that and she's just going to choose a weight that she's able to hang on to that is an appropriate stimulus for her that she's not feeling any heaviness, pain or leakage. So for this athlete at eight weeks postpartum, five rounds for time, either 40 toe taps or line hops or decreasing that rep scheme and adding in single unders to work on that impact with the rope swing. Three modified wall walks or walking up as high as she can. Ten hanging knee raises and 20 double kettlebell deadlifts at a lighter weight. Let's take this athlete, hit the fast forward button and now we're 12 weeks postpartum. Same workout, same athlete. Five rounds for time. We're going to let her play with double unders.

12:27 INTRODUCING IMPACT

So these 12 weeks postpartum, let's say we've been working on impact. Eight weeks we did some single unders or some line hops. That's four weeks of time to have built up the stimulus of maintaining or responding to that impact. So instead of setting a set number for her, I'm going to give her a time domain. I want you to spend about 30 seconds of effort working on your double under. Doesn't mean it has to be breakneck speed. Maybe she's getting two to three, getting into that pelvic recovery position, resting and then picking the rope back up. This is giving her time within that workout to work on the skills that we are hoping to get back to while progressing along in that impact. We're going to swap out wall walks. Maybe not three wall walks, maybe just two. She may be able to do three, but if not, then we are going to drop that number down to two. We can always scale volume with movements. Same thing for toes to bar. So maybe she's back to toes to bar. She's able to hang on to four or five and then she starts feeling some fatigue, hops down from the bar, jumps back up for that second set. Again, this is five rounds, so that cumulative volume does add up. So instead of 15 toes to bar, maybe we're dropping her down to eight toes to bar instead. And then finally, that double kettlebell deadlift, we're going to let her send it and we're going to think, okay, at eight weeks she may have done a certain weight. She's probably at a little bit heavier weight at this point. Maintaining able to breathe, not having leakage, not having heaviness, not having pain, but choosing a weight that feels great for her. Double kettlebell deadlifts are an incredibly functional thing if you're a mom, constantly picking up diaper bags and car seats and kiddos and all the things. So one workout, one person, three different timelines. There are options even within each timeline for this athlete. There is no one right answer when it comes to modifying a workout for an athlete. We need to consider the stimulus of the workout. We need to consider this athlete's history. We need to consider this athlete's recovery and we need to consider the athlete's goals. So when we take all of these things into account, this is kind of a day by day process starting out, but eventually we want to get to the point where our athletes understand how to make these modifications themselves and they feel comfortable. Okay, I can press the gas on this or maybe I need to take a step back on this. At the end of the day, our job is to help them figure this out as we are actively working towards getting back to doing all the things that it is that they want to do. I hope that makes sense. I know it's kind of hard without like, I'm a whiteboard person. So I hope you guys learned something this morning. This is an area that we cover in our online cohort. So if you are looking to learn more about modifying workouts for the postpartum athletes from a programming standpoint especially, hop into our online cohorts, come hang out with us live on the road. We've got tons of courses coming up between September to December and hopefully we'll see you guys soon. Bye!

18:02 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses using curved, self-powered treadmills for running & gait analysis, including the differences between metabolic output on overground running, motorized treadmills, and curved treadmills. In addition, she talks about pros & cons of using curved treadmills for gait analysis. 

Take a listen to the episode or read the episode transcription below.

If you're looking to learn from our Endurance Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid. And it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money-saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 RACHEL SELINA

Alright, good morning everyone. Welcome to the PT on ICE Daily Show. My name is Rachel Selina and I am with our Endurance Athlete Division, so both our rehabilitation of the injured runner live and online. So first, sorry that this is a little bit later. I'm in Southeast Michigan and we had some crazy storms come through last night, so I have no power, I have no internet. So I am currently at my sister's house, so a little bit of a travel today to do this, but I'm glad to be here. So today we're going to dive into using curved treadmills for gait analysis. It's a question that comes up a lot in our live and online courses, which if you're hoping to get into the live course this year, we have only one more course for 2023. So the next or the last chance for this year to do rehabilitation of the injured runner live would be in Knoxville, Tennessee, November 4th and 5th. Like I said, that's our last course for the year. And then we have another online cohort coming up as well. That one is September 12th. It starts so you can jump into either one of those or both of those at PTonice.com.

02:38 CURVED TREADMILLS FOR GAIT ANALYSIS

So like I said, we get asked this question a lot as to whether or not you can use a curved treadmill for gait analysis. And so by curved we mean like the non-motorized curved treadmills, which are common now in a lot of CrossFit gyms. So they're self-propelled. Probably the most common one is the Woodway Curve, and that's the one that's become more common in CrossFit too. There's a Rogue branded one. That's kind of the official treadmill of CrossFit and CrossFit Games. And then there's also like the Assault Fitness brand has a Assault runner. In true form is one that has another or another brand that has the same like type of treadmill. So there's some different ones out there, but they're all essentially the same. Like it's not motorized, so it's powered by the athlete. And it has that kind of curved surface instead of the flat belt that we would be used to seeing on a treadmill. So the claim by kind of manufacturers about these treadmills is that they better reflect over ground running, mostly in terms of the self pacing. So when you're outside and you're running, you can just kind of spontaneously decide, hey, I'm going to speed up and start speeding up or kind of not consciously. Decide to do that and you speed up or slow down. So you can do that on the curved treadmills because they're not motorized or you don't have to like push a button to tell it to speed up or slow down. You can just kind of naturally do what your body would do. So they're marketed as being more reflective of over ground running. They're also purported to decrease impact and therefore reduce your risk of injury. Right. Claim that they promote good running form, good running technique, and then also that they cause more posterior chain muscle activation during running. So that's kind of all like if you were to jump on any one of those websites for those brands of treadmills and kind of read about what they say the purpose of this treadmill is, that's what you would find. When we take it to the research, though, one, there's not that much yet of just good solid research as far as like how running on this type of treadmill actually does change your running form or how it causes muscles to activate or definitely not yet. Like, does it reduce risk of injuries? We don't have that yet.

05:16 GREATER METABOLIC DEMAND ON CURBED TREADMILLS

What we do see kind of consistently in the research is that there is a greater metabolic demand from using these treadmills. So like for the same, you know, if you were to do a 5K and you did that outside, you did it on a standard treadmill, like with a motor and a flat belt, or you did it on a curved treadmill, it would it would be harder in terms of there'd be more oxygen uptake. You'd have a higher heart rate and higher RPE for like the same pace on the curved treadmill versus the other ones. And so that's consistent. Like that has maybe not great quality evidence, but there is that evidence out there from the research. We also see on the curved treadmills that we do get a little bit of a reduced ground contact time. So that's the like the amount of time your foot is actually in contact supporting your body on the treadmill. And we tend to see a shift or just like a, I don't know, not not in everybody, but we see that trend to take pressure off of the rear foot, especially when we're striking and go to a more mid foot or forefoot strike when we're using a curved treadmill. So that's really all like, and not even super conclusively, but that's all that consistently we see in the research about using a treadmill like that. Inconsistently is the muscle activation piece. Like there's there's not solid research to support that you have more posterior chain activation. One of the studies that looked at that was actually not using a curved treadmill. It was just using a flat treadmill that was self powered. So in that one, they saw like a little bit more soleus activation and a little bit more rectus femoris activation. But like I said, we can't necessarily apply that to the curved treadmill because it wasn't on a curved treadmill. Like that just might be something about being self powered, but can't say for sure. It also happens when we're on that curve. So some inconsistent stuff like maybe they don't quite do what we what we think they do, but we're not just not quite sure on that yet. In terms of how we use them in the clinic or in the gym, right, like if you want to do a running analysis, is this a viable option to do so? Can you use this treadmill and still get good data? So I'd say you can get good data. We just kind of have to take it in stride with what else we know is going on. So just like on a normal treadmill, we want someone to have a period of being able to adapt to that treadmill if they're not already comfortable running on a treadmill. So what we mean by that is if someone's coming in for a gait analysis, we want them to at least have had exposure to running on a treadmill before we assess the mechanics on a treadmill. Otherwise, you're going to get a lot of inconsistencies because they're just not comfortable running on that surface. So the same thing applies here. We definitely would want someone to have exposure to running on this curve type of treadmill if that's where we're going to then assess the mechanics. Otherwise, we're just not going to see a gait pattern that really is consistent with how they would typically run. So you could use it to make sure they have that period to be able to adapt. So usually that's like three sessions on the treadmill. It doesn't have to be full like you run for five miles three times. It can just be like 15 minutes, three separate times of getting used to that treadmill before you try to do the analysis. The other thing is that we have research for motorized treadmills.

09:45 RUNNING MECHANICS & TREADMILLS

We have that research showing that someone's gait on a motorized treadmill, a standard one, is consistent with what their pattern would be over ground. So we can take what we see on that treadmill and assume that that's what we also would see if they're running outside. And we just don't have that yet for these curved treadmills. So we can't 100% assume that the pattern that someone would be showing us on that curved treadmill would be what they would go out and run like over ground. The claim, and I wasn't really able to find where this was coming from, but the claim is that running on that curved treadmill is actually more similar to running uphill. So the one kind of caveat there would be if someone runs uphill a lot, like they're doing a ton of maybe trail or just like big ascents, then it might be more accurate because you can't really on a standard run. You could run on an incline, but that's the one case where it might be more similar to their over ground running if they're running uphill. But that's not like the majority of our people, especially kind of in that more traditional gym or clinic setting. So we have to kind of take it with a grain of salt. What we're seeing on the treadmill might not be 100% reflective of what we would see over ground. The other thing though would be if someone, say you're in that gym setting, if someone is only going to really be running on this type of treadmill, by all means then assess their gait on that treadmill because that's how they're going to be running. So if someone only runs during CrossFit classes when running is programmed and that's where they'll do their run is on that treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of running on a treadmill, then that's fine because that's the type of running that they're going to be doing. Otherwise, if you're going to use that curved type of treadmill for someone that's just kind of normal, maybe recreational runner, I don't think it's pointless. I think we can get some good data. We'll probably be able to pick up on big, just like big faults going on. We'll still be able to see from that coronal plane if they're, you know, from Dellenberg, how their knee separation is, all of that we still could see. We just need to keep in the back of our mind that this type of treadmill might reduce their tendency to overstride, like to have their foot land far in front of their center of mass. It might reduce that, and it might also make them run a little bit more biased towards their forefoot or midfoot, which we might not really see, like they might overground be more of a heel striker. So I think we just have to kind of keep those in mind. The one other kind of big, big picture thing to keep in mind is if we're going to use that type of treadmill for gait retraining, like we want to start changing someone's mechanics, there's going to be a few gait retraining drills. There's going to be a few gait retraining drills that are really challenging to do on that type of treadmill. So the main one would be retraining cadence. When we're retraining cadence, it's really important initially that the runner keep a consistent pace. So usually that's why like a standard treadmill is super useful because we can set their pace, right, say we're going to set it, their comfortable running pace is a 10 minute mile. So we can set that treadmill to 6.0 and we know the belt's going to stay at the same speed. So if we're encouraging them to increase their cadence, right, to listen to that metronome, to turn over their feet faster, we know that they can do that without speeding up. Because otherwise the tendency, if you just increase cadence without being able to control that belt speed, is just to go faster. All right, so if we're trying to retrain cadence on a curved treadmill, you can see the speed, but you would have to consciously like work to keep that speed the same while you're also trying to consciously pay attention to a cadence. So it would just be a really challenging setup to kind of internalize that cadence and learn that really well.

14:04 CURVED TREADMILLS & OVERSTRIDING

For some of the other tools, though, like the curved treadmill might actually be a good way to help someone who does over stride to start to learn what it feels like to keep their foot closer. So the curved treadmill would almost force them to not over stride because they keep over striding, right, that they're going to be landing higher up on that curve. They're going to just make the belt go faster, which is why that treadmill causes you to kind of keep your foot closer. So it could be a good tool for someone who does over stride to get on that type of curved treadmill and start to feel, OK, this is what it's like to keep my foot closer to kind of find that that more centered spot. But we would also need to make sure as they learn that that we make sure that transitions for them back to over ground running. And I think that's just the big thing, right? Like, I'm excited to see more research that comes out on these treadmills to kind of show us, hopefully, where where the usefulness of them is and how it actually does really change our mechanics. So we know best how to use that. But I think as long as we keep in mind that, you know, some of the things we see might not be 100 percent reflective of over ground. If we can also get a little bit of an over ground sense of what this runner is doing, we can use both of those together to make this still a really good tool for assessing and for retraining. So that's it. I'd love to hear your thoughts. If you typically use this type of treadmill, whether from like you personally run on it a lot or you do a lot of assessment on it. I'd be curious your thoughts. So definitely put those in the comments. And then, like I said, if you are hoping to catch one of our live courses, our last one is coming up in November. So feel free to jump into that. We'd love to see you there. All right. Perfect. Have a great weekend, everyone, and thanks for being here!

15:43 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up. And we'll see you there.

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses being wrong about dogmatic approaches to physical therapy, the harmful influence of technology on daily life, and long-term changes to the American healthcare system.

Take a listen to the podcast episode or read the full transcription below.

If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your morning is off to a fantastic start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at the Institute of Clinical Excellence and a faculty member in our fitness athlete division. We're here on Leadership Thursday. We talk all things practice management, small business ownership. Leadership Thursday means it is Gut Check Thursday as well. This week's Gut Check Thursday is a little test, Cooper's test in fact. This was a test created way back in 1968 by an Air Force Lieutenant Colonel Kenneth Cooper. He was a doctor in the Air Force and he wanted to figure out how to start to objectively assess the aerobic fitness of our military personnel, the Army and the Air Force, way back in 1968. This test is great. It has been studied a lot. It has a lot of normative data behind it. Very kind of similar to the six minute walk test that we use in the clinic with a lot of our patients to assess aerobic capacity. This is a 12 minute max distance run. Basically how far can you run in 12 minutes? So set a timer. The idea behind this test is that you would run it on a track or you would otherwise just basically run 12 minutes in a straight line. You don't want to end up running maybe in the CrossFit parking lot or the neighborhood where you have to turn and stop a lot. You really want to be able to pick up speed and stay at speed as long as possible. So make sure you're on a track. Make sure you're doing maybe six minutes out, six minutes back, or maybe 12 minutes straight out and then come on back with a walk. And then if you're on a treadmill, make sure you have the grade at 1% to imitate kind of the uneven nature of outdoor pavement. And then that's it. Figure out how far you ran in either meters or miles. There's some equations in the Instagram post to calculate, predict your VO2 max based on how far you ran. And then we've posted some normative tables as well. So this is a great test for ourselves. This is a great test for our athletes or patients as well to see how we stack up. So figure out Cooper's test. Yes, you can row it. You can bike it. Just be mindful that those are unloaded assessments of aerobic fitness so they don't quite translate directly to running. But as long as you retest under the same parameters, have at it with a biker row as well. Courses coming your way related directly to Leadership Thursday. Brick by brick, our practice management startup course starts again September 12th. That course just has one seat left. That's taught by yours truly. We cover everything you'll need to know about starting your physical therapy practice literally from step one of all the legal paperwork you'll need to figure out and file to get started. And then we get a little bit more into what it actually looks like to open and begin your practice. So that starts September 12th, one seat left. And then live courses I want to focus today on total spine thrust manipulation taught by our instructors Justin Dunaway, Jesse Witherington and Britt Lotteman. We have a couple courses coming your way through the end of the year. September 9th and 10th you can join Jesse down in Clearwater, Florida. September 16th and 17th you can join Britt out in Chicago. September 23rd and 24th Jesse again will be on the road this time in St. Mary's, Georgia kind of down in the southeast corner of Georgia by Savannah. October 7th and 8th, two chances to catch total spine thrust either in Columbia, South Carolina with Jesse or in Hendersonville, Tennessee right outside of Nashville with Justin Dunaway. November 4th and 5th Jesse will be out on the west coast, Simi Valley, California. And then two chances again in November before the end of the year November 18th and 19th. Britt will be on the road in Santa Rosa, California this time Northern California and Jesse will be in Albuquerque, New Mexico. So total spine thrusts coming your way. Today let's talk about this topic. So I do have some research to share with you regarding this topic but I really want to talk about the top three things I think I've been wrong about so far in my career. So we're going to talk about what it looks like to treat a comprehensive plan of care with a patient. We're going to talk about technology and we're going to talk about long-term changes to the health care system.

04:08 BEING WRONG ABOUT DOGMATIC APPROACHES TO PATIENT CARE

So I want to start with talking about the kind of back and forth dogmatic guru battles that we see all day long on social media of manual therapy sucks, it doesn't do anything, you shouldn't do any manual therapy, if you do manual therapy you're committing malpractice. And then the far other side of that same continuum of if that's exercise only then the belief that manual therapy is the only thing we do that matters that we can somehow cure or fix patients with our hands, with our dry needling, our cupping, our spinal manipulation, whatever stuff we do with our hands. So two different kind of camps fighting and barking at each other on social media and then talking about the research supporting one side or the other or both or neither. So what I've realized and keep in mind I'm coming from a point where I have sat in both of these camps at different points in my career of coming into school as a background as an exercise physiologist, of having no way and no knowledge of how to put my hands on people because I was an exercise physiologist so my intervention, the only intervention allowed to me was exercise. So coming into grad school with a belief that exercise is medicine as taught by the American College of Sports Medicine and that exercise is the way that creates the long-term fix and that manual therapy has no value. So I certainly sat in that camp in the beginning of my PT school career and then I've sat in the other side of the campus while getting into PT school learning more about manual therapy residencies and fellowships and diving really deep into the weeds especially behind spinal manipulation and dry needling and going to the other side of manual therapy is one of the most robust tools we can offer and a little bit of exercise maybe at the end for the patient to keep up their progress in between but being very heavily in the manual therapy camp and holding the the previous belief that maybe folks who are in the exercise only camp are there just because they're not that good at manual therapy so I certainly held that belief for a while. Now I would say I'm in in neither camp and maybe not even in the middle of coming to the belief of the unfortunate belief that we just can't talk or exercise patients into better lifestyle choices no matter how much we have the answer of some sort of combination of both maybe one more than the other is needed for our patients depending on who they are and where they're at in kind of their health and fitness journey and this can be maybe I think the most frustrating part of being a physical therapist and being a health care provider in general of knowing the answer right of knowing that exercise and a solid nutrition plan go a very long way into helping you become and stay a healthy fit individual but that from time to time some hands-on treatment is needed so knowing knowing the answer walking the path but really unfortunately not being able to just give that to another person especially maybe a patient that at the beginning of their plan of care has no formal relationship with us yet. I myself have an unshakable belief that I will continue to probably encounter some minor musculoskeletal injuries within lines of statistical norms due to the impossible ability to balance a lot of different things essentially balancing workload versus recovery of there's going to be days where I don't sleep enough there's going to be days where I don't eat enough there's going to be days where maybe my training volume is higher than I wanted to be my overall life volume is going to be higher than I wanted to and otherwise I put myself at a greater risk for an injury and sometimes we'll actually encounter an injury so I believe that is just part of the journey of health and fitness. I also have an equally unshakable belief that the current meat suit that my brain sits in has been evolving and adapting to stress for over two million years and that it's a naturally resilient structure that's capable of healing itself from most injuries maybe not a car accident or getting hit by a bus but certainly encountering some shoulder pain or knee pain in the gym or out on the run or something like that so that's what I believe but it is hard to transfer that to another person that my third unshakable belief is that it does not matter how much I trust my own body how much I believe that the body can heal itself I can't just take that belief from my brain and put it into somebody else's brain no matter how much I want that to happen no matter how much I talk to that patient in front of me we just can't talk people better we can't talk people into better lifestyle choices we kind of have to show them and that can come from a couple of different angles that can come from having them do some manual therapy techniques maybe even self-manual therapy techniques that helps alleviate your own symptoms to help connect that stress recovery adaptation cycle maybe some exercises or maybe both but otherwise we we do need to show people that this this thing that I've been wrong about is that seeing is believing and 99 percent of people can't be talked better the interesting thing is we have more and more research supporting this now we have some fantastic articles coming out of the pain neuroscience education space that support this that we cannot just talk people better we cannot talk people out of pain we cannot talk people into being healthier we have to show them both by our own example but also by them seeing the success as well and part of that comes from showing them some sort of change manual therapy exercise based doesn't matter whatever you think the patient needs so they begin to buy in to I'm not broken I'm resilient my body can fix itself I don't need surgery I don't need an MRI I don't need pills but that we can't just talk that person better really fantastic article if you have not read it yet by shala and colleagues 2021 the journal of manual and manipulative therapy saying that same thing literally the title of the paper is can we talk patients better and the conclusion is no we can't that we need to combine these things and that the most successful interventions for pain are multimodal they involve yes education discussion of sleep and diet but they do also involve manual therapy and they do also involve exercise it's everything together it's and not or most physical therapy studies if you read the methodology if you read the inclusion and exclusion criteria and if you read and find out in these papers why they initially studied a thousand people but only 760 people completed the study what happened to those other people well yes people get busy yes people get injured or whatever else they drop out of the study but in a lot of these studies folks drop out because they're not getting better they are maybe even going to get care somewhere else outside of the research study which you can imagine creates a lot of confounding variables that makes us need to exclude that person's data from the study there's a lot of really cool research now looking at that of that if we do not offer hands-on care there seems to be a sub-population of people who will leave our care and go get it somewhere else that if you try to talk somebody better and you say i am not going to do anything hands-on because i'm going to make you addicted to manual therapy there are people who will leave your clinic and immediately go get a massage or go see a chiropractor or maybe go see another physical therapist they will go get the care they think they need somewhere else sometimes immediately after your appointment and we need to to be cognizant of that likewise there are people who believe that if there's nothing hands-on as far as doing exercise of them being hands-on that the therapy has less value and likewise they will leave your clinic and go get extra care somewhere else so we need to be cognizant of that as well i think often of i get my hair cut every three weeks on thursday afternoon i see the same stylist i've seen her for years now she has had what i believe to be a pretty gnarly case of achilles tendonopathy from overdoing it increasing run volume i see her i've seen her progression of having a soft brace on to having a walking boot to now having a full cast on of chasing down what she thinks is going to help her in the health care system even though she talks to me for about an hour every three weeks and i try to talk about anything i can to get her to try literally anything else except pills and casting and surgery and imaging and she still won't come down to my clinic to see me even though i've offered to treat her for free of i cannot take the beliefs in my mind and put them in somebody else's mind they have to come unfortunately to that conclusion on their own so being wrong about being able to talk people better about being able to exercise people better and more understanding and recognition as my career has gone on that i need to recognize that every single person who comes into the clinic is different they have different beliefs and i need to recognize what those are and address them accordingly some people may need to start with a bunch of front-loaded physical therapy some people may not like to be touched at all they don't want to do any manual therapy they only want to do exercise and maybe some sort of blend for folks in between.

04:08 THE DANGERS OF TOO MUCH TECHNOLOGY

The second thing I've been wrong about is technology if you know me you probably have the belief in your mind that i am the biggest nerd you've ever met and i'm okay with that i grew up playing world of warcraft you can find me in my limited spare time probably trying to sneak in a video game or two every now and again so i'm certainly a giant fan of technology but as my career has gone on as i've gotten older i now have the belief that i think technology creates more problems than it solves the previous point was a great example of we would probably not have these dogmatic arguments and be so fervent in these different camps if we did not have technology to use to yell at each other from across the planet that the computer the internet the mobile device the whatever you're using has revolutionized humanity maybe for the better but i think nowadays more bad than good that having access to all the combined knowledge of our species is amazing but also being a button push or click away from constant contact with friends family frenemies work whatever can be really bad for us especially our mental health of you maybe you're this person maybe you are the spouse of this person or a friend of this person of that person who says did you see what so and so just posted this person is is my wife in our relationship of getting really upset at what other people put on social media and kind of letting it ruin your day and i think that happens a lot in modern society i think back to a question that i was asked very very early on and again i used to have the belief that more technology was better that we could talk other practitioners into better practice habits if we just argued with them on social media if we yelled at them on twitter and about nine years ago jeff moore saw me in an argument on twitter and just sent me a simple message that said hey do you think this is the best use of your time to advance the profession of physical therapy and obviously probably most things in our our life if we ask ourselves that question is this the best use of my time the answer is probably no but definitely to that question the answer was no definitely not and so i often ask myself that question a lot and what i've found over the years is that question and that answer that question takes me further and further away from engaging a lot on social media if you follow my social media now you see pictures of my son in my workouts and that's pretty much it right if far by far and large disengaged from physical therapy social media as a whole i don't listen to any podcasts anymore i listen to the news in the car and music when i work out and that's pretty much it so i've pushed technology away as i've gone through my career as i've gone through my life and i think i'm the better for it and i think having access to all of the gadgets that come along with technology is really doing us a disservice as well of i used to be a big proponent of whoop if you've listened to us here before if you've come to our fitness athlete classes you've heard us talk about whoop and other devices like that and likewise i think those cause more harm and good that having a constant stream of data letting us know you're not moving enough hey you need to move you need to exercise you're not eating enough you're not eating right you're not eating enough you're not sleeping enough you're drinking too much you're overeating this specific type of food i think those constant technological inputs into our life really set us up for a lot of unhappiness of folks who look at a whoop and think what if my resting heart rate is high because i had a beer last night what if it's low because i underate what if my respiratory rate is high because i'm sick what if i have coven 19 what if i have cove 23 what if i put strawberries up my butt would my fart smell better like we can what if this stuff to death and we i think we are doing that with our technology that i do think there is a sub-population of people who have to see that data that have to see whoop say hey every time you report drinking two or more beers you have an 18 reduction in your sleep quality i do think there is a group of people who need to be smacked in the face with that realization of again they can't be told that by somebody else a friend or a family member they have to be showing that objective empirical data but i also think there's an equal sub-population of people who will go completely insane festering about that stuff of worrying themselves to death about what does this data mean i shouldn't exercise today uh maybe i ate so wrong my resting heart rate my hrv is messed up i'm just gonna fast today or i'm not gonna work out for a week and they literally what if themselves to death about this stuff until probably the end result is that most of those people just ditch the gadgets i no longer wear a whoop i haven't wore one for many many years i have a pretty neat cassio g-shock this is a solar powered watch its only thing it does is tell time and then i have a fitbit which tracks my steps i try to hit 25 000 steps a day and that's it right i have no access to any sort of heart rate data or sleep data and i think i'm all the better for it so i think technology is really doing a disservice and i think the more we can intentionally disconnect from some of these data streams and communication streams we will find that we're a lot happier for doing so.

20:07 LONG-TERM CHANGES TO THE AMERICAN HEALTHCARE SYSTEM

My third belief is maybe a little bit pessimistic that i think unless something considerable changes with the american health care system i think the way that our health care system currently works is not going to alter significantly at least in our lifetimes that when we step back and zoom out and look at how a lot of stuff in our life is run they're run by for-profit companies the power company is a for-profit company the internet company is a for-profit company the health care clinic company is a for-profit company the insurance company is a for-profit company so we need to ask ourselves are we just victims of people trying to maximize profit and that's why we can't really seem to get ahead in a lot of big system changes and i think the answer that question is yes that's 70 percent of all americans still get their health insurance through their employer so they receive health insurance insurance from a for-profit employer that's run by a for-profit agency the insurance company that uses that insurance at a for-profit health care company so it's no wonder that we are trying to keep margins really narrow high profit low expense and at the end result the person that suffers is usually the health care provider and the patient while the overarching organizations post record profit after record profit year after year after year that both the input and output sides of the system have a vested interest in minimizing costs and maximizing profit and at some point we need to acknowledge and recognize that we also need to recognize acknowledge that with some exception health care providers are really uninvolved or minimally involved with the ownership and management usually of the business that they work for insurance companies are led by led by corporate executives and large health care systems are also led by corporate executives and if we look who sits in the leadership positions of a lot of these companies they're not health care providers they are investment bankers venture capitalists that sort of thing they're interested in profit it really starts to explain and i hope that this doesn't come off as a conspiracy theorist of why our outcomes are so poor despite how expensive our health care system is and that we really need to see big system changes if we're really going to make a dent in the issues that we have which is 90 of humans are sedentary 70 of of americans have chronic pain and we seem to be going backwards despite how hard we get up and go to work ourselves individually every day what do those changes need to look like i don't know i'm not i'm not a big picture person i'm kind of a logistics person but i think that's kind of the frustration that we all experience day to day of yes our individual patients are getting better but why are we still seeing people who got a knee replacement two days after going to see a provider about knee pain why have they not tried physical therapy first why have they not tried literally anything else first except getting booked right into surgery we feel those frustrations we wonder where those are coming from and it's no surprise i think it comes from our giant for-profit health care system as a whole so three things i've been wrong about been wrong about being on one side of the fence or the other the belief that we can talk or fix somebody with our hands or just help them with exercise only that we can take the beliefs in our mind about our bodies and the proper plan of care at least in our mind and put that into somebody else's brain been wrong about leveraging maybe too much technology especially both in personal and professional life and been wrong about the belief of really creating long-term systemic change in the health care system so i'd love to hear what you've been wrong about i'd love to hear questions comments discussion about this topic as well i hope you all have a fantastic thursday have fun with with cooper's tests if you're going to be at a live course this weekend enjoy yourself other than that have a great thursday bye everybody.

21:41 OUTRO

Hey, thanks for tuning into the pt on ice daily show if you enjoyed this content head on over to itunes and leave us a review and be sure to check us out on facebook and instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning cus from home check out our virtual ice online mentorship program at pt on ice.com while you're there sign up for our hump day hustling newsletter for a free email every wednesday morning with our top five research articles and social media posts that we think are worth reading head over to pt on ice.com and scroll to the bottom of the page to sign up

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Dustin Jones discusses recent changes to the Modern Management of the Older Adult Division and its mission to help clinicians provide the best possible care to older adults in their community as the provider of choice.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody, welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need and with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site and from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy, book their one-on-one demo with a member of their team and if you're make sure to use the code ICEPT1MO when you sign up as that gives you a one-month grace period that gets applied to your new account. Thanks everybody. Enjoy today's show.

01:33 DUSTIN JONES

We are live on Instagram. We are live on YouTube. Welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the faculty members within the older adult division. This is Older Adult Wednesday. Today we are going to be talking about what is MMOA? What is this division? What are we about and what are we trying to achieve? We are going to spend some time diving into this because we have so many new folks that are new to the ICE community. We want to make sure that you're crystal clear on what MMOA is about and if you'd want to join forces with us. Before we go into the goods, I want to mention a few courses we have. We have a few live courses coming up in the next couple of weeks. We're going to be in Southern California this upcoming weekend with Alex Germano. I'm going to be in Windsor, Colorado outside of Fort Collins on the 9th, so the weekend after Labor Day. I believe Julie Brower is going to be down in Fort Mill, South Carolina, so you can catch MMOA live on the road the next couple of weeks.

02:43 MODERN MANAGEMENT OF THE OLDER ADULT

What is MMOA? Modern Management of the Older Adult. Our division, we just went through our big live revamp, so our MMOA live course is all new material and we're spending a lot of time reflecting on what we are about as a division. What are our goals? What is our mission? How can we get to that mission and what traits do we want our MMOA team to really demonstrate? I want to share this publicly just so you all are very clear of what we're about, so our goals and where we're headed and to propose that you join forces with us to achieve that mission of really changing the game for physical therapists, occupational therapists, fitness professionals that are working with older adults. So MMOA, Modern Management of the Older Adult, it really grew out of a big problem that we still see that we're still fighting. That older adults by and large in our society are underserved in so many areas, but in the context of rehabilitation, in the context of fitness as well, that most individuals, most professionals that are working with older adults will look at a date of birth. They'll look at medical diagnoses. They'll look at the medications that they're on and make assumptions about what that person is able to do. And when those assumptions don't line up with reality, we have a very, very unfortunate situation where people are not being served appropriately. They're being underdosed. They're being handled with kid gloves and we're not getting the results with these folks, the life changing results with these folks that we can get. That is a huge issue that pains every single MMOA faculty to see and we are on mission to try and solve that problem. How do we solve that problem? It is you. It is you that is watching this on Instagram, on YouTube, that is listening to this on the podcast. It is you, the rehab or fitness professional that has, we believe, has the most qualified skills to influence this population compared to any other healthcare provider. And we mean that. When we look at the research of how we can really influence older adults, it continually points back to that fitness forward approach. That exercise, that movement is such a big lever that we can pull to change these people's And you all watching and listening to this are the best professionals in the context of healthcare to administer this to this population that we love so dearly. Another big problem that we see that we're trying to solve is we have so many clinicians, so many fitness professionals, especially coming up in their training that they think, man, I want to work with the athletes. I want to work with the sports teams. I want to do the fun, sexy outpatient ortho clinic. And we go through our training and our training talks about a lot of things, but by and large, not a lot about older adults and how to best serve these individuals. And then we get out into the real world and what happens? You wanted to work with the sports team. You wanted to work with athletes, you know, from 8 a.m. to 5 p.m. or whatever. And who are you working with? By and large, on average, over half of your all's caseload, everybody watching this or listening to this, over half of your caseload is likely someone that is on Medicare, someone that is over 65 years old. And are you equipped to serve that person? And what happens when you're not equipped and yet you have these folks as the majority of your caseload, there becomes a big mismatch, right? It can be frustrating. It can be challenging and could lead to a lack of fulfillment and enjoyment in your work. And we're trying to absolutely crush that, to show you, the clinician, the fitness professional, of the life-changing impact you can have on these folks. When you use your skill set and you embrace that old-not-weak mindset, that you give interventions that actually meet that person where they're at to drive change, that it can be some of the most fulfilling work that you can do in the context of rehab and fitness, that you can change someone's life in a matter of weeks in certain situations with this population. And that has really driven a lot of the MMOA faculty. And we just want to spread that and share that just far and wide, as much as we can through many different means. So those are the big problems. The solution that we are trying to provide is we're trying to create an army. We're trying to create a community of like-minded clinicians that are locking shields to really fight ageism, to fight the under-dosage in our profession, and to show people what is possible when we serve these folks with an evidence-informed, fitness-forward approach. We do that through many different avenues. We'll do that through this podcast that you're watching or listening to, the PT on Ice Daily Show. We also have an MMOA podcast that's specifically older adult material. We have a Facebook group of about 5,000 clinicians from across the world that serves as a resource for so many individuals in terms of certain research cases. So much good conversation is going on in that group. We have our MMOA Digest. It's a bi-weekly email where we're sending out all the relevant information related to geriatrics. And then we have our courses, our certification.

07:49 CERT-MMOA

Cert MMOA. This is the certification that is our promise to clinicians. That if you go through our certifications, three courses, MMOA Live, our two online courses, Essential Foundations and Advanced Concepts, that you will confidently be able to serve that person, that older adult that walks through your door, or you walk into their home, or you walk into their hospital room. It's also a promise that when you see those letters behind someone's name, you can trust them. Our goal is that cert MMOA means I am 100% confident that my mother, that my father, that my grandmother could go to you and you are going to deliver an evidence informed and a fitness forward approach to my family member. That is what we're trying to do, selfishly trying to do to ensure that that cert MMOA holds some weight and you've got the goods. And so there's a group of 10 individuals from across the country that are working towards trying to solve these problems and providing the solution through those different means. We absolutely love what we do and it is such an honor to serve you all and to interact with all the students when we're out on the weekends and live courses and the online courses as well. And this team, this team of 10 all-stars of folks that really embrace that old not weak mindset that have been through our curriculum are spreading this information far and wide to try and equip you, the rehab and fitness professional, to better serve your older adult patients or clients. And each member is going to demonstrate three main traits. We call this our DNA. And what we're going to do over the course of the next couple of weeks on our MMOA channel or Instagram account, we're going to go live and really dive into what these DNA traits are and the specifics of them and how we may see that play out whenever you come to a live course, whenever you interact with us online as well in essential foundations or advanced concepts. These three DNA traits that we're all going to embody is that we're all leaders. Regardless of your role on the team, we're all leading someone and there are certain characteristics and traits of leaders that we embody. We're also teachers. We understand this material, but we're also methodical in how we relay that information to our students so you can use that come Monday. And then last but not least, we're performers. We are performing. We're trying to entertain you so to continue to engage and learn. And whenever we're having fun and you're having fun, we know learning goes up across the board. You will never come to an MMOA course and see someone read off of a PowerPoint presentation for three straight hours while you're sitting in your butt getting a pressure ulcer. That ain't happening, right? We're going to have fun. We're going to get the music cranking. We're going to be moving. It's going to be an absolute blast. So over the next couple of weeks, we're going to dive in. What does it mean to be a leader? What does it mean to be a teacher? What does it mean to be a performer? And how are you going to see that within the MMOA division? So tune in there. We'll be posting over there, but I just want to take this opportunity just with all the folks on here now, I just want to say a big thank you. We've had a lot of change as a division, a lot of growth as well. We're interacting with so many of you all in person on Instagram, you know, in our courses as well. And it is an absolute honor to get to do this, to get to share our passion with you all through these means. And you all just really fill our cup up. When you share, when you execute, you know, that particular tip or intervention, or you just share, man, I got to use this on Monday after this course, that makes it all worth it for us. So we're just incredibly grateful for you. All right. If you have any thoughts on that, or if you've experienced some of this in our course, we'd love to hear in the comments, but just wanted to share this, put it out into the world, and we're going to continue to break down our DNA leaders, teachers, performers over on the MMOA account. We're grateful for y'all. You have a lovely rest of your Wednesday. Talk to you soon.

11:46 Outro

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant debunks common myths surrounding the IT band. Mark emphasizes the importance of exercise in enhancing function. He mentions two types of exercises: local tissue exercises and functional activities. Local tissue exercises are designed to respect the irritability and stress levels of the tissues. These exercises may include variations of hinge movements, knee bends, or squats that are unloaded enough for the individual to handle. They provide a healthy stimulus to the tissues and help build strength and capacity.

Functional activities, such as step downs, squats, and deadlifts, are also incorporated into the treatment plan. Mark explains that coaching these functional movements is crucial in helping the individual return to their normal activities. By gradually increasing the training volume and appropriately dosing the force, they can both manage symptoms and provide a beneficial stimulus to the tissues.

Take a listen or check out the episode transcription below.

If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRODUCTION

Alright, what is up PT on ice crew? Hope you're doing well on this Tuesday morning. I'm Dr. Mark Gallant coming at you here on clinical Tuesday. Lead faculty of the extremity management division alongside Lindsey Huey and Eric Chaconis. Want to talk to you today about IT band syndrome and some common myths. Before we get into that, we've got a few upcoming courses. So I'll be in Amarillo, Texas, September 9th and 10th. So a lot of tickets flying off the shelves for that one. So make sure if you're in Texas and want to check us out on for extremity management, that you get some seats to that. And then the following weekend, I'll be in Cincinnati, Ohio at Onward Cincinnati. So love to see you out there for that one as well. Again, for any of the ice courses, if you have not already signed up for the ice course that you want for the fall of 2023, the courses that are on the website are the only courses that are going to be added for this year. So make sure make sure you hop on there and sign up as soon as you can.

02:38 COMMON ITB BANDS

So IT band myth. So IT band syndrome is one of those syndromes that we had a lot of ideas that came out of research from the 70s, 60s, even early 80s that for whatever reason or another have stood the test of time and stayed in our profession for over 50 years. And that's influenced a lot of the way that we treat a lot of the common manual therapy we see, the interventions we see. And we've got a lot better research that's come out in the last 10, 15 years to direct us how to treat these these IT band patients. And so we want to look at that. This is not to bash the researchers that have come before us. So Renee and Ober and those folks that did a lot of the research in the 1970s. We owe everything we know now to them. And I sincerely hope in five years, six years, a lot of you are looking back at these podcasts and go, man, like all all the stuff that Mark was saying or his colleagues at ICE, it seems kind of silly now. That's what we want to happen. We want you all to take everything we're we're looking at now and make it way better over the next five or six years. So so thanks to Ober. Thanks for Renee. And now we can stand on their shoulders and really move forward. So what were some of the common myths that came out of that research in the 70s? Well, the first one is that the IT band, the iliotibial band track starts at the proximal hip with the TFL and glute. And then it has a very simple unidimensional insertion point at Gertie's tubercle. So one single insertional point for that big, massive iliotibial band structure. What we now know is that the the iliotibial band insertion point is actually quite more complex than that. It attaches at the tibia. It attaches at the lateral femoral condyle. It attaches to the patella. And not only does it attach at multiple sites, these attachments are firm. So so that that distal IT band is not really moving very much at all. The second myth is that the IT band is tight. That that iliotibial band is going to get tight and it's going to limit that person's hip adduction. What we now know is that the structures that are most commonly going to limit someone's adduction are the glute medius, the glute men and the joint capsule. So the IT band is rarely going to be the primary driver of limited adduction. And the TFL, the glute max, the structures that it attaches to are also not typically going to be the primary driver of adduction. What we then see is the third big myth that that iliotibial band syndrome is a pain dominant syndrome being caused by a friction of that iliotibial band rubbing along the lateral structures of the knee because it has a unit dimensional insertion point. Because that thing is tight that it's starting to rub. And that makes a lot of sense going after those those old ideas. Right. If you've got a certain kind of problem, you can go to the doctor's office and you can get a prescription. If you've got a single insertion point and there's extra force causing that that to be tight and it starts to rub, certainly we can see tissues being irritated because we now know that it's got a complex insertion that's really firm, that the IT band is rarely tight. What we now know is that the typical pain presentation is often being caused by repeated force due to an increase in volume change in that person's activity and the lack of frontal plane control. So the most common thing you're going to see is someone really picks up their volume of running. They've got they've got poor control over the hip, knee and ankle. And that knee starts to ping in when you get that at a really, really high volume, the opportunity for the lateral structures structures of the knee to become sensitized gets significantly increased. Another one we see it in is as folks who do a lot of downhill running, they increase their trail running their downhill running by by high volume. So you're getting a ton more load into those those structures and you're getting that lack of frontal plane control and those tissues are going to get irritated. So what are we going to do about that tissue irritation? So so like any other pathology that we're going to treat, our first step is to calm things down. We want to put out that fire initially.

05:30 CALMING DOWN TISSUE IRRITATION

So with IT band syndrome, the primary thing that you're going to do to put out their fire is you're going to you're going to get control of their volume. All right, Chris, you were running 10 miles a day, five days a week. We're going to cut that down to five miles a day for three days and see if we can calm that tissue down. So it's rarely full on abstinence. Where we like to start is can we find that sweet spot where your symptoms are starting to calm down and we're still keeping you involved in your functional activity? So whether it's running Olympic lifting, whatever the activity may be, can we control the amount of load, the volume of force that's going into that system and get those symptoms to calm down? In addition, using using our manual therapy techniques to modulate pain. So you're dry needling, your myofascial decompression, your soft tissue mobilization. You're going to base these off irritability. If that person's high on their irritability, then we're often going to needle massage and cup tissues that are a little more distal to where the pain is at that lateral knee. So looking a lot at the glutes, maybe lower down on the ankle. And then as symptoms calm down, we can get at the tissues more more close to that knee, that tibialis anterior, the distal vastus lateralis, the short head of the biceps and really try to modulate people's our patient symptoms and and get those tissues a little healthier. From there at the same time, so we're not waiting until the pain modulation comes down, we're going to start doing some therapeutic exercise to get those tissues to tolerate load better. So we've got to strike that balance of we're trying to lower their symptoms and we want some healthy, good force to go into their tissues. So oftentimes that can be open chain exercises. So they're going to have typically a little less load on the tissue because you're not dealing with so many structures. You're not dealing with ground reaction forces. So keeping that that low to improve the overall tissue health and then progressing them into more closed chain exercises that are going to stimulate those tissues in a little bit closer environment to their typical activity. So things like hip hikes, closed chain clamshells, your side steps, all those sort of things. Then we want to get into some functional exercise. Can we get compound movements that are going to be close to the activity that that person is typically doing with those compound movements for IT band? We're looking at things like step downs, single leg squats, all of those type of activities. Kickstand deadlifts are another good one.

08:25 PT 1.0 & MOVING FORWARD

Now we're PT 1.0. A thing that we did in our profession that we would like to move on from now is we said, OK, we're going to do our local tissue stuff. And when you get good enough at the local tissue stuff, then we're going to graduate you into doing these functional components. What we what we know now is we want to get all of this involved as early as possible so that we can influence the nervous system better and make that person less fearful of doing these these more challenging activities. So you're going to hit your local tissue exercises, respecting their irritability, respecting the amount of stress that that tissue can handle. And you're going to start doing variations of functional activities that they can tolerate again with their pain level, their irritability and their stress. So finding a hinge variation that's unloaded enough that the person can perform, finding a knee bend variation or squat variation, single leg squat variation that's unloaded enough that that individual can handle. So that's two components, local tissue with three components, pain modulation with our manual therapy, local tissue exercises to get some healthy stimulus into those tissues. Looking at a functional activity, squats, deadlifts, all those sort of things. All these are happening relatively at the same time. And then the fourth piece is looking at the activity that caused the problem. Was it running? Can we get them on the treadmill and do do a run a run gate analysis? Shout out to Jason, Megan and Rachel in the in the injured runner division. Can we look at their their Olympic lifting? Are they getting IT band syndrome because they started doing split jerks all the time and that position of their knees a little bit irritating? You know, the whole CMFA crew, can you really look at and coach well through a video analysis what that person is doing on their their Olympic lifting and start moving them forward there? So we're going to modulate the pain by controlling their volume. We're going to modulate the pain by using some manual therapy to influence the central nervous system to calm those tissues down. We're going to start exercising, getting good healthy stimulus while respecting irritability into the tissues through open chain and closed chain local tissue exercises. We're going to get a big functional movement, step down, squat, deadlift to start building robustness and capacity overall. And we're going to coach them on the functional activity that may have been the aggravating, whether that's running, downhill running or or their Olympic weightlifting. Now, what this does that's really cool is it positions you as a wildly unique provider to this individual. We are the only profession or one of few professions that are able to control that entire experience for that person. We've got the education where we can control their training volume. We can say, hey, look, I looked at your programming. Looks like you had a huge jump here and all of a sudden you're doing like three times the volume. Let's see if we can cut that back a bit. You can poke them with some needles. You can do massage. You can do myofascial decompression. You can do joint manipulation to calm that lateral knee down. You're the expert in local tissue exercise. You know, if I put this amount of force into this tissue and dose it appropriately, we can both keep symptoms calm down and give a good healthy stimulus to that tissue. You got to know how to coach the step down, the squat, the deadlift to get them back to their functional movements. And we've got to start getting better at being able to do those run gate analysis, video analysis for the big lifts, the Olympic lift, the squat, all those that we can really coach those well. And that will uniquely put you in a position to take that person through a whole plan of care and get them back to the things they love. That will really position you as the best possible guide. So again, to recap, IT band syndrome, we no longer believe that this is a friction based component because we now know that the IT band is firmly anchored to that lateral knee at the tibia, the femur and the patella. We know it's more of a volume increase and a lack of frontal plane control that's really irritating the system. If we can get that frontal plane control by getting a better step down, a better squat, better functional movement, use our local exercise to get better healthy stimulus into that lateral knee so those tissues can tolerate increased stress and improving our efficiency with the movements that we want to do, our running, our Olympic lifting, those sort of movements. Hope this helps. Love to discuss this more in the chat bar. Can't wait to see you all on the road in a few weeks. Hope you have a great rest of your Tuesday.

13:01 OUTRO

Hey, thanks for tuning in to the P.T. on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at P.T. on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to P.T. on Ice dot com and scroll to the bottom of the page to sign up.

Dr. Christina Prevett // #ICEPelvic // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Christina Prevett breaks down two recent studies, one that is VERY new to challenge beliefs on prolapse, the pelvic floor and strength training.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter!

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor Jane. If you don't know about Jane, Jane is an all-in-one practice management software with features like online booking, scheduling, documentation, and a PCI-compliant payment solution. The time that you spend with your patients and clients is very valuable, and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back, with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment, and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code ICEPT1MO at signup to receive a one-month grace period on your new account. Thanks everyone. Enjoy today's episode of the PT on ICE Daily Show.

01:22 CHRISTINA PREVETT

Hello everybody and welcome to the PT on ICE Daily Show. My name is Christina Prevett. I am one of the team within our pelvic health division. If you are interested in learning more about our pelvic health division, we have a online newsletter that goes out every two weeks that focuses on the research, which I'm going to talk about today, in pelvic health. One of the things that is so exciting, but maybe a little bit overwhelming about being in public health and being in this area of exercise and rehab in the pelvic health space is that it is constantly changing. The research is coming out at a very fast pace, fast being relative because research is very slow, but we try and focus in on getting that research to your inboxes every two weeks. You can go to PTonICE.com slash resources and sign up for that newsletter. I am writing it this week and it goes out on Thursday. Also all of our online content, our next online cohort, and all of our upcoming live courses, our two-day live course is in that email newsletter. I hope that you all sign up to get all that research straight to your inbox.

02:48 ACUTE EFFECTS OF RESISTANCE TRAINING

Today I'm going to be talking about a new study that came out of Carrie Bowes' lab, talking about the acute effects of resistance training on the pelvic floor. And so before I do that, I kind of want to set the stage for you all around some of the thoughts in pelvic health around heavy strength training. Where we have started this journey was that one of the risk factors for pelvic organ prolapse or descent of one or more of the vaginal walls towards the vaginal opening is that occupational heavy lifting. So individuals who lift heavy weights for their job, consistently lifting heavy weights, were shown to be at risk for more objective descent of one or more of those walls compared to those that didn't. And that because we didn't have any research on resistance training was extrapolated and said, well, maybe we shouldn't do any strenuous heavy lifting as females in order to mitigate or prevent the risk of pelvic organ prolapse from occurring. That was kind of the thought. Since then, we have really pushed back against that narrative and said, well, that doesn't really make a lot of sense because it's very different to go in for eight hours a day doing lifting versus, you know, the 30 to 90 minutes that individuals are doing. In your job, you can't control if you're feeling bad or feeling weak and just take a rest day or modify the way that you're doing your exercise. So again, there isn't really that comparison.

04:24 ACUTE CHANGES TO THE PELVIC FLOOR

And now we're starting to get more and more research come out that's talking about kind of this acute change to the pelvic floor that we're seeing with different amounts of strength training or different types of strength training. So Carrie Bo came out with a study and what she was doing was she was taking individuals who were resistance trained. So on average, these were individuals who had never had kids. They were Nellie Parris. And so I never had a delivery and were trained resistance trained athletes. So they had on average about two years of experience. They were then put into a crossover design. So what that means was they took half the individuals and got them to strength train first and then took half the individuals and got them to rest first and then kind of compared. So what they were trying to look at was after a high load resistance training session, what was the impact on the pelvic floor? The thoughts were one of two camps. There's two camps in this space. One is that individuals who strenuously lift are going to have bigger pelvic floor muscles, stronger pelvic floor muscles. And the other is that it may actually create damage over time that they're going to see a big change in symptoms or change in vaginal descent. So you kind of have individuals in both of these camps and we're trying to figure out which hypothesis is correct. And so they took, they did a one rep max or a perceived or rate of perceived exertion that was very high in the squat and the deadlift on one day. And then they got them to come back the next day. So after that one rep max test, they kind of flushed out, let the body recover, came back in. Half the group started with a rest window. So took pelvic floor muscle strength measures at the beginning pre, then half of them rested and did a post and then half of them did a four by four strength training session between 75 and 85% of their one rep max on the squat and the deadlift with reps in reserve between one and three and then did a post assessment and then they flipped, they flipped them. So what they saw was that there was no big differences, no statistically significant differences between the rest pre post, but then also the resistance training pre post. And I think that's really interesting because one of the things that we kind of explain around our, our thoughts around heaviness or prolapse are things like that it's a fatigue issue or so maybe it isn't fatigue or maybe it is, but doing a supine assessment, which is our traditional way of conceptualizing pelvic floor muscle strengthening, isn't sufficient to look at this type of, of fatigue, like to really evaluate this type of fatigue in individuals who are experiencing these symptoms. So that was really interesting. The other thing was that, you know, they did see some individuals who complained of urinary incontinence in this sample around 28%, I believe. And so those individuals, the study wasn't powered enough to be able to subgroup those that experienced incontinence versus those that didn't, but there, what it was not just on individuals who were symptom free. I think that's a pro to this study because we can say, well, of course there isn't any fatigue or any downstream effects of individuals who've never experienced pelvic floor dysfunction, but that's not the case in this study. There was a significant cohort of these individuals who did experience leaking with lifting and the study just wasn't powered enough to subgroup this out. So the first step was to kind of take a full circle approach and say, was there any differences? And then the next step is going to say, is there any differences for individuals who do experience pelvic floor dysfunction versus those that don't? And then the next step is those that are multiparous or multiparous, like multiparous, we kind of, tomato, tomato, those who have had vaginal deliveries before or have given birth before vaginally versus those that haven't. And so this is kind of setting up this conversation around the way that we message things. So another study was done in 2016 and I just found it because it was in the discussion section of this paper around vaginal descent. So Carrie said the Bowe study was looking at pelvic floor muscle strengthening, pelvic floor muscle strength and assessment.

09:23 VAGINAL DESCENT AND EXERCISE

The next question is around vaginal descent and are you more likely to experience symptoms of prolapse or heaviness post resistance training? And so this study was done in 2016, I believe it was published out of Janet Shaw and Ingrid lab that was looking at CrossFit athletes, those who experience, sorry, those who participate in strenuous exercise. So they got CrossFitters and they got them to do pre-post on the pop cue versus those that participate in non-strenuous exercise. So let's kind of break this study down too, because I think it's important. So in this second, this, I guess it was the first study, what the group from Nygaard and Shaw's lab did was they took individuals who were CrossFitters, got to check their pelvic floor muscle strength and the pop cues. The pop cue is an objective assessment of prolapse that has good reliability that looks at the different segments of the different walls of the vagina. And then as they do a strain maneuver, they see what the range of motion or the amount of each segment of each component of the wall are, and then create a grade based on the most amount of movement in whichever section of the vaginal wall that may be. So they took individuals who were CrossFitters and then they took individuals who participated in non-strenuous, non-high impact exercise and got them to come into the lab. And then the strenuous group was, they did a pelvic floor muscle strength exam and then the pop cue and then in the non-strenuous group, they did the same thing. And then they got the CrossFit group, the strenuous group to do a 20 minute AMRAP of sit-ups, heavy deadlifts. There was an impact movement in there and kind of went for 20 minutes. And then they got the non-strenuous group to do 20 minutes of an exercise of their choice at a self-selected pace. And then they did the pop cue again. Here's something that's really interesting. So the strenuous group was participating in CrossFit for over two years. They had an extensive history of strenuous exercise versus the non-strenuous group. And they kind of conceptualized this based on looking at what they did for exercise and the amount of loading in their bones to try and get some sort of measure of impact, which I thought was kind of brilliant. And they compared them. Strenuous group had done a lot more loading of their bones and musculature and therefore loading of their pelvic floor compared to the other group. And what they saw was that before their pre-exercise, descent in pelvic floor muscle strength was not different. Was not different. So this created preliminary research that the strength, individuals who are participating in strength training for several years, so it was like on average 22 months plus or minus, and they had to have at least, I think, a year of doing CrossFit regularly, three to four times per week to be able to get into the study in the first place, that there was no difference in vaginal descent. They had, there was no differences between the two. So that kind of goes against this argument that resistance training is going to cause a prolapse, resistance training in general for individuals who haven't had a vaginal birth yet. So I think that's interesting. And then post-partum, or post-exercise rather, they did see differences in descent in both groups. So both groups saw a difference in descent immediately post-exercise, which again, I think is really interesting because this does not support that resistance training and high impact is going to lead to prolapse down the line. Now again, we have a lot of work to do within this space. This was one study. I'm not going to just start shouting from the rooftops that all of a sudden, you know, we know all of the things that we need to know. I'm not saying that, but the fear focused language that is coming into this space around resistance training and avoiding Valsalva and all these types of things isn't founded objectively. So the other interesting thing was that there was only one individual, even though there was a change in descent, right? There was some changes pre-post-exercise and they didn't re, they didn't kind of follow them further and further forward. I would have loved to see them do multiple time points to see how long it took before that changed or kind of returned to baseline. There wasn't anything that, that was looking at what, what that change of symptoms were.

12:57 RESISTANCE TRAINING & PROLAPSE

And there was only one person with subjective symptoms of prolapse. So again, we're, we're seeing this disconnect between objective signs and subjective experiences, which I think again is really interesting because we are focusing a lot on the grade, like what grade do you have? What grade do you have? And the evidence isn't really supporting that we, that should be our focus. If you are thinking surgical routes, if it is coming past the level of the Hymen, absolutely, because then we're going to say, is this impacting your quality of life? Is there sufficient imaging data to see that a surgery, for example, would be warranted? For individuals in the conservative space, again, we're, we're, we're questioning, does the objective signs matter? And, you know, we can't answer that question, but it is an interesting thought experiment and we're starting to have more evidence accumulate that, you know, there is a big disconnect. And yes, our body is going to change and show signs of fatigue with things like impact, but what's the cost benefit? What is the risk of telling people that they shouldn't be getting strong for their 60-year-old self, for their 70-year-old self, for their 85-year-old self, when we know that strength is such a huge, huge component of independence in later life? So it is so exciting, kind of going through Carrie Bowes where she didn't see any change in pelvic floor muscle strength to some of the research coming out of the Nygaard and Shaw lab that are talking about changes in pelvic organ support with heavy lifting and long-term heavy lifting. I think we're starting to get more and more data that the fear-focused messages aren't warranted, that we're going to start treating the symptoms and that we can expect changes to the pelvic floor when the pelvic floor gets a workout. Again, I don't think for anybody in the ice fitness forward community that that is necessarily a surprising finding, but it is definitely pushing some of the narratives in pelvic health and I think pushing them in a really necessary direction to try and change this narrative around the fear-focused language of resistance training in the pelvic floor. If you are interested in those studies, I'll post their DOIs below in the comment section. I am so excited to be talking about this research. Again, if you are a research nerd like me and you want to see the new studies that are coming out in this space, which these two studies are going to be in our newsletter this next week, I encourage you to go to ptonice.com slash resources to look for the pelvic newsletter. I am really excited to see some of the changes happening within our course and I just can't wait to continue connecting with you all about research in the pelvic health space. All right. Have a great day, everyone, and I will talk to you soon. 

16:40 OUTRO

Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses three postpartum physical scars that are often invisible to rehab providers. She explores how these scars can impact exercise prescription for clients in the early postpartum period.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody, we are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one on one demo with a member of Jane support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything, they offer unlimited support and are always happy to jump in. Thanks, everybody. Enjoy today's show.

01:27 APRIL DOMINICK

Welcome to the PT on ICE Daily Show. Dr. April Dominic here. I am your host representing the ICE Pelvic Division. Today we'll focus on three postpartum physical scars that are often invisible to the rehab provider. We'll talk about how these scars can affect exercise prescription when it comes to working with a client who is early postpartum. But before we dive into that, let's chat about all things, updates and course offerings for the ICE Pelvic Division. If you're looking for a virtual option to learn all things fitness, athlete, pregnancy Our next Level 1 online cohorts starts September 5th. Otherwise, you can catch us on the road. We've got tons of courses coming up for this fall. And our next one is September 23rd and 24th in Scottsdale, Arizona. This is going to be with the lovely Dr. Alexis Morgan and Dr. Rachel Moore. This course is chock full of literature outlining the ins and outs of pelvic floor basics, pelvic floor dysfunction, the assessment for the pregnant or postpartum fitness athlete that includes an external exam or an internal exam option. We also have a lot of super fun labs that are going to cover core and c-section management. We also have tons of labs on reintroducing or continuing to use the barbell, do rig work and endurance exercise. Please go hop on PTONICE.com. Get yourself in one of our courses. We would love to see you there virtually or in person.

03:23 PHYSICAL SCARS POSTPARTUM

Today I wanted to hop on and shed some light on physical scars that a postpartum body endures early on. These scars aren't always visible or front of mind for the rehab provider. So think about it like this. You may have someone who is coming in very early postpartum due to some sort of orthopedic injury like for their hip, their shoulder, maybe their back, or they may be coming in for core and pelvic floor work. So it's important for all of us to be aware of these scars as they heal and the role that they play early postpartum with movement and exercise prescription. So when someone is pregnant, there is usually some sort of baby bump or something that is a visible reminder to others of their condition that they are pregnant. Enter the postpartum period. For many postpartum folks, those visible reminders of pregnancy fade and the physical impact the labor and delivery on the body are invisible to others. When someone is postpartum, there's no physical sign that they and their body have gone through this incredibly challenging feat. There's no cast for like when we have for a broken bone. There's no crutches for that ankle sprain. There's no sling to support the wounds. Unless maybe they have their newborn with them, there's really no obvious physical sign that someone is recovering postpartum. So three invisible scars that we'll chat about today are the uterine scar, the perineal scar, and the lower abdominal scar from a cesarean section. Let's circle back to wound care from school. Remember for our healing stages, our tissue healing goes through four major stages. Starting with the first couple, the hemostasis and inflammatory stages. This is going to be a period of local swelling. Next, the proliferative stage. And that's going to be the stage focusing on covering and filling the wound. And then the remodeling stage is characterized by scar tissue formation, which this can last for a year or two, if not. So let's unpack those three major postpartum scars. The first, the uterine scar. I feel like this is the most invisible. It's as the name indicates, a wound on the uterus. And in terms of time to heal, the uterus typically involutes or returns back to its pre-pregnancy size that's smaller by six weeks. And muscles that may be impacted by this scar, by this wound on the uterus, would be indirectly the pelvic floor and the abdominals. In terms of considerations to return to movement when we're thinking about uterine healing, if someone does some physical activity and there is an increase in vaginal bleeding, then that is going to be a sign for regression that the uterus and body may not be ready for that specific intensity level of physical activity or the duration of physical activity.

07:33 PERINEAL SCARRING

Our second scar is the perineal scar. In terms of where it is, it is on the perineum. And the perineum is the tissue that's between the vaginal opening and the anal opening. A perineal scar or injury may occur due to a large stretch on the tissue at the vaginal canal as the baby exits through that vaginal canal. In terms of time to heal, a majority of the stitches are dissolved by about two to four weeks. So there are two ways to tear the perineum. And that's either naturally or via an episiotomy. And that's going to be when the provider actually makes a cut in that perineal tissue. In terms of levels of severity of the perineal tear, there are four. The first degree is the licevier. It's small, skin deep. The second degree is going to involve the muscles of the perineum. The third degree is going to be a tear of the external anal sphincter. And that is what we use to keep poo in or keep poop out, like allow for defecation. And then the fourth degree tear is going to be the most severe. And that's going to be a tear that likely involves the internal anal sphincter, the external anal sphincter, and the rectal mucosa. One time I was talking to a group of OBs and one of them said, you know, we were talking about perineal tears. And one of them said, you know, the vagina is just simply remarkable. It gets to heal in real quick and nobody F's with that vaginal tissue. So that is the one good thing about perineal tears is that the vagina takes care of business. So muscles that are impacted by the perineal tear, the pelvic floor. And then when we're thinking about return to movement with someone with a perineal scar, movements that are wide-legged, like maybe a sumo squat or lateral lunge or really deep squat, there may be some discomfort at that perineum due to that stretch on the tissue in those wide positions.

09:01 C-SECTION SCARRING

And then we have our C-section scar. So where is it? I'll talk about the most common cut that is done is called the bikini cut. And then it's about four to five inches long and it's stretched across the lower abdominals. In terms of time to heal, that's going to depend on various factors. But some scars start to close at the skin level as early as two weeks. And then we know by six weeks, generally speaking, the scar is fully healed if there are no complications. And that's about the same timeline that someone is likely returning back to their provider. Some complications with scarring may be hypertrophic scarring or keloid scarring. And the keloid scar is going to be when the body over heals and the scar tissue extends beyond the original boundaries of the wound. So we want to make sure that we are referring them back to their provider if that is the case, if we happen to see that scar on the client. We know that around six weeks, abdominal tissue has only regained about 50 percent of its tensile strength. And by six to seven months, it's approximately in the 75 percent range of its tensile strength pre-incision. And muscles that are impacted by this scar, the C-section scar, are going to be our abdominal group. So the rectus abdominis, internal-external obliques, and the transverse abdominis.

14:01 CORE-CENTRIC MOVEMENTS & EXERCISE

In terms of considerations for return back to exercise specifically for a C-section scar, we're thinking we got to watch for that core heavy work, any sort of rig or gymnastics-based movements, or any lifting that may involve some sort of contact at the lower abdomen. So those are the scars. Now let's talk about two movement categories more in depth that may be affected by those scars. We have the return to exercise and then return to intimacy, which we'll dive into. So in terms of movement early postpartum, when dosed appropriately, it can assist in so many areas of recovery. We're talking reduction in postpartum depression risk or reduction in risk of blood clot, promoting tissue healing, promoting getting better sleep. That's just to name a few of why movement is important early postpartum. But when it comes to exercise, variables such as sleep and fuel not only influence the risk of injury and recovery, but they also directly relate to the energy status needed to participate in exercise. So sleep, we should be getting nosy and ask about sleep status. Be realistic and recognize that you're talking to a person with a newborn. So their sleep is going to look a little different given the newborn schedule. But we do want to make sure that the client in front of us is optimizing their sleep. Are they creating the best environment? Is it a cool environment? Can they make everything dark? Can they talk with our partner and be like, hey, I need this chunk of time for sleeping. Can you handle the baby while I do this? And then maybe they switch. In terms of fueling, are they able to nourish themselves with nutrient dense packed meals that are full of protein, packed with plants, reduced processed sugars that have sufficient calories, especially caloric intake is important, especially if someone is breastfeeding. They'll need about 400 to 500 extra calories. Okay, let's talk about return to exercise. Generally speaking, when we're talking about return to exercise for someone who's early postpartum, it's a great idea to start somewhere close to where they left off at the end of pregnancy and then build tolerance from there. Early postpartum, that's a time to determine the body's capacity for tolerating exercise. As a provider, it's helpful to have a conversation with our clients about ways we can manipulate exercise dosage to meet their current needs of their current physical status. These modifications are temporary. This is something that we want to communicate with them. We want to educate them on signs for regression with, hey, they did a certain workout or did certain exercise and then, hey, they experienced some leakage of urine or fecal matter. They had some pain or increased abdominal discomfort or vaginal heaviness. So we want them to communicate this to us so that we can then show them how we can alter a workout if needed through load, through adding rest intervals, maybe modifying the intensity or changing the volume and duration. That way they can still continue exercise without symptoms. So now let's talk about scar types and different types of exercise such as core, impact, or lifting. So during the early days and weeks postpartum, walking, reconnection with the core, the pelvic floor, and breathing is a really great place to start. This is going to be when we are starting to add in a little bit more after the first early days or a couple weeks. So with core-centric movements, as we move towards adding more intensity or load, we want to ensure that that abdominal incision is healed to avoid dehiscence. We can begin to experiment with its tolerance, with the anterior abdominal core walls tolerance to stretch in all planes, specifically going into extension, flexion, side bending both ways, rotation, a combination of all those movements. We want to be mindful of tolerance to pressure on the scar, whether that's pressure from simply just the workout clothes, or maybe they are baby wearing while they work out and they have some irritation there at the abdomen. Or maybe it's increased pressure at the abdomen from a set of dumbbells when they're doing a hip thruster, or when they slam down onto the floor with a burpee, or the rig or barbell making contact with the abdomen during gymnastics movements or lifts. With return to impact exercise, such as walking, running, or jumping, we want to be mindful that someone with a vaginal delivery and significant perineal tearing could experience an increase in their pelvic floor symptoms. Remember symptoms reported may be heaviness, vaginal bleeding from the uterine scar, or irritation of their perineum. And someone with a C-section could also experience these as well, but we're thinking that it may be more common with someone with a vaginal delivery or more likely to happen. So with return to impact, we're going to find their guidepost in terms of how much impact their body can tolerate, whether it's starting with a walk around the block, then adding a few more blocks each day, or if it is explosive calf raises, single unders, or step ups. And then for return to lifting, maybe we start with a PVC pipe, or a light kettlebell, or a barbell only movement. This is going to allow the client to re-familiarize themselves with the movement pattern, say of a clean or any sort of overhead press, and then they will be simultaneously building tolerance and in ranges of motion and load at their perineum and abdomen, where some of their scars may be. So return to any exercise will be person dependent, but knowing their history, mode of delivery, current symptoms, and scar status can help you guide them. And bonus, maybe this is a time that they slow down and dial in on foundational pieces of complex lifts or impact training.

18:07 PAIN WITH INTERCOURSE

Besides return to exercise, we also have a different return to movement, and that is return to intimacy, specifically penetrative intercourse. Once cleared by their providers, return to penetrative intercourse, the postpartum person may run into difficulty tolerating that vaginal penetration. This could be from a finger, a toy, or a partner student, Natalia. So it's estimated that 43% of women report pain with intercourse in that first six months early postpartum. And this is something major that we should be thinking about when someone is maybe sharing with us things that are going on with penetrative intercourse for them. A C-section or perineal tear can contribute to painful intercourse. There's a greater risk associated with pain with intercourse with an episiotomy versus a natural perineal tear. Just as we would practice scar desensitization in any other part of the body, we're going to do the same here at the vagina. And a pelvic PT is going to be really great in assisting and making recommendations for internal massage, stretching, or using a dilator set. So let's recap. Today we talked about three main scars that a postpartum person may have. A uterine scar, a perineal scar, or an abdominal scar from a C-section. Remember to respect these healing timelines. They will be unique to each person. The next time you have a client who's early postpartum on your schedule, encourage them to start small. Go slow for returning to exercise and intimacy. Educate them on progressive overload and how that may not be a straight line for them. Maybe a series of peaks and valleys that are impacted by external factors such as sleep, fuel their body's current physical capacity. Communicate with them. Get curious about their invisible physical scars as they may not feel comfortable telling you and offering you that information that, Oh, they have pain at their vagina at the bottom of a deep squat or their abdominal incision site is really bothering them when they're doing a hollow hold or hanging from the bar. So they will no doubt be thankful if their provider considers these scars, asks about them, and because they're not often discussed. So thanks for tuning in, everyone. I hope you gain some awareness of these physical invisible scars that a postpartum person may be dealing with. Next episode, I'll be discussing the emotional invisible scars in the postpartum period. Cheers y'all.

20:28 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Mitch Babcock // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Mitch Babcock discusses that consistency in the gym, combined with attention to lifestyle factors, can lead to significant rewards in terms of fitness and overall health. By being present and dedicated to regular training, individuals can see improvements in strength, conditioning, and cognitive function. Additionally, by addressing lifestyle habits such as sleep, nutrition, and alcohol consumption, individuals can further enhance their fitness journey and ultimately live longer, healthier lives.

Take a listen to the episode or read the episode transcription below.

If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everybody, welcome to today's episode of the PT on ICE Daily Show. Before we get started with today's episode, I just want to take a moment and talk about our show's sponsor, Jane. If you don't know about Jane, Jane is an all-in-one practice management software that offers a fully integrated payment solution called Jane Payments. Although the world of payment processing can be complex, Jane Payments was built to help make things as simple as possible to help you get paid, and it's very easy to get started. Here's how you can get started. Go on over to jane.app slash payments and book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice by seeing some popular features in action. Once you know you're ready to get started, you can sign up for Jane. If you're following on the podcast, you can use the code ICEPT1MO for a one-month grace period while you get settled with your new account. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Ideally, as soon as you get started, you can take advantage of Jane's time and money saving features. It only takes a few minutes and you can start processing online payments right away. Jane's promise to you is transparent rates and unlimited support from a team that truly cares. Find out more at jane.app slash physical therapy. Thanks everybody. Enjoy today's episode of the PT on ICE Daily Show.

01:26 MITCH BABCOCK

Hey, welcome everybody. Welcome to the PT on ICE Daily Show. Welcome to Friday. Welcome to Fitness Athlete Friday. I'll be your host today. Mitch Babcock, lead faculty in the fitness athlete division, all things online and live course. And it's been a minute since I've been on the podcast. So I'm excited to be back joining all of you this morning. So thank you. First of all, if you're downloading us, listening to us on your way to work, if you're on live with us on Instagram or YouTube, thanks so much for making this part of your morning or your evening, whatever it is for you. And thanks for downloading wherever you download your podcast from. We always appreciate it. Don't forget we're the only daily physical therapy show on the market. So thank you for subscribing and liking and signing up for those automatic downloads. It really means a lot to the whole team here at ICE. Before we jump into today's topic, which is post CrossFit Games for the rest of us. Okay, I want to talk a little bit about some of the courses that we have coming up for the live division. We have a very busy September in October and even leading into November and a couple courses in December. So looking at Q3, Q4, we've got quite a bit on the books. The fitness athlete team as a whole was a little quiet through the summer. As our team, many of us on the lead faculty, not us, but others on the lead faculty, welcomed some new additions to their family or kind of spending some time at home. So the summer months were a little quiet and we're excited to ramp up on the road here in Q3 and Q4. So you can find us all over. Zach's going to be out in the Bay Area here in September. The end of September you can find him out in California. I'm going to be out in Seattle, just north of Seattle in Linwood with Joe as well. We got a course in British Columbia coming up, Alabama, San Antonio, Florida, New Orleans, Colorado Springs. We're hitting some big cities and covering a large part of the map this fall. So if I just named off any cities, your cities or near you, please check those out on the PTA On Ice website. We'd love to see you at one of the live courses.

02:16 POST CROSSFIT GAMES

All right, let's get into today's show, shall we? If you didn't tune in last week to Kelly Benfey's episode on her post CrossFit Games Reflections, you should definitely do that. CrossFit fan or not, whether you train this stuff or not, you need to understand the level at which Kelly is at in humbly speaking herself. She's not going to give as much credit as she deserves. Making it to the CrossFit Games is a feat 99.9% of people that participate in CrossFit will never achieve. You can be pretty good at CrossFit. You know, you could be pretty good at pickup basketball, but you're not going to make the squad and play with the Lakers. You know, like that's kind of the comparison of which we're dealing with now in the CrossFit sector. And so for us to have someone like Kelly, who's went there, who's done that, who's trained at the highest level, who's rubbed elbows with the best of the best in the game and to get some reflections from her, it's worth the 10 or 15 minutes about what it's like behind the scenes. So great episode, Kelly. But today I want to talk about after the games, what about the rest of us that just train this stuff because we like it? We want to stay healthy and fit. We enjoy getting stronger, but we also have nine to five jobs. We also have families, husbands, wives, kids. We got to shuttle kids off to soccer practice. Maybe I coach the soccer team, right? What is what does it look like setting and reframing goals after the CrossFit Games for the rest of us? Because we still want to be motivated. We still want to be inspired. We watch the games and we see what's out there and we see what people are capable of and and all of that is fun and it's all a great part of the sport. But when it's our time to take the floor, it's important to reframe those goals and context and the things that matter to us and are achievable to what we can set our sights for over the next six, nine or 12 months. And that's really what I want to focus today on.

04:35 SETTING & REFRAMING GOALS

What can you reasonably achieve in the next six to nine months or even set your sights on before the next open rolls around? Because we know we're going to throw the hat in the ring and do the open. You know, what are some realistic goals, realistic goals that are going to turn into real change in your health and fitness and overall well-being? And that's ultimately what we're doing this for. We're not most of us aren't going to make the games. Hat tip to Kelly for putting in a ton of work over the last five to 10 years, probably to get to that point where she was able to make the games. But for the rest of us, we're looking to check that box. We're looking to do it safely and effectively and making sure that when we come out the other end, we come out unharmed and we come out healthier and a better person after doing the training than when we started. So here's some goals that I have for you today for post CrossFit Games goals for the rest of us. What part of your training really behooves you to spend time training?

06:30 INVESTING IN FOUNDATIONAL STRENGTH

And what I mean by that is strength and monostructural conditioning work. It's really going to benefit you long term to invest hours weekly daily into getting stronger. So I want you to set a goal to try to put 30 pounds on your deadlift over the next year, to try to put 20 pounds on your back squat and to try to put five to 10 pounds on your strict overhead press. Those are realistic goals that are going to require you to train those movements consistently. And because you're training the foundational strength movements, the squat, the deadlift, all of your other movements will then reap a reward from having done so. Your clean and jerk, your front squat are going to benefit from your back squat being trained regularly. All your Olympic lifts and all your other movements are going to benefit from you training your deadlift frequently. Your shoulders are going to be healthier from having done more strict press. So set some realistic goals. I'm going to put 30 pounds on my deadlift, 20 on my back squat, 10 on my overhead press And that's going to require me to make sure that I'm hitting those boxes week in and week out over the next handful of weeks, months, and the better part of the next year. So it really is helpful that you spend time working on the foundational strength. The other thing that's going to benefit you for your gymnastics movements. So spend time benefiting or getting increased reps or getting your first rep of a strict pull up. Many of you in the CrossFit space are still gung ho about your kipping pull ups, your toes to bar technique, all these other things. I want to bar muscle up, but you haven't laid the foundation with the strict pull up yet. You need to stay there. Over the next six or nine months, can you add one or two reps on your max strict pull up? Can you get your first strict pull up by going through a beginning strict pull up progression and over the next six months, get your first strict pull up. Those are going to be big rewards for your long term health in fitness training. The same thing with your push ups. We in the CrossFit space, those of us that coach a bunch, boy, we're used to seeing a lot of crappy push ups, right? Poor midline stability, we can't hold a good plank position, we don't have a strong shoulder position to be able to press out of the end range of extension, and we have athletes wanting to bang out a lot of reps and not even one of them looks solid. So spend time mastering your strict pull up and your strict push up. You're going to be a better athlete and your fitness will reflect that if you do. Master a skill over the next six to nine months. Get better at double unders. Figure out how to climb a rope, right? Finally take some coaching advice from your team at your gym and figure out how to put down a new skill. There's a lot of reward that goes into the neural motor, the coordination, all of the things that come together to allow you to build and develop a new skill. And if there's one that you've been putting off, because let's face it, your ego is kind of getting in the way, you don't like to look like you can't do the thing so you just scale out of it a lot, spend time over the next six months and learn that skill. Just one, pick one. I want to get better at double unders, I want to be able to do 20 unbroken double unders. Cool. Over the next six months you're going to attack that and that's going to be a goal that's going to elevate your fitness long term. You're going to have that skill for a long time and you're going to be able to use that skill in a lot of workouts coming up. So spend a couple of weeks, a couple of months and develop a new skill. And then your model structural work.

10:06 LONG DURATION ZONE TWO WORK

Add in one day a week where you're adding in some longer duration zone two, you know, longer duration stuff on the bike or the rower going out for a long paced run. Like we don't do enough of that. And every single expert in the space says from a longevity standpoint, it is so key from a health standpoint, from a fitness standpoint, it is so key that we get more long duration zone two work in. And now some of the research, some of the leading experts are saying 60 to 90 minutes, 120 minutes a week. Look just start easy with one day a week where you stretch it out more than 20 minutes. I mean low hanging fruit one day a week. I need to do a long duration piece that's more than 20 minutes. If we can check that, then we'll start talking about increasing the model structural workload and be able to increase that more. But that's a foundational component to your fitness. That's on the base of the CrossFit hierarchy pyramid that says, hey, we need to be really good at metabolic conditioning. And when we have a better aerobic base, everything else steps up above that. So build that aerobic base. Add in one day a week of model structural work zone two on a bike, on an erg, on a runner and stretch it out more than 20 minutes. So you're prioritizing strength. You're working on a skill. You're getting better at your foundational gymnastics movements and you're adding in some longer aerobic work. 20 minutes one day a week.

13:21 MORE CONSISTENCY IN THE GYM

From a class perspective, I would just say it ain't volume. It's not loading that's going to make the difference for you. You don't need to be lifting heavier weights and metcons. You just need to be present more frequently. Just be more consistent. If you normally make it three days a week, try to make it four. If you normally make it four, can you make it five? Can you just add one more day a week making it to the gym? Can you slide in that little Saturday morning class that you typically skip out on? Because you're going to see big rewards coming by just simply the consistency in the gym. You don't have to do anything heroic. You're just more consistent. You're getting five sessions instead of four. And week after week, that aggregates into a lot more training sessions at the end of the year. So bump it one day a week. If you have other skills that are going to make you a much better athlete six, nine, 12 months from now, set a bedtime and actually stick to it. Get the water intake that you need and try to reduce the alcohol. Can we go 30 days with no alcohol and just see what that does for your overall health? See what it does for your sleep, your concentration, see what it does for your overall training, your fitness in the gym? How much sharper am I cognitively when I'm at work? Measure all those things after 30 days of no alcohol. If you make it 30, can you make it 60 days no alcohol? 60, can I go 90 days no alcohol? And just start aggregating these days of optimizing all the little details that you can. And you're going to see such big rewards on your fitness. They're little challenges. They're hard ones. They're not easy, but they're ones that we can bite off and actually stick to for a month, make one month into two months, make two months into three months. The majority of us don't need a new competitors program. We finished watching the CrossFit Games and everybody's selling their hard work pays off, their Matt Frazier program, the new Mayhem Rich Froning style stuff. And while all those are great programs, for most of us, that's not what we need. We don't need additional loading. We don't need more volume or longer duration workouts. What we really need is more consistency in the gym. We need to get stronger at the things that matter and we need a better conditioning, a better engine to be able to do more things. And then the lifestyle stuff comes along with that. We're going to be one hour in the gym and the 23 hours out of the gym. What are we doing with the 23 hours out of the gym? Can I set a bedtime? Can I get better sleep quality? Can I eat better? Can I reduce my alcohol consumption? All of those little details that will stack up and aggregate over a year or six months or nine months into a much fitter version of yourself. The stronger and healthier you get, the longer you're going to live. And ultimately that needs to be all of our game plan. Why are we doing this? The oldest, not the oldest member, the most tenured member of my gym, we call him the Godfather just for that reason, says all the time, I'm just trying to still be doing CrossFit when I'm 70. Like every decision he makes in the gym day by day, he keeps that greater focus. He's not coming into the gym saying this is the year I make it to the games. He's coming into the gym every day saying, I need to make a decision that's right today so that I can still be doing CrossFit when I'm 70. Because I know that if I'm still doing CrossFit when I'm 70, I can be doing all the things in my retirement that I want to be doing. So keep the long term vision in play. We're looking to be able to do this over a lifespan. Stretch out and increase your lifespan, the number of healthy, good years you're living. That's what ultimately this is all about for us. So here's some small actionable goals that people like you and me can really bite off and really set our sights on over the next six or 12 months. Throw our hat in the ring when the Open comes around next year and say, hey, you know what, because I put that work in starting in August, I'm really a much better version of myself now in February. Comment below if one of these, if you've got a goal that we listed off and you're like, look, I need to jump on that. Drop a comment below whether that's YouTube, whether that's Instagram, whether that's on a podcast format. Let us know. Reach out to us. And then as always, if you need help with any of these things, that's what we're here for. So talking about all things lifestyle related in our live course as well. Excited to see those of you that are going to make it for your first time out at one of those courses. We're hitting the road heavy this fall. So looking to see you guys out there. In the meantime, if you're training today, have a great session. Get some caffeine in you and ramp it up. I will see you guys out on the road very soon. Have a great day, everyone.

15:56 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses average arrival rates in physical therapy, what the research says about how to improve arrival rates, leveraging technology to improve arrival rates, and creating policies & systems that ensure your clinic still gets paid for missed appointments.

Take a listen to the podcast episode or read the full transcription below.

If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Good morning, everybody. Welcome to the PT on ICE daily show. Happy Thursday morning. Hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as the chief operating officer here at ICE and the faculty member on our fitness athlete division. We're here on Thursdays. We talk all things leadership Thursday, small business ownership, practice management, that sort of thing. Leadership Thursday also means it is gut check Thursday. This week we have a 17 minute AMRAP, as many rounds and reps as possible in 17 minutes of the following 21 plate ground to overhead. Our Rx weight there for guys 45 for ladies 25. So grabbing a bumper plate, hinging down, tapping one side of the plate between your feet and then up and over overhead, almost like a snatch. Moving into 15 cows on the rower for guys 12 for ladies and then finishing with a small dose nine burpees to plate. So looking for somewhere between three to five rounds of that great workout for home, the garage, the basement, the clinic. Just need a rower and a bumper plate. Great to maybe take out to the park as well and sub the row for some running or something like that. So that is gut check Thursday. Course is coming your way. We have so many about to enter a very, very busy season for ICE here as we get into the fall, get away from the summer, school starts back up, that sort of thing. We have a couple hundred courses coming your way between now and the end of the year. So if you're looking for live courses, head on over to p10ice.com, click on our courses and check out our map to see what's coming to your neck of the woods. Some online courses I want to highlight. Pretty much all of our entire catalog of eight week online courses are starting back up after Labor Day. So if you don't know about our online courses, they are eight weeks online. They are synchronous, which means that you meet with us every week. They are not completely self study, a mixture of lecture, of reading, of homework and of live meetups. They're meant to simulate the feeling of a two day live course, but stretched across eight weeks to make it a little bit more accessible, save you a little bit of money on travel. So online courses, pretty much like I said, all of them are starting after Labor Day. We have ICE Pelvic Online. That's our entry level online pregnancy and postpartum course. That's going to start September 4th. We have Fitness Athlete Essential Foundations taught by yours truly Mitch Babcock, Kelly Benfee and Guillermo Contreras. That's going to start September 11th. The very next day, September 12th, Brick by Brick is going to start very relevant course to this day of the week to Thursdays. We talk all things practice, startup and ownership and management in that course. Injured Runner Online also starts September 12th and then Virtual ICE will open back up September 26th for our next quarter of enrollment. So let's get into today's topic. Let's talk about how do we handle, how do we get better at when a patient reschedules, cancels or no shows. I want to talk today about three main topics. I'm going to talk about what are the average no show cancellation rates, what we would call an arrival rate across the country, across physical therapy, what's normal, what's abnormal. I want to talk about how to improve those arrival rates. And then I want to talk about how to get paid when somebody does not show up for those appointments.

05:46 ARRIVAL RATES IN PHYSICAL THERAPY

So let's start at the beginning and let's talk about what is a normal rate. If you have been practicing physical therapy for a while, if you have been practicing in a traditional clinic, you may have heard that the common recommendation for the maximum arrival rate is about 93%. That is to say that 93% of your appointments show up for their appointment that day. That there's some margin of error. We recognize that 100% of people probably won't make it, but pretty typical. 93% is the standard that's set and sometimes enforced by the clinic that you work for. Maybe if you fall below that, maybe you get a warning, maybe you get a talking to, or maybe they actually dock your pay for visits underneath that 93%. What's awesome about this topic is that we actually have a lot of research, surprisingly, supporting the numbers that I'm about to tell you. So we have a great survey back from 2015 of about 7,000 outpatient physical therapists. This is from Bo Kinski and colleagues, sorry if I mispronounced this, of 7,000 outpatient PT's looking at a couple of different things. Looking at finding the average cancellation no-show rate, but also finding what things seem to help fix that. So across the country, we see an average no-show cancellation rate of actually about 10 to 14%. So thinking you may have been told 93% is the gold standard, in reality, somewhere between 85 to 90% is actually probably more realistic. If you had 10 patients scheduled for the day, you could expect maybe eight of them to show up for the appointment. You could expect maybe one to two appointments to be unfilled. I like this survey because it goes a couple levels deeper. It asks why. Now knowing that rate, knowing that 10 to 14% rate, why do people not show up for the appointment? What is the number one cause? The number one reason why patients do not attend their appointment is not that they can't afford it, not that they don't like you, it's that they forgot and that the clinic that they went to physical therapy to had no reminder system. So that's a huge error, that's a very easy fix. When we delineate outpatient physical therapy from hospital-based outpatient physical therapy, so private practice versus hospital-based, we see that hospital-based clinics actually the no-show cancellation rate of a private practice clinic. Why is that? I would imagine it's probably due to having a modern reminder system, but again, that number of 93% isn't the gold standard that we think it is. In private practice, we can expect maybe 85 to 90% arrival rate, a little bit lower in hospital-based, maybe 75 to 80% arrival rate. Now this survey looked at the concept of a multi-method reminder system. What does that mean? That means that the patient received multiple reminders across multiple communication methods. That they usually received some sort of automated phone call reminding them of their appointment. They received probably a text message and then maybe also an email message. So they received two to three different reminders ahead of their appointment across different modalities, basically reminding the patient as much as possible of their upcoming appointment. Now they found that those clinics that used a multi-method reminder system had a significant reduction in no-show cancellation rates, about a 50% reduction. So they cut their no-show cancellation rate in half just by having a reminder system. And we're going to talk about how to set that up at your clinic here in a minute. The second reason that clinics did better with no-show cancellation rate was those clinics who had a 24-hour appointment change policy. That is inside of 24 hours, you will be penalized if you cancel or reschedule or no-show your appointment versus if you give more than a 24-hour notice that you need to reschedule your appointment or otherwise cancel it. So those clinics which had a 24-hour policy and enforced that policy on their patients also had a reduction in their no-show cancellation rate. So that brings us to the question of if 10 to 14% is the mean of the average of no-show cancellation rates across the country, then how realistic is 7%? The answer is not very, right? Even if you are treating one-on-one for an hour and you maybe only have eight patients on your caseload for the day, it's probably unrealistic to expect 100% of those people to show up every day. That we have to recognize at some level that the reason we see so much overbooking in traditional physical therapy clinics is it's just that leadership strategy to limit the impact of those inevitable no-show cancellation rates. That if you see eight patients in a day and 10 to 15% don't make it, you may see five to seven patients. So kind of the aggressive leadership solution here is just to make you see more patients. That if you see twice as many patients and you still have that 10 to 15% no-show cancellation rate, then you'll still see more patients than originally intended and scheduled to and the clinic won't lose as much profit. But that being said, that is an aggressive way. That is a way that puts all of the burden of the work on the therapist and none of it on the ownership, none of it on the leadership and none of it kind of on the backend logistical side of the clinic. Instead of making you see more patients, why don't we just have a 24-hour policy that we enforce? And if we're not using a reminder system, why don't we start using one? Why don't we do some more conservative approaches to reduce that no-show cancellation rate, especially now knowing that we have research that supports, does those actually improve our no-show cancellation rates? So let's talk about that.

08:48 IMPROVING ARRIVAL RATES

Let's talk about aside from having a reminder system, aside from strategies to remind patients to get to the clinic and aside from having a policy, how can we approve improve those arrival rates? You know us here at ICE, if you've been listening to us for a while, Jeff Moore, our CEO says it best. The first thing you can do to make patients show up to physical therapy more is make sure that you're focused on getting good and not getting busy. That when people see results, when they begin to associate value with their physical therapy appointment, they come to their appointment more often. I think this is so overlooked, especially in a higher volume clinic where a therapist may be expected to see multiple patients per hour. By providing lower quality care, patients aren't able to get results or they're not able to get results as fast as maybe they want to. They don't really associate physical therapy as a valuable use of their time and it makes sense that they find better stuff to do and that you get that message at 4.55 p.m. that your 5 p.m. patient is not going to make it in today. So really focus on getting good, not getting busy. We also need to recognize that people are not stupid. When they show up to PT and they see that you are working with three other people at the same time and you have forgotten about them in the corner at the TheraBand station or on the recumbent bike or the pulleys, again, that really begins to lower the value proposition that patients have with physical therapy and it's not surprising again that they begin to find better stuff to do with that hour of their time. The counter argument here is that you can get so good as a physical therapist, I'm good enough that I can see multiple patients at once or patients aren't as fragile as we think. We don't need to give them one-on-one care, but we need to recognize that at some level, patients are paying for it, especially if they're paying cash for a one-on-one visit. They are expecting one-on-one treatment. Even if you are an insurance-based clinic and using a patient's insurance, that insurance is still paying you based on one-on-one care. And not only that, but the patient expectation is that you are going to give them the care that they need. And I often relate this to other professions of you would lose your mind if you had a therapy appointment with a psychologist, a mental therapy appointment, if you showed up and there were three other people getting mental health therapy at the same time as you. No one would put up with that, but for some reason, it's just expected and normalized that that's the kind of care that we give in physical therapy. So then it's no wonder that patients, again, find something better to do with their time for the hour. So really focus on getting good and not getting busy, of taking really quality care of that patient that you have on your schedule for that hour. And you'll be surprised how much they come back to physical therapy when they see their range of motion improving, when they see their balance improving, when they feel stronger, when their pain is getting better, whatever their goals are, as they can see progress towards their goals, it's much more likely that they're going to come back to physical therapy. And I think that is often overlooked. My second point with improving arrival rates is to leverage technology, implement that multi-method reminder system. It's 2023. There is no reason why your clinic does not have automated reminders, text, email, phone, whatever. It's all built in to a modern EMR. If your EMR does not do this, you need to get an EMR that does this. If your front desk person is still calling people by hand to remind them of their appointment, you're a little bit behind the curve, right? to do the work for you so that you can focus on treating your patients while the technology sends out those reminders for you. We need to recognize that people are busy and that the more we can be prominent in front of mind with reminders, the more likely people are to attend their appointments. We have research that supports this, right? We can cut these no-show cancellation rates in half with a multi-method reminder system, but also it gives the patient a chance to reschedule if they know they already can't make it, right? That text reminder, when they get that phone call, when they get that email, it gives them multiple chances to reschedule. And if they don't, it also kind of builds the case for you against them that you gave them plenty of chances to reschedule and they still did not. And that makes it a little bit easier to charge them money, which we'll talk about in a few seconds here. So remember, we can cut that rate in half, that no-show cancellation rate in half with a multi-method reminder system. So if you're still using Google Drive as your EMR, if you're still using paper documentation and scanning it into a computer, consider getting a modern EMR. They're not that expensive. EMRs, we're big fans of Jane here, obviously, at ICE, other EMRs, Prompt, PT Everywhere, pretty much all the modern web-based EMRs are going to offer reminders and more often than not, they're free for you to use. So why not use them, right? It's one more push of a button when you're building out that patient chart for them to get reminders. In addition to reminders, leverage technology to create an online booking and waitlist system so that when you do send that reminder, it should come with a link where it says, hey, if you can't keep this appointment, please click here, right? So that your appointment comes off my schedule and that you get a little link to rebook at a time that works better for you. So we still keep that visit on the schedule, but we also open up that visit to maybe somebody else who can use it so that we don't have a missed slot on our schedule. Pretty much just like reminders, modern EMRs are very good at having automation with waitlists of where when a patient reschedules and a slot opens up, usually automatically or with the push of a button, you can pull people in from your waitlist and make sure that that slot stays filled without having that patient get charged for cancellation or no-show because they were able to go in on their own and reschedule their own appointment. So make sure we're leveraging technology whenever possible to do this work for us. My last point here on improving arrival rates is probably something that we don't consider very often of making sure in that initial evaluation that the patient actually has the time and or money to come to their physical therapy appointments. I feel like a lot of time patients feel beholden to maybe a referral they had from a doctor or what you tell them of some sort of verbal contract of the doctor said I have to come here three times a week for six weeks or maybe that's what you wrote on your documentation is the physical therapist and they feel like they have to come no matter what, even if they know they do not have the time or money. I feel like this is something that should be discussed as we're wrapping up our initial evaluations that just doesn't get done. As we're building the bike for that patient, we're explaining our findings, we're demonstrating that we can help that person reach their goals by showing them some improvement in that first visit and as we begin to discuss what that plan of care might look like, also making sure that the patient is on board, right, including the patient that conversation of hey, Diane, this seems to be a pretty irritable tendinopathy. You know, I think I would like to see you here in the clinic twice a week, probably for at least the next four weeks. And instead of stopping there, take it one step further. How do you feel about that? Right? What do you think about my plan for your care? And we don't necessarily have to ask, hey, can you afford this? Or do you have the time for this? But that's what we're hinting at of how do you feel about coming here twice a week for four weeks? How do you feel about coming here once a week for the next four weeks and getting the patient's input because that's a great time for them to say, that's going to be tough with my schedule. You know, I have 17 kids or I work 30 jobs. I won't be able to do that, right? That's a great time to make sure that person does not get put on your schedule for a bunch of visits that they're not going to attend. And then making sure we're following the law, right? No surprises act that was passed last year that were very transparent with how long we think the plan of care is going to take and what that's going to cost that patient. Whether you're charging cash, whether you're billing insurance, you need to provide that information upfront to the patient. I would argue you should be doing it even if it's not the law, just so you don't have people on your schedule who are not going to show up. But being very forthright and how long you think it's going to take and what's that going to cost and get that patient's input on it before we talk about scheduling out for their visits.

19:05 GETTING PAID FOR MISSED APPOINTMENTS

My last point here of talking about what average arrival rates are, what improves arrival rates is how do we get paid when somebody does not show up to the clinic? This is another area where I think physical therapists are very uncomfortable with asking people for money to come to rather not come to their appointment. And it's an area where again, when we look at the research, what improves arrival rates, multi-method reminder system and having a rescheduled cancellation policy that is enforced. If you don't enforce it, you can't get paid for these missed visits. And if you try to enforce it like halfway through the plan of care, the patient is probably going to be upset versus if you're straightforward from the start in your intake paperwork and with your expectations before they begin physical therapy, it's not as jarring to that patient when you charge them for that canceled or rescheduled appointment. So remember, combination of a reminder system and a clearly stated 24-hour rescheduling policy that's enforced are the keys to reducing your no-show cancellation rate by as much as 50%. So first things first, create a policy. What do you want your policy to be? Make sure that policy is very clear, very transparent and that patients see it before they actually come to the clinic. So for us here at Health HQ, this is the first thing that patients see when they go through their intake paperwork. They see our cancellation no-show policy. They see our rates. They know what they're going to be charged. They know the maximum they can be expected to pay out of pocket if they do have insurance and they're going to see what they can be expected to be charged if they cancel or reschedule appointment within 24 hours. So ensure you have a policy, make sure it's actually written out, make sure that it gets in front of patients before they commit to a plan of care and then decide on what you want to charge that person. Decide on what your rate will be. I would argue it should be what you would want to get paid for that hour even if the patient had come. A lot of clinics will have what I would call a dinky, kind of a really lackluster enforcement policy where maybe if you don't show up to your appointment, you're charged $10 or $15. That's really not enough for people to have skin in the game. Being charged $10 or $15, especially if you don't actually enforce it, is really not going to set the expectations for your patients the way you want it. For us, we want to be sure the patient, sorry, the therapist gets paid as if they had seen that patient even if the patient no shows or cancels. So we charge $75 and we enforce it. Right? How do we enforce it? Well, you should probably start obtaining payment methods before the plan of care begins. So again, somewhere in your intake, transparent, clear, laid out should be what you charge for cancellation, a no show, a reschedule, the amount, and that you should take a payment method and have that payment method on file even before the initial evaluation happens so that even if they don't show up to the evaluation, your therapists are able to get paid for that hour. And then actually enforce it. You have to enforce it. You have to rip the bandaid off and actually do it. If you don't do it until somebody has done this to you 19 times, it's going to be difficult to actually start enforcing it because you've let them get away with it so many times. Maybe your personal policy in your mind is that everybody gets one freebie. Whatever that is, stick to that and then start actually enforcing it. What you'll find is that when you enforce it, guess what? The first time that patient gets charged that money, guess what they never miss again? Physical therapy. Or they reschedule so that they don't leave an empty spot on your calendar book. So recognize that we have to enforce this. Yes, it's uncomfortable, but the more you do it, the sooner you do it in the plan of care, the more you'll find patients will either adhere to it or they might decide therapy with you is not for them and that's okay too because the end result is we want people on our schedule who are actually going to come to physical therapy. We need to recognize that this is not unusual. Oftentimes we said, well, this isn't something physical therapists do. They don't charge people for not coming to appointments. Literally every other industry on the planet does this. When you make an appointment to get your haircut or whatever personal beauty grooming thing you do, they have a reschedule cancel no show policy where if you don't show up to your appointment for whatever reason, you're probably going to get charged a little bit of money. Massage therapists do this. Lawyers do this a lot. You have to pay money upfront to even talk to a lawyer, right? You have to have that retainer money on file. Dentists do this. Other healthcare providers do this. This is very, very common across a wide range of industries except for physical therapy. People often ask me, why do you think that is? I think it's because we spend a lot of time with our patients and we begin to almost view some of our patients maybe as friends or at least acquaintances, which makes it that much harder to begin to charge that person for missing a physical therapy appointment. So we need to recognize that yes, it is difficult, but again, every other business does this. Every other industry does this. The sooner and more comfortable you get with enforcing this, the less awkward it's going to feel. And remember, leverage technology to fill those missed appointment slots so that ideally the therapist still gets paid for that person not showing up, but maybe they can also fit another patient into that spot still. I love when I pull up our schedule and I see that somebody has canceled, they've been charged for it, and we've been able to pull another patient from the wait list to fill that same slot. That therapist went to work, came to work here that day thinking, I'm going to see seven people and they actually got paid as if they had seen nine. That's fantastic, right? That's way better than systems where you may be expected to clock out if a patient doesn't show up and not get paid at all for your time, or you may be expected to clean the toilets or something like that in that missed time versus actually getting paid for that time and either being able to use that time for whatever you want or trying to fit another patient into that slot. So remember, it's really important here. This is all an end, not or situation that there are different components to this that we need to implement. It's not just we need to charge people for not showing up. It's not just we need to have a reminder system that we need to understand that at some level, having 100% arrival rate is unlikely. People not showing up is unavoidable, whether kids, family emergencies, that sort of thing. But there are things that can be done to reduce those rates. They're not unavoidable that we can deliver great outcomes to patients so that they do not find other reasons and other things to do instead of coming to physical therapy. We absolutely have to get with the program and begin to leverage technology, begin to send these reminders out if we're not doing it already, begin to use technology to have a waitlist system so that we can fill empty slots quickly, create and actually enforce a policy, get credit cards on file, begin to actually charge people for not coming to those appointments, hold them accountable, hold their feet to the fire, but also recognize and have that conversation early on of what is realistic for that patient. Do they actually have the time and money to come to therapy two or three times a week? Or do we need to look at maybe, hey, I can see you once every other week, but you're going to have to be really judicious at home with your homework because you're not coming here as much. So having those conversations early and often in the plan of care so they don't come back to bite us later on and then utilize technology to get paid for those visits and fill those empty slots. So reschedules, cancels, no shows, not to the end of the world, things we can do better to get better at them, I should say. Leverage technology, enforce a policy. So I hope this was helpful. I hope you all have a fantastic Thursday. Have fun with Gut Check Thursday. If you're going to be on a live course this weekend, have a wonderful weekend with our faculty on the road. We'll see you all next time. Bye everybody.

24:17 OUTRO

Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult Division Leader Christina Prevett discusses the need for falls prevention initiatives to shift their focus towards early identification of individuals at risk for falls. By doing so, healthcare professionals can implement targeted interventions and reduce the occurrence of falls before they happen.

Christina emphasizes that outcome measures should be used to guide interventions. She mentions the Mini-BEST as a specific outcome measure that assesses various aspects of balance and mobility. By administering this measure at the beginning of a session, the clinician can immediately identify areas of deficit and tailor their intervention accordingly. For example, if the person shows deficits in dynamic gait and reactive posture control, the clinician can focus on exercises and strategies to improve these specific areas.

Overall, the episode highlights the importance of outcome measures in falls prevention and emphasizes that they should not be conducted for the sake of it. Instead, outcome measures should provide meaningful and actionable information that guides clinical reasoning and informs interventions.

Take a listen to learn how to better serve this population of patients & athletes.

If you're looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show.

01:33 CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on ICE Daily show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division, part of our geriatrics team. Everyone, we are flying high this week because we got everybody from our MMOA division to descend on Lexington, Kentucky at Jeff and Dustin's Stronger Life facility, which was beautiful. And we got to show the world some of what we have been working on, which is some revamped material. So we got to really focus on dialing in live to be about lab. We were moving all weekend. It was so fun and so amazing. If you were thinking about joining MMOA live, we have a couple of opportunities coming up in the remainder of this month. So this weekend, Dustin and Jeff are going to be in Bedford, Texas, and Julie and Ellen are going to be in, oh my gosh, I'm blanking on where they are. They're in Minnesota. And then there I was like, I know this. And then the next weekend, Alex is going to be in California. And so if you are looking for where MMOA is going to be, we have a ton of courses into the end of 2023. We are not adding any more locations for MMOA live in 2023. So if you're kind of waiting for one to come closer to you for the end of this year, that isn't going to happen if it's not there now because we're kind of locked in. We have lots of offerings that's going to come up for 2024. So if you're looking to see that live material, that is where to go.

03:29 A FRAMEWORK FOR BALANCE INTERVENTION

OK, so today I wanted to talk a little bit about a framework for balance intervention. When it comes to balance, I think it's a bit tougher for us to put this marker of effort or intensity on, maybe more so than other styles of fitness. What I mean by that is when we think about aerobic training, it's easy for us to conceptualize effort because we're seeing that perspiration, we're seeing that heart rate response. And that's correlating to our rates of perceived exertion. When it comes to resistance training, right, the amount of effort is either going to fatigue kind of in those higher rep ranges or our personal preference is getting to fatigue and effort through higher load. And again, it corresponds to changes in rates of perceived exertion. When we're trying to conceptualize intensity and then we're really trying to dial in our balance interventions, it's a bit tougher, right? We don't really have the same magnitude or the same outcome measures with respect to gauging intensity well. And so within MMOA, we really try and create this framework for individuals to help guide them through this kind of thought process and then create a kind of stepwise framework within our mind for how we implement this in clinical practice. The way that we do this is by first looking at the mechanism at which individuals are falling or where they are having near falls. This is important, right?

05:00 FALLS PREVENTION INITIATIVES

Our falls prevention initiatives are only preventative if we are identifying individuals early rather than waiting for them to get hurt and then working in secondary tertiary prevention. We want to be able to identify those who are at risk for falls before that fall has happened, which unfortunately is not as common in our health care system as it stands right now. So we want to figure out the mechanism. We want to identify risk factors that are intrinsic to the individual and extrinsic around their environment. And then in order for us to put objective data on those things, we need to take that information from our subjective and use the appropriate outcome measure in order for us to have a good data point or multiple data points in order to guide our interventions. And then we want to make sure that those outcome measures that we are selecting are giving us tangible information, right? We don't want to be doing outcome measures for the sake of doing outcome measures. We want to do our outcome measures so that they can guide our clinical reasoning. And so let's kind of go through this very briefly and speak to the different aspects of this framework. So the first thing is mechanism, right? When we are asking about our person subjective, many times they're kind of cursory with their storytelling. A lot of individuals are when they're speaking about falls. Oh, well, I stubbed my toe and I fell over. What were you doing when you stepped your toe? What was your frame of mind? Were you really rushing to get from point A to point B? Were you really tired because it was late at night? Were you holding something in your hand when you tripped and that created an other barrier or other cognitive load in your mind that created more of a predisposition to not be able to keep your center of mass over your base of support and respond to that perturbation? Was it that there is a visual issue going on and you were having trouble with depth perception? We need to kind of dig really deep into some of these stories because that's really going to triage this risk factor profile in our brain. But you're probably thinking, well, Christina, a lot of my clients just can't do that or they don't remember or they are not able to give us some of that really tangible information. And I hear you. And so when we don't have that information, the next step is for us to go to the literature and look at what are common scenarios that lead to falls in different settings. Right. And how much do those mechanisms and that group of individuals that are being conceptualized in this research study relate to the people that are in front of you? An example is if you're an outpatient orthopedic therapist looking at some of the acute care mechanisms of falls may be relevant, but probably is less relevant to you. So you're going to be wanting to know, well, what is happening for our community dwelling older adults? What is their profile look like? What age group are individuals looking at in this study? And then how does this relate to my current caseload or people that I have that I am seeing right now? And so there is a recent study that came out in 2023 that was doing a prospective. So following older adults forward in Boston that was looking, for example, at mechanisms of falls in community dwelling older adults. So what they did was every month they sent older adults in this study. So they consented to this study. They were in their 70s or older. They sent a postcard to them and asked some questions. Did you have a fall in the last month? If yes, what was the mechanism? What were you doing at the time of the fall? And what was the cause of that fall with what you were doing? And I think this is interesting because they are two different things, right?

09:26 SLIP & TRIP TRAINING

So the cause of the fall in our community dwelling older adults over 70, for example, more than half was a slip or a trip. The activity when they were having that slip or trip was walking forward. That gives us a lot of information in terms of where we start with our older adults. We're not going to start standing on one leg. We're going to start with slip and trip training. We're going to look at reactive stepping, volitional step training. Maybe we'll do that in standing first to see where a person's control is, but we want to see what happens when they start having perturbations. And so if that slip or trip is happening going forward, it also tells us that that perturbation is often backwards or lateral. People aren't falling forwards, right? It's that they're slipping and coming to the side or they're slipping and coming back. And that's a really important piece of information for us. And then it's going to guide where we go. So the next thing is now we're going to look at a person's risk factors, right? So extrinsic risk factors when individuals are having slips and trips was, was this in the wintertime and they're slipping on ice? Was this a step? Was this a rug that we know we're never going to get rid of, but we may ask about trying to tape down? These are things that we may be considering when we are looking at these mechanisms or are asking these questions. And so that's extrinsic. So we're taking this mechanism. We're looking at some extrinsic factors. And then the intrinsic people are going to be telling us in their narrative that they may feel like their balance isn't really great, or they're having trouble holding on to objects and navigating around their home or navigating outside. Or they recognize that the pain in their knee is making them not feel as strong or confident in their gait. And it's going to create them to have a hesitation to react when a perturbation happens because they've had times where their leg has given out. Or they they don't feel like they're strong enough to move their feet, right? They're they're telling us these things in their subjective. And so when we take that information, now it's going to guide us into our outcome measures. So if individuals are saying that they're having falls because of a strength deficit or a weakness issue in their lower extremity, we may want to make sure that we have a general mobility or a strength focused measure in our assessment to get a good idea of where our triage list is going to be. So we may use a five times it to stand or a 30 seconds to stand test, or we may go a bit more general and go to the short physical performance battery because the mechanism of their fall is showing us that potentially that being that capacity to move their feet is coming from a weakness issue.

11:54 REACTIVE POSTURAL CONTROL

We are also going to want to in this example, look at their reactive postural control. We heavily leverage the mini best because there is a subsection of the mini best that looks at reactive postural control in each direction. So we're going to look at a person's capacity to react to a forward perturbation, backward perturbation and lateral perturbation. Right. If a person is having pain in the lower extremity, they're worried about it and we do a lateral perturbation, they may not move their feet out. They may want to cross because they're worried that that painful knee on that left hand side is not going to support their weight. So their reaction may be a step out to the right and a crossover to the right because of that painful knee. So now we've learned two things, right? We know that their pain is a contributing factor to their falls mechanism. It's an intrinsic risk factor that's creating troubles with clearance. It's impacting their gait, whether it's causing deviations in their gait or it's making them not lift their foot enough and now slips and trips are more common. And we recognize that their lateral posturing, the way that they are moving to the side is impaired. So now we've really dialed in our assessment, right? We've gotten a good idea about what's going on and we've picked the outcome measures that are going to give us that information. Because if we just focused, for example, on a burg. Because that is our go to balance assessment, not only are community dwelling older adults more likely to sealing that out, but it's not really getting to the two really big issues that they spoke to in their subjective assessment, right? They are probably going to be able to stand up once and do a pivot transfer. But that five time or 30 seconds to stand that's requiring a repeated chair stand is going to hit into maybe their pain thresholds that they're going to start having some compensatory mechanisms. And they're talking about having perturbations in a forward movement pattern. So the burg is in capturing backwards and lateral perturbations. So we have to be using those mechanisms and risk factors that they're discussing with us in their subjective and then leveraging the outcome measures that have strong reliability, validity, responsiveness, interpretability in order for us to have a good idea of what the next step is. But we're not going to do outcome measures for the sake of doing outcome measures. The next step is that we need to use those and leverage them in our interventions. One of the reasons why we also love the mini best is that oftentimes the way that we implement this is not day one. It's a little bit more of a longer intervention or sorry, it's a longer outcome measure. But we use it at the beginning of a session because it drives us into our intervention immediately. So if we have, for example, there's the anticipatory sub scales, sensory orientation, dynamic gate and reactive posture control. If we think that dynamic gate and reactive posture control are the two areas that based on a person's objective, they may struggle with more. We may use those, see where they're starting to have these deficits. It may be obstacle navigation, for example, with that still going with this example of having slips and trips because of a painful knee and seeing gate deviations where they're not clearing obstacles as readily as they used to when pain was a bit more managed. And they may have issues with reactive postural control backward and laterally. And we're going to see that it's coming to the left because it's their left knee that's painful. So now we have a lot of good information. We have a lot of good data. We use those outcome measures and we're directly going into intervention, right? Like I may use a clock yourself app and block out the forward stepping and I'm going to be focusing on reacting backwards. Or I may take out the right hand side of the clock and I want them to react to the left. And that is going to do at different cadences and then see, you know, what does the threshold look like? What does the step length look like? Does pain start to increase? What is that pain threshold like? How long does that pain take to come back down? And we're also intervening. We can also take, you know, some of these obstacle courses and put them into our interventions that day. Throw all of them together and put them into a round for time or an AMRAP where they're going back and forth between reactive stepping and obstacle courses. And now you're working on some strength because they're doing bigger clearances. We may put a step up in that obstacle course and then we're working on reactive control to the side that they're experiencing difficulties. So when we kind of take a step back, when we slot in what we see into this framework, it can be really helpful. So to bring this full circle, we want to think about balance intensity just like anything else. It's just like aerobic training. It's just like resistance training, but we cannot get good outcomes with bad data. So how do we do this? Our subjective, we need to dial in on mechanisms and risk factors. We need to be asking questions. If we do not have the answers to those questions, we're going to rely on the evidence of where older adults in different settings tend to fall. Then we're going to use outcome measures and we're going to select the outcome measures, if we can, based on our setting, that are going to give us the information we need to see where those thresholds are. From there, we're going to drive ourselves right into intervention based on where those deficits lie. And we're going to get to an intensity where individuals are either weary, we're pushing into potentially some low-grade pain, or they are self-reporting high amounts of fatigue or nervousness.

17:31 PROGRESSIVE OVERLOAD & FEAR

So we may be doing some graded exposure into fear. And that is a form of progressive overload, especially in the geriatric space where fear of falling is a big risk vector for future falls. So kind of bringing this full circle, here is the framework for you when you have a person coming in who is having falls or is worried about their balance. And it'll allow you to really dial in your interventions. Let me know if you have any other questions. What are your thoughts on this? I would love to have a dialogue. If you are interested in learning more about some of this research, we just put that 2023 paper into MMOA Digest. So every two weeks there is a research email that we send out that allows you to stay up to date with the evidence. We put all of our new courses on there, so definitely go to ptnice.com slash resources and sign up for Digest. If you are not on Hump Day Hustling, please make sure you do that too. That is all different types of research from all of our divisions. Have a wonderful Wednesday. Bye everyone.

18:34 OUTRO

Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you are interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE Online Mentorship Program at ptonice.com. While you are there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top 5 research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Kelly Benfey // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Kelly Benfey discusses her experience competing at the 2023 CrossFit Games, the role of rehabilitation providers in competitive sport, and the capacity of the human body for exercise as it ages.

Take a listen to the episode or read the episode transcription below.

If you're looking to learn from our Clinical Management of the Fitness Athlete division, check out our live physical therapy courses or our online physical therapy courses. Check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 INTRO

What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show.

01:33 KELLY BENFEY

Good morning and welcome to the PT on ICE Daily Show. It's Fitness Athlete Friday and my name is Kelly Benfey. I just wrapped up an amazing CrossFit season where I got to compete at the CrossFit Games. And so what we're going to get to talk about this Fitness Athlete Friday is going to be a couple takeaways from the CrossFit Games that I think are relevant in the rehab space. Before we jump into that, though, within our Fitness Athlete crew, we have a couple of online courses coming up that I just want to bring to your attention. So we just wrapped up an awesome cohort with our clinical management of the Fitness Athlete Essential Foundations course online. And so our next course is going to be kicking off in a few weeks on September 11th. That course always fills up. So if you're thinking about it, please jump in with us, grab your spot right now. And then if you've already taken that and you're looking to continue developing your skill set, our Advanced Concepts course that's only offered two times a year is also starting September 17th. So rarer opportunity to hop in on that one. So if you've been looking to take this course, that's going to get started quite soon. And then we have a handful of live courses for the remainder of the year. So all of that information is going to be on PTice.com, PTonice.com. So we hope to catch you live on the road. I'd love to see you all. So we'll be getting back on the road for the remainder of this year to finish strong. So let's get into our topic. Of course, I could talk about this stuff all day if you know me. So we're talking CrossFit Games takeaways. A couple of things that I experienced and found were relevant in the rehab space. This is Fitness Athlete Friday, so we get to geek out on all things, CrossFit Games, CrossFit competition, all that good stuff. So number one, I have five different things that we'll kind of work through.

03:35 HUMAN CAPABILITY

So number one, I always leave the CrossFit Games feeling absolutely motivated and inspired by what the human is actually capable of doing. So I really it was it was just such an honor to be on the same field as some of these amazing, amazing athletes, be behind the scenes and all that good stuff. So a couple highlights that I saw now just to I competed in the team division. So it actually didn't allow me to watch as much as the individual competition. I'm still working through catching up on that all the live the live coverage that they had. But I got to be within the team division. So one of the athletes in the team division, she clean and jerked 250 pounds and then a couple hours later ran a 5K, 4.5 ish K, 5K in under 20 minutes. So it just always impresses me that people can excel in things that I also excel in the strength events, yet also push their aerobic capacity and monostructural skills to an insane level as well. So it was just absolutely mind blowing to see athletes also just I know how hard we worked on my team and just having other athletes really push the boundaries. I find to be super inspiring as a competitive athlete. And then moving moving towards almost even debatably more inspiring.

04:11 OLDER ADULTS PUSHING BOUNDARIES 

The age group divisions are always just such a blast to watch. I wish they had a little bit more coverage because arguably that's more these are more the athletes that are relatable and even more inspiring. For example, the 60 plus division, I believe the 60 60 to 64 division, both men and women had bar muscle ups in their last event. So these are our older adults crushing it, doing high skill level at a very high competitive level. Just absolutely amazing. And like I had the opportunity, my mom came and watch. She's going to watch me and have a blast, obviously, but she's not necessarily going to see like watch me and think, oh, wow, that's something I can do. She's going to see something in her age division and then become inspired of, hey, maybe I'm going to start my barbell class in my gym, for example. So I just think the human capabilities, even in our older adult divisions, is just as important as what the individual and team athletes are doing. The professional athletes, if you will. And then we also have the adaptive visions that are starting to grow and the upper extremity adaptive athletes were performing rope climbs. Rope climbs are hard enough when you have two upper extremities to grip onto the rope with. They were doing it with one and we're also sealing our lower adaptive lower extremity adaptive divisions, doing things like box jumps and maxing out their clean and jerk and snatch and really just taking no opportunity to have an excuse to not push their fitness forward and continue to be athletic and competitive in their sport. So I absolutely love seeing those. I wish I got to see a little bit more of it. I wish we got to view a little bit more of it on the broadcast, so hopefully we'll be able to continue pushing that forward. I just saw a couple posts of highlighting those athletes, so keep keep those in the forefront of your mind. That's what's really inspiring to more people, I think, in this world, in our country. OK, so the next three points that I want to kind of work through all kind of build off of each other.

09:20 INJURY RATES & PROGRAMMING

So one thing that I thought was really relevant this year at the Games was the programming. And like I said, I have paid attention a lot to a lot more detail of our team division programming, but I just wanted to bring your attention as a rehab professional, as a movement specialist that's working with athletes all the time. I think it was important to note this. So just a couple examples. So in our competition, we had four days of competition. On day one, we had overhead squats at 135 pounds and 95 pounds. Then day two, we had a one rep, one rep max snatch. And then on day three, we had more snatches at 185 pounds and 135 pounds with running. So that's back to back days that we're seeing a barbell shoulder stability type exercise that is very demanding on the shoulders. In general programming, we would probably look to spread the frequency out of when we're doing things like overhead squat and snatching. Being able to do those back to back days can challenge the shoulder and challenges your ability to recover and perform repeatedly. Another thing that I noticed as on our day two, we had a strict ring muscle up to a front support hold. So going through that pole to deep press and hold at the top of the unstable rings is really challenging for the shoulders. And then right into day three, we had 30 synchro ring muscle ups on the long straps, which are tough. And then 63 more parallet bar dips. So that's a lot of vertical pressing for the shoulder to get through back to back days. And so I've personally experienced issues with pressing with shoulder pain. I've worked with a handful of athletes that recently have been that's a common theme in our clinic that I'm working with. So that is I remember if I was in the middle of having a flare up of that shoulder pain presentation, it would be really hard to be able to do that back to back days because you can always push through one workout. Adrenaline is a really strong drug, I would say that helps you get through it. But the next day when you wake up and things are a little bit inflamed, it's really hard to be able to repeat those motions. So that was just one thing I noticed that was not necessarily what I would have expected in programming, just how frequently the same movement is tested. And it's one thing to test the fitness of it, but it's also one thing to test the tissue capacity. So those are things that the my rehab mind was kind of evaluating while I was going through it, which brings me kind of into that next point I want to bring up was injury rates this year. I'm not sure if I just noticed more injuries and pain happening. A lot of KT tape being thrown on our limbs because I was in the background. But there did seem to be a lot of withdrawals from individual and team, excuse me, team athletes this year. We know the injury rates in CrossFit, the highest injury rates that we're seeing are in the shoulder joint. And based on that programming, it kind of makes sense. It makes sense that we're seeing a lot of shoulder issues. And so just from an athlete's perspective, it's absolutely devastating. It's so upsetting to have to withdraw from an injury, whether it's yourself, whether it's a teammate. We put so much time, money, effort and dedication to an entire long season. This started in February. So working day in and day out, making decisions based on that this specific weekend. It's just an absolute shame to see an athlete have to pull out of competition because of shoulder pain or whatever issue they may have. So I know I got to talk to a couple of the teams that had to withdraw. And the common theme that they were telling me was like, oh, yeah, I had this lingering issue for a while. I just retweaked it about two weeks ago. So they weren't necessarily the Roman Krenikov situation where they just, unfortunately, came down and rolled an ankle and had a new injury. This was a couple of these things were like lingering elbow issues that are really tested in the moment of competition with all the stress on board. Exposing to really deep positions of that dip position. If we have lingering shoulder stuff going on when you're pushing to 150 percent of your capacity, it's not likely that you're going to come out OK sometimes. So as soon as some of the workouts were announced, these athletes were like, well, I'm not feeling too great about this. So I take it's just such a shame because I think as rehab professionals, we need to have the skill set to be able to address these issues that our competitive athletes are experiencing and make sure that we're not just getting them back to be able to do a ring muscle up and take an ibuprofen. That's a whole other issue. We don't want our athletes to be doing that, obviously, but we want to be able to get them back to baseline and then beyond baseline because that originally that shoulder with that skill set got injured. So it's definitely up to us to be able to have the resources and provide rehab for these athletes that they find valuable. Not every single one of these athletes has a team of physical therapists that are top notch, that are traveling with them, that are on like on them 100 percent of the time. And so it is very likely that you may come across a CrossFit Games team athlete that's going to need to go through four days of competition with repetitively dips and butterfly pull ups and pulling, pulling whatever it may be. All these really challenging things for our shoulder girl to be able to tolerate. So that just I walked away being thankful that I came out unscathed, essentially, because if you followed any of my CrossFit career, I've had issues with my shoulder before. And strength always is super protective against injury. And I feel really lucky, essentially, to have all the knowledge that I have to put myself in the best scenario. Even within my teammates, we had a shoulder issue that we had to train around a little bit where we couldn't our best choice wasn't to continuing to do 30 muscle ups the week before, for example. But we rehab the crap out of it and put ourselves in the best situation possible to be able to come away without withdrawing by any means and putting up a pretty good performance over the course of the weekend. So that just brings me to want to plug our courses just one more time. So I mentioned the beginning, we have a couple of online courses coming up. I would say 75% of the clinical decision, clinical decisions I'm making on a daily basis are all things that I learned from these courses. The other 25% is probably all the other stuff I learned from my ice courses. So I know I'm biased, but I promise I'm not lying. If you at any point would feel nervous, nervous if I came into your clinic saying I can't do ring muscle ups, help. Please hop in one of our courses. It's really a fun, fun way to spend your eight weeks online. And so the last point I wanted to make kind of along the same theme was the importance of stress and recovery. So if you are an ice in the ice world, I'm sure you have heard us talk about the importance of stress and stress that the body takes on and how it helps us or doesn't help us recover well.

11:04 COMPETITIVE ATHLETES & REHAB

And competing in the CrossFit Games this past weekend really made this become like full picture for me. I prioritize sleep, I prioritize what I'm putting in my body, and I prioritize managing stress as well as I can with all of the training that we were doing. But at the CrossFit Games, I will say I was probably at a peak stress level in my life. I don't live there on a daily basis, but the couple of weeks leading up to it, highly stressed and enduring also highly stressed. For example, day one, the volume wasn't really high. We were coming off of two sessions a day, up to two hours per session. So training heaps, I would say. And day one, all I did was three leg assault climbs, 30 overhead squats and then four laps on the bike track, which was aerobically really challenging, but not high impact. And the next day when I woke up, my fitness tracker is showing me my heart, HRV is plummeting. I felt like I did probably triple that amount of volume at minimum. And I was really surprised because volume wise wasn't crazy, wasn't out of my realm. But I felt the I think what I was feeling was the high level of stress that competition brought on. So and just to circle back a little bit, if you're having lingering shoulder pain, it's probably not going to get better with how much we're ramping up as far as volume in the eight weeks leading up to the CrossFit Games.

15:10 HIGH STRESS IN COMPETITION

And then in the high, high stress environment, it's also going to be asking a lot to be able to recover and repeat these highly demanding movements like snatching, overhead squatting into ring muscle ups, to fatigue into dips where we're highly fatigued and moving at 150 percent of our capacity, essentially. So it just really is that's another way that I think bringing like stress and managing our recovery is just too important to ignore as the physical therapist, because we all know that person that's chronically stressed, chronically in that sympathetic state that maybe they are going into the gym and adding more weight. More stress onto their body. It's I absolutely can understand how they probably don't feel well at the end of the day, day in and day out. And so you have the ability as their rehab pro to help change their foundation of what they feel on a daily basis, too. So don't forget those things when you're dealing with any type of person that comes into your clinic. Stress management can really hit hard on so many levels and prevent maybe just set them up to rehab even better with all the good rehab skills you're doing with them in the clinic. And then lastly, I just wanted to share a couple of highlights because I feel like I had so many so much amazing support from our ice community. So just a quick couple personal highlights. Having been a spectator of the CrossFit Games for the five or six years or so has been in Madison. It was just such a cool opportunity to be able to push the Bob to do ring muscle ups with the long, long straps on the Zeus rig to use that four person axle bar for the deadlift. Those are things that you just never would see in a norm or any other CrossFit competition that's really only going to be at the CrossFit Games. So I remember pushing the Bob to the finish line and just reflecting on North Park, like, how cool is this? I've always wondered how it felt. So that was a really cool personal highlight that was really motivating throughout the weekend. Another personal highlight was our one rep max snatch. I have had some issues with shoulder pain and snatching and tweaked my elbow before from kind of poor movement patterns. So all season I was in a bit of a snatch funk. I'm sure you can relate if you are an athlete that tries to snatch frequently. It's sometimes good, it's sometimes not good. And so just about two or three weeks before the CrossFit Games, everything kind of clicked and I was able to hit a PR and perform really well on stage. So as an athlete, it just felt really special to be able to showcase the hard work that I put into that movement all season. And then lastly, I just had the best time with so many friends and family that were there to support at the CrossFit Games. I had my gym community from Milwaukee, my gym community from Chicago when I lived there, my ice community was there, our onward community. We had such a large cheering section, essentially. And trust me, that helped us get through that whole weekend. So thank you so much for everybody that was there, that sent messages, that supported us. It was such an honor to be able to represent this crew and we had a blast doing it. So thank you, thank you, thank you. So those are my takeaways from the CrossFit Games. I would like, like I said, this is stuff I can talk about all day, every day. So if you have any thoughts on programming, injury rates, anything you noticed from your spectating view, I would love to chat about it. So feel free to comment and tag me on this post, send me a message. Other than that, have a wonderful weekend and we will see you next or on Monday with our PT on Ice Daily Show. Have a great weekend.

19:06 OUTRO

Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on Ice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore challenges the common belief that vacations and time off are necessary to decrease stress levels. He argues that the expectations around time off may not align with reality, often leading to discontentment. Jeff suggests reconceptualizing the idea of time off and vacations to have better trajectories and lower stress levels.

Jeff then discusses what creates low stress levels and a healthy ecosystem. He addresses the issue of returning from vacations to a chronically disorganized routine. Jeff explains that when our day-to-day lives lack discipline and organization, we often find ourselves in a cycle of feeling like we need a vacation, being disappointed by its inability to meet our expectations, and feeling worse off as a result. Jeff emphasizes the importance of taking ownership of our day-to-day routines and reorganizing them to break free from this cycle.

Take a listen to the podcast episode or read the full transcription below.

If you're looking to learn more about courses designed to start your own practice, check out our Brick by Brick practice management course or our online physical therapy courses, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

Alright team, what is up? Welcome to the PT on ICE Daily Show. Welcome to Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice. Thrilled to have you here live via Instagram or YouTube. Thrilled to have you on the recording if that's the way you're taking in the show. It is Gut Check Thursday. Let's get right down to business. What is the workout that all of the Ice Train folks are going to be taking on this week? It is as follows. 35, 25, 15, 5. So we have 4 rounds descending in volume. They are going to be double dumbbell push press but not real heavy, 35 and 20. And then ab mat sit ups are going to be paired with that. Okay, so you've got your 35 dumbbell push press drop down. You get your 35 ab mat sit ups. In between each round, you're going to run 200 meters and the rounds are going to be 35, 25, 15, 5. Okay so you should be able to keep a pretty high intensity up because the volume on those rounds are dropping. Make sure you get a snippet of that. Put it on Instagram. Let us know what's up. Hashtag Ice Train. We love seeing everybody throwing down on those Gut Check Thursday workouts. Real quick, courses coming up. I want to highlight cervical spine. If you want to be out there solving neck pain, radiculopathy, headaches, all the things that come with that upper quarter region, get to this class. We've got 3 options coming up. August 26, 7. It's going to be at Onward Charlotte. September 9, 10. It's going to be at Onward Atlanta. In October 14, 15. Going to be at Onward Greenville. So going to be in North Carolina, going to be in Georgia, going to be in South Carolina. So belt there and hit that course. Learn those skills. Serve those patients well. Okay, welcome back to Leadership Thursday.

02:01 VACATON & WORK-LIFE BALANCE

We are going to have a conversation about why I think we've gotten vacations wrong. And I want to talk a little bit about the origin of this episode. So the other day I posted on Instagram some of the best advice I've ever received. It was from a friend. It was many, many years ago. And he said to me, if you play between the ages of 25 and 35, you will work hard for the rest of your life. If you work hard between the ages of 25 and 35, you will play for the rest of your life. And as I've watched now coming up on wrapping up the second decade of my career, I've seen a lot of people finish off their careers, seen a lot of people start them, myself going through my own. A lot of observation and the amount of truth embedded in that quote has been nothing short of shocking. When you get in the right lane early, and you get to you get with the right people early, you wind up doing what you love and excelling at it. And of course, just like investing, the earlier you do that, the more it compounds. And it really creates a scenario where the back two thirds of your career not only are more of what you love, but really decompress the stress. On the other hand, if you kind of get yourself into a financial hole and you're not in the right lane, and you're nearing the halfway point of your career, it really becomes a tough thing to dig out of. And it just sets you up for a bit more of a grind on the back end. Now we could have a whole episode about that quote alone, but that quote got a lot of feedback. And anytime you talk about working hard, you tend to get a lot of DMs and messages about the need for people to avoid burnout. And specifically that people need vacations and time off to decrease their stress levels.

03:46 EXPECTATIONS AROUND TIME OFF

That's what I want to zone in on because I think that our expectations around time off are really, really aired, if you will. And the problem with your expectations not being aligned with reality is that discontent is the inevitable result of that. So let's see if we can't reconceptualize this a bit and wind up with better trajectories. So think about what creates low stress levels. So if we're going to talk about stress levels, what creates low stress levels? What creates a healthy ecosystem? The answer is the following. Now we could put nine bullets here, but let's go with the really, really big rocks. That when you have them dialed in, your stress levels tend to be low, your nervous system tends to be really under wraps, you tend to feel really dialed. Probably the biggest one we'd all agree on is sleep quality. The consistency of it we know is the primary driver. But the other small things, having it cold in the room, having it dark when you're eating food, not having those late meals, sleep consistency is probably, or sleep quality, driven primarily by consistency, is one of the biggest drivers to day to day having low stress, having more energy. Number two is a regular fitness routine. You're getting to the gym at the same time that you're engaging in quality fitness. Number three is nutrition, that you're eating a quality, clean, well-balanced diet. Sufficient in protein, void, hopefully, of a lot of nonsense and processed foods, that you're eating quality nutrition. When you're doing these things that we preach about all the time, your ecosystem tends to be optimal, your stress levels tend to be low, you tend to feel your best when those variables are dialed in. Now think about how those variables fare when you're on vacation. And I think we would all agree the answer is poorly. You're sleeping in a totally foreign environment, your consistency of your sleep is all over the map, you're trying to get some fitness in but it's random, it's not nearly as structured as usual, and your nutrition, let's be honest, leaves a lot to be desired. It's usually very fun food, you're usually trying a lot of new things, but you tend to be eating late at night, it affects your sleep quality, all of the primary metrics that create that really well-defined healthy, low-stress human are significantly disrupted, specifically when you're on vacation. Now does this mean, right, and I think it's worth saying that if that's not the case, if those things, if your sleep quality, your gym routine, your nutrition, if those things are better when you're on vacation, your day-to-day routine needs a serious second look. So if you don't have those things dialed in better on your day-to-day and your usual environment compared to when you are out in some random state or country where you've got no control of the other variables, if you do better on those things out there, you need a serious look at your level of discipline and organization on your day-to-day life. But I think for the vast majority, as we would agree, those things are pretty dialed when we're at home and they are very erratic when we're on vacation. Now does this mean that we shouldn't take vacations? And the answer to that is of course not, right? A lot of the coolest memories in your life, right? The things that you're going to do that you're going to look back on and say, gosh, that was crazy or do you remember that? And the stories that fill your life, a lot of those things are going to be formed when you're on vacation. Your perspective will expand, right? You're going to be in new environments. You're going to be seeing new people. You're going to be looking at things differently because you're outside of your usual routine. Your relationships with those that you go on will often deepen, whether it's your partner or your family or your friends, right? You rarely spend that kind of concentrated time and it creates incredible opportunity for those relationships to deepen. All of these incredible things are going to happen when you're on vacation. What will not happen though is usually that your stress level will drop because the things that drive that are generally disrupted. So then what's the secret sauce?

08:18 DEVELOPING A ROUTINE FOR VACATION

The secret sauce is developing a routine that allows you to look forward to, but never need a vacation. That's the most important thing, right? You can't wait to do it. It's going to be a blast. You know those memories are going to be formed, but you don't need it because your routine day to day is so dialed that you feel outstanding, even under the presence of high workload because you've dialed in those metrics. So developing a routine that allows you to look forward to it, but not be desperate for it, not require it. And number two enables you to bounce back upon your return because if you do vacations right, a lot of that stuff is probably disrupted and you're probably coming home, hopefully thinking the classic quote, I can't wait to get back into my routine. That is a very healthy thing to be thinking, right? Like, hey, we went out there, we collected incredible memories, we got new perspective, we deepened relationships, we did all of the enriching things that vacation can bring. But now I'm pumped to get back into my dialed in routine because that's what's going to drop back down my stress level. That's what's going to allow me to perform optimally. So hopefully you're coming back to a routine that's dialed that not only did you not even need the vacation in the first place, you're bouncing back in two to three days, as opposed to having that post vacation hangover for weeks on end where you can't get your act together, which only increases your stress, which makes you need to step away again. And now you're in this vicious cycle of trying to survive when you're there and always wanting to be gone. The exact opposite should be true. You should love when you're gone and be taking a ton from that, but you should be strengthening while you're home to be able to enable that. Not weakening while you're home, hoping that it can do something that it can't when you step away. That's the challenge. The bottom line is people need more disciplined lives to decrease their stress levels. And people need vacations to enrich their existence. Unfortunately, a lack of discipline in our day to day lives requires a need and a desire for vacations chronically and a hope that they can do something that they usually won't. Simply because the organization of them doesn't tend to organize our nervous system. It tends to disrupt it, which in the right amount, when you've already got it balanced, is an amazing stimulus to get you to think differently, to get you to freshen up, if you will.

11:14 TAKING OWNERSHIP OF ROUTINE

But if you are coming back to a routine that's chronically disorganized, you're going to be in that vicious cycle of, I feel like I need a vacation. The vacation didn't do what I wanted it to do. Now I'm a little bit worse off. And we go back and forth and back and forth. And there's really no getting out of that wheel until we reorganize and take ownership of what we're doing on the day to day. Then we can enjoy the vacations and be strengthened by our routine. So just want to put that out there because so often people are saying that people need vacations to decrease stress. I think we can live in a way that we don't need that at all. And yet we do get great things from those breaks and can certainly take them as opportunity allows. Hope that makes some sense. Had some great conversations this week. Feel free to continue those in the comments. Everybody have a wonderful Thursday. Thanks for being here on Leadership Thursday.