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The #PTonICE Daily Show

The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com
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Aug 18, 2023

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 MITCH BABCOCK

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

02:16 POST CROSSFIT GAMES

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

04:35 SETTING & REFRAMING GOALS

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

06:30 INVESTING IN FOUNDATIONAL STRENGTH

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

10:06 LONG DURATION ZONE TWO WORK

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

13:21 MORE CONSISTENCY IN THE GYM

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

15:56 OUTRO

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

Aug 17, 2023

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

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

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

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

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

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

05:46 ARRIVAL RATES IN PHYSICAL THERAPY

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

08:48 IMPROVING ARRIVAL RATES

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

19:05 GETTING PAID FOR MISSED APPOINTMENTS

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

24:17 OUTRO

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

Aug 16, 2023

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

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 CHRISTINA PREVETT

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

03:29 A FRAMEWORK FOR BALANCE INTERVENTION

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

05:00 FALLS PREVENTION INITIATIVES

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

09:26 SLIP & TRIP TRAINING

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

11:54 REACTIVE POSTURAL CONTROL

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

17:31 PROGRESSIVE OVERLOAD & FEAR

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

18:34 OUTRO

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

Aug 11, 2023

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 KELLY BENFEY

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

03:35 HUMAN CAPABILITY

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

04:11 OLDER ADULTS PUSHING BOUNDARIES 

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

09:20 INJURY RATES & PROGRAMMING

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

11:04 COMPETITIVE ATHLETES & REHAB

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

15:10 HIGH STRESS IN COMPETITION

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

19:06 OUTRO

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

Aug 10, 2023

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


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

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

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

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

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

02:01 VACATON & WORK-LIFE BALANCE

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

03:46 EXPECTATIONS AROUND TIME OFF

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

08:18 DEVELOPING A ROUTINE FOR VACATION

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

11:14 TAKING OWNERSHIP OF ROUTINE

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

Aug 9, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Jeff Musgrave discusses a randomized control trial that investigates the impact of inflammation and different intensities of strength training on global inflammatory load and immune response. The study involved 81 participants, aged 65 to 75, who underwent a 12-week strength training program at varying intensities. Thigh muscle volume was measured using computed tomography, and blood tests were conducted to assess inflammation markers.

The results of the study revealed that moderate and high intensity strength training yielded superior improvements compared to moderate and low intensity training. Participants in the moderate and high intensity group experienced a 15% increase in thigh muscle volume, while those in the moderate and low intensity group only saw a 9% increase. Furthermore, the moderate and high intensity group exhibited reduced thigh fat volume, decreased pro-inflammatory cytokines, increased anti-inflammatory cytokines, and elevated free floating leukocytes.

Jeff underscores the significance of incorporating moderate to high intensity strength training for older adults, particularly those in the 65 to 75 age range. He highlights the sedentary and overweight state of many older adults in the US, emphasizing the need to address frailty in this population. Jeff also discusses the risks associated with not implementing moderate to high intensity strength training, including increased inflammation, decreased muscle volume, and heightened body fat.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:43 JEFF MUSGRAVE

Welcome to the PT on ICE Daily Show. It is Wednesday, so that means it is all things geriatrics. We like to call this Geri on ICE. So can't wait to get into a deep dive of this randomized control trial that just dropped last month in July, talking about inflammation, various intensities of strength training, how that impacts our global inflammatory load, as well as things like our immune response. And then we're going to deep dive after the article into what happens if you don't follow the results of this study and if you do, what the opportunity is for your patients. But before we get into that, we've got lots of opportunities. If you want to continue the learning process, if you want to sharpen the sword when it comes to working with older adults, we have got just a handful of seats left in Essential Foundation. So if you want to jump in, you need to do that quick. There are only a few seats left. We can still get you on boarded. You're not going to miss a thing. If you want to hop in for advanced concepts, you've already had Essential Foundations. The next cohort is going to be October 10th. And then if you want to see us live on the road, the revamp is releasing this weekend. I cannot wait. All of the faculty of the older adult division are descending on Lexington, Kentucky. We're coming to the bluegrass to show show out with this new content. It's going to be super fun. If you miss getting your seat for that this weekend, next weekend, we're going to be both in Bedford, Texas, as well as in Minneapolis, Minnesota.


06:20 IMPACT= OF MODERATE AND HIGH INTENSITY STRENGTH TRAINING FOR OLDER ADULTS

So as promised, the study, Intensity Effects of Strengthening Exercise on Thigh Muscle Volume, Pro and Anti-Inflammatory Cytokines, Immunocytes in the Elderly, a randomized control trial. So this trial had 81 participants. We've got adults 65 to 75 years old. 39 of those were male. 41 of those were female. And they were taken through a 12 week strength training program at various intensities. Baseline measures were thigh muscle volume via a computed tomography and blood test. They also did their due diligence. We know how important nutrition is to get an idea, at least of their caloric intake. Now, did not go into detail of how much protein, how much fat, how many carbs. Didn't look at macros, but they did identify that all the adults in the study were consuming about the same calories on average. So the control group spent 10 to 15 minutes doing meditation and stretching. Not things that are awful, but definitely the control group when we're talking about effects of strength training. The experimental group did 50 minutes of exercise three days a week. They had squatting, they did pressing movements, spine flexion and extension on Mondays and Fridays. On Wednesdays, they hit those knee flexors, extensors. They did ankle planar flexion, chest flies and rows. All of this was primarily done on machines, machine based exercises. And then when they broke down the different intensities, what they did is they recalculated each month and they worked them off different repetition maxes. So the low intensity strength training group worked off of a 10 rep max, a 9 rep max and then an 8 rep max. If you're looking consecutively across those three months as it was a 12 week study. The moderate intensity group hit 10 rep max, 9 and 8 rep maxes and recalculated their strength each month. And then the high intensity group worked off an 8 rep max, a 7 rep max and a 6 rep max. So I thought that was pretty cool that they recalculated their strength and then they used the same measure there of course to calculate their intensity for their strength training. So, after 12 weeks of strength training, the moderate and high intensity strength training group had superior improvements in their thigh muscle volume. Their thigh muscles got larger at a percentage of about 15% versus 9% on the moderate and low side of things. They showed reduced thigh fat volume, reduced pro-inflammatory cytokines, increased anti-inflammatory cytokines as well as increased their free floating leukocytes. Lots of $10 terms in there, but the reality is when we're looking at the impact of moderate or low intensity versus moderate and high intensity. It was statistically significant that moderate and high intensity strength training for older adults superior. Whether you're talking about adding muscle, reducing fat, reducing inflammation and even bolstering the immune system, which really I thought was super cool. So that's the basics of the study. If you've been hanging around the Institute of Clinical Excellence in this community, you're not going to be surprised to hear the results of the study. But what I want you to do is I want us to go a level deeper.

09:30 AGING & STRENGTH TRAINING INTERVENTIONS

I want you to think about your patients on your caseload that are 65 to 75 years old. The state of the union on older adults, especially in the US more so than other places in the world, is we are inactive. We are overweight. We are not hitting ACSM guidelines. Most older adults in that 65 plus category are on somewhere on the continuum of frailty. They have low physical reserve. They have low physical resiliency. They are vulnerable to injury and decline, losing their independence. So most of our clients are on this very rapid downward trajectory. And we have got at our hands the tools, rehab clinicians. We are able to intervene with strength training intervention. If we will go moderate to high intensity, we know we can increase their muscle mass. We can reduce reduce their body fat. We can reduce inflammation. And let's think about some of the conditions that are on board outside of low reserve, low resiliency. We like to think about a thing called one repetition max living. They are very near their 100 percent capacity to get out of a chair. Think about your client who cannot stand from their normal chair without using their arms. Their one repetition max squat is less than body weight. And think about how many times they have to stand up and sit down throughout the day, giving a near one repetition max effort. Crazy! How exhausting is life for those people that are barely able to do their activities of daily living? I want you to also think about some of these global inflammatory conditions. These inflammatory markers increase the risk of progressions in arthritis, cardiovascular disease, metabolic syndromes like diabetes. Think about how many of our patients are sitting in this very vulnerable situation. So we've got this picture of our older adults on the decline, probably on the frailty spectrum. If they're on our caseload, probably have arthritis, probably have inflammatory conditions. Then we think about the opportunity that we have if we just add high intensity strength training intervention. Think about the change that you can make for them. How you can bolster their strength, their function. Get them away from that line of independence where they can just not barely get through their activities, but start building some sizeable reserve. Think about how much we can do if we hit moderate to high intensity. If they don't have inflammatory conditions yet, think about isolating them from that risk. And then not even covered in the study because these were not primary measures they were tracking, but just knowing the literature for older adults.

12:06 FRAILITY & AGING INTERVENTIONS

Think about the benefit of heavier loads that's not even discussed in this study. Think about their bone density. Think about their confidence. If they know they can lift way more than they have to in daily life, is that going to impact their confidence? Is having more confidence going to help them lift with better mechanics more confidently? Is it going to help them balance in unusual scenarios more confidently? Absolutely. Confidence in that psychological impact. Don't count that out. So just think about all the opportunities with heavier load. And then what I want you to think about is maybe you're still on the fence with this stuff and you're like, I don't know if that's safe. I'm a little concerned. Maybe you don't feel quite equipped or you've not seen that modeled before and you're a little bit nervous. But I want you to think about this. I want you to think about the risk and what happens to these older adults in a very vulnerable situation if you don't. If you don't hit them with moderate to high intensity, I want to outline some of the results of the control group. During just that 12 week period where they did not perform moderate to high intensity or any strength training whatsoever, their resting inflammation went up. Their muscle volume went down. Their body fat went up. Their leukocytes went down. They became way more vulnerable in a 12 week period, just 12 weeks of not doing what they should be on the strength training train. Think about what happened to markers that were not tested. Think about their bone density. Think about their ability to get through their day with enough reserve and enough strength to really make it through the day. Just think about all the missed opportunities. I'm going to recap real quick. I know I'm super pumped about this. This is what it's all about, team. But I want you to think about the opportunity with moderate to high strength training interventions. Based on this randomized control trial, we can feel confident that we're going to increase their muscle thigh volume. Thinking about things like sarcopenia, frailty, all those categories. We can reduce their body fat. We can reduce pro-inflammatory markers. We can increase anti-inflammatory markers. We can bolster the immune system. Just based on this study, forget about bone density. Forget about one rep max living. Forget about confidence. We know those things just from this study. Then I want you to think about what you can do for your patients if you start these interventions. Think about how powerful of a tool you have. You have the keys to the castle in your pocket. If we can just go a little bit heavier. Remember, it's relative. It is relative. Yes, I will be sharing the link to this study in the caption. What happens if you don't? If you don't, we know this steady decline of frailty, deconditioning is going to continue. We know based on this study that if we don't intervene here, our older adults are going to become more frail. They're going to lose reserve. They're going to lose more muscle mass, be at higher risk of sarcopenia. We know that they're going to have higher inflammatory markers. They're going to be more at risk for progression in arthritis, metabolic conditions, cardiovascular disease. Just think about what processes you're allowing to hasten on. What's going to happen to your client if you don't get on board? Team, super spicy, super pumped about this. Got a little impassioned about this. I'll be sharing the link to this study in the caption. Super cool. Lots to think about here. Would love to hear your thoughts. Would love to hear if you have any success stories of clients that you've been using, moderate to high intensity strength training, and what the results have been. Otherwise, team, I hope you have a wonderful Wednesday and we will see you soon.

14:10 OUTRO

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

Aug 8, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses recent research evaluating the effects of training programs that prioritize the back squat vs. the barbell hip thrust. 

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRO

What is up PT on Ice Crew, Dr. Mark Gallant here having some trouble with YouTube webcams this morning so we're going to be solely on Instagram and we'll get it downloaded for you on the on the back end for the YouTube. Again, I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey, Eric Chaconis. We're going to get into some hip thrusts versus back squats today. Before we do that, if you've been looking to sign up for an ice physio course, the courses that are on the website now are the only courses that are going to be there for the remainder of 2023. So if you've been on the fence thinking about jumping in, those fall courses are the fall courses. So go ahead and get that dialed up and come join us on the road. If you've been looking to join the extremity management faculty on the road, Lindsey is going to be in Rochester Hills, Michigan this weekend. So if you want to it's a beautiful time of year in Michigan. If you want to jump up there, grab a seat. The course with Lindsey that's still available. And then I'll be in Amarillo, Texas September 9th and 10th. So I'd definitely love to see you all out on the road. One of the things that Lindsey and I and Cody and Kristen and all the staff for extremity management, one thing we're always trying to help do is to simplify our exercise selection and dosage so that for any n equals one patient that comes into the clinic, it's a bit easier for us as clinicians to go like, based on these parameters, this will likely be the best choice exercise and the best choice dosage for this individual.

02:39 HIP THRUSTS VS. BACK SQUATS

And we had an article released last month. It's not even published in a journal yet. It came out of Auburn University. That's going to help us do just that. So the lead author on the paper is Daniel Plotkin with Brett Contreras, aka the glute guy, also being an author on the paper. And what they did in this paper is they wanted to compare. If we gave a group of people hip thrusts for nine weeks, and we gave another group of people back squats for nine weeks, of those folks getting those individual programs, who would have the greatest strength gains and who would have the greatest hypertrophy gains to the glute max specifically. So that's what they looked at. They took a group of individuals, about 34 individuals, who were 18 to 30, who had not done any significant training in over five years and were relatively healthy. So BMI under 30. So relatively young, relatively healthy and under trained. At baseline, what they assessed was they assessed three rep max for their back squat. They assessed three rep max for their barbell hip thruster, three rep max for a deadlift, and hip extension against a force plate to see how much output that glute max was doing. They also, which is kind of cool, they threw them through an MRI tube. And that's how they got a measure of how dense and how robust their glute max tissue was. So they threw everyone, day one, through that MRI, got an assessment of how thick their glute max was, how thick that booty was, and then they reassessed that after nine weeks. The final piece they assessed was they took EMG output for both the back squat and the hip thrust. So what did they do for an intervention? So over the course of nine weeks, one group got hip thrusts and one group got barbell back squat. Each group did nine weeks. Week one, they did three sets of eight to 12 reps. Week two, they did four sets of eight to 12 reps. Weeks three through six, they did five sets of eight to 12 reps. And then week seven through nine, they did six sets of eight to 12 reps. So over the course of the program, they were getting a lot more volume as time went on. The way they controlled for the intensity, if a person was able to do more than 12 repetitions at any given set, they bumped the weight up. If they were unable to get to eight reps, they lowered the weight down. So they always wanted to keep it between those eight to 12 reps while making it approaching failure. So getting close to failure for each of those individuals to really challenge those tissues overall. So each group did twice a week, only back squat for the back squat group, two days a week with those loading parameters. Hip thrust, twice a week, only hip thrust for that nine weeks with those loading parameters.

05:12 THE LAW OF SPECIFICITY

What shook out at the end of the nine weeks was pretty cool. We're starting to see some strength and conditioning principles that are becoming clearer for us as better studies come along, as time goes on. The number one thing that we continue to see is the law of specificity. If you want your client to get better at back squats, have them do back squats. If you want your client to get better at hip thrusts, have them do hip thrusts. If you want your client to get better at deadlifts, have them deadlift. You want them to get better at step ups, have them step up, so on and so on. And that's exactly what we saw in this study. The group that did barbell back squat got significantly stronger at their three rep max back squat at the end of that nine weeks with only minimal gains in their barbell hip thrust, in their deadlift, in their force plate. They made gains in those other things. They were not nearly as significant as the gains as they made on the specific exercise they were doing. Same for the barbell hip thrust. The group that did the barbell hip thrust made significant gains in their three rep max on the barbell hip thrust. We did not see the same significance in their back squat, in their deadlift, and in their isometric hip extension against the force plate. Again, they made some gains, not as significant as the specific exercise. So again, we're seeing this article reinforce. If you want to get better at a specific thing, that person will need to do that thing as soon as their tissues can tolerate it, as soon as they're ready. Get them doing the thing that they desire to get better at. The other cool thing about this paper was hypertrophy. What we saw with hypertrophy with this study is both groups hypertrophied their glute max equally. So it didn't matter whether you were in the back squat group, whether you were in the hip thrust group, both groups showed glute gains.

09:58 HYPERTROPHY AND EXERCISE SELECTION

And what we're seeing in a lot of the hypertrophy research is exactly this, where as long as the tissue is being stimulated at a challenging level and enough volume, that's good enough for the tissue to grow. So this study met those two criteria. It had an extreme amount of volume. So getting up to six sets of eight to 12 reps is a ton of time under tension for a tissue. And by controlling that they always wanted those folks to be approaching failure at a challenging range between eight to 12 reps, we got both high volume and high intensity. If those two parameters are on board and the tissue is getting some stimulus, almost always we're going to see some local tissue change or some growth. So again, law of specificity, do the thing that the person wants to do. And if you're looking for local tissue changes, hypertrophy, it seems to not matter as much which specific exercise. As long as the tissue is being challenged at an appropriate volume and at an appropriate intensity. The other interesting thing about this study was the EMG output did not seem to matter. So the barbell hip thrust had a higher EMG output for the glutes and that did not correlate to either strength gains or to more hypertrophy. Again, the strength games came from specificity. The hypertrophy gains came on board because the intensity was appropriated up. Now, looking at any study, we always want to be aware that there's problems with every study or challenges to any study that comes across the board. There are no perfect studies out there. The challenges with this study were it was a relatively low population. So there were 34 individuals, 18 in the hip thrust group, 16 in the squat group. So a fairly small population. They were all young and relatively healthy, which is going to be different than our general physical therapy population. And they were all significantly undertrained. So no one that was accepted in the study had more than one day a week for over five years of weightlifting experience. So appreciate that likely these gains that we saw in strength and these gains that we saw in hypertrophy are somewhat attributed to that. These folks were so significantly undertrained. And we've all seen that the more undertrained the person is, the easier it is for them to adapt early on. Also, with this, nine weeks is a fairly short amount of time to have a strength and conditioning or a hypertrophy program show results. It's likely that because they were undertrained is why we saw results in nine weeks. With our general physical therapy clients, some of whom may have been weightlifting for 15, 20, 30 years, we would expect a bit longer time to get true tissue adaptations and to get true strength adaptations. So again, to recap, study showed hip thrust versus barbell back squat. If you want to get better at the hip thrust, do the hip thrust. If you want to get better at the barbell back squat, you want to get stronger at that, do the barbell back squat. If you want to hypertrophy, whichever exercise you want to choose is great as long as you've got the intensity and the volume. The final cool thing that this study showed was that when someone did the barbell back squat, they had a ton of adductor activation and ton of quad activation and a ton of glute activation versus the hip thrust, which had primarily glute activation with far less hip adductor or quad activation. So if you've got a patient who comes in and they're in a lot of pain and you say, man, they've got some knee pain on board, their adductors seem a bit irritable, those quads are all gummed up. And we want to make sure that that athlete or that client is maintaining powerful hip extension, which is one of the most important movements for all humans. Then let's bias early on to the barbell hip thrust because it's not going to challenge those adductors and those quads. When that patient starts to get better and their adductors and their quads are not as irritable and they're not as gummed up, then let's go straight after that squat. Or on the flip side, you have no tissue irritability on board and that person's daily life requires a lot of squatting. It's going to behoove you to go right after that squat instead of spending time on the hip thrust early on. In reality, we've beaten a dead horse with this saying over the years and not more. For most of our folks, you're going to want to program hip thrust. You're going to want to program some squats. You're going to throw your deadlifts in there to have a nice well-rounded program. Law of specificity. Make sure the intensity is good. Make sure the volume is good. Have a great Tuesday treating clients. Can't wait to see you all on the road. Have a great rest of your day. Always grateful to be speaking on this podcast and hope to see you all soon.

11:37 OUTRO

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

Aug 7, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses considerations for postpartum exercise include the type of birth, birth trauma, sleep deprivation, and nutrition. It is important to take into account the impact of the birth on the postpartum exercise plan, especially if it was traumatic physically or emotionally. Respecting the individual's experience is crucial. Additionally, sleep deprivation and nutrition should be considered. If a mother is struggling to get proper nutrition due to the demands of caring for a newborn, adjustments may need to be made to the exercise plan. It is also important to consider specific goals when designing a postpartum exercise plan.

The episode highlights three recommended exercises to initiate postpartum impact: heel drops, alternating hops, and jump rope exercises. Heel drops involve going up onto your toes and dropping your heels down. Alternating hops are done by moving side to side and can be performed with or without a jump rope. Using a jump rope adds an extra challenge and requires coordination. The third exercise is small hops with both feet. These exercises are ideal for postpartum women who want to regain strength and fitness after giving birth. However, it is crucial to consider the type of birth, any birth trauma, sleep deprivation, and nutrition when starting these exercises. Monitoring for symptoms such as leakage, pressure, pain, and bleeding is also important during the progression into impact exercises. Breastfeeding moms should be advised to wear a supportive bra during exercise for added comfort.

Jess emphasizes the importance of utilizing progressive overload principles when starting with small impact movements and gradually increasing intensity. She stresses the significance of meeting the individual where they are and understanding that progressive overload is a natural part of the process. This means that as the individual progresses and adapts to the small impact movements, they should gradually increase the intensity of their exercises to continue challenging their pelvic floor muscles and promoting strength and function. Jess also highlights the importance of speaking positively about exercise and the pelvic floor, as it encourages individuals to stay active and avoid deconditioning. By incorporating progressive overload principles, individuals can safely and effectively strengthen their pelvic floor muscles while minimizing the risk of injury or negative symptoms.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:25 JESSICA GINGERICH

Good morning PT on Ice podcast. My name is Dr. Jessica Gingrich and I am on faculty with the pelvic division here at ICE. So we just finished up a wonderful weekend of the CrossFit Games. We have a huge congratulations to extend to Dr. Kelly Benfey. She is on faculty with the CMFA division. Her team took 16th place this weekend and boy was that fun to watch her compete. So I was on virtual ice last Tuesday and what I want to do today is talk a little bit about that virtual ice. So I've been on here the last couple times talking about the benefits of certain things early in the early postpartum period. So within that first 12 weeks postpartum. So I wanted to continue that and just what a wonderful time to do it as we did have a mom on the podium this year. So Ariel Loewen took third place. She has a child as she's a mom and she's just out here crushing the fitness space. So before we dive into that we're going to talk about early impact which is going to be really fun. We're going to start to reframe that a little bit but we do have courses coming your way. So hop on the website PT on Ice dot com to check that out. We have two courses here with the pelvic division. We have an eight week online course that bridges everything from gymnastics and barbell lifting to handstand push-ups to everything with the pelvic space with using the internal exam to help get people back to where they need to go. And then we have a two day live course and that one is just really fun. We get moving a lot. So if that is something that's on your list go ahead and head over there to secure your spot.

03:45 THE FOURTH TRIMESTER

So we are going to talk about that early impact in the fourth trimester. So the fourth trimester is the first 12 weeks postpartum. There's a lot of things that matter here but I want to start to reconceptualize the phrase of this or certain things put a lot of pressure on your pelvic floor. So we know that growing a fetus is going to put more demand on the anterior abdominal wall as well as the pelvic floor as well as a lot of other systems in the body. So does a sneeze. Like when we sneeze it puts a lot of pressure on the pelvic floor. When we lift weights it puts a lot of pressure on the pelvic floor. When we lift our child that then wiggles around it's going to put a lot of pressure on the pelvic floor. The phrase this puts a lot of pressure on your pelvic floor we want to maybe refrain from doing that can be a very fearful message. And also one that's just incorrect at this point. We want to do it in a way that is going to allow the pelvic floor to succeed. We don't want to blast through symptoms of leakage or heaviness or pain but we need to start reconceptualizing this especially speaking to our clients. So now before we jump in, no pun intended there, impact, we want to understand the demands placed on the pelvic floor in the day to day. So number one when you have a baby whether it's a c-section or a vaginal delivery we do have a healing process. So with a vaginal birth if there is no tissue trauma, so this is a vaginal birth with no tearing, no episiotomy and episiotomy is where they would cut to allow more room. We know that the tissues stretch approximately three times, 300 times their original length. So right then and there we can put that as tissue trauma, right? That is tissue trauma without any disruption to the sarcomeres or the skin or the connective tissue. Patients will need about four to six weeks for healing but this doesn't mean that we can't do nothing for four to six weeks. Now there's going to be probably a lot of questions that come with this because everyone is different, right? So we need to understand that and set the expectation early can be super helpful. So in educating our patients I love to give a timeline. So I usually say between six and twelve weeks, sometimes six and eight weeks depending on where that person is. And that's kind of nice because then when they get back to doing impact things that's now something where they're like oh I was kind of anticipating twelve weeks instead of now, right? And so that gap is pretty big but at least it allows them to be like okay I have this set date or timeframe if you will where we're going to start working back to that.

04:16 PRESSURE ON THE PELVIC FLOOR

Number two, we need to start talking about toileting. We need to teach people how to poop. We need to teach people how to pee. If we are not asking that question, are you burying down when you go to the bathroom? Are you pushing your pee out? You're going to be missing a big mark here. Your pelvic floor is reflexive. So as pressure gets put down on it, it should be turning on. So if you're going to the bathroom and you're burying down, we're putting a lot of pressure on the organs if you will. However, we're also putting pressure on the pelvic floor that's likely kicking it on and if it's not, it's just pushing it downward. So we need to be asking about that. We need to be encouraging a squatty potty. We need to be encouraging fluid, water intake, fiber intake and really the time spent on the toilet and this goes for males too. So spending a lot of time on the toilet just isn't what you want to do. If they are the person that takes their phone in with them, you could even tell them hey let's try not taking your phone in to see if you get off the toilet sooner.

08:12 BLADDER IRRITANTS

So number three, we do have oral intake. So we talked about water intake just a second ago, but just recognizing that beverages like carbonation, alcohol, artificial sweeteners, they could be bladder irritants. And so I went to the gym this morning and I did one of the CrossFit Games workouts today called Halina, which is a three rounds of 400 meter run, 12 bar muscle ups and then 21 dumbbell snatches. I went at 7.15 so I had coffee and I had to go to the bathroom probably three times before I went and did the workout because that is a bladder irritant for me. So when we talk about bladder irritants, we are not saying stop having these things. It's just saying hey this may be a trigger and so if this is happening to you, that's okay. Just recognize that if you have double unders or running or something, box jumps, that may be we try to have the coffee after the workout or maybe you have one cup instead of two or can we sandwich that coffee with some water to dilute the urine a bit. That's one of the big things is not necessarily taking those things away but just telling them hey this could just be a bladder irritant for you. It looks different for everyone. Number four and probably one of the biggest ones is the symptom threshold. Helping your client find their symptom threshold is going to mean that they're going to be reaching their symptoms. They are going to likely be leaking. They're going to likely be maybe feeling like they're going to leak and that can be a very daunting thing but it's going to give us a lot of feedback, a lot of them feedback and it's going to give them a lot of freedom when they're in the gym. If you reach this threshold, take a second, pause, take a breath. Maybe we do a little bit of jumping and then we back off and we do the bike and get a sprint in. Or we do another option for jumping. I'm going to talk about some options here in a second. Speaking positively about exercise and their pelvic floor is huge. They are not going to ruin their pelvic floor. I would rather, we would rather have someone stay active in the gym or whatever that looks like for them rather than telling them they're going to ruin something so they stop and then fast forward 30 years later and now they're in a skilled nursing home sooner because they're massively deconditioned or they have a massive injury because of being deconditioned. Now that we have some guidance on the return factors that we want to manipulate and play around with, let's start using pressure rather than, or rather forces if you will, to strengthen the pelvic floor. Now there are considerations we need to keep in mind, like the type of birth, we talked about that earlier. Birth trauma, so this could actually be physical as well as emotional. So if you have someone who is identifying that their birth is pretty traumatic, we're going to respect that. Sleep deprivation, nutrition, if your mom is having a hard time getting protein in and carbs in and good fats in because every time she goes to eat her baby starts to cry, that's something to just talk about and maybe we push that back a little bit and that's okay. And then of course specific goals. So our top three exercises to initiate post-part or impact in that time is going to be heel drops. So that's where you'll go up onto your toes and drop your heels down. Alternating hops is just going to be alternating side to side. You can do that without a jump rope or with a jump rope. Doing it with a jump rope is actually very difficult. It takes a lot of coordination. And then small hops. And that is going to just be small hops with two feet. Something to keep in mind in here are breastfeeding moms that can be very uncomfortable. So just talking to them about wearing a very supportive bra when they come to that visit. As always, we are going to ask about symptoms during your progressions into impact. So the symptoms are going to be leakage, pressure, pain, and then also bleeding. So in that early trimester we want to just keep an eye on bleeding. It is normal to have an uptick in bleeding, but we want it to not be like that they're passing clots after they start upping their intensity. Keeping the conversation positive even if they're hitting symptoms early and we're regressing. All we're doing is we're meeting them where they are and understanding that progressive overload is going to happen. And even talking to them about that is a really fun thing. So to recap, pressure doesn't have to be a bad word when talking about the pelvic floor. Understand other factors that may be influencing the pelvic floor, such as toileting, nutrition, type of birth. And essentially linking that to their symptom threshold. Utilizing small impact movements at first and start to initiate those progressive overload principles. So I'll leave you with that. Have a great Monday and we'll see you next time.

13:40 OUTRO

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

 

 

Aug 4, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the efficacy of mobility programs to produce meaningful, function change in range of motion for patients & athletes.

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

Article referenced

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:32 ALAN FREDENDALL

Good morning everybody, welcome to the PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and lead faculty here in our fitness athlete division. It is Fitness Athlete Friday, we would argue it's the best start day of the week. We talk all things CrossFit, functional fitness, powerlifting, Olympic weightlifting, endurance athletes, runners, bikers, swimmers, everything related to the person who's regulationally active here on Fridays. Before we get started with today's topic, we're going to be tackling mobility. We're going to define mobility versus flexibility. We're going to discuss a recently published paper showing the effects of long term stretching on mobility changes and address concerns related to that paper. Before we get started, let's talk about a couple of announcements. It is the CrossFit Games individual and team competitions began yesterday. Age group and adaptive athletes began Tuesday. We have a day competition all week long. You can catch it on ESPN. You can catch it on YouTube. Our very own Kelly Benfee here from the fitness athlete division will be competing with her team. Plus 64 CrossFit Army end game in the team division. So you can check her out. She had a couple of events yesterday and she's got events every day the rest of the weekend. Speaking of fitness festivals, the I Got Your Six Fitness Festival will be June 21st and 23rd down in Charleston, South Carolina with our friends at Warrior WOD. We had the virtual competition this year, but next year it's going to be in person. So it's a ways away, but look forward to that calendar if you want to come down to Charleston and join us for a weekend of approachable fitness courses coming away from us here in the fitness athlete division. Your next chance to catch our live course will be September 9th and 10th. That will be in Bismarck, North Dakota with Mitch Babcock or the end of September, September 30th and October 1st. You can catch Zach Long out on the West Coast. He'll be in Newark, California. That's in the Bay Area. Our online courses, Clinical Management Fitness Athlete Essential Foundations, our eight week entry level online course begins again September 11th and Fitness Athlete Advanced Concepts, our level two online course begins September 17th. So mobility, let's talk about it. How much can we really move the needle? My goal today is to define mobility as it's often talked about in kind of common terms with athletes in the gym, patients in the clinic when they talk about mobility, defining mobility versus defining flexibility. Talking about a paper that was published a couple of weeks ago, looking at the effects of long term stretching specifically at ankle mobility, which is a joint we're always after to improve the range of motion within and then really how to approach mobility from a practical clinical standpoint.

2:01 EFINING MOBILITY VS. FLEXIBILITY

So let's start first with defining mobility versus flexibility because they're often used interchangeably and that's not the correct way to use them. Then when we talk about flexibility, we're talking about the capacity of soft tissues of muscles, tendons, ligaments to be passively stretched, whether me as the therapist stretches you the patient or whether you stretch yourself using your own body, using stretch straps, things like that. The ability to passively stretch muscle tissue at a specific joint. Now mobility is different. Mobility is the ability of a joint to actively move through a range of motion. And of course, we're always chasing a full range of motion. So the ability, for example, of the need to advance across the toes in active closed chain dorsiflexion, the ability of the hip to externally rotate or flex sitting down into a squat, that would be an assessment of mobility, actively moving the joint through the range of motion. And you, the patient or athlete moving yourself through the range of motion, aka how much motion can you actually access? Because we see some folks have a big difference between their flexibility and their mobility. We may be able to passively move their ankle, passively move their leg into a normal or above average range of motion. But when that person stands up, they re-encounter gravity and they try to actively move that joint. We can sometimes see a big difference between mobility and flexibility. And that brings us to a really important point that a lot of what we see in marketing, in programs, in our own home programs for athletes and patients is that we say we're prescribing mobility. But really, what we are giving for the most part is flexibility, that a lot of passive stretching is what is given out, which can improve flexibility. Yes, but may not always result in any sort of functional change in mobility. We see a ton of programs all over social media, especially in the fitness athlete space, that are marketed at improving mobility. But when we actually look at the content of those programs, things like ROMWOD, things like GOWOD, things like whatever WOD, that we actually see a lot of passive stretching, a lot of flexibility. And so it's no wonder that folks come in and have been doing one of these programs for weeks, months, years, and have not seen any sort of beneficial improvements. In their mobility, their ability to actively move joints through a range of motion, because they have not been doing any sort of mobility work, they have been doing a lot of flexibility work. And we know those two things don't always translate. We don't always see a bunch of flexibility work translate into any sort of improvements in actual meaningful functional mobility.

7:32 THE RESEARCH ON STRETCHING

So what does the research say? There's a bunch of research on passive stretching. There's a bunch of research on the benefits specifically of eccentric loading to improve range of motion, to improve active mobility. And we've always kind of wondered the question of what is the dose response relationship with flexibility training, with stretching? We have a great paper that came out last month in the Journal of Strength and Conditioning Research by Wernicke and colleagues. I'll post the link on Instagram and in the show notes on the podcast that sought to answer that question. So this was a study that sought to look at the effects on maximal voluntary muscular contraction, flexibility and muscle thickness of the ankle plantar flexors. Now, the experimental group had a lot of stretching prescribed. Specifically, they stretched six times a day for 10 minutes each session for six weeks. So about 42 total hours of stretching through the calf complex, an hour per day for 42 days. They perform the stretching with a night splint type orthotic of a boot that prepositions the foot into ankle dorsiflexion with the addition of a strap assist to pull their ankle into additional dorsiflexion if able. So essentially stretching the gastric complex 10 minutes, six times a day for six weeks. Now, what did the results show? The results did show an improvement in range of motion of when they remeasured ankle dorsiflexion. There were improvements that reached statistical significance. But really, when we look at the results, when we look at the actual data itself and not the summary of data in the discussion, we look at the raw data. What do we think about the results? We think that the functional improvement here is probably questionable. Then we actually look at the ranges of motion increases experienced by these subjects that most folks experience the change of about 0.25 to 0.5 centimeters or about one tenth to two tenths of an inch of an improvement in ankle dorsiflexion. Now, when we measure functional ankle dorsiflexion in the clinic, we use the closed chain half kneeling knee to wall task to measure the ability of the knee to advance over the toes with a planted heel. We show this assessment in our online essential foundations course, and we show this in our live seminar as well. And what we'd like to see there is that an athlete with the heel flat can advance their knee over their toes about four inches. That ideally they would contact the wall. We know if they can contact the wall, they have about four inches of motion there or possibly more. But that is enough motion, for example, to be able to advance the knees over the toes and sit down into a nice full depth squat. And so when we look at changes of 0.1 inches in a test where we're looking to see four full inches of range of motion, we realize that's not really that much of a functional improvement of yes, the results did reach statistical significance. But the practical application here is very, very, very minimal of that person. If we improve their ankle dorsiflexion and it was, for example, zero inches, somebody like me, somebody with a very stiff ankle, particularly my right ankle that has about zero inches of closed chain dorsiflexion. What good really is 0.1 to 0.2 inches of closed chain dorsiflexion improvement? The answer is not. It's not right. It's not a functional improvement. It's not a meaningful improvement. Yes, it was a statistically significant improvement, but in real life, it would not help that person move any better. It would not improve that person's mobility, even though their flexibility, yes, has technically changed. So we need to be mindful of how to actually interpret results of studies like this. We also need to now talk about what is the practical application of a study like this to practice, because this study came out and a lot of social media posts were made, a lot of podcasts were made that said, look, you're just not stretching enough. If you stretch an hour a day for six weeks, you can see an improvement in joint range of motion. And yes, again, while true, not functional.

10:14 APPLYING RESEARCH TO PRACTICE

We also have to step back and really analyze the methodology of this paper and also analyze things like the inclusion and exclusion criteria of this paper. We're probably unlikely to find an actual real person, a patient or athlete who's going to do six hours a week, an hour per day, seven days a week for many, many weeks of flexibility training, essentially, right? We hear time is the biggest barrier to exercise. We hear time is the biggest barrier to home exercise program compliance. So it doesn't really make sense that if we can't get somebody to perform a 12 minute remom for the home exercise program, what's the likelihood that they're going to do an hour a day of home exercise program on top of maybe also trying to exercise an hour or more per day? The answer is unlikely. Right. We know that if we if we dose that out to somebody, there are very few patients who are going to come back and say, yep, I did. I did six sessions a day, 10 minutes per session, and I did it every day, seven days a week, just like you prescribed, doctor. That's a very unlikely result. So we need to be mindful of that when we're talking about applying this to real actual people. We also really need to dig into the inclusion criteria and look at the baseline assessments in a study like this, because this study would portray that some of these folks were stiff and saw improvements. Some of these folks had OK mobility and saw improvements. But really, when we look at the baseline assessments, the quote unquote stiffest person in the study still had three point four inches of closed chain dorsal flexion, right? More than enough ankle mobility to be able to squat to depth, assuming nothing was wrong mobility wise in that person's hip or knee. That person would have all the dorsal flexion needed to be able to, for example, functionally squat to depth. So we have to ask ourselves, is this actually representative of the populations that we treat? Is it representative of somebody who might come to us and say they need help with their mobility? What's the likelihood that they're actually going to do an hour a day of this type of training? And also, this is not the person that's going to present in our clinic, right? Of the person who can close chain dorsal flex at least three point four inches. You're not even going to consider that their ankle is stiff and maybe even prescribe some mobility stuff for their ankle to them, because they already possess all the range of motion needed to squat. On the high end in these subjects, they were beyond three point four inches, right? There were people with four, five, six, some folks close to seven inches of closed chain dorsal flexion. Way above average mobility. And so we need to recognize and ask the question of why are we studying the effects of flexibility and mobility on people who already have adequate, above average, perfect or excellent mobility, right? We see this a lot in medical research of we study the effects of, for example, resistance training on bone loading in older adults, and we exclude people with osteoporosis and osteopenia and folks who have any sort of issue that might throw an extra variable into the study. And what we find ourselves is studying interventions on people who don't need the intervention, right? And this study is exactly that case of we are studying the effects of flexibility training on the mobility of people who don't need any help with their flexibility or mobility. So again, can we generalize studies like this to the general population? Probably not. And for a lot of reasons, the ones we've already discussed here. And what we need to realize when we look at this data and look at a big picture is when we look at the results of studies like this, when we look at all the data aggregated, yes, but also unaggregated on those data tables, what are we looking at? That we tend to find that folks fall into buckets, that we can classify them. We know that, for example, with low back pain, we can find people who are flexion intolerant, extension intolerant, shear intolerant. We know they may or may not respond to directional preference type exercises, but people tend to fall in classification buckets based on what's going on. And we need to recognize that mobility is no different. Even looking at this study, looking at the baseline measurements of folks, we have folks who appear to have great mobility, who improved with intervention. We have folks who have great mobility, who did not improve with interventions. We had folks with poor mobility, who improved with intervention. And then we had the most unfortunate group of all, folks with poor mobility, who did not seem to improve with intervention. So we need to recognize that the person we're working with in the clinic, in the gym, probably fits into one of those buckets. If they are somebody who is interested in working on the mobility, even if we may not need it, right? We have that person who can hinge all the way to the floor with a perfectly flat back and locked out knees and touch their palms to the floor. A very bendy, flexible individual who is asking you for help on their mobility, right? That person does not need mobility help. They do not need flexibility help. But yet they are maybe seeking some extra mobility programming. We have folks with poor mobility, who need mobility training, who we know will not work on it anyways, especially an hour a day. So we see that our patients and athletes fall into these buckets, and we need to recognize which bucket they may fall into. We may not know early on how they're going to respond to interventions, especially if they haven't tried anything previously, but we'll know very quickly across the plan of care of their physical therapy if they're going to be somebody who responds to interventions like these. So what do we actually do with that person in front of us? Well, I think what we don't do enough is ask people a few simple questions of I see that you have some mobility things you could work on. How much time do you actually have for this? I don't think we ask that question enough. I think we give people what we want to see them do, what we hope they will do, and then we're often disappointed when they don't do it because we haven't asked first of all how much time they're willing to dedicate to it. I appreciate over the years how I've started to ask this question, and people have been very honest of I'm never going to do this at home. I'm only going to do this when I come here to physical therapy. Well, I appreciate that honesty, right? Because I'm not going to waste my time writing out a really detailed program that you're not going to do. So I think starting with that, excuse me, that question is very, very important. And then also recognizing and being really, really thorough and methodical in your reassessments along the way so you know if this person appears to be somebody who's going to respond to mobility type interventions. This study in particular has a lot of issues with the methodology, only including people who already possess a lot of nice functional mobility. It did a lot of long-term passive stretching, and we also need to recognize that primarily due to the way the intervention was done in this study, they primarily stretched the gastroc but assessed mobility and range of motion by the closed chain dorsiflexion test, which really looks at soleus muscle flexibility more so than gastroc. So we're stretching the gastroc, but assessing the ability of the knee to advance over the toes in a kneeling position, which is really looking at the soleus muscle complex. So we need to recognize the limitations of this study, and in our own practice of actually making sure we're giving the right mobility to the right person based on the deficits that we're finding in their assessment. We hear often, what are some great shoulder stretches? Well, it depends on what is limiting your shoulder mobility. If I give you a bunch of lat stretches and you seem to be really limited in external rotation because of maybe something going on in your subscap or your internal rotators not related to your lat, if you pass all of the screens we see for the lat, then giving you a bunch of lat stretching, a bunch of shoulder stretching, it's really not going to benefit and improve the mobility we need to work on. So we need to be sure we're working in the right area and addressing the right area with our exercises as well. So mobility, how much can we move the needle? Well, it really depends. It seems to be maybe a genetic component. It seems to be a combination of how well people respond to this type of training, and we also need to recognize that it appears to take a lot of time, possibly more time than the patient or athlete in front of us actually has. So understand the difference between flexibility and mobility. Flexibility, the ability for us to stretch muscles passively or a patient or athlete to stretch themselves passively versus mobility, the ability of the person to actively move their joints through a range of motion under gravity, functional movements, things like a squat, a lot of close chain type movements. We have research that looks at long-term stretching, but we know the quality of the research is not that great and the practical application of the research itself is not that great. Yes, we can reference the study and say if you're willing to stretch six hours a week, you might see changes in your ankle mobility, but again, we don't know that for sure. In practice, we know that our athletes and patients tend to fall in buckets. We need to be able to recognize those folks where they lie in our assessment. And again, always ask the question of how much do you really want to work on this? How much time do you really have to work on this? Somebody who says I have an extra hour a day before bed at night. Okay, that's a person who maybe could try out an hour of flexibility training before bed. Whether you give them a program, whether they sign up for something like ROM WOD, GO WOD, Mobility WOD, whatever WOD, Stretch WOD, the millions of programs out there. Or somebody who goes I'm not going to do this at all. I know myself, I'm not going to do this at night before bed. I'm not going to do it in the morning. I'm not going to do it before I work out and I'm not going to do it after I work out. Okay, that is a person that we probably should not spend our time on trying to give a bunch of mobility homework already knowing that they're pretty intentional and honest that they're not going to do it. So mobility, can we move the needle? Maybe. Jury's still out. We still need to see more research, of course, more impactful research, more functional research, and more practical research. Research that actually looks at what sort of changes can we expect to make in maybe 12 to 15 minutes a day? The range of time that we're probably prescribing to most of our patients and athletes. So I hope this was helpful. I hope you have a fantastic Friday. Hope you have a great weekend. If you're going to be at a live course, enjoy yourself. Enjoy the CrossFit Games. Watch Kelly Benfee and Ruth Huron. Have a great Friday. Have a great weekend. Bye everybody.

20:32 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up. You

Aug 3, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes the importance of considering individual circumstances and not allowing blanket statements to hinder progress. While the general principle of "do less better" is often advocated for efficiency and clarity, Jeff acknowledges that there are exceptions to this approach.

Jeff encourages listeners to think about situations where a person may come into the clinic with psychological barriers or feeling overwhelmed. In these cases, Jeffg suggests that overwhelming the individual with multiple interventions or exercises may actually be beneficial. By providing a variety of options and allowing the person to choose one or two to focus on, it can help shift their psychology and get them on board with the treatment plan.

Jeff also mentions that this concept applies not only to exercise but also to other aspects of healthcare, such as sleep hygiene and diet. Instead of overwhelming individuals with a long list of changes to make, it is more effective to start with one or two manageable changes. This approach makes it more approachable and minimizes barriers to compliance.

Overall, the episode highlights the importance of considering individual circumstances and being flexible in treatment approaches. While the general principle of "do less better" is valuable, it is essential to recognize that there are times when overwhelming individuals with options or interventions can be beneficial in getting them on board and moving in the right direction.

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

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE
Alright team, what's up? Welcome to the PT on Ice Daily show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and thrilled to be here on a Leadership Thursday. Always wonderful to have you on Instagram, on YouTube if you're live streaming or over on the podcast. Thank you so much for carving out a few minutes for us today. It is Thursday, it means it's Gut Check Thursday, and it is a doozy. So many of you are at the CrossFit Games, you're probably going to be throwing this workout down together. I know it comes from our friends at Mayhem, they're probably going to be doing it as well. But the workout is, and it would be simple if it was just the first part, it is a hundred for time at a relatively manageable weight. Okay, so we've got 75-55 on the bar. Many of you probably remember the 100 clean and jerks for time that we've done I think twice now. The problem is you also have an EMOM of 15 air squats, and that's going to make it a different kind of stimulus, and that includes starting at zero. The first thing you're going to do when the timer goes off or Gut Check Thursday is you're going to bang out 15 air squats, then you're going to grab your bar and start rocking your power snatches. You're going to keep doing this every minute, 15 air squats, as many power snatches as you can until you've accumulated 100 power snatches at 75 or 55 pounds. Can't wait to see some of the post commit, I already saw one this morning, somebody said their low back was on fire, I'm sure that's the case, I can't wait to try it. Probably going to knock that out here on Saturday afternoon. Alright, as far as upcoming courses go, I want to highlight, speaking of power snatches, I want to highlight our Fitness Athlete Live courses because the ones that are coming up, I see those courses swelling. So Mitch is going to be in Bismarck, and that is going to be on 9-9. So that's in four weeks, a little over four weeks. That class is already pushing 30 people, we're about at capacity, so if you want to jump into Bismarck, you're going to need to probably do that in the next week or so. Similar story for Newark, California, Zach is going to be down there on October 7th, and again, I'm seeing that course edge towards capacity, so if you want to jump in Fitness Athlete Live, you're going to want to make that move pretty quick. We do have Linwood, Virginia following that, so it goes Bismarck, 9-9, it goes Newark, 9-30, it goes Linwood, Virginia, 10-7. If you want to jump into one of those courses, try to make it happen in the next week or so to make sure you get your seat. Alright, it is Leadership Thursday, but this one's a little bit more clinical, but I do think that it really revolves around leading people, so I think it's appropriate for this day of the week.

02:56 "DO MORE, BETTER"

I want to talk about doing it more, better sometimes. Now the obvious caveat we have to open with is the fact that we have preached do less better on this show, in this company, for the better part of a decade almost constantly, and there are good reasons for that because the majority of times, doing less better is what makes it work, is what makes for an efficient avail, is what allows you to know which intervention you did actually have the effect. If you're doing a million things with a small dosage, you have no clue what moved the needle. More importantly, your patient doesn't know, so they don't know what to focus on, they don't know what to attach their outcome to. If you're doing a ton of things, it gets messy, it lacks clarity, and it's very hard to get treatment effect. Additionally, it's very hard to give sufficient dose of anything if you're doing everything. Do less better is a hallmark statement and should generally be observed. The challenge I want to make for all of us, including myself this morning, is it always the case though? Is there sometimes, and there should be exceptions to all of this stuff, are there sometimes where overwhelm is exactly what the doctor ordered? Are there times we have to go big? Right now, what's very in vogue, and I generally like this, is things like don't do more than three exercises. There's actually a bit of research showing from a compliance perspective that statement makes sense. If you give somebody a whole laundry list of things to do, they're not going to do any of them. But it's not just exercise. We're hearing these comments around things like sleep hygiene. Don't try to make a bunch of changes, just make one. We hear it around diet. Don't change a ton of things, just start with one or two. I myself preach this all the time. Make it approachable, try to minimize barriers, just choose one or two. But I want us to pause for a second to make sure we don't just make this our default And think about when the opposite might make more sense.

06:30 MANAGING RELUCTANT PATIENTS

I want us to think about that reluctant encounter. What I mean is that person who comes into your clinic and you can tell they are really suspect, they're suspicious about whether or not this is really going to work. And you know this person. This is not the person who gets rehab consistently. It's not the person who's already bought into this being the primary treatment choice. It's the person who's like, I don't know about this. My doctor said come so I'm here, but I just don't know about this. Think about that person who's really reluctant. For some people, for that person in particular, this might be the only time that they're going to be in this stage where they're even considering this route. It's not the route they've used in the past. They're really unsure about it, but they've heard some good things. They were told to be here. It's a small window of opportunity. You might only get one at bat with this patient. You can all picture this person. You've got him on your caseload right now. You can just feel what their energy is. I don't know about this. I don't think this is going to get the job done. You might only get one shot at this person. And I want to make a two-part argument about how we manage this individual, especially at that first encounter, which might be the only encounter if things go wrong. The absolute worst outcome with that person is nothing. The absolute worst outcome is no change because it's kind of what they think is going to happen. This is a waste of my time. This isn't going to work. Getting no change is the worst possible outcome. The second argument I'll make is that while I totally agree, especially this person, won't do a bunch of things for a long period of time, they will not do the long litany of exercises, they won't make a million changes, they won't do those things for a long time, but I think they will do it for four or five days. I think they will make a really aggressive change because they're wondering if their time is being well spent. They almost want to prove it wrong sometimes. Like, see, it didn't work. While I don't think a long list of massive lifestyle or exercise changes is sustainable for that person long term, I do think they'll do it for a few days, especially if we tell them, hey, listen, this is not sustainable for a long period of time. What we're trying to see is if we can move this needle. So let's figure it out once and for all and right out of the gates. What if we go this route where we tell them, you don't have to do this for a long time, we're going to put all the guns on early, we're going to see if anything changes. If nothing changes with a high dose, we can both agree that this isn't going to work. But if something does change, what we can then do is begin to look at what you've got on the board and we can tease that down to the things that were the most manageable for you to alter. And that's the stuff that we can ride out into the sunset. Right. Then we can pare down the program. What I'm saying is, should we be asking a ton upfront, prove that change will happen with the highest dose that they can tolerate and then refine and make it sustainable? Should we be telling them, I'm going to ask you never to continue this, but I want to know if we can make a difference and then we'll choose the things that were the easiest for you to stay with. And that's going to be our long term program. It's not for everyone. It's not even for most.

08:38 SWING FOR THE FENCES

But on those people who are particularly doubtful that PT will work, I think we need to swing for the fences. And I'm bringing this episode to you because I've had numerous conversations recently with people who did the less better thing, right? Small changes that were easy for the patient that didn't do anything. Where the patient was like, I don't really think I felt a difference. That's fine. In someone who's committed to rehab being the solution, that is not fine. In someone who's testing you out to see whether or not they're wasting their time. On that second person, we need to identify them and say, look, they're only going to give us one chance. We don't need to make it sustainable. We need to make it noticeable. I want to say that one more time. In the highly speculative person, we don't need to make it sustainable. We can worry about sustainability later. We need to make it noticeable. We need to tell them what I'm about to ask is you're going to eliminate a bunch of stuff from your diet. You're going to change a bunch of things about your sleep environment. You are not going to have to maintain these long term. This is going to tell both of us if you're in the right spot. Once that person comes back and you've all had the person who's made really drastic diet changes, think about fasting or total sugar elimination. What do they come back and say? They say really drastic things like, my gosh, I feel less swollen all over my body. I had carpal tunnel as well and that feels better. I used to have headaches and now I don't. They tend to see things happen because they made such a drastic change to the ecosystem. In the unsure speculative patient, that is exactly what the doctor ordered because the number one goal with them is psychological. We've got to get them to believe, oh my gosh, this stuff can actually have an effect on my condition. Now the moment they realize that these are the things that I should be tweaking to make a change, now we alter that program to make it sustainable and do less better.

11:29 OVERCOMING PSYCHOLOGICAL BARRIERS

But I am making a call to action on this episode that for the reluctant individual, for the person with the psychological barrier, doing more in the very short term to show them that what won't happen is nothing is the most important thing to get that initial piece of traction that allows you to then refine, pare down and make sustainable a program they now believe in. Give it some thought. Is there a place to go with overdoses, overwhelm, to shift psychology, to get that goal in mind and get that patient on board? I hope it makes sense. In general, I'm always going to believe in do less better but there are always exceptions and let's make sure that we're not letting a blanket statement prevent those people from moving in the right direction. Cheers everybody, PT on ICE.com, you know where the goods live. All of you at the CrossFit Games, good luck. Kelly Benfey, especially good luck. I hope the 64 Army crushes it this weekend. I will certainly be watching from right here. Cheers everybody, take care.

12:20 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning Check out our virtual ICE online mentorship program at PT on ICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE.com and scroll to the bottom of the page to sign up.

Aug 2, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the idea that passion alone is not sufficient for thriving in a career. She mentions that while it is possible to sustain a career solely based on passion, it is not sustainable in the long run. Julie shares personal experiences and acknowledges that many colleagues and friends have also encountered this issue. She emphasizes the importance of considering the entire ecosystem, including supportive management, colleagues with similar philosophies, and a network of supportive friends, family, and partners. Without this support system, Julie warns that burnout is likely to occur and that the initial passion will start to diminish. The episode emphasizes the need for a supportive ecosystem, where managers value and understand the contributions individuals bring to their work. Julie also mentions the importance of growth and opportunities for advancement, as well as being surrounded by like-minded individuals who share a fitness-forward approach.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? Welcome back to the PT on ICE Daily Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show.

01:43 JULIE BRAUER
Good morning, crew. Welcome to the Geri on ICE segment of the PT on ICE Daily Show. I'm brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Excited to talk to you all this morning about five things I've changed my mind about in Jerry PT over the past, I think it's like eight-ish years now of my career. So I actually have a list of like eight or nine. It keeps growing as I keep thinking about things, but I'm going to try and keep it to around five. And so my hope is that over the past eight years of all the mistakes I've made and the paths I went down and the things I've learned, I'm hoping that someone out there listening today, if I can inspire and encourage you to think a little bit differently, to do a little bit differently, if I can save you a little bit of heartache that I've experienced, then I will call this a 100% success. Okay, so these aren't necessarily in order of importance except this first one. So number one of five things that changed my mind about in Jerry rehab, changing settings will fix your burnout. Changing settings will fix your burnout. It will not. If you are in a situation where you feel really unhappy, you feel burnt out with the job that you currently have and the setting that you currently are in, please know that the grass is not always green around the other side. I promise it's not.

03:08 "CHANGING SETTINGS WON'T FIX BURNOUT"

It's not necessarily that changing settings is going to fix your burnout. Identifying why you are burned out and doing something about the root of the problem is going to fix your burnout. So I'm not going to get into this too, too deeply because I've done an entire podcast specifically talking about burnout and those of you who are thinking home health will fix that. So if you are interested in that specific podcast, send me a message and I will send you the link. But as an overview, I just want you all to know that you have to identify why first before you jump ship. So the why could be a multitude of different things. Is it truly that you are not passionate about an athletic population and you actually are passionate about a more acute, medically complex population of older adults? Is it that you really want flexibility in your schedule and you can't stand the back to back, the back to back schedule of inpatient rehab? You have to be able to verbalize and write these things down about why you are so burned out in your job.

04:51 BURNOUT IN DIFFERENT THERAPY SETTINGS

I spent many years starting out in acute care, getting burned out, thinking that I was going to love inpatient rehab. I was convinced I'm going to have more time with my patients. I'm going to be able to follow them. I'm going to be able to do higher level therapy with them. It's going to be so much better. I went into inpatient rehab. I absolutely hated it. And then I was like, all right, home health, total flexibility. I'm going to be able to see less patients a day. That's definitely going to be the setting for me. Nope, that wasn't it either. What I was doing is thinking that changing up setting was just what I needed to do. And in reality, for me, I came to the conclusion that full time clinical care is what was burning me out. It did not matter what the setting was. And I wish that I would have realized that very, very early on in this process. Now, I learned a lot and I'm really happy that I have experience in all of these settings. However, I could have been much further along in really dialing in what I want to spend my time and effort towards. If I would have thought of that earlier. So those of you that are really burned out, you're thinking about jumping ship. Don't do it. Start to really evaluate those things. Okay, next, you can give a really high quality session and a really efficient session without timing yourself. This is simple. No, you can't know. You absolutely cannot give a really high quality session that is also efficient unless you have yourself on a clock. For the entire session and truly throughout your entire day of doing your job. I think it's really hard because we go from PT school where all we have to do in a day is study, right? Like if our eyes are open, we are like, well, I have to learn the brachial plexus today. And that's all I have to do. So all I'm going to do is sit here for hours upon hours upon hours and study and memorize things from a book. And then we get into clinical and then we get into the real world where we have this thing called productivity. We have to meet while we are also trying to maintain our sanity. And all of a sudden, it is very overwhelming to try and bring quality at the same time as being efficient. So my call to action to you all is put a clock on yourself for your entire day. When you are with your patients, when you are not with your patients, it will change your life. I promise you when I started doing this in home health and you start this just like you start anything, like if you are starting to train for a race, for example, and you know you have to hit certain macros, you need to just start by tracking. What do you normally eat? How many calories are you actually bringing in? So you don't change anything at first. You just track. So you time yourself all of your breaks, your bathroom breaks, your snack breaks, your chatting with colleague breaks, the amount of time it takes you if you are in home health to drive to patient to patient, the amount of time that you are sitting in acute care at the desk and documenting. You time everything. In addition to how long you are actually spending with your patient and how long you are actually doing those subtitles of your session like education or neuromuscular read or gate training, whatever it is, you time everything. You will realize all of your inefficiencies. You will realize, wow, my hourly rate is actually crap. So when I timed myself when I was in home health, I timed everything. And I realized that if I was spending 60 minutes with the patient and I was actually hustling to get everything else done, calling doctors, etc, etc. I was making $40 an hour. Not ideal. Once I started timing myself and figuring out where I could cut, I went from $40 an hour to over $60 an hour. I have an entire podcast just on how to improve efficiency in home health. Again, if you were interested in that, message me and I'll send you the link. So again, my call to action for you all is use your phone. Your lap timer on your stopwatch is really helpful. Wear your Apple watch time every single thing. Start there, track it for a week, and then start chipping away at where you can cut places where you're really inefficient. Not only will you be able to give time back to yourself, which is what we want at the end of the day because taking care of humans all day is exhausting, but your patient sessions, you will get them so much more fit in so much less time. That's a win-win. So start timing yourself.

10:53 PT's DON'T NEED TO TAKE PATIENTS TO THE BATHROOM

All right, next. PTs don't need to take patients to the bathroom. PTs don't need to take patients to the bathroom. That is an OT's job. That is a nurse's job. That is a tech's job. Man, this is one thing that I may be like the most sorry about. What I feel so guilty about for years in my career is that I'm with the patients and I'm wrapping things up, right? I know that I want to get out that door so I can get to my next patient. I'm done. I've done my PT thing and they ask me to take them to the bathroom. It's that moment you're like, I really need to get out this door. And what would I say many times? You know what? OT is coming to see you later this afternoon. They will take you to the bathroom and work on toileting. Then for right now, I'm going to press that button and your nurse is going to come and take you to the bathroom. So many of you have been there. I know you are. I know you've done this. But guys, what do we know happens or not happens? We press that button. Nobody comes. Our patient is sitting there uncomfortable. They may not actually get to the bathroom for a very, very long time. What we know from the literature why we have to change our mind about this and start doing this differently is that many falls in acute care. A very high percentage of them happen in the bathroom. This is avoidable because what is happening? Our patients ring the bell. Nobody comes. And then they have the choice of urinating on themselves or continuing to, and sitting there and waiting or breaking the rules and trying to rush to the bathroom where maybe they're on pain meds, their balance is off, they slip, et cetera, et cetera. We need to realize that is our job. We are not above any freaking job when we are with those patients in acute care. They need their butt wiped. We wipe their freaking butt. That is our job. It is patient care. We are all in this together to get that patient out of this DM hospital and back to their life wiping their butt, taking it in the bathroom. That's included. The very basics of giving this dignity back to this human. It is not a particular person's job. And think about it, even from a self-serving perspective, how much information you learn from taking a patient to the bathroom. You are watching them transfer. It gives them motivation to get out of bed versus like, let's get out of bed and go on a walk and lift these weights, right? You get to see how their ambulatory capacity, right? You get to see their balance. You get to see their problem solving, their stand pivot, how they have e-central control getting down to that toilet. Are they able to problem solve how to sequence those steps? Can they grab the toilet paper? Do they know how to use it? You get so much valuable information. And maybe watching someone toilet and saying, I know that looks off. It seems like they don't know how to sequence this, but I don't know the language to put to it. And I don't, this isn't really something that I understand how to treat, right? Yes, your OT partners are going to be able to take that baton that you hand them after you give them an information. And they're going to be able to do a much better job in that specific task, right? It's collaboration. We need to be setting our patients up for success. Never, ever, ever, ever from today forward, please PTAs ever tell your patient, that is someone else's job, someone else's job. I'll go tell the nurse when I leave. It is your job. You should start planning for this in your sessions. Just give some time before you absolutely have to get out that door. Give five, six minutes to a lot for this patient needing to use the bathroom. It is your job. We are part of a team and you can prevent something drastic happening like falls or someone losing their dignity by literally having to urinate on themselves.

18:21 ALTERNATIVE HOME EXERCISE OPTIONS

Next, weights are the best pieces of equipment to initiate loading with older adults. Weights are the best pieces of equipment to initiate loading with older adults. Look, I love being able to get my older adults, especially those who are pretty medically complex and deconditioned, lifting weights, right? All of you all, this ice crew, your fitness forward, you are incredibly enthusiastic about this. However, if we focus too much on that, I think we can be actually increasing the barrier to loading versus decreasing it, which is our job. We need to realize that the best equipment older adults are using to introduce loading are not necessarily weights. The best equipment are the objects, the animals, the people, the boxes, whatever the odd things are that are in someone's life, an older adult's life, that they will lift, push, carry, pull, hinge. Those are the best pieces of equipment to introduce loading for an older adult. That may not be a weight ever, ever. If it is, amazing. I love it. Bonus points. The best equipment is the one that our patient is actually going to use. I love how enthusiastic we are. And if we can get our older adults lifting weights, wonderful. But ask yourself, like, is this sustainable? Is this only going to be something that they do with me? What am I doing to allow sustainability and longevity of loading with this older adult that they will continue to do after I am no longer caring for them? When our plan of care is over, have I decreased the entry point to loading so much that they have a technique that they can use on their own? Are they going to buy those weights off of Amazon that you've told them? Are they going to have a family member go and buy the dumbbells from Walmart? If they're not, then you better have another option. You better have something that they can use around their home that's less intimidating, that's cheaper, whatever it is. And not over here. Try to introduce the weights, but also give them something that's incredibly, incredibly convenient, right? Where you're decreasing the barrier of making the right choice, which is introducing loading, and we need to make it convenient. So I would argue that while I would bring weights in my backpack, walking around the hospital, I will bring weights in my trunk when I go to see my patients in home health. A resistance band, not a TheraBand, a rogue resistance band, many times was the best piece of equipment to introduce loading to an older adult. It's not intimidating. It's versatile. Not only can you use it to introduce loading and resistance, but I love to use those resistance bands for balance reactions. You can do a lot of perturbations with them. You can put them on the floor and use them as like an agility ladder. They are incredibly versatile. They're light. They're easy to carry around with you. Many older adults are not intimidated by them. Many times, a resistance band is the way to go. Many patients, I am not getting weights into their homes for these really sick folks in home health. It's just not going to happen. They're not going to make it there. So you need to make sure that you have something that is going to be practical for them and it's going to be sustainable. For me, it has been a resistance band. Give that some thought. Maybe go onto Amazon today when you're ordering your other stuff and getting your cart ready for Prime. Add a rogue or some other brand. It doesn't have to be rogue, but a actual resistance band to your cart. Okay. Last one here before we go.

23:53 SUPPORTIVE ECOSYSTEMS IN YOUR CAREER

Last one, most unpopular opinion. You can thrive in your career on passion alone. You can thrive in your career on passion alone. I don't think this is true. I have experienced, and I know many of you have experienced this, many of my dear friends and colleagues have experienced this, that you can survive in your career on passion alone, but it's not sustainable. You have to think of your entire ecosystem. If the only thing that is able to get you up and get you out of bed and get you going to your clinic, your hospital, your patient's home is that you love treating older adults. You love the relationships you build. You were so called to better serve this population. If that's it, if you do not have supportive management, if you do not have colleagues that think in the same way that you do and share your same philosophy, if you don't have supportive friends, family, partners, you are going to really start to burn out. That passion is going, that fire is going to start to diminish. It may not go out completely, but damn, it's going to be a lot harder to keep that going. It is absolutely critical that you are in a supportive ecosystem, that your managers value you. They understand the value that you're bringing. They offer you opportunities to grow and advance and to really stretch your skills that you are surrounded by other people who feel the same way, who want to charge forward with a fitness forward approach. You need to have friends and family and people that you're maintaining your relationships with, and they need to be supportive of what you're going after. You need to create that ecosystem. When you don't have that, I think so many, and I believe this for a long time, as much as I care about this mission, this thing, this job, older adults, as much as I care about it, it will be tempered. That fire will not burn as bright if we do not have the support from all those different parts of our ecosystem. It just gets to a point where maybe you're just running on fumes. Start to think about who your ecosystem is within your job, your managers, your colleagues. Do you have growth? Are you challenged? Are you very passionately connected to your team, to the mission, and about your personal relationships? How are they supporting you? How many individuals have you built up around you that are there to support you? Really start thinking about that. Okay, that's it. I think that was five. Just to review, five things I've changed, or maybe six, five things I've changed my mind about in Jerry Rehab. Changing settings will fix your burnout. You can be efficient and give a high quality session without timing yourself. PTs don't need to take patients to the bathroom. Weights are the best pieces of equipment to use to introduce loading to older adults. You can thrive in your career on passion alone. Five things I've had a massive, massive thought switch as I've gone through my career. Hopefully you all found some of those things to be really helpful. It gave you some things to think about. Please, if any of that spoke to you, do one thing today to change how you think or change what you do. To close this out, I will let you guys know what we have coming up in the older adult division. We have tons of courses. We are going to be in Lexington next weekend. That's our MMOA summit. The entire crew is going to be there. We get to check out Stronger Life with Jeff and Dustin. They're spot there. We absolutely can't wait. We are in Texas, Minnesota, and California for the rest of August. Then MMOA Central Foundations starts next Wednesday. One week from today, our online cohort starts. That cohort is filling up rather quickly. We took a little bit of a break in June and July. If you're interested in that course, I would not wait. I would get your ticket ASAP. All right, guys. Have a wonderful rest of your Wednesday.

25:49 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Aug 1, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the significance of addressing the underlying ecosystem challenge to achieve better outcomes for patients. She specifically highlights the prevalence of poor diet and obesity as contributing factors to this challenge. Lindsey points out that there is evidence suggesting a link between these factors and knee pain, as overweight and obesity are often observed in individuals experiencing knee pain.

Lindsey emphasizes that focusing solely on physical therapy interventions, such as knee range of motion and strength exercises, is insufficient. Instead, she argues that healthcare professionals, including physical therapists, need to consider the broader ecosystem in which patients exist. This includes addressing mindset, mindfulness, exercise, diet, and sleep.

To guide patients along this path, Lindsey  suggests that physical therapists can play a role by providing support and education. She compares physical therapists to shepherds, who can assist patients in navigating and making positive changes in their overall lifestyle. By addressing the underlying ecosystem challenge, Lindsey believes that better outcomes can be achieved for patients.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How's it going? Welcome to Clinical Tuesday. I'm Dr. Lindsay Hughey coming to you live from Edgerton, Wisconsin. So good to see you all today. I am going to chat with you about playing offensive medicine in our folks with degenerative meniscal injury. Before I dive in to what that looks like, I'd love to share with you a little bit about courses Mark and I have coming up in extremity management. So we have a couple options in August and actually one of them, well we did have a couple options, we only have one now because all the tickets in Fremont, Nebraska August 19th and 20th are actually sold out. So our last ticket went I think yesterday. So the only option in August to check us out and learn all things best dosage and tendinopathy care of the upper and lower quarter is Rochester Hills. So August 12th and 13th I will be teaching there and so join me if you can. And then in September Mark has two options for you on September 9th and 10th out of Amarillo, Texas and then September 16th, 17th out of Ohio. So Cincinnati will be coming your way. And then some fall and winter courses but again opportunities are dwindling. We hope if we don't see you this summer to see you in the fall or winter.


01:48 STOP THE SCOPE

But let's chat about how do we play offense for degenerative meniscal injury because today is really a call, another call to stop the scope. I've hopped on here before over a year ago, I'm kind of charging us with those folks that have that gradual onset of symptoms of pain in their knee, maybe a little bit of swelling but have no specific injury or twisting event that happened that's more related to a degenerative process or like or I would like to refer to as a living life process. They don't need arthroscopic meniscectomy. And so we had more literature just come out this year to really bolster that argument of why physical therapy is really the number one choice, exercise medicine is the way to go. But I would like to first highlight that new literature that came out in January of why it's not appropriate to have surgery for these folks and then to also take a moment to reflect on why are we still seeing the arthroscopic partial meniscectomies being done if we keep finding literature that says let's not do this. And then also reflect on how can we do better as a profession to stop this continued over medicalization. So I first just want to briefly review in January 2023 we had a systematic review and meta-analysis come out from the Osteoarthritis and Cartilage Journal and we actually did share that on hump day hustling a while back. But this systematic review and meta-analysis again let us know that degenerative meniscal injury, the scope is not the way. And so let me unpack a little bit about this study because it was pretty inclusive this systematic review and meta-analysis. They looked at tons of RCTs so that the pool data of all patients was 605 patients. The study populations in each of the RCTs ranged somewhere between 44 and 319 so decent size overall in each study. The mean age of these folks was about 55 with the standard deviation of 7.5 so kind of that middle age and then majority were female about 52.4 percent. So you also see an even distribution almost of males and females in this study and then mean BMI was 26.5 standard deviation 3.7 you know below or above that. And what they investigated was the effectiveness of using arthroscopic partial manisectomy and they compared that via non-surgical so either sham which was exercise treatment or some form of exercise program so every RCT they looked at had to have the comparator of exercise. And degenerative meniscal findings were confirmed on MRI in all of the studies. The primary outcomes were knee pain, overall knee function, and then health-related quality of life and they looked at outcomes for up to two years so we see again a long-term follow-up in these RCTs this collection of RCTs that they looked at. And so the conclusions January 2023 so we're you know over six months out over half a year through and the conclusion was for insidious onset of knee pain so non-traumatic with MRI confirming degenerative meniscal tear in adults arthroscopic partial manisectomy is not the answer.

05:15 "NO CLINICALLY RELEVANT EFFECTS OF PARTIAL ARTHOSCOPIC MENISECTOMY"

Literally if I'm going to quote verbatim no clinically relevant effect of arthroscopic partial meniscectomy was detected for overall knee function health-related quality of life or mental health. They did find one small marginal difference in pain levels a couple points but there was no evidence that there was superiority in having surgery. In fact they even took a look to see are there subgroups of patients right that might have a greater benefit from APM that were just not recognizing and when they looked and compared again the non-surgical to sham exercise therapy they did not see a subgroup that existed. They made other conclusions to say most degenerative meniscal tears are going to improve over time without the need for that arthroscopic partial menisectomy. Other findings that I think are really important to point out before we kind of reflect on why if we have this evidence do we keep seeing surgeries being done is that when they looked at the individuals in the studies those with BMI over 30 so obese individuals compared to the healthy BMIs less than 25 they had a 4.7 fold increased risk of progressing to knee osteoarthritis whether they had surgery or not. It was really a call to action when they found this in this pool data of all these folks is that body weight reduction strategies need to be on board for pain and function effects.

07:28 "...NO SIGNIFICANT ADVANTAGE OVER NON-SURGICAL TREATMENT"

So just to send it home about this study and what they said one of the final things that they wrote in their conclusion was and I'm going to read it verbatim we recommend that physicians minimize the use of arthroscopic partial mastectomy to treat patients with degenerative meniscal tears because there is no significant advantage over non-surgical treatment. This is the osteoarthritis journal right this is a pretty high tier journal osteoarthritis and cartilage journal making this statement. So why are we still seeing a ton of them? Why does this keep happening where we see patients I have one of my caseload right now right why is this happening? Well we're obviously not reading the literature as a health care team and as physicians right because patients still think this is a primary defense. I'd love to reflect on that even 10 years ago in 2013 we had a study from Yim et al where they compared meniscectomy versus non-operative strength care and this was in 103 patients them and the same exact message was there there are no significant difference between arthroscopic meniscectomy and non-operative management with strengthening exercises again when we look at knee pain function and satisfaction at the two-year mark. So even 10 years ago we had this evidence but yet it's not translating to practice that's a lot of surgeries a lot of over-medicalization so I we need to really step it up here in our not only in ingesting this information but advocating that this is not a new message. In this article they point out that in 2017 so the systematic review and meta-analysis that we just reviewed that in 2017 an expert panel that regarding the degenerative meniscal injury said that the use of arthroscopic partial meniscectomy in nearly all patients with degenerative knee disease that several guidelines do not support this procedure. They've literally made clear statements against it again yet we're still seeing it so we can do better here and that probably takes some building relationships with surgeons right and chatting with them and letting them know like PT first get them to us right but really advocating that message in the community because we know that's not always going to work talking to the health care team. I think this message needs to be broadcasted widely more widely than it is currently. The other reason I think we keep seeing it besides like poor translation from what we're reading to the general public is there's this image mismatch so we see this a lot in the extremities and if you've been to our extremity of course you know we have a lot of conversations around this in different areas of the body shoulder hip knee but you see degeneration on the MRI right but there is no clear link that that's the cause of their pain symptoms it's an incidental finding but yet patients think oh you know my knee is really banged up right they leave hearing this message of harm rather than hearing you know I'm glad this is a normal age-related change so there's the image is linked inaccurately to pain and so again another opportunity to educate in this space and then the other reason I think that we keep seeing a ton of them being done regardless of what we know in the literature regardless of what we know that imaging doesn't tell the whole story is that there's this message put out about the fear of progression right if you do not get this meniscectomy you will go on to having knee OA or early onset knee OA which will lead to a knee replacement.

11:12 "IT'S DOING MORE HARM THAN GOOD"

Let's stop allowing this message to be passed on it is harmful right it's doing more harmful than good and we don't actually know that right any fear-based messaging is not the way and so that message that is a thought virus and if our patients are coming into us or even like people in our community right our family or friends um we have to really um call BS on that right because we don't know that for sure and we're not seeing that link so finally kind of the background of the that we just had in January 2023 tell us that having surgery is not the way we've kind of reflected on why do we keep seeing this so what do we actually finally do about it well promote PT first faster right when someone's knee is starting to ache right stop ignoring it get into PT stop going to a medical provider even primary care orthopedic first come to physical therapy first so we can help you um with your hip and your knee pain and your um any associated muscle weakness or swelling so that we can get these healthy messages into our folks and into the community these folks get lost in the system letting them know that it is very common what they're experiencing and a plan for success that's our job that's our wheelhouse we need to manage expectation too so folks right some of our patients are going to want to do the surgery anyway right despite any of the things we can tell them about the evidence right they're set on it their belief and expectation it's going to help well i need you to manage those expectations as well because surgery after surgery i don't know about you all but all the ones i see doesn't actually take away their pain and swelling in fact the surgeons have actually told my patients you can expect swelling for up to six months which is literally the reason they came in there they want to feel better and they want the swelling to go away well guess what at least for six months it's not going to happen folks so letting them know that in a kinder less passionate way probably so while these folks might return to work or sport they're going to have ongoing symptoms and that's swelling so letting them know that that even if they opt for that it's still going to be a challenge they're still going to need pt so i tend to want to say why not play offensive time along those six months where you don't have to um respect healing time frames after surgery where we can really get after strength around that that knee and that hip the other thing we need to reflect on and how we can do better is that it's not just promote pt faster it's not just managing expectation but we have to understand the underlying ecosystem challenge that is present in a lot of these folks we see and especially in the systematic review and analysis that came out in january 2023 we see an underlying poor diet and we the reason we can know that it's related somehow to diet is it's we see overweight and obesity being precedent being present excuse me and so we have to understand that we have to intervene in these folks not just on knee range of motion and knee and hip strength and proprioception but we actually have to consider there's that underlying ecosystem piece and here's where pts can help too right we can help with mindset mindfulness exercise diet sleep and really guide them along that path as a shepherd we can help so we need to know that we can help right so some of us maybe don't even realize that our own you know 2018 cpg guidelines at the josp t let us know that exercise is medicine and whether patients do opt for surgery not that guideline really points out that supervised exercise so how many folks you see after arthroscopic partial metastatic go on they have the surgery and then the docs just give them a standard h.e.p. right so they go on having swelling quad like because they don't have an individualized program with progressive resistance exercise let those folks know too you need to be a part of their care in our own clinical practice guidelines say that it's not good enough to just do a an h.e.p. that's not tailored to the individual and then what that cpg highlights is we're always going to do a mix of hip and knee strengthening we will have manual therapy on board we will do proprioceptive activity and neuro re-ed for those joining this morning thank you to summarize where we are at when thinking about our degenerative meniscal care we need to advocate against surgery with that insidious onset of knee pain we need to share this evidence far and wide that it is not recommended as frontline defense we need to stop the fear messaging as a health care profession and let folks know that degenerative changes found on images are normal signs of living their life and that pain does not equate to imaging findings we need to dose hope and let folks know that at that two-year mark we can see just as great of improvements in pain function satisfaction of care with just p.t. right and i don't take the just p.t. lightly we don't need that overmedicalization p.t. first is the way i'd rather see a patient taking control of their ecosystem and knee health for two years rather than that wait and see approach will surgery help stop the scope folks have a happy tuesday and thank you for joining me

16:35 OUTRO
Hey thanks for tuning in to the PT on ICE Daily Show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home check out our virtual ice online mentorship program at pt on ice dot com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to www.ptonice.com and scroll to the bottom of the page to sign up

Jul 31, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses how virtual pelvic floor care can prove beneficial for physical therapists in both virtual and in-person settings. Alexis shares that engaging in virtual pelvic floor care has significantly improved her overall abilities as a physical therapist, particularly in asking questions and gathering necessary information. She also notes that virtual care seamlessly integrates into both virtual and in-person worlds. Alexis highly recommends physical therapists to explore virtual pelvic floor care as it can be incredibly helpful. Furthermore, she mentions that a future podcast episode will delve into objective exams for pelvic floor virtual PT, indicating the importance of further exploring virtual care.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show

01:27 ALEXIS MORGAN
Good morning, Instagram. Good morning, PT on ICE Daily Show. My name is Dr. Alexis Morgan. I am one of the faculty with the Ice Pelvic Division. Really happy to have you all here joining me this Monday morning. My voice is a little raw from the weekend. We were just in Denver, Colorado, right outside of Denver at Onward Denver in Parker. This whole weekend, April and I spent with an awesome, awesome group of individuals and we were going through all of our material in our live course. We did our internal exams, supine and standing, and dove into all issues of pelvic floor dysfunction. We of course didn't stop there. We progressed through everything that our athletes are doing at the gym. So talking about how pelvic floor dysfunction fits into weightlifting and Valsalva and using a weightlifting belt and jumping and running and doing gymnastics. We had an absolute blast with this last weekend and we hope that you all will join us in the future for not only our live course but also our online course. I want to talk with you all today about virtual pelvic floor PT. We get a lot of questions asked over Instagram and on our Ice Students Facebook page. Sometimes we answer you all directly with some help. A lot of times we like to use your questions to teach everyone else about the topic that you asked.

03:10 VIRTUAL PELVIC FLOOR PT
This particular topic actually came from an Ice student who was wanting to know some more information about how to really apply what we talk about in our live and online courses into the virtual setting. And so that's exactly what I want to dive into today. Kind of similar to what we talk about really in all of our courses is that our subjective exam should be very detailed. It should be specific and we should be taking a while to do our subjective exams. I will say that when it comes to doing an assessment virtually, the subjective becomes huge. Not everything but a vast majority of especially that initial assessment. I'll talk through some ways that we do some objective exams but I want to before we even get there really emphasize to you all the importance of that subjective exam particularly in the virtual setting. So when I say be specific, there's a couple of things I mean with this. Depending on the issue that they may be coming to you for, whether that's leaking urine, whether that's pelvic organ prolapse or feelings of heaviness or vaginal bulge, that might be leaking bowels, whether that's anal incontinence with stool or potentially with flatulence. Maybe it's constipation. Whatever that may be, we want to get very specific on their problem. Again, this is true in person and in virtual but it really does become extremely important in this setting because all you've got to track changes are your words. By you having conversations and by asking questions, that's how you track the person's change. So it's not in session, which sometimes we can gather on that first virtual, but definitely between sessions. It's really, really important. So maybe you use the patient specific functional scale where they fill this out ahead of time or maybe you help them out and ask them further questions when they tell you they leak with double unders.

06:26 LEAKING WITH DOUBLE UNDERS
When I hear I'm leaking with double unders, that is not enough information for me to help you just yet. I've got a lot more questions and you should too because depending on how they answer, it could really change how you're going to treat them for that leaking. Not all leaking with jump rope is treated in the same way. And we've talked about this so much yesterday in our live course as we were going through jumping rope. But what we need to do is ask questions. So when does the leaking occur? When in that workout? And tell me what jumping rope looks like to you. Is it single unders? Is it double unders? If it's double unders, is it always doubles? Did you just gain that skill or is that an old skill for you? At what point during the workout? If it's early on, that's going to be different than if it's later on, right? I'm starting to think fatigue plays a role in their leaking. If it's later on in a workout, does it matter about which exact workout it is? What is the volume with that? That's going to be different, right? If it's 50 double unders versus 500 double unders, that's going to be different. And so we need to figure that out and we need to ask those questions. So you can use the patient specific functional scale and make that work for you. You can also use the PFDI, a specific to pelvic floor questionnaire. Now that is not an open box. That is marking, marking symptoms on a questionnaire. But what we've got to do is we've got to get information about their specific number one problem that they have. And moving forward, we need to understand what is their entire pelvic floor environment like. So we're going to ask questions and see if they have issues in other pelvic floor realms. Realizing we understand the number one reason why you came to me and I promise you I'm going to help you with that. But sometimes some of these other issues kind of play into your main leaking problem. Or as we're addressing your leaking, we can also address these other issues and together everything within your pelvic floor is going to function better. So a couple of those questions, again, depending on what they're coming in for, whether that's vaginal or bowel issues, you're going to ask, are you experiencing any leaking with maybe coughing or laughing, sneezing? And even with that, sometimes people are like, no, I don't leak with sneezing, but I do have to cross my legs together aggressively in order not to pee. OK, that's a problem, right? We're going to add that to our list. Do you feel like you can fully void? How frequently are you peeing? This one's a hard question for people to answer, but I generally want to know like, is it every 5, 10, 15 minutes or is it more like every hour or two? If it's very frequent, like every 15 minutes, that's going to be something that we note down and address early on. If it's every hour or two, we're going to lower that on our list. We may get to that if it's every hour and bothersome, we may not get to that. If there is high frequency, we're going to send them with a bladder diary and that's going to be one of our first trial treatments that we do with them.

12:00 STRAINING TO POOP
We want to actually pull up the Bristol stool chart. I always laugh when I pull this up. I'm like, OK, listen, I'm going to ask you a weird question. I promise it's relevant. And then I pull up the Bristol stool chart and I say, give me a range like where do your poops normally fall within this Bristol stool chart? Looking at that to see, we want to see around that three or four that are relatively normal. But if it's above or below that, we're thinking, what does diet and hydration look like? And that may lead us into more questions. How frequently are we having a bowel movement? Is it every one to three days? Because that's normal. Or is it six times a day or every six days? Those are not normal. And so we can dive into that. Do you feel like you have to strain really hard in order to have your bowel movement? We have evidence and plenty of it on straining to poop. And we need to be teaching people not to do that for their pelvic floor health. It's a very simple and effective intervention. Do you use a squatty potty or do you use something under your feet to bring your knees up higher than your hips? For most cases, that's going to dramatically improve the ability to go have a bowel movement. And that's really, really helpful. And again, is there any leaking, any anal incontinence that is, again, flatulence or potentially stool? All of these, again, are good questions to ask, even if they're not coming in with bowel problems for you to resolve. We want to go through this with them. And then vaginally, we're going to ask some questions as well. Do you have any pain with insertion? So that insertion could be anything from a tampon to a penis, sex toy, or speculum exams. Do you have any pain with that insertion? And asking, do you have any loss of air, especially with our active individuals who might be going upside down, whether that's in yoga, Pilates, CrossFit? Sometimes people can have loss of air or queefing. And we want to know about that because all of these things really paint a picture for us. Now, usually, this takes up quite a bit of time. I mean, I've been talking about what questions to ask for the last 10 minutes with absolutely no answers behind them. So this typically is a really good starting point and often is the vast majority of my first virtual pelvic floor assessment. However, I like to leave time for a few more questions and then getting into education as my trial treatment. So the few other questions that we always want to know is what is exercise or movement look like, how is sleep, and what do you do for stress management? Some of these questions you can ask in your intake paperwork. You may want to go over that with them as well. But looking at them as a whole person and looking at their pelvic floor issues as a whole. And then from here, we do trial treatments as education. So depending on how they answer any of these questions, typically, and it's beyond the scope of this podcast to really talk about various education pieces for each of those questions, but I'm going to educate and I'm going to intervene. So maybe that is let's start hydrating. Get yourself a favorite water bottle and I actually want you to hydrate. Or potentially it's the opposite if they're over hydrating. Maybe it's can we decrease that intake throughout the day or right before bed? Maybe it's get a squatty potty or get your toddler's stool that's right in front of the sink and slide that under your feet for when you need to have bowel movement. Going back to our initial example of the leaking with double unders, perhaps it is I want you to video yourself doing double unders from the side view and the front view and send it back to me. But between now and then, I want you to make sure that we are videoing it at the end of you're having that leaking. And after we get that, I'm going to have you take more rest breaks if that's what they need. Or maybe it's go into your single unders since double unders are always causing leaking and throughout our plan of care, we are going to dive into that. I try to find some piece of education and something that we know will help them resolve a little bit of their issue and get us rolling with this. We talk about it in our live course, but we have good evidence for education actually improving pelvic floor symptoms. And I think there's no better place to really feel that as a practitioner to feel the difference in the amount of education that you can provide and the amount of change that can occur. There's no better place than in this virtual care where truly we are guides. I can do nothing with my hands. I can do nothing with my body to change how that individual is functioning. I purely have to use my voice and teach and ask questions. If you have not done virtual pelvic floor care, I would highly recommend it. It has made me a much better physical therapist altogether, much better at asking these questions and getting the information that I need. And it blends into both worlds, both virtual and in person. So if you haven't done it, I highly recommend getting some patients in that virtual care because it can be really helpful. That needs to be all for today. I have a lot more that I could say, especially if we dive into the objective exam and how to do that. But I think that's going to need to be a podcast part two for virtual care. So I will do that the next time I hop on to the daily show and talk with you all about how we do objective exams for pelvic floor virtual PT. Thank you all so much for joining me and listening in this Monday morning. Or if you're listening later on the podcast, thank you for listening. One quick note, it is CrossFit Games Week and we are so, so excited to be cheering on our very own Kelly Bimpy at the Games with her team this year. So tune in to the Games. If you're going to be there, let us know. There's several of us ICE faculty that are going to be at the Games. We would love to see you and say hello. And I don't know, maybe we can snag a workout in or something. But we are so excited. It is Games Week. Have an awesome week. Hopefully we'll see you up north. If not, catch you later. Have a good one.

19:26 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

 

 

Jul 28, 2023

Dr. Guillermo Contreras // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses how manipulating reps within a set can alter the intended stimulus of the set to bias towards power, strength, hypertrophy, or endurance gains. Guillermo discusses new research highlighting that depending on population, some individuals may still experience strength gains at lower loads & higher rep counts and that most individuals will improve hypertrophy regardless of rep dosage.  

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

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one on one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show.

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

19:04 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the institute of clinical excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home check out our virtual ice online mentorship program at www.ptonice.com while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to ptonice.com and scroll to the bottom of the page to sign up

 

Jul 27, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses the state of physical therapy in 2023 with regards to pay. In this episode, the question of whether pursuing a career in physical therapy is worth it is addressed. It acknowledges that individuals may have concerns about the return on investment for the time and money spent on education and training to become a physical therapist. Alan mentions that some may be discouraged by the long time it takes to see a return on their investment, as it can take 15 to 20 years to pay off the debt associated with advanced certifications or residencies.

To address this concern, Alan suggests the need for better guidance for future physical therapists in terms of education and career choices. He emphasizes the importance of providing information to students considering entering the profession, as well as those already in school or practicing as physical therapists. Alan suggests informing future PTs about alternative routes to becoming a physical therapist that may be quicker and more cost-effective, such as completing prerequisites at a community college and transferring to a four-year program if necessary.

The episode also highlights that not all PT schools require a bachelor's degree and that there are various paths to becoming a physical therapist. Alan suggests providing better guidance to students during observation hours or while they are still in high school or undergrad, to inform them about the available options and help them make informed decisions about their education and career paths.

References

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

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

EPISODE TRANSCRIPTION

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

Jul 26, 2023

Dr. Alex Germano // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses  how treating individuals with sensory-based approaches at an early stage of their disease progression may help prevent or delay limitations later on. Alex suggests incorporating a variety of sensory challenges into treatments for individuals with Multiple Sclerosis (MS). These challenges include exercises that activate the inner ear and engage the eyes, aiming to improve proprioception and challenge the integration of sensory information. Alex emphasizes the importance of carefully dosing and scaling the exercises, taking into account the limitations of fatigue, in order to maximize the benefits of these interventions. Furthermore, Alex encourages starting the sensory-based approach in individuals with MS in their 20s and 30s, as it may potentially prevent or delay the onset of limitations later in the course of their disease progression. This approach focuses on enhancing sensory fitness and training the visual system through ocular motor training. By utilizing central vestibular system outcome measures and incorporating a variety of sensory challenges, clinicians can effectively identify and address the sensory integration component in their treatments for individuals with MS.

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 ALEX GERMANO
Good morning everyone and welcome to the PT on ICE Daily Show brought to you by the Institute of Clinical Excellence. Welcome to today's segment of Jerry on ICE. I'm Alex Germano. I'm a member of the older adult division and today what we're going to do is discuss some of these effects of multiple sclerosis on the vestibular system, what we need to look out for as clinicians, how we can assess better and treat this population. First, let me tell you some of the offerings within the older adult division before jumping into these questions. We have two courses coming up this weekend, one in Watkinsville, Georgia and the other across the country in Boise, Idaho. We have some seats left for both courses. We also have a course coming up in Frederick, Maryland, August 5th and 6th. We have our MMOA Summit in Lexington, Kentucky on August 12th and 13th and we have courses in Minnesota, Texas and California to round out August. First, let's talk about multiple sclerosis. This is a chronic, immune-immediated inflammatory disease. It causes neurodegenerative processes within the central nervous system. Now, typically onset of this condition is somewhere between 20 and 50. That's when people are getting diagnosed. We've seen a shift, however, towards people getting diagnosed a bit later in life and then these people go on to become older adults. So that's why we're kind of, we're having this discussion land within Jerry on ICE or this older adult discussion because we are out there treating a lot of people who have MS and have had it for a number of years. Now based on where these demyelinating plaques occur, people with MS can present in a wide variety of different ways, right, different patterns. And very often what happens with some of this demyelination is it occurs across the vestibular system, right? It impacts some of this vestibular information. Remember that vestibular system is vast. It touches many different points within our peripheral and central nervous system. We have parts of the vestibular system, not just in the inner ear, it's part of the cranial nerves, part of our brain stem, parts of our cerebellum. And interestingly, the vestibular nuclei in that root entry zone of the eighth cranial nerve have been shown to be some of the most common neuroanatomic locations for sensory demyelination. Okay? And very commonly the vestibular nuclei in the entry zone of the eighth cranial nerve have some demyelination. And oftentimes people with multiple sclerosis have abnormal tests on vestibular function both centrally and peripherally. Centrally people with MS may struggle with the ability to sensory reweight with most of their reliance of balance coming from the visual and proprioceptive systems. So they're not really integrating that vestibular sense. They're maybe too visually reliant. Really our brain is just trying to balance out all this information to give us a sense of balance. Now researchers really think that this central integration of peripheral input is where the dysfunction lies within the disease process. Interestingly, this type of central integration problem could actually be causing one of the leading debilitating features of MS, which is fatigue. The hypothesized relationship between central vestibular integration and fatigue could be explained by this poor ability to gate sensory information. The person with MS is unable to process all the signals incoming. The cerebellum can't do its job to override some other sensory noise such as like the vestibular ocular reflex as it normally does. That causes a poor perception of verticality. That contributes to increased sway. And imagine all this little sway that's going on all day. That can contribute to fatigue. So this information can really help guide us on our journey in assessing people with MS and their vestibular system. Now most of the information I'll talk about today regarding testing and the treatment of the vestibular system in people with MS comes from a group out of the University of Alabama at Birmingham led by Dr. Graham Cochran. And I'm going to link all these on Instagram for you. But this group really looks at the influence of the central vestibular system on function in people with MS. They concluded that we should be selecting measures that actually test central vestibular integration versus purely peripheral vestibular function. Because some people with MS don't have that peripheral vestibular dysfunction. Really the problem is central. So what tests can we use to capture that central integration problem? Now these central integration tests are more significantly correlated with measures of fatigue and walking capacity. They do mention a limitation of the studies that they perform on people with MS are that they are using this more on ambulatory patients. They're really testing the ambulatory community of people with MS. So it's very much something to consider if you go to apply this to non-ambulatory populations or people kind of much further in their disease progression. Now the two tests that they think we should be performing are VOR cancellation and the subjective visual vertical. The VOR cancellation tasks, remember that's our ability to kind of override our vestibular ocular reflex and remain fixated on a moving target. The VOR cancellation, it requires the integration between vestibular signals and visual system to produce an equal smooth pursuit eye movements, right? To keep vision stable on a moving target, moving at the same speed as our head. So VOR cancellation can really give us insight into this sensory integration. The subjective visual vertical, for example, is a task that requires integration of our otoliths, right? Our kind of gravity dependent inputs of our vestibular system and the visual system to help us orient to a true perceived vertical. So if you've ever seen people kind of presenting with maybe a tilt of the head or folks that are kind of leaning one direction or the other, they might have a sense of, they might have a mismatched sense of verticality and they're aligning their head or their eyes a different way to line up with what they perceive as vertical. So the subjective visual vertical task, or sorry, the subjective visual vertical assessment can give us insight into the combination of otolith input and visual system input. So again, that sensory integration that we're looking for. The subjective visual vertical test can be measured via a bucket test. There's like research-based, lab-based ways to measure this that are more accurate, but we can do this clinically with what's called a bucket test. Reactive therapy and wellness has a really good video on YouTube for that test and how to set one up with like a Home Depot bucket. Pretty simple. Vestibular rehab is a great addition to therapy protocols for people with multiple sclerosis. Vestibular rehabilitation programs have not only shown change in our folks' balance and disability due to dizziness or disequilibrium, but has also been shown to impact fatigue, which is amazing. The protocols for vestibular rehab and the research look like a lot of sensory integration work. We want to work on visual, vestibular, and proprioceptive inputs over a variety of different conditions. What we're really trying to do is beef up someone's sensory fitness, so to speak. So you are going to see the themes of eyes closed, standing on foam, moving the head around in different planes, moving the body both forwards, backwards, and laterally. You're going to see working in a variety of different positions, standing, kneeling, changing up that base of support, performing dynamic movement as well, such as walking. Then you're going to see some ocular motor training added to the mix to enhance that visual system. We want to train up the visual system as well. So you are going to be seeing some ocular motor training. Now, they perform this in a progressive manner, just like we would do with resistance exercise. They're consistently progressing the difficulty of set exercises, just like we would do. That is what makes the biggest difference for these patients. The missing piece to some of our treatments with people with MS might be that sensory integration component, or that central vestibular system work. To identify these problems, we need to use central vestibular system outcome measures, and we need to look at the VOR cancellation and subjective visual vertical. We need to include a variety of sensory challenges to our treatments. We need to select exercises that turn on the inner ear, that make the eyes work, that improve proprioception, and challenge the way our patients with MS integrate all of this information. We need to be masters of dosing and scaling, loading up people in a progressive, stepwise manner, while respecting the limitations of their fatigue in order to see the benefits from these interventions. I hope this gave you just a little bit of a different approach to folks with MS that you might be seeing that have balance or disequilibrium. Hopefully you can start to apply some of these concepts a bit earlier in the trajectory of their disease progression. So imagine starting to treat someone in their 20s and 30s with this sensory based approach. Maybe you can work to stave off some of these limitations later in the course of their disease process. I think that's really exciting stuff. I hope that helps you out in your clinical practice. I hope you have a great rest of your Wednesday, and we really look forward to seeing you on the road with MMOA Live soon. Have a good one.

11:25 OUTRO
Thanks for 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 CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

 

Jul 25, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses carrying as a valuable skill unique to humans as hunter-gatherers. She points out that humans, with their opposable thumbs, are well-suited to carry objects for long distances and extended periods. However, Lindsey also notes that this skill is being lost in modern society due to sedentary lifestyles and technological advancements.

Lindsey references Michael Easter's book, "Comfort Crisis," which challenges readers to step outside their comfort zones and recognize the importance of carrying as a skill. She suggests that carrying should be trained and incorporated into various healthcare professions, regardless of the specific patient population being treated.

The episode highlights the benefits of training carries. It mentions that carrying trains aerobic tolerance and grip strength, and it is a primary functional skill for picking up and transporting objects over long distances. Lindsey encourages listeners to consider how incorporating carries into their practice can lead to long-lasting functional changes for their patients, enabling them to carry objects without assistance and without needing frequent breaks.

Additionally, the episode emphasizes that training carries not only benefits specific body parts like the trunk, shoulders, and spine but also the entire system. The act of walking while carrying is described as the "magic" of training carries, as it trains the cardiovascular system, respiratory system, and central nervous system. The episode concludes by stating that not training carries means missing out on a unique opportunity, regardless of the specific issue being treated (upper quarter, spine, or lower quarter).

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How is it going? I am Dr. Lindsay Hughey. I will be your host this morning. We are going to chat all things Cary today. But before I do, I would love to just tell you a little bit about some courses that the Extremity Management Division has coming up. There are a host of opportunities. So just this upcoming weekend, I'll be in Madison right before the CrossFit Games. We're so excited to cheer Kelly on and her team, representing her team this morning. My shirt just came in. We're so pumped for that. But if there are a couple spots, like one or two left, so if you're on the fence, sign up now because those spots will probably go. But moving throughout the summer, we have lots of opportunity. So the next opportunity will be August 12 and 13, Rochester Hills, Michigan. There's lots of spots left in there. That's one of our more empty courses. So sign up for that. Because we're not in Nebraska, the following weekend, the 19th and 20th, is actually almost stacked. I don't think there are any spots left, maybe just a couple. So then your next opportunity would be in September with Mark. And there's lots of opportunities to jump in there in Amarillo, Texas. And that is September 9 and 10. He would love to see you there. And then September 16, 17. So we're moving more into the fall season. Cincinnati, Ohio. Mark has some spots there. Take a look on PT on ICE.com. If you're looking for a little bit later in the year, there are opportunities through the winter to join us. But we're not putting any more courses on the books for this year. So 2023. So opportunities are dwindling. But if you want to learn about met best management in your dosage strategies and about tendinopathy and how to load the upper and lower quarter, we would love to have you join us. All right. Today's topic I mentioned is carrying, right? And if you've been to our extrogyn management course, you know that carry lab is a big fun part of the end of day one. And then if you've been to MMOA, you know, carries are really important there as well. And most of our divisions at some point probably talk about the value of carrying. And a little bit about the background that got me inspired to chat about the value of training carries in our patient. It's really from a book I just recently read by Michael Easter Comfort Crisis. It's really challenged me to think about kind of how the evolution of technology and advancement in our society has really evolved away some of our valuable apex predator skills because we have more sedentary lifestyles and just our job demands and our ability to do that. And so we're losing a skill that's really unique to us as hunter gatherers. And because we have the opposable thumb, we are like the prime species to carry objects for long distances for a long time. And we aren't training ourselves in that way, even though we are the most well suited species to do so. And that book, dive into that if you're interested in it because it really challenged my thinking about everything we do in our world today is pretty comfortable. And the book really challenges you to get outside of your comfort. I'd love us to challenge us as a profession, no matter if you treat pediatrics, older adults, summer and summer. In the middle, treat in acute care, treat in home care, treat in outpatient orthopedics, training fitness athletes that carry is a skill that needs to be trained no matter what whether you're seeing upper or lower quarter, or whether you're seeing someone with a spine condition. Let's not keep losing this skill. Even I want you to think before I kind of dive into the three reasons why I think we don't want to lose training carries and their importance is you can even see it in the objects we do carry right like our book bag. Even I want you to think before I kind of dive into the three reasons why I think we don't want to lose training carries and their importance is you can even see it in the objects we do carry right like our book bags, or if you travel a lot your suitcases we even have roller apparatuses to make carrying easier. In our clinics, we need to make carrying harder. One of the three things and value that carries bring our number one from an extremity management perspective is it trains the shoulder elbow wrist hand, right, to be functional to work in this locked out engaged fashion. We have tons of evidence in the relationship between grip strength and mortality. If you have a weak grip, your mortality is poor. We even see it likened to associations with tons of metabolic diseases, and specifically frailty in our older adults. We need to train grip strength, because of that strength that it gives our grip, but that it trains our shoulder elbow wrist hand as well. But not only does it just train the upper quarter. We are actually training the spine, we are training the spine to hold the line as Mitch Babcock would say, right, because it's not just about locking out and training our shoulder elbow wrist hand in a stacked fashion, but we're actually challenging the trunk for those watching on YouTube or on Instagram I'm kind of, if we do this lateral lean we're not getting the benefit right, it's a stack trunk the whole time right while we load. This helps to be not only train the spine to take on load and asymmetrical load right if we're holding it in one side. But it also can be protective of our spine because we teach our spine how to light up right all of our lumbar stabilizers. And if you were to pick up an object that was pretty heavy right now, you will notice that it actually trains the lower body as well right it demands that the glutes the quads the hamstrings all kick in rather than this lazy like me unlocked position you have to actually stack not only the trunk, but your lower body to hold and carry well. It trains the entire system, the whole system gets the goods when we train carries. But guess what the magic isn't just in training shoulder elbow wrist hand and in training the spine. The magic is in the walk, so we don't just have someone carry and stand there. Right. If we think back to hunter gatherer we would carry over long long distances right to bring that meat back home. We need to train folks to carry and hold an object locked out and move and walk so the magic is actually getting our folks moving with weight. This trains our cardiovascular system. This trains our respiratory system and even our CNS right to take on load and be able to go for long durations. If you aren't draining carries you are missing out on a unique opportunity. It doesn't matter if it's an upper quarter issue a spine issue even a lower quarter issue. You need to be training your carries in your folks that are in your clinic or in the hospital, because this is a primary functional skill to be able to pick up objects and carry them for long distances. It trains aerobic tolerance, it trains grip strength and ability. Let's not let this skill be lost to our species. Let's not let this one evolve out. I want you to think about today how you can use carries in the clinic and kind of reflect on what if we got our humans, our patients carrying more for longer. Think of the healthy long lasting functional changes we could make, but not just functional in the ability to carry their objects without needing help from a family member, right or needing to take multiple respites. But I want you to think about mortality, right. We need clear links to grip strength and mortality. Offensive extremity care across the lifespan, young to old requires carries. I hope you'll consider putting this in your plan of care this week. Thank you for your time to join me on this short and sweet PT on Ice. Take care folks. Happy Tuesday.

08:40 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

Jul 24, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses that PTs need to be aware of the signs and symptoms of preeclampsia in pregnant women. Preeclampsia is a high blood pressure-related condition that typically occurs after the 20th week of pregnancy. It can also manifest during delivery and postpartum, although it is less common in the postpartum period. The three main symptoms of preeclampsia are swelling of the face and hands, persistent headaches, and pain in the upper right abdomen or right shoulder. PTs should be familiar with these symptoms and know when to refer their patients for further evaluation or treatment. It is crucial for PTs to monitor vital signs, especially in the postpartum period, as they may be the first healthcare professionals to detect an increase in blood pressure. Preeclampsia is the leading cause of mortality in pregnant women, so early detection and management are essential to prevent it from progressing into a life-threatening condition. While PTs may not be responsible for ordering tests or directly managing preeclampsia, they should be aware of the condition and its potential impact on their patients.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let's chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you're looking for an easy way to navigate payments, here's what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane's support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you're ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you're in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today's PT on ICE Daily Show.

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

25:08 OUTRO
Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 21, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long. In today's episode, Zach shares his favorite exercises for low back strengthening, including the reverse hyperextension, heavy horizontal rowing, and Jefferson curls.

Take a listen to learn how to discuss cold plunging with your patients or athletes.

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent, and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody, enjoy the show. 

01:25 ZACH LONG
Welcome to the PT on ICE Daily Show here on the Best Day of the Week on the podcast. It is Fitness Athlete Friday. I'm excited to be with you here today. I'm Zach Long. I'm one of the lead faculty members inside of our fitness athlete division. And today we're going to talk about a few of my favorite exercises for low back strength. Before we do that, two pieces to get out of the way. Number one, congratulations Joe Hanisko, one of our faculty members here inside the fitness athlete division. He and his wife Aubrey just had their first child, so congrats Joe. Second, upcoming courses we have inside the fitness athlete division. Advanced Concepts, eight weeks online, starts up September 17th. That always sells out, so if you've already taken essentials and you want to move on and take advance, you need to go sign up for that really soon because it will sell out several weeks in advance. Upcoming live courses we have September, we're in Bismarck, North Dakota, as well as Newark, California. October, just outside of Seattle. In November, we're in Hoover, so look forward to seeing you on the road. Or in Advanced Concepts. So let's jump into today's topic and that's bulletproof back exercises. So one thing that we talk about a lot in so many of our courses, but especially in Fitness Athlete Live, is that there's just this principle of rehabilitation. Like when a tissue is injured, what do we strengthen? We strengthen that tissue, right? If you're dealing with Achilles tendinopathy, we're doing Achilles tendon loading. If you're dealing with patellofemoral pain, we're getting your quads and your glutes really strong. We strengthen the tissues around what is injured. That's a principle of rehab. But all of a sudden when we start talking about low back pain, that principle like goes out of the window. And so much of our profession then says, no, we're not going to get the back strong. Instead, we're going to worry about the glutes not activating. We're going to worry about psoas tightness. We're going to worry about transversus abdominis activation. And while I'm not saying any of that is not completely irrelevant, I'm just saying that a principle of rehab is that we strengthen the area that is injured. So when somebody has back pain, we should probably make that back a little bit stronger. And so I want to share five of my favorite exercises for doing that today. And number one for back strength is going to be the reverse hyperextension. So this is a piece of equipment that you don't see a lot of physical therapy clinics. So I'm going to describe it for those of you that aren't familiar. Imagine you have a high-low table that goes up about five feet off the ground. And it's got this nice cushiony pad on top of the table. And you lay your torso on that with your legs hanging vertically off of that. And then you lift your legs up. So it's essentially just doing like a Romanian deadlift, except your upper body's horizontal to the ground and locked in place, and you're lifting your legs up. So there's reverse hyper machines, but this can also be done a number of different ways. I have patients doing it off of beds, off of incline benches, over exercise balls, over a barbell in J-cups on a rack, over a glute ham developer. A lot of different ways to do reverse hypers. But they are a phenomenal exercise for building a little bit of low back strength and endurance. And I'd say this is probably one of my most frequently prescribed low back exercises, because it works so well, even on your highly irritable patients, so frequently they can do this and get a huge pump into those muscles around their lower back, which of course is going to help tremendously out with pain and with working through a little bit of inflammation and getting fluids moving a little bit. So really make sure you check out reverse hypers. If you've never done those before, I would highly encourage you to take a look at different reverse hyper variations. You can find some videos of that on my YouTube or my Instagram if you need some ideas on how to do that, or you can just shoot me a message and I'll send you that video. But it is a great exercise to start with. Exercise number two, any form of heavy rows. I think we very frequently think of bent over rows and other movements like that as an upper back or mid back exercise, but they're so underrated in terms of what the low back has to do in terms of holding an isometric contraction. So I love really heavy rows. So bent over rows or really, really, really love pin lay rows. So if you're not familiar with pin lay rows, here's another great exercise for you to go train and explore within your own personal fitness journey. So barbells on the ground with bumper plates on it, you hinge over quite a bit to grab the bar and you're doing a row with every time the bar goes all the way back down to the ground. And what I really focus on with my pin lay rows is that my lumbar spine stays locked in place. I let my thoracic spine round and extend a little bit as I row. And that's just a phenomenal exercise to build total spine strength. So really for sure, check out pin lay rows if you've never done those before. Next movement is a series of movements actually. So that's anything off of a glute ham developer. Not very many physical therapy clinics have a glute ham developer, but a lot of gyms do. And so a glute ham developer is an exercise, a piece of exercise equipment that has a lot of different potential variations that you can do. But really I like to do tons of isometric holds off of the glute ham developer. So the glute ham developer has this little foot plate. So you lock your feet in place and then your thighs into this other pad. And then your upper body is free hanging out here. So you can hold your upper body parallel to the ground and you're now going to do a really good isometric of your low back, your glutes, your hamstrings to hold that global extension position. But you can then do different things like hold some light dumbbells and do rows to make that a little bit more challenging. You could turn it into a hinge movement by doing back or hip extensions, either loaded or unloaded, but so many different variations of exercises that can be done off a glute ham developer to load the post of your chain and the back specifically that you really want to make sure you check those things out. Up next, Jefferson curls. So Jefferson curls tend to get physical therapists a little bit fired up because everybody seems to be on one side of the equation or the other. So Jefferson curls, where we work on segmentally flexing the spine and taking the spine from an upright position, going into global flexion with light load behind it. I love Jefferson curls because so frequently in our culture, people are absolutely terrified of flexing their spine, especially with any load. And so the lightly load that and make people feel more confident that their back can get out of neutral position and not explode. Like we see Instagram infographics happen all the time by unfortunate influencers. The Jefferson curl is a great way to build confidence that the spine can be flexed. I love this to build a little bit of submaximal strength out of positioning. I love it also for my athletes that have some neural tension. We've worked through so much of that neural tension, but I know they're going back to a sport like CrossFit where they're going to be doing a ton of hinging motion. I like to use the Jefferson curl as the in range, make sure we completely clear out any of that stiffness that might be remaining. So that's exercise number four. And you all know exercise number five, last exercise. If you've been to an ice course, whether this is total spine thrust, modern management of older adult, lumbar spine management, or fitness athlete, you know what the next exercise is. And that is the freaking dead left because that is the best exercise that has ever been invented to build low back strength as well as human's confidence in their body. It is shocking and amazing how often somebody pulls a weight off the ground that they didn't know that they could do. They didn't know that they were strong enough to do it, or they didn't know that their back wasn't so fragile that they couldn't pick up that 95 pound bar, that 125 pound bar, that 225 pound bar. They pick it up and all of a sudden, their chest pops up a little bit. They walk out of the clinic a couple inches taller because they're so much more confident in their body when they learn how to pull a heavy weight off the ground. And it's something that they weren't expecting. Dead lifts can be conventional dead lifts, sumo dead lifts. They can be kettlebell dead lifts, so many different options for it, but get your people pulling heavy weights off the ground because that builds a lot of confidence in the human body. One of our favorite research articles from that comes out from Taglia Theory and colleagues in 2020. So they looked at individuals doing low load motor control exercises and manual therapy compared to a group that did heavy loading. So they're doing squats and dead lifts and a ton of other exercises that load the spine heavy. And what they actually found was that the heavy group, the group that were getting after it lifting heavy loads, had significantly reduced levels of kinesiophobia, which when it comes to low back pain, we all know that's the key. Our patients, after they've had an experience of low back pain, are terrified of their backs. And anything we can do that reduces kinesiophobia and makes them feel more confident is really important. And in that Taglia Theory and colleagues article in 2020, low load motor control exercises, your bird dogs, your clam shells, those sorts of movements, they don't make people less fearful of their back, although they do help with their pain. Heavy loading helps with pain and makes people more confident in their body. And that's what it's all about. So five different exercises there. We've got reverse hypers, we've got heavy rows, we've got glute ham developer work, Jefferson curls, and the greatest exercise of all, the dead lift to make your patients stronger in their low back, more confident in their low back, and getting back to doing the things that they love. So I hope you enjoy this episode. As always, reach out to us if you have ideas for future topics you'd love to hear of, and we look forward to seeing you on the road. Have a great weekend, everybody.

11:12 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. And be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

 

 

Jul 20, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall introduces the concept of servant leadership in the workplace, discusses the four main characteristics of servant leaders, research supporting the use of servant leadersihp at work, and the intersection of "burnout" & lack of servant leadership at work. Take a listen to today's episode or check out the transcription below.

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

EPISODE TRANSCRIPTION

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

22:20 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 19, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Dustin Jones explores the concept of creating impactful memories for customers and how it can enhance business success through word-of-mouth marketing. He shares examples from the restaurant industry, illustrating how exceeding customer expectations can cultivate lifelong customers and improve business growth through positive word-of-mouth. 

Dustin emphasizes the significance of creating "legends," which are memorable experiences that surprise and make customers feel special. These legends become synonymous with the business and leave a lasting impression on customers. When businesses go above and beyond to provide such memorable experiences, it not only fulfills the customers but also benefits the business owners.

Dustin encourages listeners to consider what legends they can create in their own businesses. It could be as simple as acknowledging a customer's birthday with a card or text, or going the extra mile by taking a discharged patient to play pickleball or organizing a group trip. The possibilities are endless, and creating legends can have a positive impact on the business, the community, and the overall satisfaction of everyone involved.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? Welcome back to the PT on ICE Show. Before we jump into today's episode, let's chat about Jane, our show sponsor. Jane makes the Daily Show possible and is the practice management software that so many folks here at ICE utilize. The team at Jane knows how important it is for your patients to get the care they need. And with this in mind, they've made it really easy and convenient for patients to book online. One tip that has worked well for a lot of practices is to make the booking button on your website prominent so patients can't miss it. Once clicked, they get redirected to a beautifully branded online booking site. And from there, the entire booking process only takes around two minutes. After booking an appointment, patients get access to a secure portal where they can conveniently manage their appointments and payment details, add themselves to a waitlist, opt in to text and email reminders, and fill out their intake form. If you all are curious to learn more about online booking with Jane, head over to jane.app slash physical therapy. Book their one-on-one demo with a member of their team. And if you're ready to get started, make sure to use the code ICEPT1MO. When you sign up, that gives you a one-month grace period that gets applied to your new account. Thanks, everybody. Enjoy today's show.

01:43 DUSTIN JONES
PT on ICE Daily Show. It's Dustin Jones here. It is Wednesday. We're going to be talking about making legends. What, how, and then the why behind this. Making legends is going to be about how to create memorable, impactful experiences for your patients and why it's good for them, it's good for you from your professional standpoint, and good for your business. All right. So what I want to talk about first before we get into this are the modern management of the older adult courses that are coming up. We are picking back up. We usually kind of take a little break during the summer, regroup, do our revamps, update all the literature and the slides, and we're hitting the ground running. So we're going to be in Boise, Idaho, in Watkinsville, Georgia at the end of July 29th and 30th, and August 5th we'll be in Frederick, Maryland. And then on August 12th, we will be in Lexington for the MMOA Summit where all the MMOA faculty are going to come together and deliver the brand new revamp of MMOA Live. We're super pumped about that. And then we have Essential Foundations, our online course starting August 9th. All right. Legends. Let's talk about this. I'm really excited about this topic. This has been something I've been thinking about since about February when I read the book Unreasonable Hospitality. So this is a book that you probably heard some of the ICE faculty talk about that Jeff Moore recommended. Anytime Jeff Moore recommends a book, you should probably check it out. The guy doesn't recommend a lot of books, but when he is very critical of a lot of books, so when he says, hey, this is worth reading, you probably should add that to your list. And this definitely proved to be true with this book. So Unreasonable Hospitality, I'll just give you the 30,000 foot view. Will Guderia is a restaurateur, very successful in that business or that industry. And he kind of talks about some of the principles that he used to create such impactful businesses, restaurants in particular, and how a lot of those principles that he used also translate over to business in general. And just so many different industries can benefit from kind of that hospitality mindset. And so he talks about a lot of different practical strategies that all of us can use in the rehab and the fitness profession. But he speaks to one particular of how we try to create legends. And when he says the word legends, what he's really talking about is creating impactful memories for folks where they are surprised, they feel special, and they will never forget. That moment and the business that is associated with that moment. He's got all kinds of crazy examples from the restaurant business, where he just went above and beyond what people were expecting and thus created customers for life. And that really improved his business, word of mouth marketing, and a lot of different things that made their job more fulfilling. And so he speaks about that concept of legends a lot in the book. And I walked away from that book just thinking about, man, we have such a huge opportunity to create legends in the rehab space, in the fitness space. And I'm going to talk through, you know, just through that of why we may want to do that, and then particularly the how and give you some examples. So in terms of the why, the first thing that I want to acknowledge is that when we go above and beyond and provide a memorable experience for folks and do it in the mirror, that they're kind of surprised and taken back. That is very fulfilling for us. I'll give you one example. Ellen Sefi. So she teaches with MOA. She has created lots of legends for a lot of her patients. She had one patient in particular that she was treating in a more acute setting. I forget the exact situation, but she this this patient had a long road to recovery. And Ellen ended up switching jobs into outpatient as that that patient was kind of leaving that acute setting and going into outpatient. So Ellen was able to treat her in that setting. This is a long road road to recovery for that individual. And Ellen worked with this person to help her get back to being able to hike. That was a big goal for this patient. And I think this is where a lot of us kind of stop, right, is we get people to the point where they can do the thing, right? Whatever that particular goal is for this patient, it was hiking. So she worked on her lower extremity strength. She worked on her dynamic balance. She worked on her endurance and she checked the box of all the kind of prereqs to be able to go on a hike in Colorado. And that's where we stop. And that's where we have such a huge opportunity to take a one step further and create a legend. And what Ellen did is she actually organized a hike and did a 14 or with this patient, right? She gave her the prerequisite skills and abilities required to achieve that goal. But then she facilitated that goal to actually happen. And she went on that journey with that patient that for Ellen, that's one of the most memorable professional moments for her. The fulfillment of being able to see of all your hard work and time that you have invested in this person, that they're able to do something epic like that. That is so fulfilling. So it's good for you. It's also good for your business because that happens. What do you think that patient is going to tell all their friends and their whole networks? Do you think she took a thousand selfies on the top of that summit and posted it all over social media? And guess how many patients Ellen probably had from that word of mouth, from impacting that patient on such a big level that it really sets you apart from a lot of your competition that aren't doing that. They're just checking the box. They're just improving strength, improving endurance. And you're actually facilitating your patients climbing 14 years, right? That has a compounding effect over time. It's going to be good for your business. All right. So that's the what of the legends. That's the why. It's good for you, for your fulfillment, for your career. It's also good for your clinic, your business as well. And so I want to get kind of dive into some practical examples of how we can create legends in the context of rehab and or fitness. I think we can do this in very simple manners and we can do this in kind of big, big, monumentous events as well. On the small side of things, just think about how you can surprise your patients, make them feel special. This is could be as simple as acknowledging someone's birthday. You have their date of birth that you send them a card, a gift card, whatever that just that simple act kind of puts you above them. Beyond most clinics and in gyms, for that matter, it could be that easy. It could be that simple. It could be more like what Ellen did, where she worked on building physical capacity with a patient, which is usually the case in our plans of care. Right. We're trying to get them stronger, improving their endurance, improving their balance, all that fun stuff that is tied to a patient centered goal. Right. We're already asking a lot of those things. What if you take it another step further to facilitate them being able to participate in whatever that activity is? Right. I'm not saying you got to climb a 14 or like Ellen did, but what if you proactively, you know, organize the hike that they could go on? What if you address the barriers that they may have on going on that hike, like going ahead and printing out directions of going ahead and planning out the day, recommending restaurants to hit up after the hike, just reducing barriers and facilitating that or even connecting them with a local hiking group that's going to increase their odds of actually doing the thing that you help them be able to do. Right. We could do it in that manner. Ellen took someone up a 14 or for me, especially in the context of home health, this happened a good bit where it was usually something a lot simpler than going to climb in a 14000 foot mountain. It was, you know, once that person was discharged from homebound status that we would go and do something in the community that they loved about. One in particular, I will never forget this. Me and my wife went on a double date on Valentine's Day at Waffle House with Walton Peony Smith in Columbus, Ohio, that I was discharged in Peony. She was no longer considered to be homebound. And it was right around Valentine's Day. And she had just regained the ability to navigate her community safely and efficiently. And so we crushed the All-Star Special. I still remember that meal. It was absolutely amazing. A double date on Valentine's Day at Waffle House. Something like that is just takes things to the whole another level that I will never forget. Very fulfilling from the professional standpoint. Peony will never forget. And then all of her friends, her family won't forget either. And when they want PT, guess who they're going to be calling. Right. We could take it up another notch. And this is something that we have been trying to do more at Stronger Life. We have a couple examples of this recently, which has really fueled me wanting to talk about this. One is that we had four individuals compete at the National Senior Games. These four women have basically never ran their life before, about 12 months ago. They qualified at the state games last year and then went to Pittsburgh last week to compete in the National Senior Games. And one of our athletes, Carolyn Holmes, 89 year old woman, got third in the 5K. And her whole family, three kids from all across the country, their kids, and then she had a couple of great grandkids were all there to witness this. And I will never forget this. Carolyn Holmes, 89 years old, running across the finish line with her eight year old great granddaughter. We got Carolyn stronger. We improved her endurance. We improved her balance. We checked all those boxes. But we created the opportunity for them to really flex their muscles and really pursue something that they had never even thought that they would be able to do. And then to do that in front of their community, in front of their family and then the whole Stronger Life community watching this from afar. Those are potent moments. Those are legends that I will never forget. Hands down, my most fulfilling professional moment. Carolyn will never forget that. And anybody watching that story will never forget what happened on that day. It's good for me. It's good for Stronger Life. This is good for our communities. It's a win win win for everybody involved. All right. We've got another one coming up this winter where we're taking 25 of our members to Costa Rica in an all inclusive adventure retreat where we work on their balance, their strength, all this stuff inside the gym. And then we create the opportunity for them to use those skills and do things that they never thought were possible. Right. These are legends. They're good for you. They're good for your business. They're good for your community. So I want you to think what legends can you create in the context of your own business? Some of you, it may be, all right, I need to acknowledge that someone had a birthday and just write a card and send it or send the text or whatever it may be. Some of you may think, oh, man, I may end up taking that patient that I just discharged actually to go to the pickleball court and play some pickleball with them or connect them with that pickleball group. And some of y'all may climb a 14 or some of y'all may organize a group trip to the Caribbean. I don't know. But there's so many opportunities for us to take things to that next level to create legends. I've really enjoyed this. I think you will as well. And I know your business will benefit, too. All right. Let me know your thoughts in the comments. If you have any legendary stories or any ideas, I would love to hear what you're going to do. We'll get lots of ideas in the comments, which will be very helpful to make this more practical. All right. You have a good rest of your Wednesday. I'll talk to you all soon.

13:24 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on Ice dot com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

 

 




Jul 18, 2023

Dr. Dave Finkelstein // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division faculty member Dave Finkelstein makes his debut on the podcast to discuss the importance of asking patients if there is anything important they want to cover or do in their session. This question is often overlooked by therapists, but it is seen as one of the most important questions they can ask. By asking this question, therapists are allowing their patients to take control of their care and be in the driver's seat. The aim is to promote a sense of self-efficacy in the patients' care and give them the opportunity to express what is truly important to them.

The episode highlights that therapists may be surprised by their patients' responses to this question. While some patients may be open to whatever the therapist suggests for the session, others may have specific concerns or topics they want to address. It is crucial for therapists to listen to these concerns and not dismiss them for their own predetermined plans. By addressing what is important to the patients, therapists can alleviate their fears and concerns and demonstrate that they are truly listening and invested in their well-being.

Furthermore, the episode emphasizes that asking this question helps to strengthen the therapeutic alliance between the therapist and the patient. By showing attentiveness to the patients' needs and concerns, it enhances the trust and rapport between them. This, in turn, can lead to better treatment outcomes and a more positive therapeutic experience for the patient.

In this episode, the host discusses the importance of asking specific questions to patients in order to determine the direction of their care. The host shares five specific questions that can be asked to gather important information from patients.

The first question is, "How did you feel after the last session?" This question allows healthcare providers to understand how their intervention or treatment has affected the patient's symptoms. By knowing how the patient felt after the previous session, healthcare providers can make informed decisions about the next steps in their care.

The second question is, "How are you progressing with your goal?" This question helps healthcare providers assess the patient's progress towards a specific goal. It allows them to gauge whether the current treatment plan is effective or if adjustments need to be made.

The third question is about the patient's adherence to their exercise program. The question is, "How often are you keeping up with your exercises?" This question helps healthcare providers identify any barriers the patient may be facing in following their exercise program. It also allows them to assess the effectiveness of the home exercise program.

The fourth question is, "How are you feeling today?" This question helps establish a baseline for the patient's current condition. By understanding how the patient is feeling at the start of the session, healthcare providers can evaluate the impact of their intervention or treatment.

The fifth and final question is, "Is there anything specific you would like to discuss or address today?" This question gives the patient an opportunity to express their concerns, priorities, or any specific topics they would like to discuss during the session. It allows the patient to take an active role in their care and helps build a sense of self-efficacy.

Overall, these five questions provide valuable information for healthcare providers to determine the direction of a patient's care. By asking these questions, healthcare providers can gather subjective information, assess progress, identify barriers, evaluate the effectiveness of interventions, and address the patient's priorities and concerns.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 DAVE FINKELSTEIN
Alright, good morning to the PT on ICE Daily Show. I am your host today. My name is Dr. David Finkelstein and I have the pleasure of serving as a TA in the spine division. I am a TA in the cervical and lumbar spine management courses. The topic today is ask for directions. But before we jump into the topic for today, I wanted to highlight a few of the upcoming courses that we have in the spine management division. So on September 23rd, we actually have all three of our lead faculty leading courses that weekend. Zach is going to be in Henrico, Virginia at Onward Richmond. Jordan is going to be in Baton Rouge, Louisiana at Delta Physical Therapy. And Brian is going to be in Parker, Colorado at Onward Denver. So if you're looking to hop into a lumbar spine management courses, all three of those gentlemen are going to be running courses on September 23rd. If you're looking to jump into a cervical spine management course, Jordan is going to be in Brookfield, Wisconsin on July 22nd at Onward Milwaukee. Jordan will also be in Charlotte, North Carolina, August 26th at his home base of Onward Charlotte. And then Zach on September 9th is going to be in Roswell, Georgia at Onward Atlanta. So looking to jump into a cervical spine management course, those are going to be your next few opportunities in the coming months. All right, so let's jump in the topic today. The topic is called Ask for Directions. And the idea came from a conversation that I had with one of my coworkers. She was talking about one of her patients that seemed to plateau in their care, and she didn't know which direction to go in terms of directing her care. So when we're working with our patients, they're going to be giving us a lot of subjective information as the weeks go on. And my hope with today's podcast is to give you all some specific questions to ask your patients to know which direction that you want to go with their care. Right. So I have five questions that I want you to consider, and there were more prompts. So that way you can dive a little bit more into those questions as you ask them. All right. So question number one, how did you feel after last time? I love starting with this question because it helps us know how the patient felt with our intervention after our last session. Right. Usually our patients will say something along the lines of, I felt good. Don't accept that as your answer and then type into your documentation system and then move on. Right. We want to know how our intervention affected them. So you want to dive into that a little bit more. So when the patient says good, ask them, what does good mean? How good did you feel after last session? How long did that good feel for? Right. So that way we know how effective our intervention was. And if they did feel good after last time, that might be something along the lines of you want to increase the vigor, continue on with the dosage of, of what you did last time to help prolong that good sensation that they felt. Conversely, if they didn't feel good after last time, if they tell you, you know what, Dave, I actually didn't feel so hot after last time. I felt quite a bit worse. Don't panic. That's actually good news in a way because it helps you know that you were in the right place, but maybe your vigor was a little bit too much or maybe your dosage was a little bit too much. Right. Because if you weren't in the right place, their symptoms wouldn't have changed. Or conversely, they might've done something between the last session and your current session that also could have flared up their symptoms, unpacking it a bit more. Maybe John said, you know, I felt pretty good after last time, but then I mowed the lawn and then picked up a few boxes and then I did X, Y, Z. And then after that, I felt a little bit worse. So it helps you know exactly if it was your intervention or if it was something that they did afterwards. Right. It also helps you know if you establish their irritability correctly after the initial evaluation. So if you did your particular intervention, you thought they were low irritability and you intervene in an area and nothing really changed, you might want to consider going a little bit more vigorous into your examination or into your vigor to see if you can really elicit their symptoms. And then conversely, if they felt like really flared up after last time, maybe your vigor was a little bit too much and you overestimated their irritability. Right. So in both ways, that's a really good starting place when you ask the patient. So that first question is how did you feel after last time? Question number two, how did you progress towards X goal in our cervical and lumbar spine management courses? We talk about obtaining a subjective asterisk. Basically, that's something that the patient that's important to the patient that you want to measure, but you can't measure in the clinic. So what that looks like is how many times someone woke up in there in the night because of their pain or how long into their commute they're able to sit for before they have an onset of symptoms. Right. So if you ask them, John, how did you feel after or how are you progressing with your commute? And John tells you, you know what, Dave, actually, it's a little bit better because I was sitting for 30 minutes and then my symptoms came on and now I'm sitting for 45. So now you know that your intervention was effective because their commute increased. Right. Whereas conversely, if they say, you know what, Dave, after last time I was in my commute and I was only able to tolerate 15 minutes of sitting before my symptoms really started to act up a bit, then you know, once again, maybe it was that bigger or maybe it was that particular intervention that you did that was a little bit too much that that might have increased their symptoms a bit. So asking them how they felt with that specific goal, with their subjective asterisks that you obtained in the initial evaluation, seeing how they progressed with that. And also keeps those goals that are salient to the patient in the back of your mind that you continue to ask them in those follow up sessions. Right. So that's question number two. How are you progressing with X goal? Question number three, how often are you able to keep up with your exercises? I love asking this for a home exercise question as opposed to are you doing your home exercises? Because it's a little less judgmental. Right. If the patient didn't get to do their exercises, you're asking them from a place of curiosity as opposed to did you do your exercises? So when you ask the patient how often are they doing their exercises, it gives the patient opportunity to even tell you, you know what, Dave, I actually didn't. Wasn't able to keep up with those exercises. Don't judge them for not doing their exercises, but look at that as an opportunity to examine barriers to their adherence to their home exercise program. Right. So you can tell John, like John was up. How come you weren't able to do those banded external rotations? And they tell you, you know what, Dave, I just didn't have an opportunity to go out and buy the bands because I'm a little short on time and it did help after last time, but I just I wasn't able to go on by the band. So that way you now have the idea that the barrier was purchasing the bands. Right. So then you can change that exercise to a sidelined external rotation. We're holding a can of tomato sauce there. You're kind of taking out that barrier of buying a band. You got the stimulus that you wanted. And then you also taught John a way of creating a weight in his house using a can of tomato sauce. Right. So using that as an opportunity to identify a barrier. And then also, if your intervention was effective as far as a home exercise program. So take, for example, a patient with low back pain radiating down their leg. They say, you know, Dave, doing those prone press ups that you gave me, I felt pretty good for about an hour after you gave me that exercise. But then it kind of went back to baseline afterwards. And then you realize that you dose that out three times a day. You might consider asking John, hey, John, you know, you felt pretty good for about an hour after you did those exercises. What are your thoughts on maybe increasing that from three times a day to six times a day? You know, it might sound kind of aggressive, but in that way, you're increasing that dosage of that thing that was helping John. So now you're getting a good idea of how your home exercises are affecting your patient and then playing around with that dosage or that particular intervention. Right. So that question, once again, is how are you how often are you keeping up with those exercises? Question number four, how are you feeling today? Seems like a very basic question that we ask all of our patients. But I want you to think about why we're asking our patients that. We're asking that question to establish a baseline, how they feel right now. So that way, if we do some sort of intervention, that we know how it's changing their baseline symptoms. This is another opportunity that the patient might say, good, don't take that good as a as your answer. Tell them, like, can you unpack that for me a little bit? Tell me what what good means and then start to trace out their symptoms. See exactly where their symptoms are, how intense are their symptoms? So that way, when you establish that baseline, you feel really confident about the intervention that you did, whether or not it changed their symptoms for the better or it did. Right. Establishing that baseline. All right. So question number four, how are you feeling today? Question number five, I think, is one of the most important questions that we can ask our patients, but is often overlooked. So question number five is, is there anything you want to cover today? Talk about do that's really important to you. In that question, we're taking our hands off the steering wheel and allowing our patients to be in the driver's seat. We want our patients to feel a sense of self-efficacy in their care. And this is the best question to open that opportunity to know what's really important to them. Right. Maybe our patients will say, you know what, Dave, whatever you want to do today, I'm game for, which is fine. And then you continue on with that plan that you had. But your patients might surprise you and say something on the lines of, you know, Dave, I was actually thinking about it the other day that I don't really know how to get off the ground if I were to fall. And that's kind of in the back of my mind for a while. In that the patients opening up to being vulnerable and saying, hey, this thing is really important to me. What you don't want to do is ignore that and be like, well, sorry, John, you know, I had this other plan and I just want to proceed with it. We'll cover that in the next session. You want to cover the thing that's most important to your patient because it's going to help take that kind of fear, that concern out of the back of their mind. And then in addition to that, you're helping boost that therapeutic alliance by addressing that thing that's really important to them. Right. Nothing is going to tell your patient more that you're listening to them, that you're concerned about them than intervening in that thing that's really important to them that day. Right. So that question is, is there anything that you want to talk about or do today that's really important to cover in our session today? So those are the five questions I'm going to give you a quick recap. Question number one is, how did you feel after last time to know how your intervention affected their particular symptoms? Question number two is, how are you progressing with X goal? Recapping back to their subjective asterisk, making sure that you know exactly what's important to them and how that's progressing or not. Question number three is, how often are you keeping up with those exercises so that way you can identify barriers to their adherence to their exercise program in addition to knowing how effective your home exercise program actually is? Question number four is, how are you feeling today? Knowing the back of your mind that you want to establish a baseline so that way you know how your intervention is affecting the patient. And then question number five, once again, really important to ask our patient, is there anything important that you want to cover, talk about, do today that would be beneficial? Right. So give those questions a thought. Try that out. Keep in the back of your mind why you're asking these questions and then diving a little bit more. Let me know how it goes. Shoot me a message in the comments section. I love talking about this stuff. I love the conversational piece and the Therapeutic Alliance piece of patient care. If you're looking for more opportunities to jump to some courses or see some of our free resources, go to PTNICE.com. Check us out. Everyone, thanks for giving me some of your time and have a wonderful morning.

14:07 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at PT on ICE dot com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE dot com and scroll to the bottom of the page to sign up.

 

Jul 18, 2023

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the obturator internus muscle and its role in pelvic floor and hip conditions. She highlights the importance of understanding and addressing this muscle for effective treatment. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

00:00 INTRO
What’s up everybody? We are back with another episode of the PT on Ice Daily Show. Before we jump in, let’s chat about Jane for a moment as they are our sure sponsor and they make this thing possible. The team at Jane understands that payment processing can be complex, so they built in an integrated payment solution called Jane Payments to help make things as simple as possible so you can get paid. If you’re looking for an easy way to navigate payments, here’s what we recommend. Head over to jane.app slash payments, book a one-on-one demo with a member of Jane’s support team. This can give you a better sense of how Jane Payments can integrate with your practice several other popular features that Jane Payments supports, like memberships with the option to automatically invoice and process your membership payments online. If you know you’re ready to get started, you can sign up for Jane and make sure when you do, you use the code ICEPT1MO as that gives you a one-month grace period while you settle in. Once you’re in your new Jane account, you can flip the switch for Jane Payments at any time. Let the Jane team know if you need a hand with anything. They offer unlimited support and are always happy to jump in. Thanks everybody. Enjoy today’s PT on ICE Daily Show.

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

17:02 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 14, 2023

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

https://pubmed.ncbi.nlm.nih.gov/34852731/

https://pubmed.ncbi.nlm.nih.gov/33630675/

https://pubmed.ncbi.nlm.nih.gov/32023545/

https://pubmed.ncbi.nlm.nih.gov/34770213/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4493260/ 

https://pubmed.ncbi.nlm.nih.gov/31869820/ 

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines heat-based recovery including hot tubs, whirlpools, and saunas. Take a listen to learn how to discuss cold plunging with your patients or athletes.

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

EPISODE TRANSCRIPTION

00:00 INTRO
What's up everybody? Before we get rolling, I'd love to share a bit about Jane, the practice management software that we love and use here at ICE who are also our show sponsor. Jane knows that collecting new patient info, their consent and signatures can be a time consuming process, but with their automated forms, it does not have to be. With Jane, you can assign intake forms to specific treatments or practitioners, and Jane takes care of sending the correct form out to your patients. Save even more time by requesting a credit card on file through your intake forms with the help of Jane Payments, their integrated PCI compliant payment solution. Conveniently, Jane will actually prompt your patients to fill out their intake form 24 hours before their appointment if they have not done so already. If you're looking to streamline your intake form collection, head over to jane.app slash physical therapy, book a one-on-one demo with a member of the Jane team. They'll be able to show you the features I just mentioned and answer any other questions you may have. Don't forget, if you do sign up, use the code ICEPT1MO for a one month grace period applied to your new account. Thanks everybody. Enjoy the show.

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

22:33 OUTRO
Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com While you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Jul 13, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses that the decision to innovate or imitate is a career-defining choice with long-term implications. The host emphasizes that while collaboration and sharing of ideas are common in any field, blatant imitation is detrimental to one's career. The host distinguishes between collaboration and imitation, stating that imitation involves repeatedly hijacking other people's logos, sayings, or content.

The episode provides three reasons why being an imitator ensures a mediocre and short-lived career. Firstly, the process of creation, coming up with something new and contributing in a unique way, is described as the most invigorating aspect of any career. The host emphasizes the satisfaction and impact that comes from thinking differently and having others benefit from one's novel ideas or techniques.

Secondly, the episode highlights the importance of authenticity in career success. The host suggests that imitators may experience imposter syndrome because their success levels do not match their actual contribution. They are described as grabbing ideas from others, recognizing what will resonate with their audience, and building their business without truly creating or going through the challenges that lead to breakthroughs. The more their success grows without a true contribution, the greater the asymmetry and imposter syndrome.

Lastly, the episode emphasizes the value of continuous creation and innovation for a long-lived and energetic career. The host encourages listeners to keep creating and strive for novelty and harmony in their careers. It is emphasized that the decision to innovate or imitate is a defining one, and individuals should aim to put forth their authentic selves rather than copying someone else's.

Overall, the episode argues that choosing to imitate instead of innovate can lead to a mediocre and short-lived career. On the other hand, embracing innovation and creating something new is described as invigorating, authentic, and essential for long-term success and fulfillment.

Take a listen to today's episode.

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

EPISODE TRANSCRIPTION

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

13:18 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at PT on ICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ICE.com and scroll to the bottom of the page to sign up.

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