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

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.

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.

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Christina Prevett discusses the significance of research in the field of physical therapy is along with the importance of translating that research into evidence-informed practice. She acknowledges the substantial nature of their research and highlights the necessity for clinicians on the front line to have access to this valuable information. Staying up to date with available evidence and combining it with clinical expertise and patients’ experiences and desires is emphasized as crucial for clinicians. The episode also addresses several gaps in research that need attention, including the need for rehab research for individuals in sitting positions, outcome measures for wheelchair users, and managing conditions in neurological populations. The host expresses frustration at the lack of clinically relevant outcome measures for wheelchair users and emphasizes the need for research to support the role of rehab in enhancing quality of life and managing various conditions. Overall, the episode underscores the importance of research in informing and improving physical therapy practice.

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

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

EPISODE TRANSCRIPTION

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

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

20:07 OUTRO
Hey, thanks for tuning into the PT on ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at pt on ice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to pt on ice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the importance of including lumbar flexion in a robust rehabilitation program. Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

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

14:56 OUTRO
Hey, thanks for tuning into the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Christina Prevett discusses current gaps in pelvic floor physical therapy research. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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

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

19:00 OUTRO
Hey, thanks for tuning in to the PT on ICE Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at PTonICE.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTonICE.com and scroll to the bottom of the page to sign up.

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discussed several strategies that can be employed to achieve intensity, which is crucial for cognitive changes. These strategies, including increasing load, decreasing rest, and increasing work time or volume, are part of physical training and can drive metabolic adaptation and enhance cognitive benefits. By challenging the muscles and cardiovascular system through increased load, individuals can experience improved cognitive function. Similarly, reducing rest periods allows for a more continuous and demanding workout, while increasing work time or volume extends the overall duration or amount of exercise performed. All of these strategies contribute to increasing the intensity of the workout, which is essential for promoting cognitive changes.

Incorporating a dual motor task and cognitive layer during exercise can further enhance cognition. This can be achieved by integrating activities that require both physical movement and cognitive engagement. For instance, one way to introduce a dual motor task is by having individuals hold two cups and transfer water from one cup to the other while walking. This adds complexity to the exercise and challenges both the motor and cognitive systems. Additionally, engaging in mental tasks like answering questions or performing mental math while exercising can also enhance cognition. Starting with simple preference questions and gradually progressing to more challenging cognitive tasks can create a cognitive load while individuals focus on the physical activity, leading to cognitive changes. It is crucial to control the intensity of physical training by adjusting factors such as load, rest, work time, or volume to ensure the desired cognitive benefits are achieved.

Shifting exercise sessions to a busy environment can introduce cognitive load and improve cognition. Instead of conducting sessions in a quiet one-on-one room, it can be beneficial to move to a busy clinic space, a bustling hospital hallway, or even an outdoor setting with unpredictable elements. Exposing individuals to a busier environment adds a cognitive challenge to their physical activities, such as skating or walking. This cognitive load stimulates cognitive changes and enhances the cognitive benefits of training. It effectively adds a cognitive layer to the exercise session and promotes neuroplasticity. Furthermore, incorporating a dual motor task, such as moving water back and forth, and asking cognitive questions like preference inquiries or mental math can further amplify the cognitive benefits of the exercise session. Overall, integrating a busy environment and cognitive tasks into exercise sessions can be a valuable strategy for improving cognition.

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

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

EPISODE TRANSCRIPTION

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

01:33 DR. JEFF MUSGRAVE, PT, DPT
All right. PT on the ICE Daily Show. Welcome. This is Wednesday. This means it is Geri on ICE talking about all things, topics to help make your care for your older adults as good as possible to really set yourself apart as an expert with older adults. What we're going to be talking about today is exercise that improves cognition. There are a couple different types of exercise training that is really superior for improving cognition for older adults and we're going to talk about what those are and then how to incorporate them into your care. Before we get to that, just a quick rundown of what we've got going on in the older adult division. If you were hoping to catch the next cohort of Essential Foundations, that'll be starting in August, August 9th. If you're looking to get your advanced concepts, if you've already taken Essential Foundations looking for that next step, that'll be October 12th. Next opportunity to see us live, you've got three opportunities in July. We're going to be in Connecticut, Georgia, and Idaho this month. If you have been itching to see us on the road, get to do some of these fun labs and things that you've probably seen on social media, book your seat, come see us. We're going to be all over the place as we do 2023. Many of our older adults are worried about their cognition. They may already be experiencing cognitive changes. Maybe they've got just mild cognitive impairment. They don't have an official diagnosis. Maybe they've got early stages of cognitive change all the way to advanced dementia. It's not uncommon for us to be treating community dwelling older adults or older adults in an institutional setting that have experienced some cognitive changes. When we're thinking about our exercise interventions and how to prioritize, making physical change while keeping in mind we know there's a cognitive component. Sometimes a cognitive component ends up being more critical than the physical component for some of our older adults. We're talking about safety. We're talking about independence and their ability to manage their home environment, for example. This can be huge. The reality is a lot of us don't know where to start when we're thinking about how do I do both get the physical training piece and keep in mind they've got some big cognitive impairments on board that I'm concerned about. There was a 2019 article titled, Preferred Type of Exercise for Cognition Enhancement in Older Adults. It did just this. It broke down what types of exercise we should be focused on. Once you get through this article, and I'll share it in the caption as well if you want to look it up yourself, but there were two types of exercise that we're going to cover. The third thing we're going to do is just talk about the practicality of how to get those cognitive changes for our older adults in our sessions. The first type of training that was most beneficial for driving cognitive enhancement was a category called physical training. If you're familiar with CrossFit or not, I'm going to describe a workout to you that would be very squarely in this component of physical training. So MERF, very common Memorial Day workout done to honor a fallen soldier. The workout is one mile run. We've got 100 pushups. I'm sorry, 100 pullups, 200 pushups, 300 air squats. So that would very much squarely fit into the grunt workout. You're grinding. It's a long workout with high metabolic demand. So the first category was physical training that was intense. High intensity physical training was the number one thing that they found was beneficial for enhancing cognition for older adults. So many of our patients are not going to be doing MERF. So the question is, what's this look like clinically? So any workout that's using compound functional movements and you're moving at high intensity where you've controlled the work rest ratio, you've controlled the number of repetitions or the volume, and you've controlled the pace, you can modulate to get up to high intensity. But high intensity training is superior for cognitive enhancement. So for a patient that may be doing a remom, every minute we're doing different activities. We've controlled the amount of work and rest time. The patient is going to pace that themselves. So say minute one, we're doing 10 sit to stands. Then the next minute we're going to do carries over and back across the room with the weight that's challenging. So there's maybe 10, 15 seconds of rest. And on the third minute, maybe we're going to be doing some supported jumping. So grunt work type movements. There's not a whole lot of thought involved. Hold this walk, stand up, sit down, put your hands here, jump. Very simple, basic activities, but their nature of them being compound functional movements where we've controlled rest, we're going to drive intensity and we're going to drive metabolic adaptation, which was key for enhancing cognitive benefits in training. So that's what we want to be thinking about. Category one, physical training. They found that the change happened because of changes in the metabolic system and hitting intensity was key. So high intensity grunt work style training improves cognition. That's good news. That follows right in line often with what we're trying to do with our older adults because we know most of them are sedentary and need physical training. They need to be stronger. They need higher cardiovascular capacities to really keep themselves on a healthy trajectory as they age. So the second type of training that was beneficial for enhancing cognition was a category they just called motor training. So a good example of this would be a Turkish getup. So maybe you've never done a Turkish getup, but if you can imagine yourself laying on your back, you've got one arm pointed at the sky with the weight in your hand. You're going to move from lying on your back all the way up to standing with the weight overhead. You're going to be balancing the weight the entire time and then going all the way back down to lying on your back. That would be an example of motor training. It's a complex task. There's actually 14 steps in a Turkish getup for just one side. A lot to think about, lots of positions to hit, complex movement, a novel task for a lot of people in general, but especially older adults getting up and down off the floor without using an arm, but also adding load and having to balance that weight makes it complex from a motor training standpoint. So maybe our older adults are not doing Turkish getups. Some definitely can. There are research articles that have shown that older adults can do Turkish getups and it's beneficial for them, but maybe a more practical example for a lot of us would be working on floor transfers. Many of our patients need to work on getting up and down off the floor, doing that where we're working around a cranky joint, a knee, a shoulder, maybe a hip that is super stiff or doing this at a novel environment. Maybe we take them outside on the grass where maybe they don't have furniture or they've got limited furniture where we've just created a complex, novel task. It's motor training that's complex and that's what's going to drive cognitive adaptation. This motor control category, the driving factor was complexity and it was direct neuroplasticity. So directly impacting neuroplasticity when we do complex motor tasks. So getting up and down from the ground in a different environment would be a great way to drive neuroplasticity directly. So we've got these two categories. We've got high intensity physical training and then we've got high complexity motor training. Those are the two different avenues we can use with exercise to improve cognition for older adults. So the question is, well, what do we do? Which one is most important? And if you've been around the ICE community very long, you've probably heard this before. Or if you're new to following along with the journey here on what we're doing with our clinical approach, you're going to know the answer to this. And that is and not or. We want to do both. So we want to be greedy when it comes to our patients. We want to give them the maximal benefit, the maximal value out of every single session. And we can do that by driving intensity while driving complexity of task. And the easiest way to do that is a strategy we call layering. So a good example of this would be, say we want to drive intensity with gait training. Lots of great ways to do this. We can put a gait belt on our patient and hang on to it and add some resistance that way. We can do the same thing with a resistance band. We can throw a weighted vest. We can have them hold weights. Gait training just got much more intense at whatever resistance is appropriate to challenge our patient by just adding resistance to that walking. So we've already achieved intensity there. So how do we add this motor training piece? How do we add complexity to also enhance cognition at the same time? Lots of different ways to do this. You could do a weighted vest and maybe we've got someone with two cups in their hand and they're transitioning water from one to the other while they're walking. Man, we've just layered on a dual motor task while we're hitting intensity with a vest. Another great example, we can ask simple preference questions. That's usually an easy way to ease in on the cognitive load. Just ask them some random questions that sound like conversation. You may already be doing this, adding a cognitive layer and not realize it, but asking them questions while they're concentrating adds a cognitive component. We can scale that up. We can ask for mental math while someone is doing intense gait training. That can be super beneficial. We can ask, what's your favorite color? We can ask them to subtract three from 74 out loud while they're walking under intensity. We can move them to novel environment. There are lots of different ways we can add that in. You want to control the two things you've got to do to put these things together. For physical training, you've got to control intensity. You can increase load, you can decrease rest, you can increase work time or volume. All those things will help you reach intensity, which is crucial for cognitive changes. The second piece is adding a dual motor task like we talked about the water back and forth. You can add the cognitive layer by asking questions, preference questions, mental math, those type of things. Moving them into a busy environment. Maybe you have your sessions in a quiet one-on-one room. Maybe you move out into busy clinic space or into busy hospital hallway, or maybe you're in home health and you can take someone outside or into busier environment where there's unpredictable things and there's some cognitive load on just skating and keeping yourself safe. That's another great way to add cognition. That's what I've got for you, team. You want to hit intensity through physical training. You want to add complexity with motor training. The third thing is you want to add layers. You want to layer up your intensity and cognitive difficulty as much as possible to get the most bang for your buck, especially when there are cognitive deficits on board. If anyone's got any cool strategies, layering tips, tricks, things they've done that they found fun and beneficial, or you've just got questions or comments, drop them. I'd love to see those and interact with you. I hope that was helpful for someone out there. Have a great rest of your Wednesday, team. See you later. 

14:52 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review. Be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey discusses how to empower patients with osteoarthritis by shifting their mindset and behaviors. She emphasizes the importance of treating patients with MEDS (mindfulness, exercise, diet, and sleep) to combat systemic inflammation. Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

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

19:30 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at ptonice.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses when and how the tailbone/coccyx may be a contributor to a patient’s symptom behavior, as well as how to begin to assess & treat the region if appropriate. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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

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

24:37 SPEAKER_02 to some pains in the butt. Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at PT on ice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on Ice dot com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall defines cold plunging, discusses the research behind cold plunging, and how to practically approach practicing cold plunging. Take a listen to learn how to discuss cold plunging with your patients or athletes.

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

EPISODE TRANSCRIPTION

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

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

18:00 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home, check out our virtual ice online mentorship program at PT on ice dot com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PT on ice dot com and scroll to the bottom of the page to sign up.

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea of letting an audience grow around the passion you have for a particular area of practice versus continually trying to change your approach in the clinic or with marketing to attempt to reach an infinite number of potential audiences. Take a listen to today's episode. 

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EPISODE TRANSCRIPTION

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

13:09 SPEAKER_00 on leadership Thursday hey thanks for tuning in to the PT on ice daily show if you enjoyed this content head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence if you're interested in getting plugged into more ice content on a weekly basis while earning CU's from home check out our virtual ice online mentorship program at PT on ice calm while you're there sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading head over to PT on ice calm and scroll to the bottom of the page to sign up