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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the effects of terzepatide on older adult patients.  Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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

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

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

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey highlights the four pillars of healthy living behaviors: mindfulness, exercise, diet, and sleep. These pillars are essential for improving overall health and wellness. Mindfulness involves helping patients become more aware of their beliefs and mindset towards their body, and providing them with strategies to think about their body in a healthier way. For patients with hip and knee issues, mindfulness should also involve reframing their mindset to view their bodies as having opportunities for improvement through strength and flexibility.

Exercise is crucial for meeting physical activity guidelines, which recommend 150 to 300 minutes of physical activity per week. The WHO recommends aiming for 300 minutes as it is more beneficial. However, prescribing physical activity for patients in pain can be challenging. The episode suggests starting where the patient is at and finding ways to infuse physical activity, such as starting with five-minute bouts. Therapeutic exercise is also helpful but may only result in small to moderate size effects on pain and disability due to variability in patient response.

Diet involves adding healthy foods to a patient's diet, rather than taking away harmful foods. This is especially important for those who have received negative messages about their body. Sleep is also crucial for tissue healing, and strategies such as sleeping in a cool, dark room and going to bed at the same time daily can help improve sleep quality.

Overall, addressing these four pillars may be challenging, but they are essential for improving brain tissue and making the body more resilient. The goal of mindfulness is to help patients become more mindful of their bodies and to frame their mindset in a more positive and proactive way. Meeting physical activity guidelines is a must, and therapeutic exercise can be helpful but may only result in small to moderate size effects on pain and disability. Adding healthy foods to a patient's diet and improving sleep quality are also crucial for overall health and wellness.

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

EPISODE TRANSCRIPTION

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

19:32 OUTRO
 Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ICE content on a weekly basis while earning CU's from home, check out our virtual ICE online mentorship program at PTOnICE.com. While you're there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to PTOnICE.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how physical therapists don’t need to be the masters of movements in order to teach them to others, or help others begin their progression towards achieving them. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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

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

14:16 OUTRO
Hey, thanks for tuning in to the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning Check out our virtual Ice Online Mentorship Program at PTOnIce.com. While you’re there, sign up for our Hump Day Hustling Newsletter for a free email every Wednesday morning with our top 5 research articles and social media posts that we think are worth reading. Head over to PTOnIce.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, Fitness Athlete instructor Guillermo Contreras breaks down the difference between the different types of training shoes for the functional fitness athlete that are currently available on the market. Take a listen to learn how to recommend the best shoe for your patient or athlete (or yourself!)

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

EPISODE TRANSCRIPTION

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

01:33 – Dr. Guillermo Contreras, PT, DPT, CF-L2, Cert-CMFA, Cert-ICE 

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

27:30 OUTRO
Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CU’s from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, Brick by Brick lead faculty & ICE COO Alan Fredendall discusses tips & tricks for working with Medicare including the ins & outs of documentation/billing. Take a listen to learn how to make more money billing Medicare while spending less time on notes.

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

EPISODE TRANSCRIPTION

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

Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com 

In today’s episode of the PT on ICE Daily Show, our dry needling division leader, Paul Killoren, talks about how and why patients may faint during a dry needling session as well as the approach to take if this happens in your session. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION

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

23:02 SPEAKER_00 Hey, thanks for tuning into the PT on Ice Daily Show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram, at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ICE content on a weekly basis while earning CEUs from home, check out our virtual ICE online mentorship program at ptonice.com. While you’re there, sign up for our hump day hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses how to return to loading the core during the first 12 weeks of the postpartum period. Take a listen to learn how to better serve this population of patients & athletes.

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

EPISODE TRANSCRIPTION 

00:00 INTRO 

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

01:27 DR. JESSICA GINGERICH, PT, DPT
Good morning PT on ICE Daily Show. It is rainy and humid here in South Carolina, so I am already sweating this morning. My name is Dr. Jessica Gingerich and I am on faculty with the pelvic division here at ICE. Dr. Alexis Morgan and Dr. Ellison Melrose and myself are coming off a fun webinar with the CrossFit Affiliate Southeast team where we were talking about coaching the pregnant and postpartum athlete, trying to keep those athletes in the gym as long as we can throughout their pregnancy and get them back in the gym as early as we can in that postpartum timeframe. I wanted to take this opportunity to continue the conversation more specifically around the benefits of training the core during the first 12 weeks postpartum. As always, we want to just highlight some wonderful opportunities to learn. We are coming your way. Go ahead and head over to ptonice.com to see when we are close to you for our two day live course. That is where we take the internal exam and we bridge it with return to sport, return to endurance training, return to strength, gymnastics and so much more. We also have an eight week online course. That is wonderful. We have an online course for eight weeks. So if that is something that you want to hop on, if that’s easier for you to get to, head over to PT on ICE.com to snag your spot. So we are in a really exciting time within that pregnant community. We are starting to see women push boundaries and challenge the norms around exercise. However, the question always continues about returning postpartum. When to do it? We often hear what is safe and unsafe. Here at ICE we like to not use those words because it is more so about what you are ready for and what you are able to do in that snapshot of time. So we know that every pregnancy, birth, prior fitness level and so many other factors vary per person. However, we also know that returning to exercise postpartum has massive mental and physical health benefits. So what I want to do is I want to define that fourth trimester. So this is the time period between zero and 12 weeks postpartum where those physical, mental and emotional changes are huge. They’re huge in so many ways and exercise can be such a massive benefit to mom. And so we want to make sure that we’re doing them justice. So as we make recommendations for core training, we need to respect certain factors. So that’s going to be tissue healing timeframes, pain levels, the amount of help someone has at home, maybe sleep, how much sleep they’re getting, how they’re eating, what they’re eating, are they trying to get their breakfast in as soon as baby starts to cry and they’re getting their lunch in as soon as baby cries and moms are really good at putting themselves first, right? But most importantly, we have to respect function. As hard as we fight for maternity rights, for example, longer maternity leave, mom still has a job at home. She’s caring for a newborn, potentially other children are at home and likely has physical demands of a job waiting for her eight to 12 weeks later, which means she needs to strengthen her core and she really needs it now. Too often the recommendation is taking that six to eight weeks off after birth, which encourages a significant amount of deconditioning, making motherhood, return to work and a whole lot of other things a lot harder. So here at ICE, we love encouraging physical therapy to begin at two weeks postpartum. With this recommendation comes some exceptions, like how is mom adjusting to motherhood or adjusting to adding another baby to the family? Does it give her anxiety to leave the house, which virtual sessions are great for that? Does she need sleep when her appointment time is? You know, that’s a big deal. We want to encourage sleep. Or are the baby’s appointments just adding up and it’s making it hard for her to add this appointment on top of that? So during the first visit, we addressed several things, but core is absolutely one of them. That is looking at diastasis, that is looking at her ability to sit up, a full sit up. We’re going to talk through three planes of motion acting on the spine. You all probably know these from school, but we have the frontal plane, transverse plane, and the sagittal plane. There are a lot of exercises to be utilized in these planes of motion that are important throughout the plan of care for improving strength and function. But where do we start? We love teaching a transverse abdominal contraction along with the pelvic floor contraction, but it never stops there and it usually is something that we move on from fairly quickly. So we do those in supine, we do them in standing, we do them in hanging quadruped, we do them in a trunk extended position, but then we add all of those wonderful layers. So our top three exercises to begin and to start with are the Paloff Press, the Supported Sit Up. This is such a great movement, right? It encourages that full range of motion. Mom is having to sit up out of bed multiple times in the night to feed. And then the Unilateral Farmhouse Carry. I always get a kick out of moms coming into the clinic holding the carrier. That thing is heavy. I’ve carried it out for a couple of moms just to kind of get an idea of how much it weighs with baby inside. It’s heavy and they are having to carry that immediately postpartum to appointments because they can’t leave baby at home. So here we had all three planes of motion with an isometric type of load aside from the Supported Sit Up. There’s plenty of room to progress range, length, load, and then time under tension. As well as these movements mimic those physical demands of life. So again, holding the carrier, rolling out of bed, sitting up for feedings. We often get asked the question, but what about diastasis? So we are assessing that in that first visit. But the goal around diastasis is to coach points of performance. So if you are seeing coning or doming in the midline with a certain movement, can we take a step back, coach those points of performance, and then modify if your client is unable to maintain those points of performance. If they are unable to, you adjust. We need to get the core stronger. And if they have a diastasis, we have to get the core stronger. And we have research on this. So first of all, 57% of people have a gap greater than 2 centimeters. And this is not just in the pregnant or postpartum population. Therefore, we really don’t even have an accurate definition of what constitutes a diastasis. Furthermore, Hills et al. found that diastasis recti was associated with decreased sit up strength and decreased torque generating capacity. A literal weakness issue. So to recap, the fourth trimester is defined as weeks 0 to 12 postpartum. Early core intervention can and should begin at two weeks postpartum per the mom in front of you. Begin with isometrics, then build range, length, and load. As always, we monitor symptoms of leakage, heaviness, pressure, bulging in the vagina, pain, and an increase in bleeding. So with that, I hope you guys have a great Monday and I will see you next time.

10:27 OUTRO

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

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

Research discussed: 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9331349/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4314602/

https://journals.lww.com/nsca-jscr/fulltext/2020/08000/a_comparison_of_bilateral_vs__unilateral_biased.1.aspx 

https://pubmed.ncbi.nlm.nih.gov/37123275/ 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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