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

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

ELLEN CSEPE
Good morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients.

MOOD & OBESITY ARE RELATED
So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity.

BINGE EATING AS THE MOST COMMON EATING DISORDER
Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job.

THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT
So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity.

SUMMARY
So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how to incorporate geriatric treatment principles into practice to address pelvic floor concerns with older adults.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on ICE Daily show. My name is Christina Prevett. You saw me on Monday. I am one of your division leads for both the geriatric and the pelvic health division and you guys got stuck with me twice. If you saw the episode on Monday, you can definitely see that my voice is better. So I don't have the same sickness. So hopefully my voice will be a little bit more tolerable for today's podcast. Today we're gonna be talking about how fitness-forward geriatric clinicians do pelvic well. And one of the things that I often will get asked about is, Christina, it seems really weird that you're in both the geriatric space and the pelvic health space speaking to pregnancy and postpartum. How the heck are these two things connected? And they are a lot more similar than you think, especially when it comes to the quality of our care. What I mean by that is that we are not as fitness forward as we need to be in both the geriatric and in the pelvic health spaces. And there is a significant amount of under dosage that happens in both places. And in our older adult course, we talk a lot about this fitness forward mindset and we try and do the ultimate reframe, right? We worry about the cost or risk of loading people and our thoughts are, what is the risk if we don't? And What is the risk if our person gets a little bit weaker or they have an exacerbation of congestive heart failure and now they're five pounds heavier and they were barely getting up from a chair or using their hands when they didn't have that five pounds? We ask, you know, if they have low bone mineral density and we don't give them the resiliency to reactive step when they have a perturbation, what is the risk when they fall of having a fracture versus somebody else? And that reframe is potent, right? Because it eliminates a lot of the fear and it gets us having a sense, or at least it does for me, a sense of urgency with respect to getting individuals moving. When I see individuals in pelvic health, a big part of my clinical practice right now is postmenopausal females. who are struggling with incontinence or other type of pelvic health conditions, and have underlying muscular weakness or muscular reserve issues. And when I step back and I zoom out and I see that the geriatric space, we tend to underdose. In the pelvic health space, we tend to underdose. My goodness, when you slam those two things together, we see that the bias is to keep people on the table doing Kegels, or we don't even offer them pelvic health services because we assume that leaking and incontinence is a part of aging. and it's something that they have to deal with and it's part of being postmenopausal and have had babies 50 years ago and therefore we're not going to address it. Today I want to talk to some of the literature that says that we actually need to prioritize that fitness more. When we look at aging physiology of the reproductive system, we see that as men and women transition through menopause or andropause, right? Menopause blunting of female sex hormones, andro blunting, but not removal of the male sex hormones, AKA testosterone, that we see a rise in pelvic floor dysfunction. For females, there are one in four individuals are struggling with pelvic floor dysfunction that increases with age. For males, significant increases in pelvic floor dysfunction happen because many of our younger or middle-aged men, not all, but the rates of pelvic floor dysfunction are much lower and they start to increase with age, right? So pelvic floor dysfunction is talked about a lot more in the female space because it's more common. It is definitely more common as we get older. And when we are thinking about incontinence, we are thinking about different types, right? We have stress incontinence, that is more of a mechanical issue where inner abdominal pressure in the belly is exceeding the ceiling pressure of our pelvic floor to be able to close our holes, our urethra and our anal sphincter. And if we don't have enough of that capacity to close those sphincters off, then we pee or poop or pass wind when we don't mean to. Urge incontinence is that we get the urge to go to the bathroom and then we don't have the capacity or we have a very sudden behavioral intervention where I have to go to the bathroom and I have to go right now. I get the urge, I can't defer that urge, I have to go right now. That's very largely outside of any pathology in the kidney or the urethra that it's largely we're seeing behavioral issues. The other camp that we need to really speak to in the geriatric space is functional incontinence. So functional incontinence is that individuals are getting the urge to go to the bathroom or when they have to toilet, there is either a functional capacity issue where they physically cannot make it to the bathroom, or there's a cognitive issue where they get the urge, but because of some changes to cognition, They either do not act on that urge or they lack insight to have that toileting behavior. When you are working in acute care, we see a lot of this functional incontinence happen in combination with the burdens on our healthcare system, right? We see that individuals have to go to the bathroom, they're waiting a really long time because of our staff shortages, and then we're giving individuals periwicks or external catheters or internal indwelling catheters to prevent any incontinence issues from happening that are a consequence of them being sick. Okay, so when I think about stress incontinence and functional incontinence with aging, super common, a lot of times this is an issue of muscular reserve. If your body is one rep max living, where the demands of your day are at or exceeding your one rep max, your pelvic floor is a set of muscles that is acting no differently, right? If your entire body is experiencing weakness, then your pelvic floor is experiencing weakness too. And what that means is that yes, we want to be very focused in the pelvic floor. We have excellent evidence for pelvic floor muscle training across the age continuum, including older age. And we have to recognize that by increasing the functional capacity of the system, we are going to improve a person's pelvic floor symptoms, which means that you do not have to be a specialist in pelvic health in order to make a significant contribution to a person's incontinence. And this to me lights my soul on fire because incontinence is one of the leading causes of institutionalization in our older adults. It is one of the main reasons. Urinary incontinence, cognition, mobility disability, right? Those are the top three reasons why individuals can no longer be independent in their home. And when I think about the role of PT and OT, the PT OT dream team and rehab in general, we target two out of three of those issues, right? And every single person can target the urinary incontinence piece. And so the first huge message that I want to have with this podcast is that one, every clinician is a geriatric clinician because we are not going to ignore a group of muscles and just say that this is not our scope and we don't know how to handle it because we know how to work with muscles. Two, if you have a person with frailty or sarcopenia on your caseload, we need to screen for pelvic floor dysfunctions because if we are seeing outputs of weakness in the musculoskeletal system in the person that we are working with, we have a higher likelihood that we are going to see something happen with incontinence. And this is extremely important considering that incontinence is a main reason or a big driver for individuals needing institutionalized care or increased help in the home. decreased likelihood that they can age in place. And then let's talk about how we put this fitness forward pelvic approach in, whether you are a pelvic health clinician or not. Okay, when we look at the evidence of pelvic floor dysfunction in an aging population, there's a couple of things that we see. One is that individuals with higher amounts of sedentary behavior are at increased risk for pelvic floor dysfunction at age match. So when you compare a cohort of individuals at the age of 70 or 75, those that are more sedentary are more likely to have incontinence than those that are not. So by getting individuals moving around more, you are going to reduce their risk for urinary incontinence. That is number one. Number two is that individuals who are physically active have reduced rates of significant pelvic floor dysfunction compared to those that don't. And so individuals over the age of 65 who are more active are less likely to have pelvic floor dysfunction. Speaking to the musculoskeletal reserve component of pelvic floor dysfunction and aging. Number three is that for individuals with pelvic organ prolapse, those that are weaker or more sedentary, have higher amounts of sarcopenia and frailty, are more likely to experience subjective symptoms of prolapse. So subjective symptoms of prolapse are feelings like your bladder is coming out, that you feel like there is a ball in the opening of your vagina, or that there are symptoms of bother as if there is a heaviness or a dragging sensation around your pelvis. And this is one that I wanna kind of focus on. So when it comes to pelvic organ prolapse, the combination of an increase in objective range of motion of the vaginal walls in combination with a subjective complaint of bother is the way that we create the diagnosis for pelvic organ prolapse. Objective range of motion changes to the vagina are a sign of aging, right? So we are going to see an increase in vaginal range of motion. We have wrinkles on our skin. We have wrinkles in our pelvis. That is one of our wrinkles. The subjective signs of bother, though, have a discordance between the amount of range of motion that people see and the subjective reports of symptom thresholds in that person. This is true across the lifespan where some people can have a high amount of range of motion and not experience bother or any symptoms at all can be completely asymptomatic and other individuals can have a little bit of range of motion change and experience a high symptom burden. So that range of motion change is like a disc bulge on an MRI, right? We cannot just hold onto that objective range. We have to do that with subjective complaints. What we are seeing is that those with more weakness have higher rates of bother. And this is where I really want to hit on the fitness forward approach. Because if you are a person who is one rep max living, imagine the strain on your pelvis when you are doing a one rep max lift versus you are doing something that is 10 to 15% effort, right? What are you more likely to do when you're one rep maxing? You're more likely to hold your breath, your inner abdominal pressure in your belly comes out. We see a lot more people who are bearing down or straining when it comes to that activity and that repetitive straining can be a risk factor for subjective complaints of prolapse. So if I have an older adult who is 100 max living, then they are straining with activities of daily living, right? They are straining every time they need to exert themselves around their house, which means that they are more likely to experience some of those subjective complaints of something falling out, right? That is a barrier to us being able to load people. So what the heck do we do about it? First, we acknowledge that that straining can be contributing to how a person is feeling within their body, feeling within their pelvis as they go about their day, okay? That's the first thing. The second thing is that we can acknowledge what our body is supposed to do under strain. A lot of our older adults don't realize that they are pushing down into their pelvis when they are doing strainful tasks. Is that even a word? I don't even know. Straining tasks, I guess, is a better way of saying that, across their day. So the way that I will reduce that strain on their pelvis, if they are experiencing these symptoms, is one, I will get them to acknowledge or understand that the pelvic floor should be contracting, not bearing down on effortful tasks. That might mean that I'm gonna ask them to do a tiny Kegel before they stand up. That means that I may ask them to exhale as they are standing up while we are working on getting them stronger so that we reduce the strain on their system and reduce their bothersome symptoms. And the third thing is that I focus on getting them stronger so that they do not strain their pelvis throughout the day. So if I think about how taxing it is on my body when I'm straining, for a person who has had pelvic floor dysfunction, I have had two vaginal births, I understand what that means, but also a person that has a good musculoskeletal reserve, my older adults are edging into that straining a lot faster. than my individuals without that reduction in deficits. So if you are a person who's working in home health, if you are a person who's working in hospital, if you're a person who's working in long-term care or skilled nursing, they are going to oftentimes be straining down, right? And that's why individuals are farting when they get up from a chair. That is your sign that they are bearing down as they are getting up, which means that they are straining on their pelvis, and that may be a risk factor for their symptoms. add in constipation, which is much more common with our individuals in their 70s and 80s because of a combination of decreased drive for hydration, decreases in gut motility, side effects of their medications, and potentially dietary changes, that constipation that straining, that reduction in musculoskeletal reserve is kind of like this trifecta of risk factors for that pelvic burden. That pelvic burden is a huge barrier to our physical activity, right? 50% of individuals with pelvic floor dysfunction reported as a barrier or a reason to stop being physically active. And so if you are having a person who is resistant, maybe let's ask and really deep dive into why, right? So when we are thinking about our fitness forward geriatric clinicians, where I want to finish off this podcast is know that you are already doing pelvic well. Because if you are getting a person to be less sedentary, get them doing movement snacks throughout the day, if you are encouraging physical activity and exercise in your people, and you are teaching proper movement mechanics, including and avoiding of bearing down, when individuals are doing activities of daily living, you know how to teach the brace, which we get you to do in our MMA live with our plank lab, right? That's the foundations of bracing. You are doing pelvic health well, right? Because we see so many of our older adults are struggling with pelvic floor dysfunction and their musculoskeletal reserve is contributing to that risk. If you are stuck with me for MMA Live, you know I end up on a soapbox about pelvic health because it's so, so important that a deconditioned person is a deconditioned pelvic floor and our older adults do not get the care that they need in conservative management of a muscle group that is absolutely within our wheelhouse. And that is also why if you are in MMA level two, we do an entire week on conservative management for the non-internal pelvic floor physical therapist on pelvic floor dysfunction, because it is a huge part and it is not just do Kegels. It is so much more than that. And everybody who is listening to this can get on board and be positively contributing to some of the improvement of those symptoms. And when I think last kind of point to make with saying that you are all doing pelvic well, is that by adding in the screens, increasing the muscular reserve of the system, and speaking a little bit to straining and breathing, I clear up so much pelvic floor dysfunction almost immediately in my practice. It's like my geriatric PT magic trick, right? If I have a person who is having wind or anal incontinence every time they sit up from a chair because their abs are too weak and they're bearing down and holding their breath every time they sit up from a reclined position, then When I teach them to breathe out as they do that, tell them not to bear down and get their abs a little bit stronger, it clears it up almost every time. And it's embarrassing for people, right? They don't want to engage in certain activities because they're afraid, or they pretend that it doesn't happen because it happens to them so often that they just don't acknowledge it anymore, even if they feel it. Oh my gosh, 20 minutes in. Gosh, sorry, Alan. So if you wanna learn and get the rants on the reproductive system, make sure to jump into MMA Live. We are this weekend up in Hendersonville, Tennessee. Julie's up there in Hendersonville and Dustin is in Aspinwall, Pennsylvania. We are going to have incredible groups. They're looking pretty good. The next courses for MMA, because we have sampler, and we have a long weekend. I am up in Bismarck, North Dakota, the 18th, 19th of May, and Jeff Musgrave is in Richmond, Virginia, same weekend. So you either have the chance this weekend to get into MMOA Live or middle of May is your next opportunities. And if you really want to hear me rant and rave about pelvic floor dysfunction, you guys have made it to the end of this podcast. Our level two is starting middle of May, but today's April, I'm losing track of time. And the level one is our prerequisite for that. We are going all the way to the ICE app for all of our MMA courses, starting our next cohort. We are super excited about that. And let me know if you guys have any other questions, because I love blending the Jerry and pelvic worlds together. Thank you so much, Andrea. All right, have a great day, everyone, and we will talk to you all soon.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey reviews the anatomy of the latissimus dorsi muscle, its relevance to overhead movement, and discusses two ways to begin to improve long-term functional mobility. Lindsey also provides a rehabilitation every minute on the minute (rEMOM) program to begin to use for an HEP for patients who need to improve their own lat mobility.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PTonICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

LINDSEY HUGHEY
PT on Ice daily show. How are you? I am Dr. Lindsay Hughey from our extremity division, here with you today on a clinical Tuesday to share some pearls of how we'll get after our LAT mobility. So I first wanna just briefly unpack the function of the LAT, so a little anatomy review, and then I wanna discuss two ways to really get after mobility access, demo those two ways, and then suggest them in a rehab EMOM sequence for you all, so you can directly use it yourselves, or use it with your patients in the clinic. A lot of our overhead athletes, our weightlifters, our crossfitters, maybe even just our stiff shoulders need more access to lat mobility.

REVIEW OF THE LATS
So let's first just review what is the lat and where is it? Well, the latissimus dorsi is responsible for internal rotation of the arm, arm adduction, arm extension, and it even assists in respiration. in both inhalation and exhalation. It spans quite a big area of our extrinsic superficial back muscles. So we have a vertebral part that goes from our spinous processes and converges into the thoracolumbar fascia, goes all the way down to our iliac crest. There are even connections into that inferior angle of the scapula, and then even 9 through 12 ribs. So it spans quite a bit of area. The reason we review all of those areas is when you're doing your mobility work, you really want to make sure you hit all of those and make sure to challenge them.

TWO WAYS TO ADDRESS LAT MOBILITY
So I'm going to show you how we can do two versions, a way where we fix the arms overhead and move the body away to traction the lats from below. And then I'm going to review how you can fix from below and then move lats from above. What we won't do this morning, though, is just a static hold stretch. So before I review these two with you, I want you to know that purposely these two moves are so effective because in the first we're going to use a hold relax technique. So we're going to actually use isometric contraction, hold, and then lengthen tissue longer. And what we see with our ISOs, as long as you hold it at least six to seven seconds, I'm gonna make you all push to 10, but we see this increase in neural drive and we get those Golgi tendon organs to chill out and make that agonist, the deltoid relax so that we can actually gain more lat access. The second exercise, we're gonna actually go after eccentric training. So the reason we choose eccentrics as we see constant and ongoing research links to improve strength and length and even greater cortical excitability when we train in eccentric fashion versus just like a static hold or even doing concentric work for our lats. So without further ado, let me show you these two exercises. So number one, we're going to fix from above by putting our elbows on a surface. I'm going to show you on a bench here today, but it could be a bar. It could be a foam roller, whatever feels good for your body. It could even be the counter or a wall surface. So we're going to put our elbows in like a goalpost position, and then we're going to fix our arms here. And we're going to lean our hips back, but we're going to actively contract our arms down for a hold of 10 seconds, then relax and push our hips away. So we get this tractional effect from below. So it'll look like this. So elbows down, and we're going to push into the object while we push our head down. And we're going to push down for 10 seconds. and then access greater length. So you'll notice that I push my hips back and away as I gain access to new length, but that key piece is activate for 10 seconds into the surface, pushing down, and then move away. To fully maximize this particular movement, we're also going to tie our breath work, because remember I said function of lats is helpful in inhalation and exhalation, And then we have links directly to those ribs. So we're going to pair our breath with this. So we'll do it one more time, but this time we're going to link that isometric hold with an inhalation. And then on our exhalation, we're going to move away. So it looks like so we're going to go hold for 10 seconds, pushing down and then exhale and push the body away. And then we would do another rep pushing down 10 seconds. Inhale. And then exhale. For those that are just listening to this this morning, I do suggest watching the video so you get the visual. But we would repeat that for at least five to six reps. I'm going to show you how we'll do that in a rehab EMOM. But we really want to get at least a six to seven second hold of that isometric where we're pushing down before we lengthen. The key parts here being tie breathwork with it. And then don't forget to access more length and maintain it. So that next isometric hold where you're pushing down in the hold relax sequence should be in that newer length. The second exercise we are going to review today is eccentric training. So we are going, I'm going to lay in either hook lying position or you can put your legs up to put further tension on the thoracolumbar fascia. My palms are going to face toward the ceiling and I'm going to slowly lower a bar. Right now I just have a PVC pipe with a plate on it and I'm going to slowly lower eccentrically. I want the slowly lower to be three to four seconds and then a hold for three seconds at the bottom. And you'll repeat this with a goal of eight to 20 reps or what in extremity management we would call our rehab dose. Keys being that eccentric slowly lowering on the way down and the hold at the bottom. So we want about three to four seconds in each of those parts. Don't care as much about that concentric raising portion. Appreciate this eccentric could be done with dumbbells as well or kettlebells. I love starting with a PVC pipe and just a five pound change plate for those that are new to lat access. So we have two things that we've reviewed so far. We are going to do Number one, our ISO hold, where we get into a position where our lats are on tension and you push and drive the elbows down for 10 seconds. And then after that 10 seconds of inhalation and pushing down, you'll exhale and lengthen those lats into a new mobility access area. The second one is that eccentric overhead with the either Dow or PVC pipe and weight. Just these two things done.

MAKE MOBILITY EFFICIENT: THE rEMOM
So if you do each of these for a minute and you do three rounds, you have yourself a very efficient six minute rehab EMOM to attack lap mobility access. Nothing gets more bang for the buck when you combine both of these and you'll get relaxation. Start subbing your static hold stretches that either you're doing or that you're doing for your patients and really get the neuromuscular system on board to see change more rapidly. From a frequency perspective, at least two to three days a week is something I would recommend for my patients to get after and even using it as like a precursor before they do some overhead work because we know what will solidify this even more is then to actually load it and do some functional meaningful thing.

SUMMARY
If you want to learn more about how to even test if your patient has lat mobility tightness, if you want to dive a little bit more into dosage and the rationale behind eccentrics and why we don't use static stretches in our course at extremity management, Mark, Cody, and I and our extremity team would love to see you on the road. Um, and literally we have courses all throughout this year, almost every month in May, May 18th, 19th, I'll be in Bellingham, Washington, and our director of marketing say will be with me. So if you want to join us, that is sure to be a blast. And then June 1st and 2nd, we have two offerings, one in Wisconsin and then one in Texas. So check us out on ptlnice.com. if you want to learn more about how we think and treat the lats. Thanks for tuning in with me today. And if you're listening, be sure to watch the video later. Take care, everybody.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of physical therapy in the male fertility space.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in both our pelvic health and our older adult division. I'm going to apologize in advance if I sound a little hoarse. I am not feeling well, but that doesn't mean that we aren't going to be able to have an incredible episode here on the podcast. So today I wanted to dive in a little bit on male fertility. So last podcast episode that I did several weeks ago, I was talking about our role as physical therapists or individuals in the rehab space in fertility. That conversation circled very much around female fertility and around ethical considerations for fertility. We're gonna continue that conversation. We are gonna launch off of that conversation into our male fertility and male fertility related factors. So I feel like when we are talking about individuals who are struggling with fertility related concerns, a lot of our conversation centers around the female pelvis. And that makes a lot of sense because individuals who are struggling with fertility, it's oftentimes, we are hearing about assisted reproductive technologies like IVF and IUI that are largely interventions that are done for females. And so if couples are dealing with infertility, the female is oftentimes doing different interventions to allow for more successful rates of conception or implantation in the uterus based on a variety of factors. What I think is important for us to recognize, though, is that 30 to 50% of couples who are going through infertility have male-related infertility factors. Let me repeat, between 30 and 50% of couples seeking help for fertility-related concerns have a male-related factor in their journey. And I think this is really relevant for us to be starting to have conversations about because so much of our education has focused on the female pelvis and our males really don't know a lot of things that relate to their fertility. So there was a cross-sectional survey that was published asking males of reproductive age about their fertility. 55% of them, 54% could not identify factors that positively influenced male fertility. So we have a role to play sometimes when we are working with individuals. This is probably not an area of practice where individuals are going to be all of the time marketing their services in male fertility, but I think it's important that we talk about the male aspect of infertility as well. When we are talking about male related concerns, we have sexual response concerns and then we have sperm related concerns. When it comes to the sexual response related concern is that in order for conception to happen, an erection has to be able to be developed and maintained in order for that erection to lead to ejaculation in order for sperm to meet the egg. That sexual response needs to happen. If you are struggling with erectile dysfunction, if you are struggling with pain with ejaculation or testicular pain with sexual activity, those are going to be big barriers to a person being able to successfully have penetrative intercourse. We have a huge role to play in helping with erectile dysfunction and with individuals who are experiencing pain. And in our level two course, we go into a lot of these pain syndromes that focus around the male pelvis. And so the first thing is clearing some of those conditions. Secondly is we talk a lot about the sexual response being not just a mechanical property where you want to have sex, you get that sex response, and ejaculation occurs. There are a lot of bio-psychosocial factors that go into a person's sexual desire, their libido, and issues related to their want for that type of intimacy. We have a book called Come As You Are that is focused on the female pelvis and the female sexual response, but we don't have as many of the same type of resources for males who are struggling with the same thing, right? Like if you are really stressed out, if you are not sleeping well, new parents who are like in the thick of postpartum, that doesn't just affect are females, that can affect our males as well. If they are struggling with mood disorders like depression or anxiety, that can have huge side effects on their libido and their desire for sexual activity. If they are on certain medications, it can have influences on their sexual desire. And so having conversations about the biopsychosocial factors of the sexual response are also important. So when we are thinking about the bucket of sexual response for males, our role comes into helping individuals with erectile dysfunction, if that's something that we have cleared that may be in our wheelhouse around hypertonicities or different type of pelvic pain issues that are leading to that response. A lot of erectile dysfunction is a vascular response and individuals with erectile dysfunction are at higher risk for cardiovascular disease. So there's a health promotion component there. And then we're also going to have a lot of education around libido. If it is the physical act of penetrative intercourse that is a stumbling block for a couple who is dealing with infertility. We see this all the time in our female pelvis with those with vestibulodynia or other dyspareunias or pelvic pain syndromes. This can also be true for our male pelvis, which can create a barrier for individuals being able to have sex at the right time. Okay, so that's kind of our male response piece. The second is on the sperm itself. And so when we are thinking about the male sperm meeting in the fallopian tube and being able to successfully have a conception moment that happens, we have to think that there has to be enough sperm and the sperm has to have good motility or movement, which is related to its shape in order for it to make the long road to the fallopian tube. I mentioned in my female fertility podcast that it's interesting with some of our health promotion because female pelvises have all of the eggs that they are going to have in their entire life by the time they are born. They do not develop more eggs. Eggs mature across cycles. That is not true for the male side of the physiology. For females, that means that health promotion is related to their entire lifespan. For males, that is 74 days. So the maturation cycle of the sperm is 74 days. What that means is the acts that you take, the health promotion incidences that you take when you are trying to conceive, what is really important is those 74 days are approximately three months prior to conception. So if you are a couple who is trying to conceive, your health promotion factors for the male in the three months prior to trying to conceive matter, okay? They matter. So when it comes to our sperm volume and motility, what we are seeing is that there is a large influence on motility for reactive oxygen species and low-grade inflammation. And you all are probably thinking, well, that's good news because that means that our health promotion factors are going to be very relevant in male fertility. And you would be correct. OK, so when we're looking at the magnitude of improvement in fertility for those that start taking on more lifestyle related factors, health promoting factors, it is significantly more beneficial for men who are trying to get pregnant or get their partner pregnant than it is for females because females it's the accumulated reactive oxygen species of their entire life up to this point where it's still going to be beneficial but the magnitude is not going to be the same as the 74 day cycle of the male sperm. What that means is that we have several modifiable risk factors that we can be educating on when it comes to our fertility. So heat stress, use of a sauna, is one modifiable factor that seems to degrade sperm quality. Another one is alcohol use. Alcohol use can negatively impact sperm and sperm-related factors, and it should be avoided or minimized for individuals, for the male partner, for the female partner too, but specific to the male when we are trying to conceive. Steroid use and use of testosterone replacement therapy is a big cause of male-related infertility. It is not everybody who is on TRT, but in our male pelvis, right, the exogenous hormones shut down some of our spermogenesis type of physiological pathways and our body or the male body isn't producing sperm because there is an exogenous hormone that is coming in that says we're good. Okay, we're good. So individuals who are on exogenous steroids, so this is kind of our athletes. Pardon me, sorry. They're on TRT. We're seeing a lot of individuals who are topping up their T to be on the higher end of physiological normal. That may be a big contributing factor for them for their infertility. So asking about any supplements or any medical interventions that individuals are doing to top up their testosterone is a big factor. Smoking is another male related factor that can influence fertility. Smoking creates an increase in reactive oxygen species. creates chronic low-grade inflammation, this makes a lot of sense. The other one is obesity. Adipose tissue is low-grade inflammation tissue and can contribute to the burden of low-grade inflammation on the body. So a lot of these like heat stress saunas, alcohol use, TRT, smoking, and obesity are things that we can counsel on. Another very big influencing factor is a person's exercise. So sedentary behavior is linked to lower fertility rates and those who are physically active in the three months leading up to their fertility journey, starting, trying to conceive, have a higher rate of fertility. So the influence here though is a little bit nuanced from what we're seeing in the literature. So individuals who are active going into their conception journey. It doesn't seem for those who are not struggling with infertility to influence how fast a person gets pregnant, but it influences if there is going to be a male factor fertility issue. That makes a lot of sense because it's two people, right? We're going to only be able to optimize the person that we are working with. being physically active, going into your conception is a good thing to do. Especially most of our evidence, you guys are not surprised based on where my research is, like a lot of this is in aerobics, so we're trying to build up some of our resistance training literature. So being physically active, being less sedentary is good. The only flip side of that is for individuals who are really active. Okay, so for our highly, highly active, especially endurance, especially cyclists. Okay, so when we are working with individuals who are very highly active, especially our endurance trained individuals, we are seeing an influence on sperm motility for those who are cycling for more than five hours. And what that is, is the closeness of the testicles to the body when you're on a bike that is putting the seat close to the body, because the heat can influence the sperm and sperm quality. It's also some of the impact, mechanical impacts of the bike seat. We see that there are higher rates of erectile dysfunction and pudendal neuralgia, which can influence sexual response in our high-level cyclists. And we are recognizing that individuals who are in the endurance space, our male endurance athletes, are at risk for RITS, relative energy deficiency in sport. Our female athletes are much more sensitive to underfueling and that low fuel and energy availability and its impact on their physiology, but our males are not immune. And our endurance male athletes, in particular, appear to have a higher incidence of underfueling than we are recognizing. And so Exercise in general is very good for fertility. For those who are on the very high volume side of the spectrum, we may be counseling on type of exercise, fueling, and volume, and clearing for any types of sexual dysfunctions that may influence a person's conception.

SUMMARY
All right, I hope you found that helpful. I found this literature to be so fascinating. When I think about fertility and the male cycle, I just kept thinking, this really feels like a vital sign for health for our males, right? Like when I'm thinking about the sperm quality, reactive oxygen species load, like it almost feels like an HPA1C for health of the entire body. We use HbA1c to get a good idea of blood sugar responses over the last three months. We can get almost like an inflammatory load response for males in the previous 74 days with sperm analysis. Now, we're not going to go and get pupils to have a sperm analysis every couple of months to take a look at their health, but I think it is fascinating to see how sperm-related parameters can really give us some insights into the overall health of the male that we're working with. All right, if you are interested in learning all things about fertility, we dive into fertility management in our level two course across a variety of weeks. So we talk about fertility and influences for fertility. We talk about fertility related conditions that lead to infertility, and we talk about assisted reproductive technologies and the influence of different fitness forward modalities on ART technology. So if you are interested, our next level two, you have had to have taken our level one online course to get into that is in August. I have just been in Texas last weekend. It was so fun. You guys were so great. I'm so thankful for you all. Around learning about all things pelvic this weekend if you were looking to get into our live course Our next course is May 18th 19th in Kearney, Missouri Then I'm gonna be in Highland, Michigan June 1st and 2nd Alexis is gonna be up in Anchorage, Alaska and then June 8th 9th. I have a back-to-back I'm in Mineola, New York. So I'm at Garden City CrossFit close to New York City and I would love to hang out with you guys. We had so much fun at dinner. We were talking all things Pelvic health and we just had a great time. So if you're interested in any of those courses

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses incidence of knee injury in functional fitness, common types of knee injuries seen in this space, and how to begin to treat knee pain for the fitness athlete.

Take a listen to the episode or check out the show notes at www.ptonice.com/blog

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

ALAN FREDENDALL
All right. Good morning, everybody. Good morning, Instagram. Good morning, YouTube. Good morning to those of you on the podcast. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. My name is Alan. Happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and our division leader in the fitness athlete division and practice management divisions. It is Fitness Athlete Friday. We would say that means it's the best darn day of the week. And here on Fitness Athlete Friday, we talk all things for folks who are recreationally active. So those patients and athletes active in CrossFit, functional fitness, running, endurance sports, whatever, that person who is getting up every day and getting in their daily movement, we're here to help you help them. So today we're going to be talking about knee pain in the fitness athlete. And in the context of today, we're going to be talking about specifically those folks who are probably squatting on a regular basis. So CrossFit and functional fitness athletes, folks who are maybe squatting, squatting heavier, higher volume on a more frequent basis than maybe some of our endurance athletes.

INCIDENCE & TYPES OF KNEE INJURIES IN FUNCTIONAL FITNESS
So I want to talk about what types of injuries do we see in the knee in this space, describe a little bit about those injuries, and then discuss the beginning stage of how to begin to treat some of those conditions. So first things first, What do we see with knee pain in the fitness athlete population in general? The great news is over the past decade or so, we have got a lot of great high-quality research out of the CrossFit and functional fitness space about what regions of the body are injured most frequently, and then kind of what conditions follow those injury diagnoses. So we should know that in the fitness athlete, we primarily see shoulder as the most injured region. About 45% of injuries are from the shoulder. Really close behind that is the low back about 35% and then really musculoskeletal injury kind of falls off after shoulder and low back. Specifically today talking about the knee we see about 15% of injuries are related to the knee. Beyond that we have elbow, wrist and hand, ankle and foot, that sort of thing. So primarily shoulder and low back and then a real sprinkle of the knee. With those knee injuries, we're not seeing really major traumatic injuries. It's very rare, probably never in your gym, anecdotally, have you seen somebody fracture their leg, fracture their patella, tear their ACL, get hit by a vehicle, fall off a thing. That usually doesn't happen in the space of the gym. Primarily what we see in the fitness athlete population, folks who are doing a lot of impact, a lot of squatting, is that we see a lot of patellar tendinopathy and we see a lot of what we maybe would describe as a meniscus issue but really something that we could just generalize as medial knee pain. So now breaking down those two major conditions patellar tendinopathy and meniscus or medial knee pain first things first I would tell you if you haven't yet taken our extremity management course with Lindsay Huey, Mark Gallant or Cody Gingrich I would recommend you get to that course as soon as possible. That course is a really great complement to our fitness athlete courses as far as being able to recognize and diagnose and stage a tendinopathy, diagnose an extremity condition, but also treat it and learn a lot of progressions and regressions to treat those injuries. Specifically, they spend a lot of time the entire afternoon on Saturday addressing the knee in a lot of detail. So make sure you're really comfortable with these conditions. if you hear words like patellar tendinopathy or meniscal care and you think, quad sets? I don't know.

PATELLAR TENDINOPATHY & MENISCAL CONDITIONS
So talking about patellar tendinopathy, what do we know in overuse condition? who is that person in the gym that we maybe need to be aware of, or questions in our subjective exam with that person that would let us know this person may be in that bucket. Somebody brand new to squatting, think of somebody in their 40s or 50s, sedentary, maybe their entire life, that's not out of the realm of possibility these days, who is now jumping into CrossFit, jumping into Orange Theory, jumping into F45, being expected to squat at higher volume and higher loads than obviously they ever have in their life. Folks who maybe are not new to this space but are maybe incurring and encountering a higher level of squatting volume than normal may also fall into this bucket. There are also movement patterns that tend to show up in these folks. I like to stage these as two different movement patterns. The first is what I'll call the close enough squat depth pattern, right? That person who is getting to maybe just above or just at parallel. what do we know about that range of motion in the squat we actually know that's when force on the knee is at its highest that above that point at about 45 to 60 degrees or less of knee flexion and then below 90 degrees of knee flexion we know we have a deloading effect at the knee so those folks who are trying to squat to full depth but are in just that close enough bucket are putting a lot of mechanical force on their knee that they could get rid of if they either squatted more shallow, which is not ideal, or ideally squatted a little bit deeper. The second group of movement pattern folks who fall into overloading their knee is that back and down squat pattern person. So that person who does not break at the hips and knees at the same time. So as we instruct the squat, we like to tell people, imagine there's a rope around your hips and your knees and they're pulling in opposite directions at the same time. That means your hips should flex and your knees should flex. And ideally with a relatively vertical torso, you sit down, sit straight down into that squat pattern. The down and back folks tend to initiate their squat with a hinge, and then to get to depth at the last moment, bottom out that squat and drive all of that force into the anterior knee to hit depth. This is kind of how powerlifters tend to squat, especially with a low bar back squat. But folks who just have not grooved out the motor pattern of the squat yet, when they hinge back and then sit down to finish the depth, the knee again is taking up a lot of force that really we could clean up with some coaching and cueing, right? Maybe we could elevate that person's heels, give them a corrective to hold a plate in front of them, but otherwise encourage a more vertical torso and a more sit straight down squat pattern that distributes force equally between the hips, knees and ankles in their squat pattern instead of at the moment of truth, putting all the force in the knee as they try to hit depth. So that's the patellar tendinopathy bucket. What about the meniscus, the medial knee pain bucket? These are folks who are encountering a lot of impact in rotation. So we do see this a lot in the functional fitness space, right? We do running. We might not go run marathons, but we do a lot of workouts with 200, 400, 800 meter runs. We do a lot of box jumping to train triple extension. We do a lot of double unders for model structural cardio work. And we have begun to introduce shuttle runs, at least in the CrossFit space, to be able to run indoors during the winter in a competition environment where maybe we don't have access to run outside or we don't have the treadmills to be able to run inside on a machine. With shuttle runs comes not only the impact of running, but now a turning rotation moment. not too dissimilar from catching a box jump in the bottom of your squat with your double unders or with running in general. Also in this group are folks who might be new to squatting full depth or otherwise increasing their squat volume, right? No different than the patellar tendinopathy bucket that they are now encountering extra volume. So understanding who that person is is really important and that's where knowing that this person is a functional fitness athlete knowing if they are new to this or not, if they're returning after a break, if they've never done something like this in their life. Uncovering all of that in the subjective history is really important because it's going to give you a better idea of where your treatment might take you.

TREATING KNEE PAIN IN THE FITNESS ATHLETE
So let's talk about that treatment. What should be our priorities in treatment? With our functional fitness athletes, we're demanding full range of motion at every joint whenever possible. That means one of our primary goals should be if we find an asymmetry, a lack of range of motion, particularly in knee extension and knee flexion, we need to restore that as soon as possible. Again, I'll point you towards our extremity management course. I'll point you towards our fitness athlete live course to learn techniques to self-mobilize to load to restore that full range of motion. But as we're restoring that full range of motion, respecting the irritability of the patient, we need to begin to strengthen in whatever available range of motion we have. These folks do not need more volume, right? They're coming to you with an overuse, a repetitive use injury already. Giving them a 20-minute AMRAP or a 30-minute AMRAP and having them do hundreds of squats or lunges in the scope of their PT session is just adding insult to injury, especially if we are thinking that this is a patellar tendinopathy case, for example. These folks need strength, they need capacity and resilience in those structures, so that they can continue to not only stay in the gym, but perform in the gym, ideally, beyond the point at which they got injured, right? We don't wanna just return somebody to the exact moment at which they got injured. Ideally, once we clear them fully, hey, you don't need to do your PT exercises anymore, they are a stronger person than when they first began rehab with us. So we need to strengthen that full range of motion of the whole knee. Now PT school has closely associated in our brains that the knee means quadriceps and that's it, right? It's all over the research. It's all over knee extension machines and really, really focused on making sure that we have really, really strong quads, which is not a bad place to start, especially if that person is missing some knee extension, right? Some, some traction banded straight leg raises can do a lot to both begin to restrengthen quadriceps, but also restore knee extension. but we can't just stop at the quadriceps. We need to strengthen the whole knee, right? All four muscle groups of the leg that attach to the knee. So we also need to make sure we're targeting our hip abductors, our hip AD ductors. We need to target, yes, the quadriceps, but we also, especially if we're thinking this is a rotational-based injury, if we are thinking this is medial knee pain, call it meniscus, call it whatever, we really need to focus on the hamstrings because why hamstrings flexed and rotate the knee. They are pulling the knee into medial or lateral rotation in a movement like running. Ideally, hopefully, they're firing pretty much in sync so that we don't have a lot of rotation in our knee. We're primarily going through flexion extension, but our knee does have the capacity to rotate, obviously, and it's primarily driven by our hamstrings pulling the knee into flexion and in rotation. What is the problem with hamstring strengthening? The problem with hamstring strengthening is that in most functional fitness environments, we don't primarily isolate and train the hamstring. We certainly do a lot of deadlifts, we do a lot of kettlebell swings, that sort of thing, but if you think about the range of motion from the knee and the hip in motions like deadlift, kettlebell swing, it is not full range of motion of the hip and or knee, which means we're not strengthening the hamstring through its full range of motion. Yes, you'll feel a little maybe glute, high hamstring burn on high volume deadlifts or kettlebell swings, but you are not getting that deep behind the knee stimulus that you are with things like Nordic curls or even just isolated knee flexion on a knee flexion machine or banded knee flexion or anything like that. So understanding that the hamstrings flex and rotate the knee is really important to kind of finishing the drill on a really comprehensive knee strengthening program. Understanding that biceps femoris is responsible for knee flexion, but also yes, lateral knee rotation, and that semimembranosus and tendinosis are responsible for flexion and medial knee rotation. So particularly with those medial knee pain bucket folks, we wanna get into semimembranosus, semitendinosus, maybe with our hands, with needles, with cups, whatever, try to restore both that flexion and rotary component of the knee, and then get out in the gym and really strengthen those hamstrings on top of, yes, the quadriceps, the hip abductors, and the hip adductors.

TIME UNDER TENSION IS KEY
The key with strengthening the knee, again, is time under tension. The folks you're working with are already doing higher volume, higher repetition, relatively moderate to higher load training for the knee in a Metcon style workout. So adding in more air squats at high volume or light wall balls or thrusters or goblet squats is really just doing the same thing that they're already doing in the gym, which led them to be sitting on your table in the first place. So just giving them more of that isn't necessarily a prescription. When we have students at Health HQ, they're so excited to have people out in the gym moving, folks who are interested in taking care of their health and fitness, and they love to jump up to that whiteboard and write out, Remom 24, Amrap 30. We have to go, wait, stop, stop. That's not appropriate for this patient, right? This patient is already dealing with the consequences of too much volume. We need to back their volume down, especially in physical therapy, and focus on time and attention. So be careful that we're not actually exacerbating or at least prolonging the healing time of that patient's condition because our volume in PT, our volume for our home program is too high. Slow it down, less reps, less sets, more time under tension. Depending on the patient's irritability will let you determine how much tension you can apply both in the clinic, in the gym, and for homework. When someone's really irritable, I'm thinking maybe isometrics, and I'm thinking something like a reverse Tabata. 8 rounds, 10 seconds of work, 20 seconds of rest. There are apps out there. I personally like GymNext. It is a timer. It has a Tabata built in, EMOM, AMRAP for time built in. It can connect to a Bluetooth clock that the company sells, but you can also just use it as a standalone app and play it through a Bluetooth speaker or just through your phone speaker for your patient to hear. So reverse Tabata, eight rounds, 10 seconds of work, 20 seconds of rest, that gets us 80 seconds time under tension. That's a pretty good start, especially if we're doing it isometrically and the patient is really, really, really irritable. Now, as symptoms calm down, as function begins to improve, as tolerance to loading begins to improve, we want to increase that time under tension dose, especially if we're convinced that this is a tendinopathy based condition. So I like to move next to 10 sets of 10 seconds of work. I'll usually do 10 seconds on, 20 to 30 seconds off for 10 sets. That bumps the needle about 20%. That gets me 100 seconds time under tension. Then, when that patient appears ready, we'll probably progress to a Tabata. That's 160 seconds, right? It's the opposite of a reverse Tabata, a full Tabata. 8 rounds, 20 seconds of work. 10 seconds of rest. So the inverse of a reverse that gives us 160 seconds. So now we're close to pushing three minutes time under tension through that structure. At this point, you're probably away from isometric exercise, but if you're not great, keep rocking the isometric exercise for more attention. And then really for me, kind of the hallmark that someone is getting close to the end of their plan of care is when we can do isotonic movement, we can do five sets of five, and we can do some really gnarly tempo right think about a slant board goblet squat right so he was really elevated a lot of focus on tension through that anterior knee and that medial knee structure three seconds down hold the bottom and as deep of a squat as you can show me three seconds and then three seconds standing concentrically out of that squat. That's nine seconds per rep, five reps per set, five sets. That gives us 45 seconds time under tension per set. That gives us 225 seconds across the five sets. That is what the tendinopathy research tells us we need to be hitting as a benchmark for our time under tension. So understanding, depending on that patient's irritability, depending on how long this condition has been going on, that person may not be able to walk into the clinic and do a slant board, heels elevated, goblet squat, five sets of five at 3-3-3-1 tempo. That might be a lot, right? Certainly probably going to make them sore, but it might aggravate their condition. So understand how we can regress and progress, time and retention is needed. And then make sure as well that we're doing that for every structure of the knee. Again, that we're hitting the medial knee, the lateral knee, the anterior knee and the posterior knee, particularly doing things for the hamstrings like Nordic curls, curls on the rower, furniture slide curls, anything to really target the hamstrings as they insert at the knee as they flex and rotate the knee. and not just strengthening mid-range of the hamstrings and mid-range of the quadriceps.

SUMMARY
So knee pain in the fitness athlete. How frequent? About 15% of all injuries, so relatively low compared to all the other injuries that this population encounters. Primarily, folks, patellar tendinopathy, meniscus, medial knee. Why? Overuse, either a sudden spike in volume from a more competitive athlete or a new athlete, or someone who is maybe doing extra stuff outside of the gym, extra running, extra squatting, whatever. Folks to watch squat when they're with you, are they the close enough depth person? Do maybe they need some help in their ankles or hips to hit better depth and take load off the knee? Are they the back and down squat person? Do they primarily squat with a hinge and then bottom out through the knee to hit depth? That is a person that can benefit from sequencing their squat pattern a little bit better, especially if they do have a goal to be a functional fitness athlete. They need to be able to show a relatively vertical torso squat, a high bar back squat, a front squat, a thruster, a clean, that sort of thing. With our treatment, make sure that we're working as soon as possible to restore full range of motion of both extension and flexion. We need full knee flexion to squat. We want full knee extension for impact. We want to strengthen the whole knee, not just the quadriceps. Hit the hip abductors, hit the AD ductors, and particularly full range of motion hamstring work, not just things like deadlifts and kettlebell swings. They're already doing partial range of motion hamstring strengthening in the gym. And then remember, it's not about volume. It's not about coming into PT and doing 500 air squats. They can definitely do that. It's probably going to exacerbate their symptoms. What we're focused on with our strengthening with their home program is time under tension. Start with the reverse Tabata. 10 seconds on, 20 seconds off, eight rounds. 80 seconds time under tension. Move to 10 sets of 10 on, 20 to 30 off. That's 100 seconds. Move through a full Tabata. Now 160 seconds, 8 rounds, 20 on, 10 off. And then the gold standard is can we do 5 sets of 5 of a movement at 3 seconds eccentric, 3 seconds isometric, 3 seconds concentric. Can we get to that 225 second time under tension benchmark? So I hope this was helpful. I'd love to hear questions you all have, throw them here on Instagram, shoot us an email, shoot us a message over on the ice physio app. Some courses coming your way from the fitness athlete real quick before I let you go. Our next cohort of fitness athlete level one online starts April 29th. That course is already almost sold out and it does not start for three more weeks. So if you've been looking to get into that class, that class has sold out every cohort since 2017. This next class will not be the exception, I promise you. So if you've been on the fence, get off the fence. If you've already taken that course, your chance at level two online to work towards your certification in the clinical management fitness athlete begins September 2nd. And then some live courses coming your way. Mitch Babcock will be down in Oklahoma City this weekend, April 13th and 14th, if you want to join him. He'll be back on the road again, May 18th and 19th out in Bozeman, Montana. And in that same weekend, Joe Hanesko will be up in Proctor, Minnesota, which is in the Duluth, Minnesota area. That will also be the weekend of May 18th and 19th. So hope this was helpful. Hope you all have a wonderful Friday. Have a fantastic weekend. Bye everybody.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses three fundamentals to working with individuals new to a fitness routine who encounter their first injury: avoid medical imaging, stay in the gym & modify around the injury, and be goal-driven to maintain motivation to continue to create a fitness habit.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JEFF MOORE
Alright crew, what's up? Welcome back to the P.T. on Ice Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and always thrilled to be here on a Leadership Thursday, which is always a Gut Check Thursday. So first things first, let's hit the workout. Gut Check Thursday this week is going to be a bit of a partner WOD. So we've got four times, relatively simple. It's going to be 100 deadlifts, 100 power cleans, 100 power snatches. The weight is going to be 225-155 on the deadlifts, 135-105 on the power cleans, and then 95-65 on those power snatches. Essentially, you're going to decrease load with each movement, but obviously increasing complexity, and maybe more importantly, increasing grip fatigue. I'm looking at that workout thinking, boy, that's a lot of pulling on that barbell, but it's in teams of two, so break it up however you want, maybe five, maybe 10 reps on some of those things, and then pass it over to your partner, bang all of that out for time, and then post it so we can see how you did. Tag Ice Physio, hashtag Ice Train. I'm gonna do this at three o'clock with Say over at CrossFit Endure, our marketing director. We're gonna challenge this workout. I will make sure to post my time. so you have something to try and smash later on today or tomorrow whenever you have a chance to get to the workout. So that is Gut Check Thursday. Let's move on to the episode.

THE ROAD TO FITNESS RUNS THROUGH MUSCULOSKELETAL PAIN
We are talking about the fact that their life is in your hands. It sounds a little dramatic. I don't think it is, okay? We're gonna start off with the fact that whether we like it or not, we have to acknowledge it's true and that is the fact that the road to fitness runs through musculoskeletal pain. The road to fitness runs through musculoskeletal pain. We don't have to like that to acknowledge the reality of that. Meaning, if you're gonna take somebody who's relatively sedentary, is not on the path yet, and you're gonna bring them all the way to fitness, right? So through wellness, all the way to fitness, that journey, requires a lot of loading, and a lot of challenging, and a lot of recovering, and a lot of programming, and a lot of strain, and stress, and rebuilding, and remodeling. It is a journey, right, that involves a lot of stress to the organism, right, to be able to get it to adapt, to get to a point where you achieve fitness. You don't get there, first of all, quickly, and second of all, without ever experiencing any kind of symptoms, right? That's a lot of stress to the system. You're going to have some bumps and bruises and strains. I'm not talking about major injuries, but you're going to be working through some stuff, right? How we manage that stuff, especially acutely. And when I say we, I mean the entire team, right? Coaches, trainers, physios, chiros, fitness forward physicians, right? Everybody who these individuals are beginning to trust to guide them along this journey, how we all swoop in and manage the acute response to someone developing symptoms is going to dictate whether or not they stay on the path. And from our perspective, if they stay on the path, is a huge variable in the quality of their life.

MANAGING THE INITIAL RESPONSE TO ACUTE INJURY DICTATES LONG-TERM OUTCOMES
So when I say life is in your hands, what I mean is managing the initial response to someone's acute injury onset dictates probably the longevity, probably the level of thriving, probably the health span. That's why I'm saying life is in your hands because the way you respond to this will dictate those things. And those things really are the quality of this person's life. So let me tell you the three things specifically. that when someone develops symptoms in the gym, that our response kind of hangs in the balance whether or not this person continues along this path that we believe drives so many of the important metrics of the quality of someone's existence. Okay, so if an athlete develops symptoms, right, you're not going to get into a case study of how or why. It happens all the time. Somebody tweaks something, they develop symptoms. Here's the three things.

AVOID MEDICAL IMAGING
Number one, they avoid medical imaging, advanced medical imaging. If we want this person to stay on the path to fitness and they've recently developed symptoms, the number one most important thing is that they avoid advanced medical imaging, okay? We now know the problem, right? That most asymptomatic people have abnormal findings on imaging that can be really scary and knock someone off the path. I am not gonna get in to the myriad of studies here. Nobody reasonably well-read is gonna push back on this podcast and say that isn't true, right? We have now known for well over a decade, you think back to 2012 when the American Journal of Sports Medicine, right, took that cohort of folks, average age of 38. How many had abnormalities in their hips, asymptomatic people? 73%. How many had labral tears? 69%. No hip pain whatsoever, asymptomatic people. You think about that classic Brzezinski article, right? Not article, but systematic review paper. Took a bunch of different publications, bundled them all together, looked at the data, what did we see? Your average asymptomatic person, meaning no low back pain whatsoever, in their 50s. 80% disc degeneration, 60% disc bulges. We now know the average asymptomatic person has all of these findings on their imaging that can be concerning. This is why we focus on tissue health, not tissue shape. What we now all acknowledge is that your connective tissue changes over time in your face, inside your body, your spine, your labrum, right? It changes over time. It doesn't tend to correlate well to symptoms. The problem is if someone just got hurt, If they just started experiencing pain and they're nervous, right? And they're vulnerable and they get that image and they see something that looks kind of scary, it sticks with them. It bumps them off the path. They have a hard time letting it go. They say, well, yeah, I might be able to get healthier, but I saw that cartilage. It was torn. We're not going to fix that unless we go in there and fix that, right? And they get extremely fixated on this. They begin to lose confidence. in the rehab or strength and conditioning process. It really, really sticks. What we know is when that person develops symptoms, we could have sent the other 10 people in that class to get an image and we would have seen the same stuff, but it doesn't matter. We can say that until we're blue in the face. We have said that until we're blue in the face. When the person's injured, when they feel vulnerable, when they're in pain, when they're in that decision-making process and they get that image and they see something that looks scary and maybe somebody in the medical industrialized complex made it sound scary, Those things make it very, very difficult to keep that person on the path. So getting them to avoid that unnecessary image is a massive part of the acute triage process if we want to keep this person moving towards fitness. Now, it always is worth saying, But certainly there are some times when they should get an image. Of course there are. And that is why physios, chiros, physicians, I'm challenging you all to make sure you're available to these gym owners and these coaches that when something does happen, you've got that direct access training and license where you can come in and make that tough call. And it's a tough call on either side. Because if you do send them, we're risking this thought virus we're talking about here. If you don't send them and they needed it, you're possibly putting that person at significant risk. So don't make gym owners make that call. Don't make coaches make that call. This is what you're trained for. Get in there and make that call. And make sure that the gym owners know you're available that day for a quick consult to get that person's mind off of that possibility when that's appropriate, which usually it is, or doing the appropriate triage if it's necessary. Get that part accomplished, okay? Alright, number one, if you want to keep them on the path, avoid advanced medical imaging unless it's absolutely necessary. Have somebody qualified to make that tough call so that you can get over that hurdle quickly and efficiently.

DON'T LEAVE THE GYM; USE THE GYM
Number two, if you don't want them to fall off the path, You've got to convince them they don't need to leave the gym, they need to use the gym. People when injured, when in pain, are going to make a very broad assumption that they shouldn't be in the gym. It's the first thing they're going to say, right? They're going to go to put that membership on hold. Your job on the same day of injury is to help them realize that everything they need is actually in that gym. All the tools to rehab the injury that occurred are right there in that gym. The ability to regress the skill that maybe they were inefficient with is why they wound up straining something. are right in that jam. You can regress everything and build a better foundation so next time you get up to that PR or that new movement, you're more ready for it, you're doing it more efficiently, and you've done the accessory work so that you're not stressing different structures at an unnecessary rate, and now you're having a lot more success with these movements. All of those abilities, whether it's to rehab the area, to work on the skill that you struggled with, to build a better foundation, Those tools only exist in the gym. The number one place you should be after injury is in the gym. So don't let them leave, right? So help them understand that you might not do exactly what you just did, you will in a few months, but everything around here is what we're gonna use to make sure you can if you want to. Helping them realize, whoa, whoa, whoa, whoa, you don't need to be leaving the gym, you're gonna use this place, right? That's a critical part of the acute triage process.


GET OBSESSED WITH GOALS
And finally, number three, Get them obsessed with new goals or at least new angles at the same ones. What I mean by this? is that motivation is fleeting, especially in people that don't have well-formed habits yet, right? Something, some confluence of factors happened in their life where all of a sudden they became someone who goes to the gym, okay? That is a pretty fragile ecosystem early on. We know how tough habit formation is, you're learning new skills. Motivation can be fleeting and fragile. You gotta shift it, don't lose it. shift it, don't lose it. Get inside that person's brain quickly and figure out why they were coming to the gym and show them that they can achieve that while working around the injured area. If that person says, well, I'm here because I've been listening to so many podcasts and it sounds like Cardiorespiratory fitness is a massive predictor of longevity and healthspan and decreasing all-cause mortality. All the things, right? Like, I'm in, but I hurt my knee. So now I can't do the bike and run, etc. So I'm going to call it quits for a bit. You sure are not going to do that. You are going to be on the ski erg, right? Because those things don't involve high or low to those areas, but we can still challenge your cardiorespiratory fitness. We are going to get them obsessed with a different goal, right? If they had a gymnastics goal and right now their shoulders tweaked, we're going to help them realize there's nine other similar goals that don't involve that area that we have a very specific program to move towards. And we're going to get them obsessed with getting that goal. And then we're going to swoop right back around and get on the same path and grab the other one. We're just going to show them. There are so many amazing things that we can do in here. to keep chasing your original goal, add on new goals, work around the injuries, and still achieve everything you set out to do, we understand that motivation is fleeting and fragile. We are going to help them take that motivation they've got right now, and we're going to shift it a little bit. We are not going to let them lose it. And you've got to be convincing in that acute phase, because they're going to make some heavy-handed decisions with all that emotional energy, with pain on board, and you've got to be there to guide that process.

SUMMARY
Team… Whether people choose to chase fitness during their lives is going to be a huge predictor of the quality of their lives. As they chase fitness, they are going to have soreness. They are going to tweak things. We are not going to load the system for years and years and never bump into any of this stuff. How we as a support system come alongside that person in that acute emotional time when they're having pain is going to dictate if they stay on the path. If we can get them to avoid advanced medical imaging when unnecessary, if we can get them to stay in the gym and use it versus leaving it, and if we can take that motivation they have and shift it as opposed to getting rid of it, we can get this person staying on the path. and we can change the entire rest of their lives, their family's lives, everybody they interact with, their life is in your hands. Be a great resource. Think about those three things in that acute management phase. I hope it helps, team. Thanks for being here on Leadership Thursday. As far as courses coming up, We've got a bunch of them. Ice Sampler is coming up at the end of this month in just a couple weeks in Carson City. We're actually going to put a limited amount of tickets on sale for 2025 because we know this event is hard to get into. It sold out in one day last year so we're trying to make tickets available at different times to give folks an opportunity to be a part of the event in 2025. But before then, we've got a bunch of courses. We had 12 last weekend. I think we have another dozen coming up over the next weekend or two before Sampler. So get on PTNICE.com, check those out. A lot of online courses start on April 29th, which is only a few weeks away, and some of them only have a handful of seats. So get over to the website, check it out, have an awesome Thursday, do gut check. We'll see you next week, team.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer takes listeners through a case study, showcasing how therapists dig deeper into patient goals in order to create meaningful treatment sessions that improve patient function.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JULIE BRAUER
Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division and I'm going to be talking to you all this morning about make it meaningful, load it, dose it. So what is that? Make it meaningful, load it, dose it is the exercise prescription formula that the older division uses. So those of you who have taken our online course or our live course, you have heard this, you have learned about it. So what we're going to do this morning is I'm going to take you through how to apply this formula specifically for the goal of a patient who wants to return to gardening. So we're going to go through a little bit of a case study here. So to dive a little deeper into exactly what's coming up, I'm going to take you through how to dig deeper into the goal of when someone tells you I want to be able to garden on my own. We're going to dig deeper there and talk about why it's important And then I'm going to show you how you can take that goal and break it down into its functional movement parts, because that is going to give you all the exercises that you will be using throughout your plan of care. Using this formula is going to be able to give you all a way to create meaningful, effective, and efficient exercise programs for your patients. So we'll dig into the goal, we'll break it down into its movement parts. Then when I see you all again in a couple weeks, I will have my wireless mic by then and I'm going to go out into my garage and I'm going to show you what some of these exercises look like and give you some scaling options and how we would load it and dose it for intensity.

DIG DEEP INTO GOALS TO FIND THE "WHY"
Okay, so let's start from the beginning. We have to dig deep with every single patient when they give us a goal. We got to dig deep for the details. Why? Two main things. First, we want to know, in particular for this case study, when this patient says, I want to be able to garden, we want to know why. We want to know why gardening is important. What about gardening is this individual most excited about? We want to know the emotional why, because that's going to get us our buy-in. Next, we want to know details down to the nitty-gritty, exactly what this activity looks like. I want to know what this gardening task looks like from start to finish, because once you visualize it, you're going to recreate it. That is going to give you all of the exercises that you're going to ever have to do with this patient throughout your plan of care. It's the easy button. So when I say dig deeper to get to the emotional why, this is what I mean. It sounds something like this. So patient, let's call her Dolores. All right, we'll call her Dolores. Dolores tells you, I want a garden on my own and you're going to say, Dolores, tell me more about that. What about gardening is so important to you? I would love to hear more. When you are asking Dolores about her goal, you are giving her eye contact. This is not the time to open up your laptop and do any typing. You give her your undivided attention for these first few minutes while you are asking her about gardening and why it's important. Dolores, what about gardening brings you joy? What are you most excited about with gardening? This is where you can say, I love gardening. I grew up with a garden. My mom would, we would plant catnip and we would make our cats go crazy. I mean, literally this is true for me. This is what I've told my patients when they've told me they want to get back to a gardening task. Relate to your patient, right? Make that connection. When you do that, you're allowing the patient to give you more of a story behind why it's important. So Dolores is going to tell you something like this is true for a patient I recently had. My granddaughter is getting to an age where she likes to garden with her mom and I want to be able to garden with her as well and I want to be able to go outside and garden with my granddaughter and feel confident doing that. Boom, there's your emotional why. You have to dig deep enough to get to that point. Why? Because superficial goals, if you were to just leave it at, I wanna be able to garden, I wanna get stronger to be able to go outside. If you leave it at that superficial goal point, you lack the emotional connection. And Jeff Moore did a podcast, I cannot remember what it's called, but he says, and it stuck with me, this is probably a year ago, Superficial goals lack emotional connection, and emotional connection is what motivates your patient. Emotional connection is what's going to motivate your patient. So you find that emotional why, now your patient's connected to you, they believe you give a damn, you feel connected to them, you've got that therapeutic alliance, you both are invested and locked in. Okay, Moving on, the next details that you want are the nitty gritty details of what that gardening task looks like. So this is what it sounds like. I will say, Dolores, I want to visualize what this gardening looks like. Can you tell me exactly what it looks like from start to finish, from the very beginning to the end and everything in between? I want to be able to visualize it. as Dolores is walking you through all of the functional demands that she has to be able to do in order to fulfill this goal. I am using my whiteboard and I am writing this down. Now I know this was reversed for you all. I'm going to take a picture of this and put it in the comment on this post, but I am writing down every single thing she says. All right. So I have a whiteboard at the top. I'm going to put her name. Maybe I'll say this is, uh, Dolores, Dolores gets a garden strong, something like that. Those little details can make it much more meaningful to your patient. Little special things that you can add in.

CREATE TREATMENTS THAT PROGRESS PATIENT GOALS
So I have her name at the top and then as she is telling me what she has to do, I write it down. So she will say something like, I need to be able to push the door open on my own to get from inside to outside. So I'm writing that down. And then in parentheses, I'm putting what type of exercise exactly mimics that activity. So if she says, I need to be able to push the door open to go from inside to outside, To me, my fitness forward brain is what does that look like? Oh, a sled push. Awesome. So I write down push door open and then in parentheses I put sled push. Then she tells me, all right, and then I got to walk over grass and I have some stepping stones and I have some gravel. So she told me she has to walk over variable terrain. So then in parentheses, what am I putting down? Okay. So that's stepping on and over obstacles. Then she tells me, then I'm going to have to pick up some stuff and carry it around. So I got to pick up some tools. I got to pick up my mulch. My fitness forward brain goes, okay, what looks exactly like that? Pick up and carry. Well, I know that that's going to be a deadlift and that's going to be a loaded carry. Then Dolores says, then I'm going to have to get down on my knees and do some things on the ground. I'm going to have to get up and off the ground quite a few times. My fitness for brain says, what is that? Well, that's going to be a lot of floor transfer, part practice and full practice. Then she says, I got to pull weeds as well. It's, you know, usually like, Oh, well it's, it's not the best part of the job, but it has to be done. I want my garden to look really nice. I need to be able to pull weeds. So I'm thinking, what does pull weeds look like? My fitness for my fitness for brain says that's going to be quadruped position and I'm going to do some quadruped rowing. Okay. I'm trying to make it look exactly like that functional activity. You're catching on here, right? You're understanding what I'm doing. I am taking everything she's saying and I'm turning it into what the exercise is going to be. That looks exactly like that activity. And then the last thing she says is, and I need to do all of that and I don't want to fall over. So when I hear that, I know that I have to add in some perturbations. So I'm going to be giving her some external perturbations that are going to force her to take that reactive step. So I can train that. So I can train her dynamic balance. So now that I have that entire list, I am going to teach it back to her. I am going to say, Dolores, I was writing down everything you were telling me, all the pieces and parts that are important in order for you to accomplish this goal. Is this correct? And I'm going to go through and I'm going to say, Dolores, what I heard, what you told me is you need to push the door open. You need to walk over grass and gravel. You need to pick up and carry some stuff. You got to get down on your knees. You got to pull some weeds and you want to be able to do all of that without tipping over. Dolores is going to sit back and be like, wow, this person was actually listening to me. You have just improved that therapeutic alliance even more because you have heard her well. So now you have this entire bank of exercises. This is what you're going to pull from. Now that, I mean that was sit one, two, three, four, five, six. Those are six different movements there. That list could be less than six. It could be way more than six. So then you're going to think, okay, well, what's the next step here? I have all of these movements. What do I do with them?

ASSESS,DON'T GUESS THE PATIENT'S ABILITY TO PERFORM FUNCTIONAL TASKS
Next, you want to assess Dolores, how she goes through the motions of these functional movements. So when you are in an outpatient clinic, you got to recreate it in your clinic. If you're in a home health setting, this is easy peasy. You say to Dolores, all right, we're going to go through and I'm going to have you show me exactly what this looks like. All right. Something that I like to do when I, before I do this assessment to watch what this looks like is I will ask Dolores, I will ask my patients, What about all of those movements? Which of those do you feel like you can do really well? What are you really strong at when it comes to all those different pieces and parts that make up gardening? And then I will ask her, which of those movements are you fearful of? Which of those do you feel like that you don't really have the strength to do yet? I want to know her perception of her own abilities. And because as I'm assessing her, I'm looking at a lot, this is going to help me dial in exactly what I should pay attention to. I want to know the things that she's really strong at and see if she is actually strong at those. And I want to know the things that she's fearful of and see if she actually struggles with those pieces and parts. So after I asked her that, I kind of put a little asterisk sign into which of those movements are her strong movements and her weaker movements based on her perception. And then it's assessment time. So again, in the home setting, I am having her do the thing. I am not helping her. It's very similar. If you work in inpatient rehab, you just do the assessment, a FIM care tool. You're not helping them. You're simply watching how they do it. This is not the time. to assist and teach and coach, you are simply watching. In the clinic, this is where you want to set this environment up. You want to mimic and recreate this activity.

BUY FUNCTIONAL EQUIPMENT, NOT BARBELLS
So this may ruffle a few feathers, but as opposed to say you have budget and you have some money to spend at your clinic to buy equipment, I'm going to give you a potentially not popular opinion. Maybe instead of buying that barbell first for your clinic, if you're working with older adults, what if you bought functional activities that older adults actually use and that are not intimidating to them and directly relate to the goals they're trying to achieve? So what if you bought a laundry basket? What if you bought a bag of mulch? What if you bought some gardening tools? What if you brought in a, um, some laundry detergent, some pots, some pans, dog food, things that older adults are lifting and carrying and using at home pretty consistently. I would rather have those things at my disposal to use right away when I introduce loading to an older adult versus rely on jumping straight to the barbell where someone can be incredibly intimidated by that. This is not a or situation. This is an and. However, I have learned over time that I'm going to get more people to buy in if I have those functional activities those functional objects that people use at home that's going to get me more buy-in than saying all right you have to pick up uh and carry tools from um when you go out and garden well let's go do it with this barbell That's a lot harder of a sell. So here's your call to action. Spend that extra clinic money or just take stuff from your home that you don't use. You know, don't throw it away or go to a garage sale or a thrift store, whatever it is, and get this stuff and bring it into your clinic. All right, so you're going to set this all up in the clinic. You're going to assess, you're watching to see her quality. You're watching to see how long it takes her. I mean, this really is becoming an outcome measure for me. this is going to become like a benchmark workout. Okay. So think about it that way. This is, this is much more than an assessment. I'm going to use and recreate this, uh, call it a meaningful obstacle course that looks exactly like her gardening task. And I'm going to run it again and again and again. So I can track her progress and how well she's able to do this activity. So from them, I have recreated, the functional activity. I am assessing how well she does. I'm taking notes. I'm looking at the things she's strong at, the things she's weak at. After we're done, we're sitting down and we're recapping. Are the things that she thought she was strong at and weak at, did that match with how she actually performed? And we have a discussion there. From there, again, I'm looking at this list and now I'm talking to Dolores and I'm saying, Dolores, Based on what we just saw and what you just felt, these are the few activities, and you're looking for three to four here, three to four. These are the three to four activities that we are gonna focus on next session. And what are you gonna do? You are going to create an EMOM or an AMRAP with those few functional activities that you together have determined are the most important and you're going to find a way to load it up, whether that's adding physical load or cognitive load, and you're going to find a way to appropriately dose it so that you know you are at an appropriate intensity to drive adaptation.

SUMMARY
Okay, so that is how we go from taking a goal, digging deep to get to the emotional why, going through breaking down that meaningful goal into its functional movement parts. All right, that is the hardest part. It's the most important part. When I see you on a couple weeks, I will use this same exact case study and I'm going to take all of these exercises and I am going to show you ways to scale this up, scale it down, dose it, add some load, whether that's physical load or cognitive load. The idea here is we want to make our sessions and our AMRAPs, our EMOMs and the workouts harder than what the demand is that she actually has to do to reach that goal. Because if she is able to do her gardening tasks with load on her, with cognitive load on her, adding in intensity, then gardening with her granddaughter is going to feel easy. And that is the goal. All right, guys, that's all I got for you. I will post a screenshot of this list. So if you all have a patient whose goal is to garden at any point the rest of the week, you have a nice list of exercises that would probably be very relatable and meaningful for them. To end things out, I will let you guys know what we have coming up in the Older Adult Division in terms of courses. For the rest of the month, we will be on the road in Washington, Tennessee, and Pennsylvania. And then both of our online courses, Level 1 and Level 2, are starting in the month of May. We would love to see you on the road or online. PTI Nice is where all that lives. If you have any questions, any comments about anything we talked about today, hit me up. Would love to jam on anything with you all. Have a wonderful rest of your Wednesday.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses using isometric exercises for more than just pain relief including newer research emerging that isometric exercise does cause structural adaptation. Mark also discusses key points important for successful dosage of isometric exercise in the clinic.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Janex.

MARK GALLANT
All right, what is up PT on Ice crew? We got Instagram, we got YouTube. I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey. Cody Gingrich coming at you here on Clinical Tuesday. What I want to talk about this morning is isometrics beyond the pain. So isometrics are obviously a muscle contraction type that have been around since the beginning of time, really. Since humans have existed, we've had to hold things and carry things isometrically. And the popularity of isometric exercises has come up and gone down and come up and gone down as fitness trends and rehab trends always tend to change and the last decade we've been in a period where isometrics have been on the up for the last 10 years and a lot of that has been because of the research of Ebony Rio out of Australia where in 2015 she took a group of volleyball players and figured out that if we hold long hold heavy isometrics we get both cortical pain inhibition and a subjective decrease in pain. Well, that study has been looked at a handful of times over the last nine years since then. And sometimes it shakes out just as ebony Rio found in 2015, 2016. And other times we see that it does not have the same wonderful, incredible pain reducing results that we're all hoping for. And really the reason for this is pain is wildly complex. So if you do the same study that Ebony Rio did with her volleyball players, five sets, 45 seconds, 70% of their one rep max for a two minute rest, and the group of people ate something different for breakfast that day, if they did not get as good of sleep as the other group, if they are incredibly stressed, if their soccer coach yelled at them, a million different things could have possibly happened that are going to impact that person's symptoms overall. So despite pain being multivariable and very complex and maybe not being the 100%, isometrics not being a great, they're still great, not being a 100% reducer of pain every time like we saw in that Ebony Rio study, we've talked about on this podcast.

ISOMETRICS ALLOW FOR THE CONTROL OF MULTIPLE VARIABLES
The reason we're still gonna use them is the isometrics control for so many of the variables that are challenging when someone is injured or early on in their rehab process. It controls, you can control the volume easily, five sets of 45 seconds or four sets of 30 seconds. You can control the position. Is the shoulder flex? Is the shoulder down at neutral? You can control the amplitude of motion. So isometric, there is no amplitude. It is, it's exactly still. You can control the load easily overall. That load's not going to change as they're doing the motion. and you control the speed really well because it's isometric. So there is no speed once that object gets into the position or the joint gets into that position.

ISOMETRICS: TREAT THE DONUT & THE HOLE
Beyond those things, there's more exciting research that has been coming out that gives us even more reason to keep isometrics in our rehab plan, especially when it seems that the tendon and ligament are involved in that person's pathology or the injury. Out of Keith Barr's lab at UC Davis, California, they are now showing that it seems, with isometric, that we can indeed adapt tendon and ligament tissue and lay down new collagen. So classically, we always thought that the catchphrase, treat the donut, not the hole. Treat the donut, not the hole. So what we believed was that you were adapting all the healthy tissues around the degenerative or injured area so that that person can get back to their activities and you're not gonna be as concerned of healing or building back up the degenerative area. And we believed it could, it was possibly, that it was not even possible potentially. And what Keith Barr's lab is now showing, that it does seem that with long hold heavy isometrics, that we can lay down new collagen in these areas potentially. Now this is all new and exciting research, so if it doesn't shake out perfect, we'll adapt with the times. Keith Barr's lab is exciting because what they are able to do that other labs can't is they are able to engineer tendons. So they create a bunch of tendons and ligaments that they can test in all sorts of wild ways because they're literally manufacturing them. Once they get something that's cool or seems beneficial, then they move that same technique or same intervention onto rat or mice studies. Once it looks positive in the rats or mice, then they move it to a human trial. So they're doing this three-tiered system where they're getting a ton of volume from the engineered tendons and trying all sorts of crazy things. Then they move it to rat and mice. And then once they really feel confident, they can move this into human studies. And what they have been showing is through the processes of stress shielding and stress relaxation, that it does seem that we can lay down new collagen and adapt these tendons.

ISOMETRICS & STRESS SHIELDING
What stress shielding is, it is the ability for your healthy, non-injured tissues to take on a majority of the stress to protect the unhealthy or injured area of a tendon or ligament. So it's a wonderful protective mechanism for back when we were foraging for food or hunting or having to outrun predators, that the healthy part of the tissue would take on more of the loads so that you could keep moving to either get food or stay away from them. This is a great process to keep us alive, not a great process for adapting tissues. What we really want instead of that stress shielding is some stress relaxation where the healthy injured or the healthy uninjured part of the tissue starts to relax a little bit so that we get some load or some stress into the injured area. When we get that stress into the injured area of the tissue, it's gonna create a cascading signal to the nervous system that says, hey, we need to lay down new collagen, we need to adapt to be able to remodel this tissue area. The easiest way to explain this is an analogy that Keith Barr commonly gives of two individuals playing tug-of-war together. So you've got two teams of two playing tug-of-war, they're relatively evenly matched. Let's say for this case that it's Mitch Babcock and I. So for those of you who don't know Mitch Babcock, he's an OG instructor for our management of the fitness athlete. Mitch is over six feet tall, over 200 pounds, big strapping muscular guy. I am 5'7", 165 pounds. If Mitch and I are on the same tug-of-war team, early on he is going to carry a majority of that load for the team. He's going to take on most of that stress because he's such a robust human. If the other team is evenly matched, at some point during that tug of war, Mitch is going to either fatigue out or he's going to have to start to relax a little bit to start to conserve his energy. At that point, I am going to have to take on some higher portion of the stress or load. Once I start to take on that higher stress or load, my nervous system is going to start talking, going like, If this is the type of thing we're going to start getting into, we're going to have to adapt. It's the same with our ligaments and tendons. As that healthy area starts to relax or fatigue, then what we're going to see is that the injured or unhealthy areas have to take on a load. And then again, that's going to start that cascade of the nervous system to remodel and adapt those tissues. What we're seeing is that there's a few things that need to be true for this to happen. It has to be long enough duration. So that has to be held long enough, the load, so that it gives the opportunity for the unhealthy, for the healthy tissue, excuse me, and robust area to start to relax a little bit. So long enough load where the healthy areas of tissues begin to relax. It has to be a heavy enough load to create some sort of stimulus. If the person feels like it's easy and they're not having to put out a lot of effort, it's very likely that the healthy portions of the tissue are carrying all the load And it also seems to work best when that tissue is at length. So when those tendons or ligaments are at their most lengthened position, so extended elbow, dorsiflex ankle for the Achilles, bent knee for the patellar tendon, that tends to be where it works out best.

KEYS FOR DOSING ISOMETRICS APPROPRIATELY
Now, there's some keys to this depending on how robust the human in front of you is. The more robust that individual, the longer the heavier and the closer to length that we need to perform those holds. So if the person is healthy, you may need to go beyond a four sets of 30 seconds. So four sets of 30 seconds tends to be this minimum amount of time that has been shown to create this stress relaxation. If you've got that really robust person, if you've got the Mitch Babcock, they may need to hold five sets for 45 seconds. Now there does seem to be a ceiling of about 10 minutes of tendon loading, seems to be this area of diminished return. So if you go beyond 10 minutes, then you need to wait six to eight hours to reload that tendon. Somewhere between four sets in 30 seconds, five sets of 45 seconds, adjusting that depending on how robust that individual it is. It has to be heavy enough again to where that person feels an effort. So if you've got someone who's deconditioned, they have not done as much exercise recently, you can create this stress relaxation with relatively light loads. If you've got the Mitch Babcock that's been lifting weights since he was 12 years old, you're going to have to load that tissue a bit heavier to create that adaptation. It has to be a high effort load. And then the final piece is we see now that tendons and ligaments tend to adapt better from an actual structural standpoint if they're held at length. So again, for the elbow, is it extended? For the Achilles, is it dorsiflexed? For the knee, for the patellar tendon, is the knee flexed? Obviously, if someone is symptomatic, it's going to be more challenging for them to get in these positions. What we do in this case is we get them to the most length that they can tolerate for that four sets of 30 or five sets of 45. And then as time goes on, we progress them to a more lengthened position overall. If you all have been following ice for a while, a couple years ago, Joe Hanksco did a wonderful virtual ice on medial elbow tendinopathy. And one of the key exercises he looked at was wide grip biceps curls to help out those medial elbows. And if we look at this, it's a wonderful exercise for exactly what we're talking about for medial epicondalgia because when you're in that wide grip bicep curl, you are holding that during the max eccentric portion, that elbow is at a ton of length, they're in a relative wrist flexion, it's gonna be a lot of stress to that medial elbow. You can take that same exercise, do it isometrically, four sets, 30 seconds, and it becomes a wonderful thing to adapt the medial elbow, ligaments, tendons, and tissues overall. Last thing that we wanna talk about is anti-inflammatories block stress relaxation. So if that person takes anti-inflammatories early on, everything we discussed the last 10 minutes becomes much more challenging. When there's inflammation in the area of the tendon, it creates a natural stress relaxation where the healthy portions of the tendon are not gonna be able to take as much stress and load, and you're gonna get a little bit more stress and load to the injured or unhealthy area. So if that person takes an anti-inflammatory early on, they're not gonna get that benefit of being able to take less load, less strain, and get some adaptation to the injured area of the tendon. So if folks can, we tell them to use natural processes. Use your cardio to pump inflammation out of the area. Use eating healthier foods that are not going to block the entire inflammatory process. They're just going to decrease some of the inflammation and still allow for that stress relaxation. So overall, if we're trying to adapt tendons, to lay down new collagen, to remodel those tissues, We want it long load, four sets of 30 seconds, five sets of 45 seconds. We want it heavy enough to overcome that stress shielding. So it's a high effort lift and we want it at length of that tissue. So again, if it's the elbow extended, the ankle, dorsiflex, the knee, if it's that patellar tendon bent, whatever the deepest amount of, of length of that tissue that we can, that's where we want to go. Hope this helps. We're gonna come back on here in a few weeks and talk about isometrics for adapting muscle output in the central nervous system. Hope to see you all on the road. Head on over to the ICE app or the ICE website. We have a ton of offerings coming up for extremity management all over the company. My next one, I'll be in Dallas, Texas in June. Hope to see you all there. Message us, comments, love to chat more about this. Hope you all have a great Tuesday.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses pelvic floor screens such as the PFD-SENTINEL and introduces a new pelvic floor screening resource coming soon to the ICE Physio App!

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

RACHEL MOORE
Good morning, PT on ICE Daily Show. I am getting lunched on YouTube and Instagram and we are good to go. All right, what's up? My name is Dr. Rachel Moore. I am here this morning to talk to you guys about screening for pelvic floor dysfunction especially if you are somebody who is maybe not familiar with the pelvic floor space or this is an entirely new space for you or you're somebody who is like identifying or classifying as a orthopedic PT and you're like I don't know anything about the pelvis. I want to clear things up with you guys and put together or we did put together a resource for you guys that is a pelvic floor screen that you're going to be able to access through the Ice Physio app under the resources section. So you'll be able to get that off of the app, download it, either have it in your intake forms, in your paperwork so that you can use that as people are coming in and kind of have an indicator of if this would be a person who would benefit from a referral for pelvic floor PT. Where this all came from, we've been asked at our courses before for just kind of an easy, quick, general screen. A lot of us use kind of a different option. So there was some people had a couple options that they were using. Other people were using different things. So what we did is we took all of these resources. We compiled them together and we really leaned into the research and what we have out there for pelvic floor screening. So we're going to chat a little bit about what that screen is and how we kind of adapted it or modified it for this really quick, easy, downloadable version that you can pull up and have as an 11 question fast screen for your patients. So This whole screen kind of is based around or adapted from a study that was published in the British Journal of Sports Medicine in December 2022. So the screen is called the PFD Sentinel Screen, S-E-N-T-I-N-E-L. What this was was a Delphi study and they basically polled professionals that are experts in this space. So they had PTs, they had urogynecologists, they had just different healthcare providers, physical medicine and rehab providers that all had either been in this space seeing patients or been in this space researching these topics. And what they did is they polled these providers to kind of come up with a consensus. Because prior to this, there really wasn't a validated published screen in any evidence. that we could really lean into for patients that would benefit from pelvic floor physical therapy. And so they created this screen kind of as a way to have a resource specifically for sports medicine providers, and this was really kind of leaning into sports medicine PTs, like orthopedic PTs, or sports medicine doctors that were already seeing female athletes, and they're kind of range or definition of female athletes was like super broad. So across all ages, across all sports, across all profession levels, whether it was amateur athletes or professional athletes, they came up with this screen based on this Delphi questionnaire, not questionnaire, but survey. And so what they landed on were five main pelvic floor dysfunction symptoms, and then 28 risk factors for pelvic floor dysfunction. So with that, in order to be included on this screen, they had to have over 67% of the consensus of the group. And this went through two rounds. So it was like 43 and 37 were the two rounds of number of professionals. So of those two rounds, 67% or higher had to agree that they felt that these were indicators for potential pelvic floor dysfunction screens. So with this screen, there was this top section of score A, which was five main pelvic floor dysfunction symptoms. So this was things like leaking urine, urinary urgency, leaking gas and stool. And with these five, if they answered yes to any one of these, then they recommend an automatic referral to a pelvic floor specialist. Doesn't necessarily specify PT, but could be a urogynecologist or somebody that specializes in treating the pelvic floor. From there, there was 28 risk factors that they delineated. With these 28 risk factors, they either landed in the categories of score B or score C. If they were score B, that means that they had greater than 14 of these risk factors. These risk factors were pretty broad. I actually really loved the things that they included. So this was things like whether or not somebody's in menopause, if they've been diagnosed with hypermobility or connective tissue disorder, if they have a family history of urinary incontinence or a family history of pelvic organ prolapse, their BMI being under or over a certain range. So they really took a lot into account here under the risk factors. And if they had a score of greater than 14 for those risk factors, then they fell under a score B, and that would be a recommended referral to a pelvic floor PT or pelvic floor specialist. So score A, for sure, send them. Score B, we recommend you get this checked out. And then score C was less than 14. So if they didn't have more than 14 of these risk factors, Then it was just monitor, kind of keep an eye on them and see how they do. And when they made this screen, they made it as a kind of touch point to repeat. So maybe you start this at the beginning of the season, and then as they begin off season, you start or you re-screen this. So this is kind of an easy ongoing screen to see how things are changing as these athletes are evolving potentially, whether they're in off season or in season. Or if, again, we're thinking about just our general population, maybe once a year when they're coming in or once every six months when they're coming in, we're doing this really quick and easy screen to determine if they would benefit from a referral for pelvic floor PT. One thing to kind of note about this is it was specifically created for female athletes. Again, broad term for athletes here, but specifically created for females. So no males were included in this when they were breaking down the rationale for when somebody would benefit for a referral for PT. And so we don't really have a good resource of when our males need to be referred to PT just yet. Maybe that's something that'll be coming out in the research soon. And then also just note that this hasn't been like validated by any further research yet. This is kind of the kickstart point of, Hey, we've got this group of experts that have come together. We don't really have a lot of information in this space. Let's come up with something so that we can then push this out there and see how it flows. So, Love it. It's really awesome. PFT Sentinel is really in-depth. It has a lot of really great risk factors on there. When we were putting together our screen, our thought process was a little bit different. It was a little bit more leaning in towards something quick and easy that, like I said, we can put in our intake forms and just have people check things off. You could really even use this as marketing. So I actually do use a pelvic floor screen on the backside of my flyers. So on the front side, I have all of my business information. I've got a QR code for people to book a session pretty easily. And then on the back is the pelvic floor screen printed on it. So as people are setting these out, it's got our business logo on the top, set it on a counter at the chiropractor's office or at the gym or whatever, and they can pick up the screen and read through it. and it says at the top if you say yes to one of these following questions, you might benefit from Pelvic Floor PT. So, great option for marketing, great option just to have as part of your intake form in your paperwork. If you are not a Pelvic Floor PT and you're not really sure who you should be sending to Pelvic Floor PT, it's also a really great resource to have on hand. So, diving into our specific screen, what we really focused in on were what we felt were kind of the heavy hitters for recommendations for pelvic floor PT, and then maybe some of the things that doesn't necessarily jump out at somebody that's not in this space. So, some of the more obvious ones would be like experienced urinary leakage, urinary urgency or frequency, issues with remaining continent or holding in gas or stool, sensations or feelings of heaviness or seeing something bulging at vaginal opening and then really leaning into the pain side pain or discomfort and we really kept this grog because we've seen pelvic floor dysfunction show up as hip pain, we've seen it show up as low back pain, we've seen it show up as groin pain, and so we really wanted to kind of catch a broad range here, especially if you are the orthopedic PT who's maybe been seeing somebody for their hip and you're doing all the right things and you're like, I'm crushing this, but they're just not 100% better, maybe that would be the time to kick them over to a pelvic floor PT if you're not doing pelvic floor. and see if there's some contribution from the pelvic floor to that issue. Childbirth, whether it is a vaginal or a cesarean delivery, both of these situations we feel weren't a referral to pelvic floor PT, just to really kind of recalibrate and get things on the same page again. Being in menopause or perimenopause, A, from the education standpoint, there is so much education that we can provide to this population. but also just kind of staying ahead of any problems or symptoms that may arise as they're progressing into this low estrogen state. And then having a history of relative energy deficiency in sport. And this is something where we might need to lean into our providers to do some education. If somebody doesn't know what that is, really knowing if somebody's had irregular cycles, if they have these chronic injuries, or one week you're seeing them for their knee, the next month it's for their shoulder, the next month it's for their back, these signs of these chronic kind of nagging injuries would be a thing to hone in on that maybe they're potentially in this relative energy deficiency in sport state. We've got a lot of really great information out there, lots of podcast episodes about reds that we've done as the pelvic division. So if you're unsure about that, definitely go to YouTube and type that in the search bar and pull that up so you can learn a little bit more about that topic and really be able to screen that a little bit better. But again, we came up with this resource. I hope you guys love it. I hope it's helpful. We've been asked for it at our pelvic courses. I've been asked for it at our other courses that I've attended just as a participant. OrthoPTs that are like, I'm not really sure what I'm supposed to do. Can you please come up with a resource that we know how to screen? So we're really excited about this resource. It's going to be on the ICE app. So keep an eye out. In the app, we'll also blast it out on the pelvic newsletter. So if you're not signed up for the pelvic newsletter, go ahead and get signed up for that. And same thing with hump day hustling as well. Sign up for that. That way you know exactly when it gets posted, exactly when it goes live, and when you can download it to have it as part of your screens.

SUMMARY
If you are somebody who wants to be in the pelvic floor space but maybe isn't in the pelvic floor space yet or you want to learn more about pelvic floor pt then jump into one of our courses We've got so many live courses coming up. Christina and I are actually teaching in Spring, Texas this weekend at my home gym. I'm so excited. We still have openings there if you want to come hang with us. But lots of offerings for our live course coming up, as well as our L1 coming up again. And then our L2 is sold out for this upcoming cohort, but we do still have spots open. in our fall cohort so head to the website figure out where you can jump into a pelvic course if you're interested in learning more about pelvic floor pt and how to treat these women If you're not really sure how to treat these women or who should be referred out, head to the resources link. You're going to see this resource posted in just a bit. And then we are excited for you guys to have it out there. Use it for marketing if you are a pelvic PT and let us know how it goes. Thanks for joining in. I appreciate it. I hope you guys have a great day.

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

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses three factors to consider when transitioning from biking indoors on a trainer back to riding outdoors: equipment, road/weather conditions, and controlling training volume on the road.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

JASON LUNDEN
Good morning. Happy Friday, everyone. Welcome to another edition of PT on Ice. My name is Jason Lunden. I am the lead for our endurance athlete division, which entails rehab of endurance athletes, including our professional bike fitting course and both our online and live versions of the rehabilitation of the injured runner. So today I am going to be talking about a very timely topic, transitioning back onto the road after training all winter indoors for especially those of us in the northern climates. And here in Montana, we are definitely seeing our transition back to spring and everyone's getting back out onto the road. after being on the trainer for the past four to six months. So I just wanted to give some tips for either yourself or your clients on how to make that transition as smoothly as possible and not interrupt their training cycle. So we're going to cover three things, equipment, conditions, and then the actual mechanics and transitioning of back on the bike in terms of volume.

EQUIPMENT
So first thing being equipment. Obviously, when you're on a trainer, you're not really all that concerned about, you know, are your brakes working? Is your headset working, et cetera? Do you have like your kit already with a spare tube and… Spare tube and… Pump etc. So first and foremost Making sure that you're checking that your headset is indeed tight. So that is going to be the top bolt where the handlebars go into the steer tube and Way to check that tightness is depressing the front brake and rocking the back the bike back and forth and you shouldn't feel any clunking at all. If you do feel clunking you need to tighten the headset. Things can get loose over time so it's an important thing to do. So loosening the two screws on the sides and then tightening the top down and then tightening the screws on the sides back too. And then also making sure brake wear and everything are okay as well. Because typically in the spring, you're going to be encountering wetter conditions. So it's really important that your brakes are working and to avoid any catastrophic, traumatic injuries. And then probably lastly is just making sure that you do have the supplies with you if you do break down. Again, typically at the end of the season, when transitioning back indoors, We always think that we're going to get those new CO2 cartridges, replace the used ones that are in our pack that we used already, as well as making sure that that spare tube is still working and adequate. So making sure that you're kind of restocking your kit or at least reassessing your kit for while you're out on the road, as well as making sure you got those tire level levers with that too.

ROAD CONDITIONS
Number two is conditions. Uh, obviously biking outdoors, there are a lot more environmental conditions and biking indoors. Uh, and that's really important to, to take account of. So again, in the spring, we're typically going to be dealing with some wetter weather, uh, some cooler temperatures, uh, especially for us, uh, working folks, uh, working athletes. We're going to be having to try to fit our rides in around our work schedule. So typically in the early morning. um, or after work where temperatures are already going to be cooling down. And so making sure that you, you are, you or your patient are dressing and layering appropriately. Uh, as if you're, if you are riding in cold weather, um, it can get cold really quickly because of the wind resistance and all of that. Um, and your muscles can get cold, which, uh, you know, anecdotally, I think a lot of us think, well, you know, we're more likely to actually strain or have injuries in the cold with not being warmed up and there's actually some very limited evidence on that but there is some evidence on that in looking at exercises in different temperatures and the incidence or likelihood of increasing the incidence of tendon strain or muscle strain. And anecdotally, this is the time of the season when I really the only time I see cyclists coming in with quadriceps tendinopathy or tendinitis, more acute. And I think there is a correlation with the colder weather and just not muscles being warmed up as well as maybe not quite being acclimated to the volume that they want to do. in the style of riding that they want to do. So just tucking that in the back of your head and just making sure that you're prepared for that.

CONTROLLING ROAD VOLUME
And then lastly, looking at how you're going to approach your volume in your training with transitioning outdoors. Training indoors is really efficient, especially you know, more recently with our direct drive trainers that can add resistance and simulate hills, et cetera. But we're still very, it's very easy and more comfortable to have your hands up on the flats of the bars and not all the way out on the hoods or in the drops. And I think a lot of us have the tendency to ride in that position of comfort. Either if you're watching the virtual screen of racing on Zwift, or you're watching a show, just being in more comfort even with putting that effort out. So realizing that your body may not be adapted to being in the drops or being on the hoods for a long time, as well as the increased instability of being on the road where you're having to balance more. So not maybe necessarily having the core stability strength for that as well. So ideally before transitioning into back onto the road for the month prior, making sure you are getting time in the drops on the hoods, making sure you're getting time where you're getting efforts standing up on the bike, and then doing an assessment of your core and spinal extensor strength to make sure you can sustain those positions. And then even with that, when you're transitioning back onto the road with your training, Have those first rides be just shake out rides, totally, um, just going out for, for fun rides, not really, uh, equating that into your training and keeping the volume on the lower side. One to make sure your equipment's working, uh, to, you know, the, the conditions are going to be more variable. And then three, just to, to be able to have a smoother transition back onto the road because of the. wide variety in terrain, conditions with the wind, and again, that instability and maybe being in slightly different positions and having slightly different mechanics while you're out on the road. And then after a week or two of that, well, two weeks of that, then diving back into your training plan with that. So while you're doing those shakeout rides, continuing your actual training indoors. It's easy to get excited when it's nice out. I've certainly been a culprit of it, too, where, you know, we're just stacking rides back-to-back days when it's nice out, especially here in Montana, in the mountains, where the weather can be changing rapidly, and we're getting to really try to take advantage of those nice days and getting in as much as we can. set ourselves up for success and pumping the brakes a little bit and just having those rides be enjoyable a little bit a little bit lower volume before really getting after it back to our training to prevent injury. So just some practical advice for you on again transitioning from the trainer back onto the road things to consider Double checking your equipment, making sure that's functioning well, especially the headset and the brakes, and that your emergency kit is dialed. Two, preparing for the weather, mainly in terms of layering so that those muscles, you don't get too cold, perhaps increasing the likelihood of a strain or a tendinopathy. And then three, just going easy with that volume back out onto the road and having those first few rides just be shakeout rides just for fun not really training rides.

SUMMARY
So hopefully that's that's helpful for you and you are getting back outside onto the road or if you've been in the south you've been on the road all along and you know If you're interested in treating endurance athletes, please join us for one of our offerings. We're really starting to ramp up here with professional bike fit certification. Matt Keister and I will be in Asheville, North Carolina, April 19th and 20th. We still have some spots for that. This should be a great time. It's the only time that we have both lead faculty at the same course for the year. And then I'll be in Minneapolis in the middle of May. Matt will be in Denver in June. For Rehab of the Injured Runner Live, we only have two offerings so far for 2024 until Megan Peach gets back from Austria later in the fall. Uh, first offering will be in Milwaukee the first weekend in June that is filling up. So, uh, if you have an inkling to, to, to join us there, uh, sign up sooner than later. And then second offering will be in Maryland in September. Uh, we're getting some signups there too. So hope to see you at a course. And then next, um, online cohort for rehabilitation of the injured runner is May 7th. Uh, everyone have a great weekend. Get outside, do something fun, get out on your bike if you can, or get out running. See ya.

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

Dr. Jordan Berry // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses five different ways to work on correcting lateral shifts in patients demonstrating low back pain with radiculopathy, including standing, sidelying, and prone variations.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

JORDAN BERRY
All right, what is up? PT on Ice Daily Show. This is Dr. Jordan Berry, lead faculty for cervical management and lumbar spine management, as well as our T and D content over all the spine division. I've got Jenna here with me today from the fitness athlete division, and we're talking lateral shifts again. So a few weeks back, we talked about the lateral shift and how we have to be able to pick that up in order to oftentimes move forward with the planned care. So when someone comes in that has really severe back and back related leg symptoms, oftentimes the lateral shift is the number one thing that you have to be able to pick up. and clear up, because if you don't, you're not oftentimes going to be able to work into this agile plane and start resolving those symptoms. So a few weeks back, we talked about the main ways from an objective and a subjective standpoint that we could pick up on the lateral shift. Today, we're going to change gears and talk about actually correcting it. So a few ways during our treatments that we can correct the lateral shift. Now, by far, the most common is the standing variation. or we're shifting the person that we'll talk about in just a second. But oftentimes the irritability is too high to allow for that. So we can't use that variation. We have to go to something in a non-weight-bearing position. So we'll talk about a few ways based on irritability that we can regress the standing lateral shift correction to be able to match that person's irritability and move forward during the plan of care, okay?

CORRECTING THE LATERAL SHIFT IN STANDING
So I'll have Jenna stand for just a second. and we'll demo as if she has symptoms on let's say the left side. Okay, so oftentimes we turn the camera just a bit here. If we have symptoms on the left side, almost always, 90 plus percent of the time, the shift is gonna be away from the side of symptoms. So we're gonna assume today that the shift is away from the side of symptoms. And Jenna would then, if she has symptoms on the left side here, right, would be shifted away from those symptoms. So for the standing variation, I would be standing on the opposite side of symptoms. So I would be in a staggered stance here, right? She's going to have arms either across like this or at least up away from her hip so that I can get around her hip. And I'm going to have my head on the backside of her shoulder blade with my arms wrapped around the very top of the hip. And so we're right here. And then I'm going to shift over and load towards this side of symptoms, right? So she's avoiding that side. And I'm wrapped around shifting towards the side of symptoms, okay? So we covered that technique in a lot of detail during our lumbar spine management weekend course, so we're not gonna spend a lot of time on the standing variation right now. But what I do wanna do is show you a few non-weight-bearing variations, because if you go to test that out, and the irritability's high, and that person either starts to peripheralize or pain increases, we have to have a variation in a non-weight-bearing position that is a little bit less vigorous that we're gonna start from.

CORRECTING THE LATERAL SHIFT: SIDELYING
Okay, so immediately if that's not working, my first regression here is in the sideline position. So now we're going to have Ginego on the table here. And I'm actually, I'm going to change sides for the video, but it'll be easier to see here. So Jenna is lying on her side, and we're going to say that the side that's up on the table, in this case, the right side, is the side of symptoms. And so for their side-lying technique, we're going to do a side-lying lateral glide. Again, during our lumbar spine management weekend course, we cover this in depth and we typically refer to it as a way to improve range of motion and mobility, just generally speaking in the stiff back. But it's a great technique for a lateral glide or a lateral shift correction as well. And so the way that we set up is I'm facing the bottom corner of the table and I have my contact hand that weaves through Jenna's arm here. and right around my hypothenar eminence rests along the paraspinal right here that's on the top. So I'm just hooking my hand in, facing the bottom corner of the table, and I just drop my weight down here. So again, we're saying that the top leg here is the side of symptoms, and we are gliding down towards the table or away from the symptoms if you want to think of it like that. And oftentimes that, because we're not in the weight-bearing position that we were in standing, the patient will be able to tolerate that much better.

CORRECTING THE LATERAL SHIFT: PRONE
Now, what if they can't tolerate the side-lying version or they're peripheralizing or not seeing the changes that you would expect? Well, we could then go to a prone variation. And so appreciate for that last technique, right? I was standing above the side of symptoms and we were gliding away from the symptoms. So we're doing the exact same thing in this prone position now. I'm going to bring the camera slightly closer here. And the same idea here in the prone position. So we're going to say that the side that I'm standing on right now, right, the side towards me or closest to me is the side of symptoms. In this case, it would be Jenna's right side. So instead of having my hand fully on dropping down into the lateral glide, I'm still going to glide laterally or away from the symptoms here. But I've got my thumb pads here together. and they're on the side of the spinous process that the symptoms are on. So again, for those listening and for those watching, just to make sure we're on the same page, if we have right-sided symptoms, the pads of my thumbs are on the side of the spinous process on the right side. And I am just gently gliding away. This is the exact same thing as the sideline lateral glide. It's just a less aggressive version. So again, my thumbs are together like this on the side of the spinous process where the symptoms are and I'm gliding away. And oftentimes just that very, very gentle, soft mobilization is enough to start to get some centralization. Okay, but what if we can't tolerate that, right? What if, for example, the actual spinous process or the area in the low back is too sensitive to actually be able to put contact or pressure on the spinous process? So then we could do the exact same thing, only now we're contacting the torso and the hip. So our contact hands are above and below the lumbar spine. So with the exact same setup that we had, again, the side of symptoms or the right side, the side that's closest to me, I'm going to have one hand on the right glute, right to the glute on the side of symptoms. And then I'm going to have my other hand on the torso on the opposite side. and I'm pushing the glute away and pulling with the torso towards me. So again, it's the exact same thing that we're doing the previous two techniques in the lateral glide. We're just not contacting the actual lumbar spine now. So we push away with the glute and pull towards with the torso here. Push away at the glute and pull towards on the torso. And now we can do the exact same mobilization in the lumbar spine without actually having to contact the lumbar spine.

CORRECTING THE LATERAL SHIFT: BELTED MOBILIZATION
OK, I've got one more. So this is my my go to if someone cannot tolerate any of those other variations. It's very, very rare that someone would not be able to tolerate one of the ones that we just went over. But I want you to have a technique in your arsenal where if the person really isn't tolerating anything at all, where you're going right at that area where they're having to cross that leg over on the table that's painful. I want to give you a version that is completely passive on the patient's end where we're actually going to use a belt around the person to lift the hips. So for the setup here, the painful side now is actually down. So this is the opposite of that first version that we showed. So we move the camera so we can see here. Jenna's painful side would be down towards the table. And what I'm going to do is take a belt here, mobilization belt, you could use a gait belt, and I'm going to wrap it underneath Jenna's hips. So we're going to weave this through. And I'm just making a loop with the belt. And so what I can do now is actually get on the table. I'm going to be up above the person and I can lift Jenna's hips up while she's completely passive and does nothing. And what that's doing is the exact same thing as what we were doing with the lateral glide, right? When the painful side was up and we were gliding down. Well, now the painful side's down and we're the ones that are pulling up. So I would be on the table above pulling on the belt. here. And Jenna can stay completely relaxed. She doesn't have to do anything at all. And I can do a lateral glide with the painful side down. Again, very rare that I would ever have to go to that technique, but it does happen and it's nice to have that in your arsenal.

SUMMARY
So those are five ways, five of my most used ways to correct a lateral shift in the clinic. The one that we're probably all familiar with, again, is the standing variation. That's the one that you see in most courses. That's the one that you see in most textbooks. And it's a great technique when it works, right? It's a great technique when the irritability allows for that weight bearing position to be used. But plenty of times in the clinic, the person's not going to tolerate a weight bearing or a loaded shift correction. So we have to go to a non loaded or non weight bearing position. I love the lateral glide that we started with. You can also go prone and do that really small, gentle lateral glide with the pads of your thumbs on the side of the spinous process. We could also go above and below the area if it's too hot to actually get your hands in there and contact it. You could go one hand on the glute, one hand on the torso, push and pull to do the exact same loading to the lumbar spine. Or you could go painful side down, belt around, lift the hips up. All right. Well, those are five variations. Hopefully that helps you out in the clinic with managing some of these folks with back and back related leg symptoms. If you're going to be at a cervical spine or lumbar spine management course in the future, we will see you there. Have a great day in the clinic. Thank you, team.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave as he discusses three key steps to keeping older adults moving while injured: symptoms, guardrails, and modifications.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION


INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JEFF MUSGRAVE
Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday, so it is all things geriatrics. Happy to be here with you for a PT on Ice Daily Show brought to you by the Institute of Clinical Excellence. So, team, I had a really interesting scenario. One of the things that I do is I'm an owner and a coach in Stronger Life and it's fitness for people 55 and up. We had a member who had missed a couple weeks trying to go through the diagnostic process for some reactive arthritis. And actually, still, that's just a working diagnosis. About four weeks now, currently, since diagnosis. But after a couple weeks, she reached out and was like, hey, I really want to get back in the gym. It's good for me physically. It's good for me mentally. This is a member that's been with us for about four years, very dedicated to her fitness, showing up, doing what she can. Each day has gotten really strong and didn't want to lose her fitness. So here she is in the medical system advocating for herself Which is sad that during this process, you know this this PT first Idea that we're trying this mission that we'd like to see come to fruition if we're not there yet. Okay, so she's had her blood work, she's had x-rays, all these things are done, she's getting no intervention, no formal PT, and she's begging, can I go back to the gym? And we're like, absolutely. Now, are her providers and her medical team on board with this? Not quite, but that's okay, because we're going to take good care of her. So, oftentimes we find ourselves on the other end of this scenario, right, where we are trying to figure out If we've got someone we're treating for some type of injury, an older adult, and they are going to group fitness, how can we set them up for success?

3 STEPS TO CONTINUING TO MOVE WHILE INJURED: SYMPTOMS, GUARDRAILS, AND MODIFICATIONS
Particularly, we know when we're working with older adults, it's all about this game of building reserve and maintaining resiliency. We know we want our older adults to be as strong as possible. We want to put as much distance between minimal ability to function on a daily level and their fitness. We want to build as much margin, build as much reserve as possible, so when illness or injury comes knocking, because we know it's going to happen eventually, right? We want them to be able to fight back. I want to outline a few things that we do at Stronger Life that I think are just a good guideline if you're a treating physician and you want your patient to be able to go into group fitness. A lot of these things you're probably already doing, but just thinking through this lens, we know that the game is vital. We've got to keep people moving. We're trying to get people as fit as possible and keep them that way as long as possible. So I'm going to say, by and large, we believe keeping people moving is paramount. That is what we have to do. We have got to get and keep people moving despite their injuries. With our formal physical or occupational therapy interventions and or in the gym, fitness, Most of the time we can keep them moving if we can set them up for success. So I've got three steps that I think will be very beneficial. The same thing that I used for this Stronger Life member, and that is symptoms, guardrails, modifications. Symptoms, guardrails, modifications.

SYMPTOMS
I'm going to set the stage just a little bit more for this patient. So when we're thinking about this specific scenario, it was reactive arthritis in the knee as a working diagnosis. This member had been nearly non-weight bearing to partial weight bearing limited range of motion, painful loading of the knee. So focused on the knee here. And at this point, two weeks of symptoms, no better. We wanted to dig into her symptoms. So she gave us a heads up she was gonna be coming in, which is nice, we don't always get that on the fitness side of things, but you're gonna have that information as a treating clinician. So things we want to know, obviously just like during the diagnostic process, if we're thinking about what do we need to know about their symptoms going into some type of movement practice or group fitness, or maybe group fitness are already engaged in. We wanna know their ags. We wanna know what's making these symptoms worse. Is it the range of motion? Is it the pain? Is it the volume, the number of repetitions? Is it power-based movements that are exacerbating their symptoms? And this is all information you're gonna know about your patient that you're treating already. So we wanna know that. and set those baselines. So if you're treating the patient, you probably already know the symptoms. Step one, check. We know for this specific case scenario, it was painful range of motion past about 30 degrees. 30 degrees of knee flexion is about all we could get. Weight bearing Sometimes not exacerbating symptoms, sometimes it was. So the member was walking in on a cane and was very leery of weight bearing. So the things I knew about this member coming in is they've had chronic knee pain for a long time. Their baseline, she's telling me, is a five out of 10. It was a nine out of 10. She was in the ER on pain medication. Two weeks later, she's weight-bearing, ass-tolerated, on a cane, about 30 degrees of knee flexion. Loading the joint through range is painful, okay? So that's kind of the information I knew coming in. Dug in just a little bit right before class.

GUARDRAILS
And then we need to set some guardrails. So now that we know the ags, we also want to know the irritability. How irritable are these symptoms? If we flare this up, is she going to go into non-weight-bearing status? And is this going to affect her activities of daily living the rest of the day? or is she going to have a little increase and then as she rests symptoms are going to come back down. It wasn't, her symptoms in this scenario were not like once they're spurred on she's dealing with these for days. So I put her in the low irritability category. Symptoms had been severe but they have been stable. So I wasn't really too worried about her Causing any symptoms in class but wanted to have some some options to take her out of weight-bearing make sure we're limiting her range of motion because we had identified those were the things that were exacerbating her symptoms, so That was the symptom baseline irritability, I would say low and then some guardrails and So for her, we let her push into the discomfort and set some guardrails. Hey, if your pain gets five out of 10s your baseline, if you hit a seven out of 10 or above, we need to make some changes. You need to pull me over, we'll cut the range of motion, or we can reduce weight bearing.

MODIFICATIONS
And then the last thing that we need to do is we need to give her some modifications. So we knew it was range of motion, and weight-bearing positions. So those are the two things we're looking at first. So I'm going to give you the exact workout we did and then we'll walk through symptoms, guardrails, modifications, and how we went through this. So the workout was a station-based workout where it started with weighted step ups. Okay, you can see how that could be a problem. Then we had sumo deadlift high pulls, which were weight bearing. We had some time on the rower. We had a three position balance movement. So it was dynamic balance with a water tube. And the last thing was spending some time on the ski. Heard different movements with her to work on modification. So she was weight-bearing with the cane, she was not able to do much more than a few steps, so we knew adding weight wasn't going to work. So we got to the weighted step-ups, I had her try it just with a couple inches, cut the range of motion, cut the load, still uncomfortable. I took her over for a wall sit, wall sit didn't work either. Okay, so cut the range of motion, cut the load, still too painful. So what did I end up doing? I ended up replacing the movement. And this is the last thing we want to do, right? We want to stick to the body group to get the desired stimulus from I had misjudged a little bit. She was a little more irritable than I thought, couldn't tolerate a static position to work the lower extremities, couldn't handle the reduced range of motion or the reduced load. So instead of replacing it, she ended up doing a seated Russian twist, okay, working on some core work, taking her knees completely out of weight bearing for that movement. Next movement, we got sumo deadlift high pull. Since I knew she couldn't tolerate much load plus, like body weight plus resistance, I went ahead and put her on a box to do a sumo deadlift. So she's still, she's in a seated position, has a dumbbell in each hand. She's driving from her feet, giving us this nice high pull motion. So she's still working her legs, her hips, her core. We're able to maintain the stimulus on that one, which was great. She was able to tolerate that. The next movement was the rower. So on the rower, I knew that her range of motion, she had about 30 degrees. That's all we could work with. Rower, pretty friendly place for people, especially with reactive knee arthritis. So she can control the range of motion and it's limited resistance, right? We've taken gravity out of the picture here. So what I did is I had her put her feet on the floor of the rower and just drive through her feet and cut the range of motion. And she was able to tolerate that really well and actually saw progress during this workout from the beginning of the workout to the end of the workout with her getting more and more range of motion. She actually said that time on the rower made her knee feel really good. So that was good. So we modified the rower. Then we've got this dynamic balance movement where you're starting on one leg, quick step, and then standing on the other. So there's a dynamic component, there's a power piece, there's a single leg support piece, and we know weight bearing on both legs is okay. Single leg is kind of out of the picture. So we had her work on some weight shifting, holding a little bit of load and she was okay with that, which kind of surprised me. And actually as the workout went on, she ended up doing a little bit of single leg support and weight shifting until she was on one leg and then the other. So that was a replacement. So that dynamic power-based movement ended up being more like weight shifting side to side. I gave her the option to close her eyes to make it a little more challenging and the surface she was on was dynamic. So that was the modification there. When it came to the ski, knowing how much weight bearing was in there, she's walking from station to station, I had her do the ski from a seated position. So arms length away, the setup is still very similar for the ski, reaching up nice and tall, pulling to the hips. So she's still getting a cardiovascular stimulus, she's still working overhead pulling, so we're able to maintain the stimulus. So that is the process that I went through, looking at her reactive knee arthritis, trying to figure out what she could tolerate, cutting the range of motion, cutting weight bearing, but she got a great workout. Her fitness is better because of it. She's worked really hard to maintain and build that reserve and resiliency, and we're able to go through and give her a great modification, something that's meaningful and helpful, trying to stick with maintaining the stimulus as much as possible, what direction, what muscle groups, and then last case scenario on modification, sometimes we just have to replace it. What's something valuable you can do, even if it's not the same muscle group, not the same position? So oftentimes when I'm, I gave you kind of the scenario I did this with for this patient in particular, knowing weight bearing and range of motion was limited and producing symptoms. But when you're thinking about just in general, oftentimes cutting the range of motion, cutting the load, those two can help. If those don't help, you can still maintain the stimulus from going from a dynamic, to a static position. So say it was push-ups, for example, are painful, can we do a static plank? Tristatic, so cut the range of motion, cut the load, take them a little bit more out of the weight bearing position, and then tristatic. If you can't do a static with reduced range of motion, reduced load, then it's time to start thinking about replacing that with another upper extremity movement. But if you're in a scenario where you've got to make a decision quickly, or you're trying to arm your patient to make these modifications in a group class, just have them see if there's anything else they can modify going in. So the reality is this patient is still in the diagnostic process. There has not been any solid diagnosis for her, no clear prognosis, still getting no intervention. She's been coming to group classes for two weeks. Her pain is better. Symptoms are reduced. Range of motion is improved. She's walking without the cane all while awaiting her one-on-one intervention and a diagnosis. So during this time she's been able to improve her fitness, improve her range of motion, improve her weight-bearing tolerance, and the other benefit that she brought up, which we've not discussed yet, is just the mental and emotional piece. we have to remember for older adults, maybe they're seeing us for a pain or a problem, if we can keep them moving in the group setting, we can equip them with the guardrails, we know what causes their symptoms, we know what we need to modify, because we're already working around them, we just need to give them modifications they can use once they get into the group fitness environment. And she's getting better, even though she's had no formal intervention yet, which I love. But the other piece is the social isolation piece. For our patients, a lot of our older adults are socially isolated. That changes our health outcomes, team. Friends save lives. And keeping our older adults connected with their social networks is crucial to treat the whole patient. And she said mentally and physically, she has felt a lot better. And if you've done any studies, looked at any of the studies for chronic pain, We know that keeping people moving and some of these mental emotional factors can be huge in the experience of pain. The things we want to do to set our older adults up for success, to keep them moving in the group environment as much as possible, to maintain that reserve, to maintain those social connections, is we've got to know their symptoms. We've got to know their ags. We've got to know what makes their symptoms worse, their symptom irritability. After we know their symptoms, it's guardrails. If this, then that. If your symptoms get to, in this scenario, was a seven out of 10, then we need to cut the range of motion, cut the load, or we need to take you out of weight bearing. And then the last piece is to be set with those modifications just like we outlined. We knew for this client, the range of motion, the load was the issue. So those are the things that we changed. And if those two things don't work, then we completely replace it. But the more we can get and keep people moving, The more we can help them maintain their fitness and their social connections, ultimately, the better their outcomes are gonna be in our clinic. So, I hope that was helpful. Real life scenario, patients getting better, no formal PT, symptoms, guardrails, modifications. Team, I hope that was helpful. I would love to hear your thoughts on that. If you have any other strategies you like to use to modify around symptoms, in particular to equip your patients for the group training environment, I would love to hear about those.

SUMMARY
If you are interested in coming to check out us for more mmoa content we have got our mmoa level one eight week online course level one is happening may 15th if you've already had level one you're looking for level two it's going to be may 16th We've got our live course is gonna be in Raleigh, North Carolina, Urbana, Illinois. We're gonna be in Burlington, New Jersey, and we're gonna be, I'm gonna be in New Orleans, Louisiana this weekend. Team, the live courses are a lot of blast. If you've not been to one, you should come check us out. The weekend after, if you're on the West Coast, I'll be in Bellingham, Washington. Would love to see y'all in the live course. If you get a chance, love to hear your thoughts on this topic, on this case study, keeping people moving in group fitness despite their injuries and symptoms. Have a great day team. We'll catch you next time.

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

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

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the gap between social media and actual clinical practice, seeking real mentorship from real clinicians treating in the clinic instead of social media influencers, and the importance of having a healthy sense of humility regarding manual therapy treatments. 

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

ZAC MORGAN
Good morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty here with the cervical and lumbar spine management, teaching both of those courses on the weekends. And if you have not had those courses, both of them involve a decent amount of manual therapy. So we enjoy kind of teaching manual therapy, doing manual therapy on one another those weekends and kind of reframing how you might frame that manual therapy intervention with your clients. in the hopes of maybe creating a little less dependence on manual therapy and instead a lot of independence in our patients and kind of pushing them towards a more fitness-forward lifestyle. For those of you that have been to the courses, you know that's a big deal to us here at ICE and we love doing that. And this morning's podcast is titled Manual Therapy Misconceptions because I think this is definitely an area in the manual therapy world, physical therapy specifically, where I see a lot of disconnect between what happens in the clinic and then what happens on social media. So I want to start out by talking about over the last several years of spending a lot of time on the weekend, you know, teaching manual therapy techniques, fielding questions in those settings, as well as spending a lot of time in the clinic treating a lot of clients with acute back pain, with acute neck pain, with persistent back pain, with persistent neck pain. I see a lot of misconceptions and at our clinic we spend a lot of time training younger clinicians and bringing through students and then also on the weekends working with a lot of seasoned clinicians And I just see that social media has had an influence on our profession's willingness to use manual therapy and our understanding of everything. And so I think that's what today's podcast is about, is sort of how that has been influenced and maybe just reframing some of our thoughts around it.

THE GAP BETWEEN SOCIAL MEDIA & REAL CLINICAL PRACTICE
There's one thing that's for sure. If you spend a lot of time on social media and specifically follow a lot of the conversation that happens in our profession, you'll see a huge gap between what a lot of people say out there on social media and what actually clients want and what drives people to seek out physical therapy. So there's a huge gap there. And that's where I want to kind of start is with the social media conundrum. Obviously, social media platforms have become such a popular way for us to get new clients, for us to educate the public, and for us to educate one another within the profession. But there is a conundrum here. And the conundrum is that all of the platforms, really regardless of which one you spend time on, they are built specifically for the reason to drive engagement. The goal of those apps is to keep you on them for longer. That's why they exist. So within that, the content that typically keeps people's eyes on it for longer is generally framed more contrarian or more negative, that tends to drive engagement more frequently. So if you post something negative or if you point out something negative, often you will see a lot more engagement, a lot more comments, a lot more likes, a lot more just overall view of that content. And I think that this can cause a lot of issues in clinicians and has caused a lot of issues and I've seen it firsthand and that's a huge issue in our profession. So I kind of want to talk a little bit about those issues specifically and then what we might do to sort of reconcile them.

SOCIAL MEDIA DRIVES CLINICAL CONFUSION
So the biggest issues that I see and this is really regardless of whether it's a younger clinician or somebody who's a little bit more of a seasoned veteran What we see is when people spend a lot of time kind of intaking some of that negative information from social media, it drives a lot of clinical confusion. People are confused about what they should do with their patients. It drives ethical challenges. Some of these posts call into question how ethical manual therapy is, and it makes people feel like maybe it's a little unethical for us to be doing hands-on care. And they definitely often drive further away from expert opinion. So when I say expert opinion, I mean things like our clinical practice guidelines. So you think about what that is, like how those are formed, and it's really the foremost experts in our profession getting together, synthesizing all the data that exists, synthesizing clinical experience as well, and then making evidence-based recommendations. To get a clinical practice guideline published, it requires a lot of work, a lot of experts to communicate with one another and develop expert opinion. And here's what we think. This is a grade of A, this is a grade of B, and so on. To get a social media post out requires nothing other than an internet connection and a device that can do it. sometimes we're reading these opinions from non-experts and those non-experts could wind up being very loud and have a large platform and that doesn't always equate to someone that actually spends a lot of time in the clinic. So I think this is where some of that confusion can come into our practice, whether again, whether you're a younger clinician or someone that's more seasoned, it's kind of who we're choosing to listen to because of who's the loudest on social media and that being where we get most of our information.

"MANUAL THERAPY DOESN'T WORK"
So the narrative specifically, the misconception specifically that I'm addressing in today's episode is this manual therapy doesn't work narrative. So a lot of people have that feeling that manual therapy doesn't work and there are certainly studies that have challenged the efficacy of manual therapy and you see those studies get talked about a lot on social media again because they're negative and they drive engagement. But that narrative is one that I have heard often be challenged either on the weekend or in the clinic where people are just confused about whether or not manual therapy works. And that's a huge disconnect between clinicians that you talk to that do treat a lot of these issues. Those clinicians typically feel strongly that it does work and again our experts If you look in the clinical practice guidelines for back pain, for instance, you're going to see that really regardless of the presentation, there's some expert opinion that we should use manual therapy, that it should be used almost regardless of acuity or stage. Manual therapy might be something that should be included in back pain. And that's not just profession-specific. A lot of clinical practice guidelines make those suggestions, but ours certainly do. The updated ones from 2021 from Stephen George and colleagues make a lot of recommendations surrounding manual therapy. So I think that disconnect is driving a lot of clinical confusion for us. The reason this podcast kind of came up in my head, the topic, really came to me when I was looking through the recent JOSPT and there was a systematic review from, forgive me if I butcher the name here, but I think it's Ruzick et al, and this was just a couple of weeks ago that this one was published. You might have seen it in Hump Day Hustling, our newsletter. But essentially, it was a systematic review. It was done over at Bellin College. So the DSC program and the fellowship there at Bellin went in and they did a systematic review, kind of analyzing the literature, looking at manual therapy for low back pain. The question they were trying to answer was, are the methods in these manual therapy studies, the way they're described, are they repeatable? So in other words, if you read these studies, and you're an independent researcher outside of the group that just did that study, could you read through that and then actually replicate the findings? And the way they were looking at that is, are the methods described well enough for us to replicate the interventions? The answer was no. There was poor reporting in manual therapy intervention studies, and that limits the reproducibility of those findings. This is a big issue because one of the major tenets of science is that it needs to be replicable. You need to be able to check your work. If you're not able to do that, I would call into question whether or not it actually is science. At the end of the day, science has to be described well enough that an independent researcher could then come in and replicate the interventions to see if they can replicate the findings. If you then get a lot of data pointing in one direction, we start to say, you know what, I think there's some merit here. But if the methods aren't described well enough that we could even replicate them, you have to call into question whether or not that's actually science. And I guess my point here is a lot of these conclusions that are drawn on social media posts are of an independent study where maybe the methods aren't even described well enough to where you could apply them to the clinical cases you're seeing. And so we're drawing a huge conclusion that manual therapy doesn't work Meanwhile, the studies aren't even replicable. I think this is a massive issue. There's a huge disconnect there. And so I don't just want to point out the issue, I also want to talk to you briefly about what we might could do going forward, given that the studies don't guide us that well, given that they're not super replicable, and given that we can't draw those big conclusions off of non-replicable studies. And so let's address those problems.

CLEAR UP CLINICAL CONFUSION WITH ACTUAL MENTORSHIP
I think that the confusion here can be sured up by seeking mentorship. expert opinion and just time around expert practitioners. So what you will find often when you're actually seeing those people treat in the clinic, when you're working alongside of those people, is they're not confused about whether or not manual therapy works. They often have some type of a framework that they're bringing forward to the patient and they feel confident that they can often help patients because of their skill set. So I think we, as a profession, need to lean more on the empirical side of the scenario, given that our data is a bit confounded by lack of replicability. So what I mean by empirical is things you can witness, things you can see. The test-retest model, actually spending time around clinicians that utilize that and frame it positively for patients. That's what I think we should be seeking out as our evidence-based practice right now, because I think a lot of our actual evidence is challenging. That is the short-term solution. In the short-term, I would suggest if you're a younger clinician or a seasoned clinician who has some disconnects surrounding manual therapy, seek out mentors that have an understanding of manual therapy, who see a lot of back pain, who have busy schedules, busy caseloads full of patients with back pain looking to get better and see how they handle those scenarios. I think that is a much better route than seeing social media posts and drawing a huge conclusion from those posts. Meanwhile, the evidence that they're analyzing isn't that great.

RESEARCH METHODS MUST IMPROVE
The second thing would be a more long-term solution, and this is more speaking to the research going forward. We have to improve the methodology. That's what that systematic review from JOSPT That's what they suggested, and I couldn't agree more. In the future, our methodology has to improve. We have to get better at describing our techniques so that we can, over time, whittle down what is the most effective. But the problem is, that doesn't help you today. When you go see that patient that comes to see you with five days of low back pain, and they're really looking to feel better quickly, and they're starting to lose a lot of functional capacity because they're not doing much, because their back hurts so much, and you're confused about whether or not you should use manual therapy, long-term improvement of methods won't help you. You need to fix the short-term problem and get some understanding by spending time around clinicians that are used to seeing that and that can help you move that patient forward. And again, our practice guidelines are pretty clear here. they make a lot of suggestions surrounding utilizing manual therapy. And most of my colleagues that also treat a lot of back pain, that's basically my whole caseload is back pain and neck pain, occasionally shoulders, hips, knees, but a ton of back pain and neck pain. and I utilize a lot of manual therapy. And I don't feel bad about that. I feel like framed in the right way, it's so helpful to help that person reduce their concern and improve their activity. I agree that there are some ways you could frame it that might challenge someone's belief system in their body, but just don't do that. Just frame it correctly. And so that's my call to action. Seek credible mentors, contribute by pushing our profession forward with the use of these techniques that patients are going to seek out and they're going to get regardless of whether they see you or someone else. So let's be good at it so that they do seek us and then reframe the methods in future studies so that that way we can actually get good scientific data moving forward and understand what works and what doesn't.

SUMMARY
Team, in summary, I think a lot of clinical confusion comes down to a mismatch of understanding the quality of the information you're receiving. Social media has made it very easy to get your opinion out there, and often there will be opinions coming from folks who may or may not even be experts, who may or may not even be treating in that region, and challenging your belief system on whether or not an intervention works. And I see that confusion manifest as confused young clinicians who have a challenging time deciding whether or not they should utilize manual therapy. Spoken from someone who treats a lot of those problems and who has spent a lot of time around experts who also treat those problems, I've been very lucky to get a lot of time on board with experts. there's not that much confusion on the other side of the coin. So I think that mismatch of where you're getting the information from is huge. So my call to action is let's improve our manual therapy skill set. If that's what you're looking to do and this message is resonating with you at all, I'm going to tell you about a handful of upcoming courses because this is huge for us at ICE. This is why we don't hire people who aren't clinicians. It's really important to us that at ICE, when we bring forward a message to you, you're getting that message from people who actually are in the treatment room. They're behind the walls. actually trying to eradicate these problems over time.

UPCOMING COURSES
If you're looking for that in the cervical spine, May 18th and 19th, Casper, Wyoming, that one's filling up fast. So if you're in that area and you need a spot there, Casper, Wyoming only has a few seats left, make sure you jump into that. At the end of June, the 29th and 30th, will be in Kent, Washington. And then in July, the 13th and 14th, Charlotte, North Carolina. So a handful of options there for neck. If you're looking for low back, this weekend we've got two course offerings. If you want a last minute ticket, you can certainly jump into one of those. Carson City, Nevada, and then right here where I'm at in Hendersonville, Tennessee. Still seats left in both of those. And then next weekend, April 13th and 14th, near Boston in Braintree, oh I'm sorry, yeah, in Minnesota. I think I've got that down wrong. I think it's Braintree, Massachusetts and that's actually over in the Boston area. So if you're looking for either one of those and you're liking these narratives for reframing manual therapy, jump in with us. We're excited to bring forward some different ways of framing manual therapy. Thanks, that's all I've got for you team. We'd love to hear some interaction here in the comments throughout the day. Keep an eye on the thread.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses the kipping pull-up as well as modifications to maintain kipping for pregnant athletes & reintroducing kipping sooner for postpartum athletes.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

JESSICA GINGERICH
Good morning! Sorry for the late start. Welcome to the PT on Ice Daily Show. My name is Dr. Jessica Gingrich, and I am on faculty with the Pelvic Division here at ICE. My goal for today is going to be expanding on my last podcast that was about gymnastics during pregnancy, and really during the postpartum phase as well. So just a quick review of what defines gymnastics. It is a broad term that encompasses many movements and is utilized in many different sports like gymnastics, cheerleading, yoga, trampoline, and also CrossFit. So today I'm going to expand on the kipping pull-up rather than just a strict pull-up.

WHAT IS KIPPING?
Kipping is the act of using momentum to help drive certain movements. So we will see this on the rig, on the rings, and even during some handstand movements. So during pull-ups on the rig or the rings, kipping is using your lats and your core to drive into a hollow position, so that looks like a C, and then pulling into an arch position, which would be the opposite range of motion. This taxes the core through active muscle contraction, as well as putting the anterior core on a stretch. We often see coning and doming during the hollow or arch position as it stresses the anterior core during both movements. We see this during pregnancy and postpartum, but we also see this in other populations as well. Now, this is often communicated as something that is bad or dangerous, especially in the pregnant and postpartum women. And just remember, we want to help redefine that language as more of preparedness versus dangerous. Is your client prepared from a musculoskeletal standpoint to perform said movement. This is a less aggressive way of communicating. And remember, we don't want to induce fear around movement ever, but especially in this already vulnerable population of people.

WHY IS CONING & DOMING WITH KIPPING SEENAS DANGEROUS?
Now, let's unpack why coning and doming is seen as dangerous. So this was based on what we didn't know. a recommendation that came about because we didn't have research, so we erred on the side of caution, especially in the pregnant and postpartum world. We now know that coning is going to happen, and this is because of a mismanagement of pressure in that core canister. Mismanagement of pressure does not only happen in pregnancy and postpartum. It happens in all populations. We see coning and doming, and we use those words interchangeably by the way, in all populations like men, babies, and nulliparous women. That is just someone who has not given birth. Now, with this mismanagement of pressure, there are ways to optimize core recruitment to decrease objective coning or doming and increase co-contraction of the obliques, transverse abdominis, and rectus abdominis. However, you will see that many of your clients don't really care. They don't really take our advice on how to optimize their core. So will they hurt themselves? The short answer is no, they're not going to hurt themselves. Depending on overall core strength and preparedness of a particular task, they may be more susceptible to injury, but we're not scared of injury, right? We know how to rehab injury. What we don't want is to create fear around movement. So how do we negate this?

ELIMINATE FEAR AROUND KIPPING
So first and foremost, we eliminate fear. So, this can be difficult as mom, grandma, a random dude at the gym, friends, and really most commonly what we are starting to see now with Instagram is the fitness influencer that doesn't know the research. Telling your client that they shouldn't do certain movements. We train their core before, during, and after pregnancy. This includes more than just dead bugs, bird dogs, supine TA contractions, et cetera. Furthermore, we show them modifications in the gym to keep them on the rig and closely mimicking the stimulus of the workout when it comes to kipping pull-ups. The biggest point to make is your client maintains points of performance. This could be during any core movement, but specifically, kipping pull-ups is going to be, are they able to maintain the hollow position? If they are able to maintain that, then we let them go. Do your kipping pull-ups, whether you're coning or you're not. So the points of performance are going to be scapular depression and opposed to your pelvic tilt or that hollow position. This can be maintained. Can this be maintained throughout the pole? If they cannot maintain that, A, they're not going to hurt themselves if they continue. However, if you are educating around core optimizing strategies, then we modify. Modifications can look like feet supported kipping pull-ups, so that could be on the ground with a rack chin or with a box. Single foot supported kipping pull-ups, same thing, most of the time is done on a box so that other leg can hang off the box. Or they can further regress to feet supported strict pull-ups, known as the rack chin. There is always an option to decrease reps or rounds while we are choosing to modify that mimics the stimulus as well. When we choose a foot supported option, we are maintaining the kipping movement throughout a period of time rather than eliminating it. So we are saying, try this to maintain your pulling strength rather than eliminating it completely. This way they have more time or I guess less time between when they come off the rig during pregnancy and get back to it in that postpartum time. So to recap, change your language in the clinic, deal hope not fear. Bring attention to social media and how really we can't trust everything that we see and this may be showing your clients who to unfollow or who to mute in real time in the clinic. You should do the same thing for yourself and also report misinformation. So just like your client is going to be influenced by things that they see, so will you. The human body is resilient, and it does not stop being resilient once they become pregnant. Help your clients understand that. They will move with less fear, and they will come to you if they're unsure, or if they're having pain or symptoms. And so therefore, you're gonna be keeping them in the gym. And we want that, right? We want them to come to someone who is gonna encourage exercise throughout the lifespan, and that includes pregnancy and postpartum. Use modifications as necessary or if your client wants to. Remember that it may not be, they may want to use a modification because they feel better doing it. That's okay as well. Train their core in all positions and all ranges and prepare them for what life is. Prepare them for beyond what life is going to throw at them. Now, as always, we're gonna end with some courses. So if you head over to PTOnIce.com to check out our upcoming courses. In our live course, we dive into pull-ups, we dive into rig work and gymnastics. So if this is something that you wanna better your skills at, head over to PTOnIce.com to sign up. I hope you guys enjoy the rest of your week and I will see you next time.

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses the concept of kipping in 2024. After 128 years of kipping movements in Olympic gymnastics, we still have high levels of contention over the use of kipping in recreational fitness despite poor evidence to support or refute the safety or efficacy of these movements. What evidence do we have, and what can we do in the gym and the clinic regarding kipping?

Take a listen to the episode or check out the show notes at www.ptonice.com/blog

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
Good morning, PT on ICE Daily Show. Happy Friday morning. Hope your day is off to a great start. Welcome to the PT on ICE Daily Show. My name is Alan. Happy to be your host here today on Fitness Athlete Friday. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member here in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We would argue it's the best darn day of the week. We talk all things Friday related to that person who is recreationally active. The CrossFitter, the Boot Camper, the Olympic Weightlifter, the Powerlifter, the endurance athlete, running, rowing, biking, swimming, whatever, that person that's getting after it on a daily basis, how to address that person's needs and concerns and be up to date on the research in this space.

THE STATE OF KIPPING IN 2024
So today we're going to talk about kipping, a sometimes usually, it's fair to say, usually contentious topic. related specifically to the CrossFit space, but now as more and more functional fitness gyms open that are doing CrossFit style exercise, we see that even folks who would not say or know that they're even doing CrossFit style exercise are doing kipping movements. So I want to have a discussion. on where we're at in both the public facing, the clinician facing aspects of kipping, what kipping is, and really, what is our goal, especially when we have our clinician hat on? What is our goal when we're looking at kipping and considering Is Kipping safe? Is Kipping dangerous? Is Kipping right for this athlete? So let's start and talk about Kipping. So if you don't know what it is, or if maybe you have athletes or patients who don't know what it is, the public facing side of searching for things related to Kipping can be really gnarly, right? If you just type Kipping into Google, you get a real bunch of crazy stuff. What do you get? You get endless videos on kipping pull-ups specifically, but also a bunch of articles on why kipping is dangerous, why it's cheating. My favorite Google search is the top two results are in direct contention with each other, right? The top result for kipping is an article from Men's Health. Why swinging around at CrossFit isn't for everyone right so a little bit a little bit of a mean article a little bit condescending of an article But then the next article is from our very own Zach long the barbell physio the truth about kipping pull-ups right a lot of research on kipping a lot of practical information on kipping and a lot of the stuff that we're going to talk about today that is public facing, but in a very educational manner. So you see a lot of stuff. It can be very confusing for our patients and athletes because they're being given this message of, Hey, if I'm already doing this, here is really an endless wealth of human knowledge on how to get better at these, how to improve my performance. But also I'm seeing articles from people who tell me that this is dangerous. that this is cheating. This is actually reducing the effect of exercise on my body. It could be making me weaker. All of these different essentially thought viruses are going around simultaneously.

RESEARCH ON KIPPING IS NON-EXISTENT
So stepping back away from what's public facing, the social media content, the blog articles, what else is available on Kipping? Not a lot. If we're being really honest and we go way back in history to the start of modern gymnastics, we know that it started in 1896, so 128 years ago. Across that 128 years, we have watched the sport of gymnastics develop We see gymnasts use kipping on their hands, on the mat, up on the bars and rings, doing things like muscle ups and handstands, and using a lot of kipping to do so. But across that 128 years, we really still only have one research article that is relatively recent in that big span of time. that even discusses anything related to kipping. It's an article that we share in our Fitness Athlete Level 1 course by DiNuzio and colleagues. It's a randomized controlled trial back from 2019 in the Journal of Sports and Biomechanics. and it's titled The Kinematic Differences Between Strict and Kipping Pull-Ups. So a very basic article looking at subjects who performed a set of five strict and then five kipping pull-ups and just looking at what are the differences in the muscular activation patterns between folks performing the five strict pull-ups and between folks performing the five kipping pull-ups. And what we already know to be true was found in the research that we see a little bit less activation of shoulder muscles and bicep muscles and a little bit more activation of quads and of core muscles when we look at the difference between when somebody begins to kip their pull-ups or when somebody does strict pull-ups. And that's it. That's it. That's all the research we have, right? When you kip, you offload your shoulders and your arms a little bit, and the force is taken up a little bit more by your lower extremities and your core. And that's all the research we have on kipping. We have no research that it's dangerous. We also have no research that it's safe. We really have almost no research in this space, and we need to be cognizant of that. We have absolutely no research related to injury. of how many strict pull-ups can we do before we should kip. What level of strict pull-ups makes our shoulders safer from kipping pull-ups? What is the limit of kipping pull-ups volume-wise that we'd want to see somebody perform? Some sort of structured progression towards performing kipping pull-ups. We have absolutely no research on that. We need to be aware of that. And we also need to realize that's probably unlikely to ever happen. If you think about the recruitment for a study that would evaluate some of those concepts, it would look totally insane and be unethical, right? Let's take different groups of people, let's randomize them, and let's see, based on strict pull-up capacity, who does a certain amount or a progressive amount of kipping pull-ups, and then let's see how long it takes for someone to develop an injury, if ever, and then crunch that data and come up with some sort of Conclusion that we'd all love to hear, or at least be interested in seeing, of how many strict pull-ups is enough, how many strict handstand push-ups is enough, before we begin to create and allow, quote-unquote allow, kipping in our athletes. So we need to know the public facing space is out of control with this, can be very confusing to our patients and athletes, but the clinician facing, the research side, there is almost no information and there's probably not likely going to ever be something change here in a really substantial manner.

WHAT IS KIPPING?
So what do we do in the absence of research? Step back and better understand what kipping is. Kipping is just momentum creation and transfer. If you have taken fitness athlete level one in the past couple years, you know that we talk about this in week four when we talk about metabolic conditioning. We talk about why are we doing kipping? Why are we doing things the way we're doing them in the functional fitness gym, in the CrossFit gym? Well, we're primarily doing them to get our heart rate up, right? We're primarily exercising for power output. to create a cardiovascular response. That's why we're primarily going to CrossFit. Yes, we lift some heavy weights every now and again. And yes, we do some lower intensity, maybe zone two, zone three, steady state cardio from time to time. But primarily, we take a couple exercises, we smash them together in an AMRAP or rounds for time or an EMOM. and we're doing them in a manner that facilitates our heart rate getting up ideally into zone four and maybe if we're not careful, maybe sometimes a little bit of zone five. So when we talk about kipping, we're just doing it for momentum transfer. It's allowing us to do more work in the same or less amount of time. so that we can keep that heart rate elevated. You all can imagine that it would take a very long time to do a workout with 100 pull-ups if you did them all as strict pull-ups. We just had a great workout last weekend at Extremity Management up in Victor, New York. We had some pull-ups, or should I say pool-ups, as Lindsey Huey would pronounce it, programmed in the workout, and the folks that kip their pull-ups or butterfly their pull-ups got a lot more work done in that workout than the folks who just did strict pull-ups. So kipping is just momentum creation and transfer. I think it's important to understand we so intensely and closely begin to associate kipping just with gymnastics, specifically vertical pulling gymnastics, pull ups, and toes to bar and muscle ups and that sort of thing, that we forget that as humans, we kip almost everything in our life, right? I am standing still right now, if I begin to walk, I'm going to begin to use global flexion to global extension patterns, to propel myself forward. If I want to transition from a walk into a run, that is going to become even more intense. I'm going to begin to use more of my core, more of my shoulders, more of my glutes to produce a flexion to extension, back to flexion moment that generates momentum. If you don't think humans should kip, I want you to jump into a pool and not use your shoulders, core, or hips to swim. What you'll find is that kipping is very functional to daily life. If we begin to disassociate kipping from being up on the pull-up bar, on the pull-up bar, we recognize that we kip almost everything, right? It's a very functional thing. We kip to go from walking, from standing to walking and from walking to running. We kip when we stand up from a couch. We kip when we're swimming in the pool, or the pool, I should say. And we need to understand as well, some part of this, of why we don't just do strict gymnastics, why we don't just do strict weightlifting, is that it really limits our top end performance, right? Imagine if you watch the Olympics, and gymnastics was strict work only, right? Only the very strongest people would be able to do that stuff, and they wouldn't be able to do a lot of it, right? We would watch somebody come out on the floor, we would cheer for them, This is this is Steve from Belarus. Hey, Steve. And he does like maybe three strict muscle ups, right? He's not swinging around on the bars anymore. We don't really care about his landing, because he can't generate momentum to swing around to land. Imagine if Olympic weightlifting did not allow momentum and people just performed a deadlift to a strict high pull to a strict press, it would limit top end performance, we would not see people clean and jerking 500 pounds, we would not see people snatching 300, 400 pounds. So that momentum generation is a very functional part of being a human being and of performing these functional movements. And we can't take that away from people. Because even if for nothing else, it would become really boring, right? So not only is it functional, at some level, it's kind of fun to do. And it's fun to move along that progression from Okay, I can do some strict pull ups. Okay, I can do some kipping pull ups. Cool. Now I'm working on muscle ups, so on and so forth.

WHAT IS THE GOAL WITH KIPPING?
So what is the goal? If we put our clinician hat back on and we think, what is the goal with our athletes? Really the kind of the question we're answering in our mind, and when we ask questions like, how many strict pull-ups is enough? What we're really asking is, what level of strength in the shoulder begins to be protective of injury? And the answer we don't wanna hear is that it depends. And what does it depend on? It depends on that athlete's history, right? Somebody who has been performing a lot of strength training for a very long time that comes into a CrossFit gym or a gym where they might be doing kipping movements, that person has a lot less concern for the momentum on the shoulder or the momentum on any other joint in the body, right? We could say the same thing about runners, right? That person comes in with a higher what we call training age and therefore less worry about the capacity of that person's body as we begin to produce and create momentum with it. So the answer is, it depends. We can't say one strict pull up is enough. Five is the minimum. 13. Is five safer than one? Is 13 safer than five? It depends on that athlete. It depends on their training age. If they have never done any sort of vertical pulling, exercise, then we're just a little bit more concerned, right? We want to see that person begin to develop that strength. We'd love to see that person get one strict pull-up. We'd like to see them continue working on it. The answer, at least in our gym and the way that we coach, is that you should always be working on your strict gymnastics. You should always be doing strict pull-ups. You should always be doing strict handstand push-ups. We had a workout just last week with a bunch of strict pull-ups, and I coached it, and I was very, very adamant. Do not kip these. Do not use a band to kip these. I want a strict pulling stimulus today. If you can't do strict pull-ups, here are the scales that are going to help you get a strict pull-up. We're not going to bypass the strict training stimulus just to be able to go faster. If you can't go faster with strict work, we need to scale and work on that strict work. The other thing is, anecdotally, if you work with these athletes in a gym or you work with them on the patient side as a clinician, having a super high strict pull-up capacity does not guarantee high quality kipping pull-ups. That person who comes in who's been doing lat pull-downs and strict pull-ups for 30 years They can do a ton of pull-ups, but their kip probably needs a lot of work. What we see is opponents of kipping don't kip, and so they don't interact with individuals who do kip. And so we begin to develop this false belief that being able to do 10-strick pull-ups guarantees large, high-quality sets of kipping or butterfly pull-ups, which is completely unfounded. We all know that athlete who can jump up on the bar and do 10 or 15 or 20 strict pull-ups in a set, and then we ask them to, hey, try kipping those, and you're like, oh, God, what's happening, right? You are just swinging around on the bar. So just having the strength doesn't necessarily guarantee the technique that's going to lead to efficiency in that movement. So the truest answer is we always have to be working on both. When it's time to do strict work, strict pull-ups, strict handstands, whatever, we need to be doing those strict or finding a scale that allows us to progress to strict, and when it's time to allow momentum, kipping pull-ups, kipping, handstand push-ups, toes-to-bar, whatever, we need to find maybe also scales there, even if the person has the strength to do them in an ugly fashion, that allows the development of the technique, so the person that can do 10-strip pull-ups is somebody that goes on to be able to perform very large sets of high-quality kipping or butterfly pull-ups or toes-to-bar or muscle-ups or whatever. So once someone has demonstrated that they really have that functional shoulder strength, we need to recognize that they're naturally going to increase the volume of vertical pulling, and it's slowly going to ideally increase over time. And at that point, we're really dealing with an issue of volume management, we're no longer dealing with an issue of foundational shoulder strength, that person has the capacity to do strict work. Now we just need to carefully watch that person's volume, making sure that when they begin to develop kipping pull ups, they can do sets of five, they don't decide to help themselves to a workout where maybe they're doing 150 pull ups in a workout or 200 pull ups in a way that Volume is now the concern for the shoulder and not necessarily the foundational strength.

SUMMARY
So where's kipping at in 2024? The same place that has been for 128 years. There is a lot of public facing information out there that is confusing to our athletes and patients of how to get better. how to work on these for performance, how these can improve your performance in the gym, but also an equal amount of information on why these are dangerous or deadly or detrimental to your fitness progress. So understand the concerns that your athletes and patients are going to have when it comes to the KIP. Know that on the clinician facing side there is almost no research for or against kipping. We have just one article that looks at muscular activation patterns between strict pull-ups and kipping pull-ups and shows that when we kip we reduce the demand on the shoulder a little bit and increase the demand on the lower extremities in the core. Understand really fundamentally what we're looking at with kipping. We're just looking at momentum transfer and that we do this in a wide variety of movement patterns away from the gymnastics bar in the gym. Yes, we can kip pull-ups and toes to bar muscle-ups and handstand push-ups, but we also kip when we stand up. We kip when we transition from walking to running and jumping in the pool and swimming and so on and so forth. What is our goal? Our goal is always the pursuit of as much vertical pulling strength as we can get. So when things like strict pull-ups show up, things like strict handstand push-ups show up for vertical pressing, we need to make sure that we're working on strict work and not bypassing the foundational strict work with kipping just because we can't do the strict work. What's the answer to how many strict pull-ups is enough? Two answers. Strict work does not guarantee performance, efficiency, safety with kipping, but also you can never be strong enough. So always continue to work on strict pull-ups, even once you develop kipping pull-ups. And even once you believe that your kipping pull-ups or butterfly pull-ups or toes-to-bar or whatever are in high capacity and high quality, you're still working on that fundamental strengthening of the shoulder because we know Strengthening is protective of injury. And understand that once someone develops the strength work and begins to kip, we're not really dealing with a volume management issue. We're dealing with maybe the future potential development of a tendinopathy, not necessarily a lack of functional shoulder strength once that person can do a couple of strict pull-ups. So I hope this was helpful. I know it's a very contentious area across the functional fitness space. Happy to take any questions, comments or concerns you all have thrown here on Instagram courses coming your way from the fitness athlete division. Our next level one online course starts April 29. Our level two online course starts September 2. and then we have a couple of live courses coming your way before summer kicks off. Mitch will be down in Oklahoma City on April 13th and 14th. Joe will be up in Proctor, Minnesota on May 18th and 19th. That same weekend, Mitch will be out in Bozeman, Montana. The weekend of June 8th and 9th, Zach Long will be down in Raleigh, North Carolina. And then the weekend of June 21st through the 23rd is a really special weekend. It's our Fitness Athlete Live Summit here in Fenton, Michigan. We'll have all of our lead instructors and teaching assistants here. So Zach will be here, Mitch, myself, Joe, we'll have Kelly, we'll have Guillermo. We'll have all the fitness athlete crew here for a special offering of Fitness Athlete Live at CrossFit Fenton. So I hope this episode was helpful for you all. I hope you have a fantastic Friday. Have a wonderful Easter weekend if you're celebrating Easter. We'll see you all next time. Bye everybody.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses pursuing mentorship with individuals who are not too far removed from your current situation so that they can best understand your needs & optimize a path to facilitate your growth. Jeff argues that often, individuals seek mentorship from those so far removed that they can no longer understand what it is like to be in that situation or the steps needed to continue to see growth.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

JEFF MOORE
All right crew, what's up? Welcome back to the PT on ICE Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of ICE and always thrilled to be here on a Leadership Thursday, which of course is a Gut Check Thursday. The open is over. We are back in business with Gut Check Thursday and we've got a doozy. We've got every two minutes, you're going to do 15 calories on the bike, and then you're going to do as many thrusters as possible in the remainder of that two minute time period. at the weights of 135 for the gents and 95 for the gals. Then you're going to keep repeating that, right? Every two minutes you've got to get your 15-12 cal on the bike done before you start knocking out thrusters. The workout is over at 30 thrusters. I just did this the other day. I finished in the 7th round, 13 minutes and change. It's rough. There's not a lot of rest by not a lot I mean none. Think about scaling that weight if you're not getting over 5 reps in those first rounds. If you don't feel that's doable, maybe knock a few pounds off or you might be there. for a while because that bike only chews up more time as you get more fatigued. So give that a bit of thought. It's a wonderful workout. Make sure you tag us, Ice Fisio, Ice Train. Love watching you do all these workouts and sharing them across our social media platforms. Team, welcome to Gut Check Thursday. Welcome to Gut Check Thursday and welcome to Leadership Thursday. where I want to share a huge hack on mentorship that I think is so underappreciated. So the title of today's episode is Optimization via Degrees of Separation. Speaking of mentorship, and the hack that I want to share with you is how to recognize who you should learn from and who you should be teaching. An area that is incredibly plagued by low intention. The organization of that is not something people give a ton of thought to. It's plagued by low intention and one very common mistake.

A COMMON MISTAKE OF MENTORSHIP: FOLLOWING THE LEADER
So let's open with that common mistake. The common mistake in this, in the space is that most people think they want to learn from the star player or the leader of the organization or the person who they recognized that brought their attention to that area. They think they want to learn from that key person. You almost never do. Who you, you might want to work in their system, right? Like that absolutely makes sense. You might want to move towards their position. That totally makes sense. But who you want to learn from is very rarely that individual. You want to find someone who can over deliver for you and it will almost never be that person. The principle that we're talking about in today's episode is that you can talk across a river, you can yell across a lake, but you can't hear each other across the ocean. What I mean by that is the farther apart you are in knowledge and experience, the less effective the mentoring relationship. Now, the classic example here is when somebody says, oh, I had this great physics teacher, right? They were brilliant, but they couldn't relate to us. They couldn't teach as well as entry-level students, okay? This is not because of their intelligence. Generally, that's what it's blamed on, right? This person was too smart to be able to relate to us. That's almost never the case, right?

SEPARATION FROM LEARNING PREVENTS SOLID MENTORSHIP
It's because of separation. So many kinds of separation that make it more like an ocean than a river. Examples of that separation are the amount of knowledge this person has. That is not so much speaking to their intelligence, but they have simply accumulated a tremendous amount of knowledge over so many years that they can't understand anymore what it's like to look at a new concept in the absence of having that knowledge. because they have so much and they've had it for so long. They can't remember what it was like not to have it and what trying to learn a new concept feels like in the absence of it. They simply cannot put themselves back in that position. They can't relate to your phase of life. They can't remember what it was like when their other parts of their life beyond the professional stuff looked and felt like yours does because theirs looks nothing like that anymore. Other responsibilities. These people, that physics professor for example, is thinking about their research. They're thinking about building their team right well above and beyond the classroom. There's other areas that not only have some of their attention but arguably probably have more of their attention because as they've gained seniority that is where their unique role is probably most dependent upon. So that's what they're thinking about all the time. It's where a lot of their focus is. But when you add in all of these degrees of separation, the amount of knowledge, the phase of life, all these other responsibilities, that's what creates the ocean. And getting across that for a quality mentorship relationship is simply impossible. I can give you a personal example of this. My most effective phase of teaching physical therapists how to get better at physical therapy was when I was in the clinic about 25 hours a week. That was the sweet spot. I remember being in that sweet spot. I was one degree of separation. away from the people I was teaching. Yet, I had enough time out of clinic that I could mold and form my course and put good intention into the content That was the sweet spot. I was just removed enough from full-time clinic that I could really craft the message, but I was in it enough and I was still in phase of life enough that I totally understood exactly what these people needed to hear and what was going to have the greatest impact. When my role in the company shifted, my ability to teach clinical content noticeably declined. Oh that's better that's better because it just they had all the antidotes you could feel the fact that they just faced the same problem it was so much more relatable all the small changes in the profession they were in in and are in lockstep with and you could just feel the real. And that made it come across so much more applicable and so much more relatable. So I noticed as I began to move away and get a bit more separation, my ability to relate and be effective was significantly altered. This should guide you. This principle should guide who you look to for mentorship and who you look to mentor. You want the person who was where you are two to three years ago. That's the sweet spot. When you get in this organization you're excited about, you do not want to learn from the most veteran, clinician, person, team member.

REACH UP THE LADDER BY ONE RUNG
You want to learn very specifically from the person who was where you currently are two to three years ago. That's the sweet spot. So don't get enamored on trying to maybe look at it as reaching up, right? And try to make that relationship. You really want to reach up, but just one ladder rung, because that's going to be the river. That's going to be the most effective communication mentorship relationship. Now, similarly, you want to teach people who are only two to three years behind you. who are in situations that you very recently were in. So give that some really serious thought, right? Is there somebody you're currently teaching leading that really you should be passing that off to somebody who's a bit more closely connected to where all of those different components in that person's life are existing? Have you been hanging on to some relationships too long, or does the system need to be reshuffled where you're a bit more intentional about that time domain when you're looking at these mentoring relationships? This is not, by the way, just true in professional or clinical practice, right? It's true literally everywhere. Think about it in the gym. The athlete who just learned muscle ups is often the most effective person at helping you get your first one. Why? Because when you ask the person who knocks out 12 to 15 unbroken without thinking about it, that last part's the problem. They don't have to think about it, right? So it's very hard because they kind of say things like, I don't know, man, I just do it, right? Now don't mishear me. There are some amazing experienced coaches that have a truly unique ability to still break it down for you. But there is something to be said that once it gets so natural, once it requires so little thought, it's a bit tough to instruct somebody who is just learning their very first one. It is so true in music, right? When you're learning the guitar, somebody who just mastered their scales is an amazing person to show you how to sit and how to hold the guitar, the fundamentals. Because again, the person who has true virtuosity is going to say things like, dude, I don't know, man. I just kind of feel it out, right? I can play it by ear. Well, cool. I can't. So right now I need somebody who can understand what it's like to not be able to.

EVALUATE YOUR MENTORSHIP SYSTEMS ON A DEEPER LEVEL
My call to action for all of you on Leadership Thursday is to begin to evaluate your mentorship systems using the one degree of separation rule. You want people teaching people who were where the learner is just a couple years ago. When you go into a system, don't think it's awesome to learn from the person who's been around the longest. Think it's awesome to learn from the person who most recently solved your specific problem. And that person was where you are two to three years ago. Change these mentorship relationships from a time domain and you will drastically alter their efficiency. Give it some thought team. We are off for Easter weekend and then we are coming back with 13 live courses next weekend. all over the map. Actually the next couple weekends we've got about a dozen or more courses on tons of spots to check out PT on Ice live classes. Go to PTOnIce.com. You'll see them all right there. April 6th, 7th, the following week. Tons of options. Wherever you are, we probably are. Jump into all the fun team. Have an awesome Thursday. We'll see you next week.

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

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses loading the lumbar spine in all planes as part of a judicious rehab plan, including anti-flexion, anti-rotation, and anti-sidebending exercises. Brian shares a progression sequence beginning with plank-based loading that advances to using external resistance, and culminates in intentionally loading the spine in suboptimal positions.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

BRIAN MELROSE
All right. Good morning, PT on Ice Daily Show. My name is Brian Melrose. I'm one of the lead faculty in the spine division, teaching both cervical and lumbar courses. I'm really stoked to be back here on a clinical Tuesday to talk about loading the lumbar spine in multiple planes. And where that really comes from is I was back in Windsor, Colorado. I was at the extremity management course. And I was listening to Lindsey Hughey talk about loading the rotator cuff. She was kind of discussing the idea of loading in different positions, loading in different speeds, and varying loads. And as I'm sitting there and I'm kind of marinating on the idea of loading in different planes and speeds, I thought to myself, why would the lumbar spine be any different? And what if we approached kind of loading the spine through that lens?

SPINE RESILIENCE IS MULTI-PLANAR
And so when you begin to think about how to make a comprehensive exercise program for individuals where you're building resiliency in the spine, we have to consider that multi-planar approach. So something that would stress the spine into flexion, something that would stress the spine into extension, something for side bend, and then something for rotation. And so a full comprehensive exercise program would look like at least four exercises. And after that course, that's really when I started messing with this concept in the clinic. And it's been really helpful for a couple different populations. Number one is individuals that have had more chronic pain and you're just trying to introduce exercise overall. I think jumping to things like, you know, the deadlift or a squat with a barbell can be a bit much for them. And so it's a great way to start with some exercises and kind of progress them towards using weights and resistance. The other place where this is helpful, though, is when irritability is high. If you've been to any of our courses, we talk about how your interventions need to mirror the patient's irritability. When the irritability is high, it may not be appropriate to have them using external resistance. It may not be appropriate for them to be loading at heavier loads. And so usually I like to start things, again, in a multi-planar sense with body weight and then move more towards dynamic movements. And the last population, where I think this concept helps a lot, is for individuals that are higher-end athletes, or folks that are already kind of squatting or deadlifting multiple times a week. I know for me, that's a big issue with my powerlifting patient population and other skilled Olympic lifters and crossfitters. When they come into the clinic with back pain and I want to offer them some exercises that make their spine more resilient, they're already loading the spine with the deadlift and with the squat a couple of times a week, my window of opportunity really begins to shrink just in terms of the type of exercises I can do with them. And so really, I think that's where we have to identify kind of like a smaller lane in which we're going to intervene and bring some new stress to the spine. And so for a lot of my power lifters, I like them to begin to consider loading into planes of side bend, like so frontal plane, transverse plane, looking at side bend and looking at rotatory movements. And so if we can kind of extrapolate this idea, then I want to kind of shift towards talking about what those exercises actually look like. And so I really like to begin, folks, in this space with doing a series of planks. And so I'm going to talk through a lot of different exercises in the next couple of minutes here, 12 in total, four, four, and four, and kind of describe how and when each of those are advantageous. But if you're looking for what those exercises look like together, go ahead and head out to just our Instagram page and there's a nice reel on there where you'll see all these exercises kind of grouped together. So where do we start? Well, you know, if you've been to an ice course, you know that we want to eventually get to loading a little bit. It doesn't have to be a barbell, but something with some resistance.

PHASE ONE: PLANK-BASED LOADING
And so usually the first phase of this for me, level one is going to be more plank based. And so I'm thinking of getting the athlete or the patient in a position that's pretty optimal for them in terms of it being a neutral spine, them just being able to maintain that position and not have heavy loads on board. And so level one typically starts for anti-flexion. I like doing a Chinese plank. And so typically you're just going to elevate your heels and your shoulders on boxes or chairs of equal height to be benches in the gym. You can even place a dumbbell over the hips, which is going to introduce a little bit more of a flexion stress. as gravity kind of pulls the athlete down. They can do a longer hold here. It's a little bit like an isometric. Again, if irritability is high, this is a great place to start if they can't hinge over and grab a kettlebell or grab a barbell for a deadlift. So anti-flexion, the Chinese plank. For anti-extension, what we like here is getting a pull-up assistance band looped over the J-hooks of typically the squat rack. And I have the athlete kind of slide underneath that band and place it right over the lumbar spine. In a normal plank position, that's then gonna pull the lumbar spine down towards the floor into an extended position. And so they're gonna resist that. And so we get a nice anti-extension exercise. For side bend, all you're gonna have that person do is just flip over to their side, still underneath the band, and they're just gonna scoot it down from the lumbar spine down to the iliac crest. In this position, again, now the band is pulling the hips down towards the floor and they're resisting that, so it's an anti-side bend stress. The athlete or patient would have to get both sides there. Last is anti-rotation and I love defaulting to the nice old classic payloft press. I like loading this up pretty heavy with those bigger pull-up assistance bands. Loop it around the rig, get your feet nice and narrow and it's a great way to just start to kind of get an athlete or again a patient that isn't doing a ton of loading in the spine familiar with some of the muscles and some of the stabilization positions that they'll be seeing later on in the plan of care. And so again, as rudimentary as it is, I love the payoff to partner with some of these plank exercises. And again, neutral spine location, a little bit of body weight, a little bit of band stress. This is a great way to kind of initiate things for a lot of our folks in the clinic.

PHASE TWO: LAYERING IN EXTERNAL RESISTANCE
Level two is really where I like to kind of again, take it up a notch. We're now going to keep the spine in an optimal position, still hanging out again in a neutral brace spine, but we're going to add some external resistance. And I think this is a big step for a lot of our folks. Again, we can't leave them at bands and body weight. We have to progress them to getting their tissues stronger. And the only way we're going to force that adaptation is if we begin to load. And so again, I think this is a good step. Even when irritability starts coming down, we can begin to load in this area. So our first anti-flexion exercise in this level two is gonna be just a kettlebell deadlift. And so for our individuals that are a little bit, you know, getting more inexperienced in the weight room, it's a great way to get their hands on some weights, get them comfortable with some movement patterns, and again, stress the spine into a more flexed position. For higher-end athletes, they may not be able to tolerate the barbell at this stage as they kind of rehab an injury. And so the kettlebell allows them to get in the gym, do a little bit of work in a familiar sport-specific spot, and get the job done. So love the kettlebell deadlift for our anti-flexion exercise. For anti-extension, I want to kind of get a little bit more vertical. And so for my Olympic weightlifting athletes, I want to start working and challenging the spine for overhead positions. And so anti-extension for level two is going to be a tall kneeling overhead press with the band where the band is kind of fixed behind the athlete. And so as they come up all the way overhead, the band will pull them into extension and they're going to have to stay nice and braced. So again, we got flexion, we got extension. For side bend level two, we're going to go with a heavy kettlebell suitcase carry or march. And this is the one where I think we kind of underdose and don't load up nearly enough. And so for this exercise, I have them get a big kettlebell, stand as tall as they can. We don't want to lean. We don't want it to look like we're holding a heavy weight. And that may be enough of a stimulus for those athletes. They can feel the opposite side, again, stabilize. If they can progress towards doing a standing march or even a step up, a suitcase walk, those are all great ways to, again, challenge the spine in that side bend position. Last is rotation. And again, if you've been to an ice course, you know that we love the bird dog row. I think people underestimate how difficult this exercise is. And so again, if you're looking to see what that one looks like, head over to the Instagram post, but you're going to assume a bird dog position on top of the bench. The bottom hand is going to reach down and hold the weight. Usually start folks somewhere around 20 to 35 pounds, and then progress them all the way up to a good 40, 50 pounds here. If the athlete is in that position, as they lower, that's gonna put a lot of rotatory force through the spine, and so we begin to, again, stabilize in an anti-rotation position. If your athletes are looking pretty good with this one, the only add-on I got here is do a faster drop. If you try that, you get this big rotatory moment, and the athlete is gonna have to really work on stabilizing the low back. And so level two looks just that way. Kettlebell deadlift, tall kneeling extension overhead with a band, we got the bird dog row, and then last we have that kettlebell march is typically what it ends up at. For a lot of our folks, this may be enough of a stimulus to get them again loading their spine and moving in optimal planes, but the job is not done yet.

PHASE THREE: LOADING THE SPINE IN SUBOPTIMAL POSITIONS
The last piece is I think we have to begin to load the spine in suboptimal positions. So maybe we reduce load for that consideration, but when people tend to agitate or irritate their back, it's sometimes doing lifting, but a lot of times it's doing those everyday things. It's reaching underneath the hood of the car, reaching into the back seat. bending to put your child in the car seat. Whatever it is, you're probably not in a perfect neutral spine position most of the time. And when we work with our patients on getting them confident and comfortable loading the spine, I don't want to create this idea of fragility outside of neutral. And so I think if we're going to get our folks all the way to the finish line on this one, our last piece has to be a challenging level three, four group of exercises to challenge in all planes, but have folks start moving through a range of motion with load on board. That's how we get full resiliency. And so the last group of four exercises here, is going to be starting with an anti flexion movement. But this time, there's going to be a little bit of flexion on board. So the spine stays straight with a kettlebell swing, but we're hinging at the hips quite a bit. And every time that heavier kettlebell comes down, there's a pretty good flexion moment. And so I love to integrate this for a lot of my athletes that deadlift and even squat regularly, but aren't doing more of a dynamic, volumized stress to the back. A lot of my powerlifters, you give them a kettlebell and they get smoked in about 10 reps. So females go heavy, 53. Males, 70 if that's appropriate. If not, we'll drop those down to 35 and 53. But a good kettlebell swing can really challenge the spine in that flexion position. For extension, I love the Reverse Hyper. Jordan did a great reel a couple weeks ago, kind of breaking down the value of the Reverse Hyper, as well as different ways to modify it for different athletes. We have one of those Westside Barbell Reverse Hypers in the clinic. And again, this is my go-to for loading the spine into a more extended position. It pendulums down, but then as the athlete kicks up, we're not just going to neutral, we're going all the way into extension and really challenging the tissues in a new position. So we got flexion, we got extension. What about rotation in this group? Well, I like the barbell rotation. So typically it's going to be set up kind of more like a landmine position with the athlete standing tall. You can put a plate on there. I usually like starting folks anywhere from 10 to 25 pounds and work them up to 45 and they're just going to rotate from hip Again, if you haven't seen that one before, check out the Instagram post. There's a good demo of that. And this can really begin to challenge the back in some different spots, right? We're rotating up and down. You're getting a little bit of hip shifting. The obliques are starting to work. This is a very challenging exercise for a lot of our athletes. The last thing would be doing side bend. And I don't have a good name for this exercise, so I just call it kettlebell smiles. But you're going to have the athlete get back in that suitcase hold position, and they're just going to dip from one side all the way to the other with load on board. If you haven't tried this one before, again, it's going to feel a bit funky, but it really challenges the lumbar spine throughout the range of motion of side bend. And so typically, if you've got an athlete, again, towards level three, you've really given them that gift of fitness that we always talk about. At that point, I think they have a good, robust program where they have a group of exercises that challenges the lumbar spine in all planes. If things get irritable, they can always default back to level one. They can have a nice steady training stimulus once a week with level two in terms of some resistance on board, but staying in an optimal position. And then once a week, maybe they dance up and begin to load the spine in some of these ranges of motion. And I think if we can give all of our patients that have lumbar spine pain and are looking to get a stronger back, these kind of group of exercises, they tend to just progress much, much better than someone that's only doing deadlifting. The deadlift will always be king in terms of exercise, but our patients that get these groups of exercises, we give them that window that they're missing and we can get a lot more resiliency in the spine. So check out that Instagram post for more details. Um, hopefully this was helpful. Um, I'm going to keep piggybacking on this concept and do probably another podcast in a couple of weeks here. I'm talking about considerations for loading everything from volume and dosage to working at different speeds and even considering fatigue. Cause I think that's where I want most of our patients that have had either chronic or ongoing back symptoms to be resilient is when they're gassed. Because that's when things get a little bit sloppy. So we'll be getting those topics in the future. I hope you guys all have a wonderful Tuesday morning. Thanks for joining us. We got a couple courses coming up in the next couple weeks here. We got cervical out in Carson City, Nevada. Zach Morgan will be out in Hendersonville at his home turf. So check those things out. And again, I hope you have a great morning. Thanks for joining.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses how to close the pelvic floor knowledge gap through education in the community, prior to an individual needing formal pelvic PT.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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

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

EPISODE TRANSCRIPTION

APRIL DOMINICK
Good morning, PT on Ice. My name is April Dominick. I am Ice Pelvic Faculty and your host this morning. Let's chat about how PTs can close the knowledge gap when it comes to basic pelvic floor education in the community. Essentially, I'm presenting a case for how we can use a prehab framework to educate individuals prior to the onset of pelvic floor dysfunction, or them requiring formal PT. What really gets my knickers in a knot is how uneducated we are as a society about our bodies. It blows my mind, all of the incredible systems that are happening in our body, like breathing, pumping blood to muscles and organs, filtering through nutrients to store stool and urine. All that's happening in the background right now while you're listening attentively to me on this podcast. All is fine and dandy with those processes until one day it's not. Until one day you're listening to your friend who is a singer and she tells you that her pessary, the device that she inserts into her vagina to support her bladder, fell out on stage. while she was singing her solo for her opera. But she's never heard of the pelvic floor muscles or pelvic floor muscle training, which can also support her bladder. Or the baseball coach who's two years post-prostatectomy and now struggles going to work because he leaks pee when he's yelling out plays to the players. or when he's demonstrating a new sprinting strategy to the team. Does he know that just because he doesn't have a uterus, he also has a pelvic floor too? An entire group of muscles that he can voluntarily control to help him not leak when he's yelling or when he's running. We are undereducated about our bodies. There is a massive gap in knowledge when it comes to the pelvic floor and treatment options or associated risk factors with pelvic floor dysfunction. This gap in knowledge could be the difference between someone getting surgery or avoiding it due to prior knowledge and doing conservative care instead. Zooming out on a larger scale, I got to thinking, what role do we as PTs have in teaching individuals in our communities about the pelvic floor and any related pressure management systems before they reach the point of needing to come into our office for formal PT or surgery? Given that the rates of pelvic floor dysfunction rise with age, there's so much power to potentially reduce function, such as urinary leakage, simply through pelvic floor education at any age, at any stage in life. So that parents feel comfortable educating their kids in this space. So that grandma Betty can advocate for herself and ask for specific treatment options for painful intercourse that she learned at a talk at her community rec center. And so that Sam feels empowered to talk to their coach about leaking and lifting. One issue that's related to pelvic floor dysfunction is intra-abdominal pressure, or IAP. It's defined as steady state pressure that's concealed within the abdominal cavity, and it's created from the interaction between the abdominal wall and the viscera. It tends to fluctuate with our respiration phase and the abdominal wall resistance. the pelvic floor muscles are essential for the maintenance of this intra-abdominal pressure, as they lock shields with other muscles in the core canister, like the diaphragm, the abdominals, all to support this dynamic pressure system. If you think about it, life is a series of fluctuations in intra-abdominal pressure that affects all humans. One minute, the pressure may rise with a sudden sneeze or jumping, or it may lower to a different level when standing up from sitting, and then it may swing back up if someone is on the toilet pooping. So the ability to manage those pressure changes will differ depending on the human, depending on their relative capacity and knowledge and understanding of this pressure system. It doesn't matter whether they're a young gymnast, an older adult with low energy reserve, or a two-year-old potty training, or a yogi mom of three kids. All of those individuals are subject to changes in IAP, no matter their age or stage of life. The input IAP is the same for all of us, but we have this really beautiful ability to turn it into different outputs. We could use that IEP to manage lifting a grand kid overhead. We could use it to laugh at April's podcast this morning, to score a goal or to nail a note in a song without a pessary falling out. Education on interabdominal pressure management as it relates to pelvic floor dysfunction is not a major focus in performance, in athletics, or in life's education either. So I propose it's time for an intervention or a PT prevention intervention, if you will, So let me use the example of urinary leakage or urinary incontinence, aka UI. I'll use that as an example for pelvic floor dysfunction. UI can arise in the presence of poor intra-abdominal pressure management. A staggering 50% of female adolescent lifters leak when they are doing their sport. And that leakage, can be a barrier to entry or a barrier to continue with exercise or their sport, as well as a distractor during training and competitions. Taking it one step further, the lack of knowledge of the pelvic floor contributes to inadequate management of IAP, as say someone's lifting a heavy barbell. This lack of knowledge influences the development for pelvic floor dysfunction for some. A 2018 observational study by Cardoso and colleagues aimed to determine the prevalence of UI, urinary incontinence, in female athletes practicing high-impact sports. They also wanted to know what's the association of UI with knowledge, attitude, and practice. In their study, they found that 70% of their athletes reported UI, and none of them told their trainer about this dysfunction, and none of them sought PT care. Talk about a missed opportunity. Participants were also unaware of the positive association between high-impact sports and the development of UI. The authors found that an individual had a 2.7 times more chance to develop UI if they practice their sport for more than eight years. And this piece of information is key not only for the short term, but also for the longterm in someone doing athletics for that long. However, there was one saving grace. And that saving grace to the development of pelvic floor dysfunction was adequate knowledge of urinary incontinence. So in the study, if an individual had adequate knowledge of the occurrence of urinary incontinence in sport, then they had a 57% lower chance of developing UI. 57% chance of lowering the development of UI if they had adequate knowledge and that's just education alone. What a huge difference that can make. So in the conclusion, the authors, they called for a greater dissemination of knowledge and preventative practices for UI in sports in order to decrease the prevalence of urinary incontinence and increase adherence of young athletes to sports practice. So many individuals, some of us included, avoid talking about urinary incontinence with teachers or coaches due to shame and embarrassment, coupled with a lack of knowledge about the condition and treatment options that are available. Instead, individuals will suffer in silence. They'll spend a ton of money on protective pads, they'll restrict hydration, and some will even avoid exercise altogether. Y'all, this, this is a coaching problem. This is a teaching problem, this lack of knowledge about pelvic floor dysfunction. When the athletes in the Cardoso study were asked about whether trainers should discuss the topic of urinary incontinence, a majority agreed that the trainer should encourage prevention. But how? How can they do that if trainers or coaches aren't even educated on pelvic floor dysfunction? Research supports positive effects of education alone when it comes to improving pelvic floor outcomes. So what's needed? I believe education is needed at the community level. PTs have a unique role in teaching about the pelvic floor and intra-abdominal pressure management that could be directed either to trainers or to fine arts teachers like vocal coaches or to athletic coaches or even to the athletes themselves. This could potentially allow for the reduction of instances of pelvic floor dysfunction, as well as maybe some PRs because now they understand, oh, I have this whole group of muscles to help me, or more efficient performances where the person, the singer, the theater major isn't fatigued because they know how to optimally utilize their IAP system. Athletes and performers are not the only individuals, though, who deserve this basic pelvic floor education. The general population does, too, as it relates to their IAP management with daily functions like we talked about before, lifting the grandkid, running, sneezing, we need more pelvic floor community workshops and in services at music or dance classes in the community, in collegiate team meetings, or silver sneaker programs. These programs could potentially reduce urinary incontinence and pelvic floor dysfunction at any age or stage to allow for improved quality of life and a shame-free environment in which folks are encouraged to discuss pelvic floor dysfunction with their teachers, their providers, their friends. Furthermore, PTs can also educate on an instance that may come up, which may signal, hey, I think pelvic floor PT would be more dialed in and you could get some gold standard pelvic floor muscle training because this general education didn't work. So in a 2018 systematic review, Fonte et al and colleagues identified five risk factors for lack of pelvic floor knowledge. Number one, educational level. Number two, access to information. Number three, socioeconomic status. Number four, age. And number five, race. So community talks could focus on these populations in order to narrow the knowledge gap. I urge you to consider the role of educating your community, whether it's the grandma buddies, the baseball bends with the prostatectomy, as well as performers and athletes at any age on the pelvic floor, particularly as it relates to management of the intra-abdominal pressure, something that we all experience changes in moment to moment.

SUMMARY
So if you're looking for more opportunities on how to optimize your pelvic, your client's pelvic floor or folks in your community through breathing and bracing strategies, check out our upcoming live courses. We've got two I'll talk about. One is April 6th and 7th in Windsor, Colorado. That's gonna be with Alexis Morgan and myself. Come on out and learn with us. Another opportunity is the following weekend, April 13th and 14th, and that's gonna be with Christina Prevett and Rachel Moore down in Houston, Texas, my home state. And our next available 8-week online cohorts that aren't sold out yet, but you can still sign up for, are Level 1, it starts April 29th, and then Level 2, that one starts August 19th. Head to PTOnIce.com to sign up for those courses. Thank you all so much for listening, and I will see you all next time!

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

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras dives into all things split squats and shares its utility for improving lower extremity strength asymmetry. Also discussed: progressions for the most novice up to the most advanced of athletes and clients in the clinic and gym

Whether for the quads, glutes, hamstrings, the split squat is one of the exercises we “love to hate” most

Take a listen to the episode or check out the show notes at www.ptonice.com/blog

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

EPISODE TRANSCRIPTION

GUILLERMO CONTRERAS
Here we go, gang. Thank you so much. Sorry for the little bit of a delay. Had some technical difficulties all morning for myself dealing with some stuff here on the back end. But happy to be with you here on the PT on ICE Daily Show on the best day of the week, Fitness Athlete Friday, the day where we talk all things fitness athlete, loading progressions, getting strong, getting fit, all the good stuff. We are today talking about split squat science. And it's more of the applicability of the science of the split squat more than going into the deep, deep nitty gritty about the split squat. And the reason for this topic today is many times in the courses of the fitness athlete, whether it be the L1, L2, or even in the live courses, when we are breaking down movements like the back squat, like the front squat, movements that we tend to use in the CrossFit realm more than anything else, movements that we really preferentially push towards to get maximum loading of bony tissue for bony adaptations, muscle tissue for strength gains. The squat is how we're going to do it. However, when we're breaking down the movement pattern for the individuals in our courses, or the individuals in front of us, or our athletes and clients, many times we're going to see some deficits. We're going to see some asymmetries, whether one leg is just not pushing as much as the other, one leg caves in, whether one quad or hamstring or glute or whatever it may be is more developed than the other due to a previous history of injury. as well as also just when someone tends to shift and put more weight into one side versus the other. There can be a myriad of reasons for it. We don't know what's going on. That's why we want to assess things and not just assume anything. But once we get through that assessment phase, Bam! That's when we can see the benefits of some single leg work to improve leg strength deficiencies or asymmetries. And this topic is brought on by a recent study in 2023 that came out looking at leg strength asymmetry in basketball players. So strength asymmetries as well as the ability to kind of change direction quickly. And what they did in that study is they found that a three-to-one non-dominant-to-dominant strength training program was optimal, I could say, or they worked really, really well to improve that asymmetry in one leg versus the other. And one of the movements that they used in order to load individuals as well as kind of uncover where the weaknesses were was the loaded Bulgarian split squat. For those unfamiliar with the Bulgarian split squat, I am simply in a lunge position here. I'm away from a surface I can put my foot on behind me. So I step up as I'm going to do a lunge. My foot goes up on a bench or a box or something elevated behind me. I then hold a barbell or dumbbells or kettlebells, whatever it may be, on my back. And I simply go down, tap the knee, and then drive back up. It's a fantastic movement for doing unilateral loading of the quad, hamstring, glute, And depending on your foot position, you can actually preferentially load one tissue over the other. For example, if I want to really hit that quad for an athlete who really needs it, and they have adequate ankle mobility to be able to do this, what we do is we narrow that step so we don't make it as far of a step out, and we encourage that athlete to really dive straight down into that split squat with that knee going over that toe just slightly more, and then drive back up. You will feel a massive quad pump when you are through a set with a slightly more narrow stance. If you want to preferentially hit the glute hamstring, we go a little bit further, and we allow that individual to bring their torso, to tilt their torso forward a little bit more. So as they go down, their torso can tip forward, thinking like a low bar back squat or something like that, and you get a lot more of a stretch pulled on the glute and the hamstring, as opposed to that really upright torso. You're thinking when you would use that further one for more glute hamstring, high hamstring strains, really getting that deep end range of hip flexion towards the bottom there, your quadripatellar tendinopathy for that more narrow stance, we're trying to load that up and build strength there. In the study, they used 65, 75, and 85% of 100 max, and they were doing I believe 10, eight, and six reps at that heavy weight for that single leg. With that said, right now we're really familiar with the Bulgarian split squat, and if you've done it before, you know that you hate it, like you love to hate it. It feels awful to do, it's difficult, but it's a really, really beneficial movement, really beneficial strength exercise. Truth is, the majority of our clients, if we're dealing in general population, not just fitness athletes, we wanna be able to use this same exercise, but we wanna be able to bring it down to the lowest common denominator.

SCALING THE SPLIT SQUAT
How can I scale this movement down to the easiest form and make it even harder than that Bulgarian split squat we just did? And that's where we're gonna go here. First and foremost is just a standard split squat. Have the individual stand in place, one foot forward, one foot back, have them drop that knee down, tap, and then back up. It's as simple as that. For my older adults, when I'm working with them, and they struggle with even getting to that point, I will stack, what are those, Eric's mats, Eric's pads, whatever it is, or handstand push-up mats, or sorry, ab mats, under their knee, and have them just get a target, right? That way they know every time they go down and tap their knee on that pad, they come right back up. And then we can progress that by removing layers of weight. Can we take one away, have them go a little deeper, take one away, have them go a little deeper, and progress that further and further. Once they are comfortable with that, can we now increase that split squat range of motion even more? If they're tapping the ground with their knee and coming back up, can we now create a deficit? Because we know with the squat we want that below parallel depth. But with a split squat, we are never hitting that below parallel depth. It could be death too, depending on how tired your legs are. So for here, we bring elevation into the game. Can we have someone stand on two elevated surfaces in that same split squat stance? Can they then drop down below parallel in a deficit and then come back up? Same movement pattern, but just increasing that range of motion. Really nice progression for increasing load and stress onto the legs. You're also gonna get a little bit more of that high hamstring, that glute, because of the sheer depth of that, even that adductor. So if you have someone with an adductor strain, which I've had a handful of those in my time, that's a really good one to try and get someone a little more comfortable with that big depth, under less load, and try and get a little bit of stress onto that adductor magnus. We can have a front foot elevated split squat, where we're just focusing on the depth in that front leg, really tight anterior hips, rectus all the way down to the knee, front foot elevated, drop down, less stress on that back knee, more range of motion on that front leg, and then driving back up. Probably going to be in this kind of partial squat, partial bent knee at the top, unless they push themselves all the way back, kind of dealer's choice, however you want to load that up for the individual. from that, from that deficit, we then continue just loading these things, right? We're loading these people throughout these different variations. And then we get to the point where now we have their foot elevated on a solid surface, a stable surface, a bench, a box, something behind them, going down, going back up. And I mentioned stable because there's a variation we can do that changes it up a lot that I've had a lot of success with where we use a band on either some pins or J cups, and we have that individual put their foot up across that band. Now, that band is just supporting that back leg, but they can't push down into that band to stand up, because if they do, typically they'll lose balance, or they'll hit the ground and they'll know they're doing it wrong, or they realize, I've been putting a lot of work through that back leg. So having that unstable surface, that band behind them to rest their foot on, and then doing that single leg squat, which I just butchered there, boom, And boom, it shows how much more you have to work through that front leg when you have your foot on a band, something that's not gonna allow you to push through. So a really, really good progression, really difficult progression is to put that band on something where they can no longer support themselves through that back leg. And the most difficult variation I would recommend that we do in the clinic, with our athletes, with our clients, with anyone who's appropriate for it, is something known as a shrimp squat. A shrimp squat is simply a single leg squat. However, we are not using that back leg anywhere at all. So we can usually get some support with the hands if needed on a surface, so kind of up right here. I then pick up my back leg, I go down, I let the knee tap, and then I come back up using just that front leg. We take away the ability to push through that back leg at all, to support through that back leg at all, and then all of a sudden that front leg has to work that much harder. All of these can be used to work on strength balancing symmetries. The ones I recommend the most for my athletes, for the clients I work with, are the rear foot elevated split squat with support, because of the fact that we can actually load those really, really heavy. when we add a lot of instability, right, when I add the banded one or the shrimp squat, we can't really load that up in the same way as we can that rear foot elevated split squat, which is why that Bulgarian split squat is king. That's why you see it in CrossFit gyms, why you see it in bodybuilding spheres, why physique competitors and the Brett Contreras clients of the world are doing heavy Bulgarian split squats, because they can load it up and really pump the glutes, pump the quads and get the legs really big and strong. It would be, Wrong with me not to mention it, because we see it a lot more in the mainstream now, is that ATG split squat, in which an individual has something like a slam board. Here we have one from VersaLifts, the V-Stack from VersaLifts. We place that foot on top of the box or any sort of incline. You can even do like a 25 or a 10 pound plate. I keep that back leg straight. I drive my front knee forward. I place almost all of my weight on that front leg, getting as much anterior displacement of that tibia as I can, and then I drive back up. This has been made really popular online. You see it a lot in like the ATG, or like the knee rehab, or the ankle rehab, or apparently it heals everything. And it's a very good movement. It works really well for hip mobility. You think about the fact the leg is really straight, driving to that end range of hip extension there, that deep knee flexion position where you're exploring that full, broad range of motion of deep knee bend. But again, it's a hard movement, it's a more advanced movement. You can elevate the slant a little bit to make it less intense on the knee. And again, it's hard to start loading that when you have to get really comfortable with it before you load it. So for me, that split squat, that Bulgarian split squat is my go-to. But that standard split squat, just in place, a little bit of elevation where maybe you're just doing a two or four inch elevation behind them just to kind of encourage a little bit more load through that front leg. and then keeping in mind where is my foot, where is my torso, because that is going to change what we are loading when you're performing it. So there is your, let's call it split squat bro science progressions from the ground to a deficit to a rear foot elevated. to an unstable rear foot elevated, to a shrimp squat or a pistol squat you could even do as well, but all the single leg things that you can do with your clients to help fight and work on some of these symmetries they may be dealing with in their legs that are affecting their squats, front squats, back squats, overhead squats, cleans, snatches, you name it. If there's a squatting pattern in it, there could be some issues.

SUMMARY
If you wanna learn more, if you wanna see these live, and actually if you wanna practice these in person, we have a number of live courses coming up. Number one, this very weekend, so you're probably already headed to it if you're not already headed to it. We're in Meridian, Idaho this weekend, March 23rd and 24th. In April, we got two courses, one in Renton, Washington, and the other in Midwest City, Oklahoma. Both of those are on April 13th and 14th. And then in May, we are in Proctor, Minnesota and Bozeman, Montana. And both of those are on the same weekend as well, May, 18th and 19th. So this weekend, March 23rd, 24th, head to the course, sign up right now, I don't even know if you can at this point, for a boat for Meridian, Idaho in April, April 13th, 14th, and Renton, Washington, and Midwest City, Oklahoma. And then May 18th and 19th, we're in Proctor, Minnesota and Bozeman, Montana, both on the same weekend. head to ptiknice.com, check out those courses, sign up. We hope to see you on the road. If you're looking to take an online course, CMFA Level 1, where we learn all things squat, back squat, front squat, deadlift, push press, strict press, pull up, kipping pull up, overhead squat, how to program, how to do EMOMs, and what a METCON means, the science behind METCONs. That is Level 1. We hope to see you there. Next cohort starts April 29th. We are finishing up the current cohort right now. Super great group, hope to see you online there. And then level two. If you're looking to finish up the CMFA cert, or if you just want to learn a little bit more into programming, Olympic weightlifting, high level gymnastics, that is not kicking off until September 3rd. So two cohorts a year getting through one. I think they just finished one. They're just finishing one right now. And then the other cohort will be in September of this year. So what is that? May, June, July, August, about five and a half months away or so. No, five months away. Can't do math. Five months away from today. Gang, thank you so much for putting up with me. Thanks for being on the call with me. Hopefully you practiced some of those split squats today. Hopefully one of those was new to you. You're like, oh, holy cow, I never thought about that, never worked on that. But try it with your athletes. Try it with yourself. Make sure you practice these, play with these to know what they feel like so that your clients know what to expect because you know what it feels like as well. Have a wonderful weekend. Thanks for tuning in. Big weekend for Wisconsin basketball, Wisconsin Badgers and Marquette both playing in the tournament. So make sure to turn those guys on for me as well. Take care, gang. Have a wonderful weekend.

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

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the relationship between value & price, how to arrive at a potential price, avoiding assuming the value that patients perceive from our services, and understanding that not all physical therapy is created equal.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
All right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Fitness, Athlete, and Practice Management divisions. We're here, Leadership Thursday, talking all things clinic ownership, management, personal development here on Thursdays. Leadership Thursday also means it is Gut Check Thursday. Gut Check Thursday is back, the CrossFit Open is over. We have kind of a You're going to row 2,000 meters or 1,600 meters on the rower. That time domain is normally around the same time domain as a one mile run, about a seven to maybe 10 minute effort. But of course, we're going to make it a little bit more difficult. Every two minutes, but not the start of the workout, you're going to stop and do two rounds of three wall walks. six hang power cleans at 115.75 and then 12 ab mat sit-ups. The challenge there is when that clock beeps on the two minutes to get off, race through those wall walks unbroken, race through those hang power cleans unbroken, move through the sit-ups very fast, trying to get that work done in ideally a minute so that you have a minute or possibly even more to jump on that rower and chip away 200, 250, maybe 300 meters at a time. Extend that normal 7 to 10 minute 2k 1600 meter row out to maybe a 15 to 20 minute workout. Scale appropriately. Make sure your wall walk option you can do unbroken. Make sure your hang power clean option you can do unbroken. Make sure your sit-up option you can do unbroken. You don't want to have to stop and rest anywhere in there, or you're taking away from your time to do the real work of the workout, which is to move the distance on that rowing machine. So be careful you don't trap yourself where you're just doing wall walks, hang power cleans, and sit-ups, and you never actually get back to the rower. Scale that appropriately so that you have at least a minute, maybe a little bit more, each round back on the rower to chip away at that distance.

VALUE VS. PRICE
So today, sorry, Leadership Thursday, what are we talking about? We're talking about value and price. So we had an interesting conversation. The last cohort of our Brick by Brick Practice Management course just ended a couple of weeks ago. And one of the big themes of that course is folks deciding, especially those folks who may decide to be 100% cash-based, how do I know how to price my services? A lot of folks don't know where to start. A lot of folks look to maybe competitors in the area. They look to maybe national clinics that have different prices listed online to try to get an idea of what they should price their physical therapy visits at. And insurance providers are very similar of what is good payment for physical therapy quote-unquote good and so I want to talk today about Discussing what is value? Discussing what is price? Discussing how they can sometimes be the same but how usually especially if we're doing it, right? They are very different and some tips and tricks for you out there on to hopefully understand that the services we offer, at least as we teach them here at ICE, are probably much more valuable than what your competition is offering, and therefore worth a lot more when you're considering charging your rates, especially if you're going to be a cash-based physical therapist.

WHAT IS PRICE?
So understanding price is maybe the best and easiest way to start. If we talk about what is literally the definition of price, it is the arrival at the amount of money we'd like to make after we've accounted for the expenses of whatever it is we're selling. The physical cost, the expenses of making a thing to sell it, or the costs that go into what we might price a service for. So understanding that we're in the service industry, our expenses might not be as high as maybe a company that sells furniture or cars or something like that, but that our services do have a cost. We do need to pay ourselves or pay those individuals who work with us. And we also need to account, we do have some supply costs. We have to pay for power and heating and cooling and internet and needles and linen and all the sort of stuff that goes into keeping a physical therapy clinic running. And that comes at a cost. And so factoring in cost of expense, otherwise better understanding, especially on a patient by patient basis, What does it actually cost you to see that patient? So if you're already in practice, having an idea of what that number is, is really, really important because it lets us better come to an educated arrival on what our price could be. At the end of the day, though, we need to recognize that that is really just a guess. It is yes, assuming costs. Yes, it is assuming what we need to pay ourselves or pay someone else. and then having some sort of idea of ideal profit, but that it is a guess at what the perceived value of what we're offering is to our patients, to our customers for the sake of argument today. A calculation of ideal potential profit. How can we better understand the value that we're offering people?

THE SWOT ANALYSIS
I highly recommend, if you've never done it, even if you don't think that you would ever own your own practice or manage a practice or anything like that, I recommend that you do a little thought experiment called a SWOT analysis. S-W-O-T SWOT. Strengths, weaknesses, opportunities, and threats. This can be very in-depth, this can be very short, it's kind of an experiment that it's what you make of it, but sitting down and thinking what are the strengths of myself if I'm an individual practice owner, what are the strengths of my clinic if I have maybe one clinic with multiple providers, maybe multiple clinics with many providers, What are our strengths? What services can we offer? What are the strengths of the clinicians that I have on staff? What are the strengths of essentially the value of the product that we can offer? The inverse of that, what are the weaknesses? What are areas maybe of practice that we don't have somebody who could treat it? Maybe we don't have anybody who could work with pregnant and postpartum patients. Maybe we don't have somebody that's very keen on treating the vestibular system, treating folks maybe with falling or dizziness or balance issues. Maybe we don't have anybody who's comfortable working with older adults, youth athletes, so on and so forth. So understanding where are the weaknesses in your practice. And then O is the opportunities. What opportunities are there, not only in shoring up those weaknesses, but what opportunities exist outside of our clinic? Do we live in a town that's really big on running, right? Maybe we live out in Asheville, North Carolina, or we live in Johnson City, Tennessee, and we have a big mountain bike or trail running population. Are we able to target that population? If not, we know that's a weakness, yes, for a clinic, but also an opportunity to provide value to a new pool of potential patients. And then threats. Threats can be, yes, direct competition, but threats can also be external things. We can label things like inflation under threats. We can label higher than normal cost of commercial real estate under threats. But going through that SWOT analysis and saying, do I have any chinks in my armor? If yes, then I know the value of what I'm offering is probably a little bit lower than I'd like it to be. If I go through this analysis and I think, gosh, especially compared to the competition, I think we're doing really well. Then now you have an idea of actually I think what we offer here is more valuable than the competition. And that will overall let you better arrive at how to price your services.

TAKING A GUESS AT PRICE
And at the end of the day, when we're thinking about price, I love what our CEO here at ICE, Jeff Moore, says of thinking about what you need to charge per hour is really working in reverse. A question of what does it take to make a certain amount of money for a year, whatever that is for you or your clinicians or both, to treat five to eight patients per day, three to five days per week, 48 to 50 weeks per year, right? Having two to four weeks off for vacation, seeing maybe 30 to 40 patients one-on-one. What volume do you need to treat at and what do you need to charge as far as your price goes to achieve the amount of money that you would like to make each year? And now we need to understand, back to the threats portion of the SWOT analysis, that there are always going to be forces we can't control that are going to affect that, right? If we live in a really big city and with a really high cost of living, then we know we're either going to need to be happy taking less money home, or that we're going to need to charge maybe more than we're sure is going to be an appropriate price to offset some of those expenses. So at the end of the day, setting a price but not being so locked into it that it can't go up, ideally it won't go down, you won't continually lower your price over time, Ideally, your price will continue to increase as more folks find your services valuable, but at the end of the day, picking a price and starting there and then seeing how expenses, seeing how external threats, market forces, inflation, that sort of thing, change your price over time. And if you're doing it right, and this is maybe a personal belief, I don't have research to support this, but if you're doing it right, if people truly find your services valuable, you should find yourself slowly getting busier over time such that you can begin to charge more because you will end up in a position where you have more people that want to see you than you have time to see. And of course, that's where we can discuss growing beyond yourself into multiple clinicians, but that is a really good point to be at. It's not great to start with a full caseload and need to slowly decrease your price to try to hang on to it over time. It's a race to the bottom and that never ends well regardless of what industry that you're working in. So that's a conversation on price.

WHAT IS VALUE?
Talking about value, I love the quote by George Westinghouse. If you don't know the story of George Westinghouse, his company eventually defeated Thomas Edison in the race to electrify America, essentially in the late 1880s. He said, the value of something isn't what someone's willing to pay, but what it contributes, right? And that kind of says that the customer drives the bus on value. We can certainly set our price, But the folks who are buying our service, paying for physical therapy, buying our widgets, whatever, they ultimately dictate the value that they perceive from what we're offering and that that's going to be different from person to person. Some folks are going to find more or less value even if our price is flat and never changes. And we need to accept that just like we need to accept that price is never permanent. There's no business that's selling stuff for the same amount of money 50 years ago as they were today, for example, except maybe Costco with their $1.50 hot dog. But for most businesses, things tend to get more expensive over time to adjust for inflation and that sort of thing. So value is kind of in the eye of the beholder. A lot like price is not really a fixed thing for us on the other side of the equation.

DO NOT ASSUME PATIENT'S VALUES
In most businesses, and I think especially in physical therapy, we do way too much assuming about how our customers, our patients, our clients, what have you, perceive the value of our services. We see a lot in brick by brick. We see a lot on social media. We see a lot of conversations. that I'm worried about charging too much. I'm worried that my patients won't find value with the price that I'm charging. We are assuming way too much about how much money people have to spend, but also again, that value is this fluctuating thing. and that folks place different levels of value on different products and services in their life in ways that are, yes, in line with the price, but sometimes that are not in line with the price, right? A good example is cell phones. Almost every human being on the planet has a cell phone. In the United States, 94% of all Americans have at least one cell phone that connects to high-speed internet. In particular, they have a smartphone. What does that tell us? At least as Americans, we highly value having a smartphone, right? We're willing to pay $1,000 to $2,000 out of pocket to initially buy it. We're willing to spend $100 or $200 a month on the subscription so that that cell phone has access to the cellular network and can text and email and look at apps and all that sort of stuff. So there's a high value on something like a cell phone. What we're really talking about in the conversation between price and value is that we need to show folks the value of physical therapy such that they don't even consider the price of what it is. Of yes, of course, if we try to charge $1,000 a visit, we're probably not gonna get too many takers, but also we shouldn't feel like we need to undercut our competition and perform visits for $50 or take insurance payments for $40 because we're uncomfortable asking for too much money. Again, do not assume what your patient values. If they find your services valuable, trust me, they will find a way to pay for what you're charging, just like they find a way to pay for their cell phone and all the other stuff in their life that they truly find value at, even if they think, gosh, that's high. If their perceived value is high enough, they will find a way to pay for it. I think of myself as an example, across the week, most days I work about 16 hours, most weeks I work seven days a week, and most months I work most weeks. On average, I make about $28 an hour across everything that I do. An incorrect assumption is that an hour of my time then is therefore worth exactly $28. And that is a misunderstanding between the relationship between price and value. There are hours of my time that you cannot pay me a million dollars to take that hour away from me, right? You cannot offer me $28 to not exercise an hour a day. You cannot offer me $28 to skip the mornings that I have with my son where I get to get him out of bed and get him ready for school or the days where I get to pick him up and bring him home and play with him and put him to bed. That has a value on it that really has no price that can be associated with it and I hold on to those hours very, very much. Likewise, when I myself am injured and need physical therapy, I place a high value on the physical therapy that I obtain because I find that it helps me a lot, right? The manual therapy helps me a lot. The guided home exercise program helps me a lot. I tore my meniscus two weeks ago tomorrow, just finished a workout. I'm back to lunging. I'm back to light impact. I'm back to light squatting in just two weeks. An injury that might put some folks out for three, six months might cause them to seek surgery. I'm already modifying around it and slowly getting back to full activity, probably realistically within a month. That has an extreme level of value that I would argue is more than the cost of what I pay for the physical therapy with the price that it holds. So do not assume what folks value, how much they value things, or that relationship between value and price. Because it's not always exactly equal, even though in our heads we tend to think value equals price, that is simply not the case.

WHAT IS THE VALUE OF TIME WITH A HIGH-QUALITY HEALTHCARE PROVIDER?
I will challenge you before we sign off for today to really step back and ask yourself the question, especially if you're in this scenario right now where you're thinking, what should I charge for my services? Should I increase my price? What are people around me charging? What is the value of a high quality healthcare provider? who can keep you from otherwise consuming tens of thousands of dollars and hours and hours of your time otherwise in the healthcare system to usually ultimately not get any better than you were doing nothing on your own. I would argue the value there is really high. The value is high to the patient. The value is high to the healthcare system in general as well. And the question then becomes, what is ethical? What is too much? What is too cheap? What is an ethical amount of money to be paid? And the answer to that, unfortunately, that we don't want to hear is that it depends. Well, what does it depend on? It depends on the perceived value of the patient for our services. Sure, you can charge $500 for an hour of physical therapy, but that probably needs to come with a really high quality level of care. That's probably more concierge care, direct access to your provider at all times, evening visits, weekend visits, visits at the office, visits at the home, whatever. That's kind of a more high caliber level service versus what is the value of a visit of physical therapy that costs $33. Well, we might assume that's so cheap, it might not be really valuable, but at the end of the day, we don't know that either, do we? There are a lot of folks accepting insurances that pay almost nothing who are providing high quality care, or at least trying to, in a way that their patients perceive value. So don't assume what the value of our care is, and certainly never assume the value of the care a competitor is providing until you know what they are offering their patients. that we can say, wow, they're charging $500. The default assumption there might be it's really high quality of care. It must be. It's $500, right? The natural association in our brain is higher price equals higher value. but that is not always the case. There are a lot of people charging a lot of money cash for patients to walk in and lay in a circle on treatment tables and just get dry needles for an hour. And I would argue that's probably not really valuable care to the long-term health and fitness of that patient. Yet they are charging and receiving that money, which again kind of shows us the asymmetry between price and value. If those patients perceive value, they will find a way to pay that amount of money, and that is true for you as well. So at the end of the day, don't shortchange yourself. Don't set your prices just because it's what somebody else is charging. Don't set them lower. Don't set them a little bit higher. Step back and ask yourself, What is an ethical payment for an hour of my time given the value that at least I believe I'm providing to my patients? Set that price and then adjust fire as needed later on. We say here at ICE, ready, fire, aim, right? Set it up, lock in the price, see what happens. Your patients will determine your value. Do not assume it for them. Do not assume someone does not have the money or cannot find the money to come see you once a month for a cash-based physical therapy treatment. Again, if those patients truly find value, they will find a way to come pay you. So price versus value. They're not always related. Sometimes they are, but usually not. We often see an asymmetry where the value that folks perceive can often be significantly higher than the price they're paying. We hear that a lot in physical therapy. I would have paid double what I paid. This was such great service, you erased a decade of back pain, I'm back to playing with my grandkids, I'm back to walking without a walker, whatever. We hear all of those things in the clinic. We hear that folks are significantly happier with the value they receive from our services than the price they were charged, so keep that in the back of your mind. What price is sustainable? What price is sustainable for you to believe that you're making enough money to do the work that you're doing? And what price is sustainable for your patients? Demographics, socioeconomics, market forces, inflation, commercial real estate, all those things that are really out of our control do play a factor in our price. What price targets your ideal customer the best? Do you want to provide a high level of elite concierge service? If so, you can probably charge a little bit more as long as you're comfortable knowing that that patient is probably going to demand a lot more out of you than if you charged less. Again, keeping in mind at least your perceived value of what you're providing to somebody, what price is ethical? I guarantee you an ethical price is not the $43 flat rate payment from an insurance that's an HMO that requires a 30 minute authorization before you can treat that patient. I don't know what an ethical amount of money on average across the United States is for a physical therapy visit, but I know it's not that for sure. And then what is a fair market value for a similar service? Again, do not assume the value that your competitors are providing until you know exactly how they treat and the value that they at least are attempting to provide to their patients. It's easy to look on someone's website and see what they're charging and just make your price $5 more or $5 less, but that doesn't really understand the whole picture of the value they're providing, the value you're hoping to provide, and what the difference between those two services might be. I think of it a lot of getting a haircut, right? Yes, I can get a $10 haircut at Bo Rick's or Fantastic Sam's or whatever. My hair is not going to look the greatest. What is the price at a barbershop? It's a little bit more. What is the price at a high-end salon? It's a little bit more. And what am I getting along the way? Well, with those services, quality tends to go up and the value tends to go up, right? The haircut tends to be a little bit better. You tend to get a little bit more time with the person providing the service as you go up each tier. And that can be the case in business, but it's not always.

SUMMARY
So remember, Price isn't firm. It can change. You're the one responsible for changing it and do not assume the value of what you're providing. Let your patience dictate that. If you set a price and you have a full caseload and you have a two or three month waitlist, guess what? Your price is probably too cheap compared to the value that your patients are perceiving, and you're okay to bump that price up at the beginning of the year. So don't assume that. Don't assume people can't or won't find the money to come see you if you truly believe in the value of the product you're providing. If you want to learn more about this stuff, our next cohort of Brick by Brick starts April 2nd. We take you all the way through from having no idea how to run a business to finishing the course in eight weeks, having all of the legal documentation you need to formally start a business, to have a better idea if you're going to take insurance, take cash, take a mix of both, and to be able to open your doors potentially at the end of that eight-week class. So we'd love to have you. More information at PeteDenise.com. That's it for me. Have a wonderful Thursday. Enjoy Gut Check Thursday. I'm going to be out in Rochester, New York this weekend watching Lindsey Huey teach extremity management. So I'm going to be at that course. I'm looking forward to hanging out with you. And I imagine we'll probably hit Gut Check at lunch on Saturday or Sunday. So have a great Thursday. Have a great weekend. Bye, everybody.

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

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Dustin Jones as discusses the gap between someone given a diagnosis and then a prognosis.
Whether it’s a matter of seconds or decades, we’ll discuss the huge opportunity in that gap to impact our patients as well as practical takeaways.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

DUSTIN JONES
Good morning, folks. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division. Today, we are going to be talking about minding the gap between diagnosis and prognosis. Mind the gap between diagnosis and prognosis. I'm going to share a personal story of some experiences I've had lately as a patient within the healthcare system. And I've experienced what many of our patients are experiencing as well, and that is that gap between receiving a diagnosis and then potentially, sometimes not even, right, receiving a prognosis of what that diagnosis actually means. This is an area that we spend most of our time in with the folks that we serve, and I think this is a huge opportunity to serve these folks well and potentially do some damage control and kind of rewrite a narrative that's going on in their head. So this Mind the Gap phrase, it originates from the United Kingdom. So if you ever go on any public transit, you're in a subway, for example, and you've got kind of the train platform and the train pulls up on kind of the curve of that train platform, it's going to say, mind the gap, basically beware, right? Beware of the gap between this platform and the train. And this, this phrase, you know, is a cautionary tale, right? That you are being careful. And I feel like that, cautionary perspective, it needs to be applied to when we give something a name, aka a medical diagnosis, and then the prognosis. That we need to mine that gap, that space in between giving someone a diagnosis and when they're giving the prognosis of that particular situation. I'll share my story. If you're watching this, you see an obnoxiously large bandage on my forehead. I have recently had a spot on my on my temple that was a little curious, right? So I went to the dermatologist to get it checked out. I haven't been to a dermatologist in, man, probably 20 years at this point. I don't get regular checkups or anything along those lines. But I went, they saw the same spot. They say, hey, let's take a biopsy of this and see what this is. All right, cool. So they take a biopsy, about five days to get results. And in that five day period, you got all this stuff running through your head, right? What could this be? Could this be some super gnarly, Skin cancer, for example, is this gonna be something serious or is it is it, you know Just something to not worry about. I don't know. I'm in that five-day period then I get the call from the office This is a call that I've been waiting on for about, you know Five days solid days now and I get a call and the individual that called me was I would say Roughly kind of 22 24 year old pray fresh out of undergrad working as kind of the billing clerk within this dermatology practice. And she calls me and says, hello, is this Mr. Jones? I said, yes, this is him. All right, thank you. It's good to talk to you. I wanted to give you your lab results and just kind of tell you the next steps going forward. So with that area on your temple, well, you have, you know, basal cell carcinoma. So you got skin cancer there. and we're gonna schedule a Mohs surgery to take that out. And then you've got a dysplastic nevus, I'm probably butchering the pronunciation of that, on your scalp and we're gonna excise that as well. When would you like to schedule these procedures? Literally, that's all this person said. And so I want you to put yourselves in the shoes of someone that may at some point have learned about the different types of skin cancer and which ones are more concerning than others. But in that moment, you may not remember, right? You're giving this diagnosis of cancer and a procedure that you have had some patients, right, that have had a Mohs surgery before. Very straightforward procedure where they basically just shave off skin and then assess if they got all the cancerous cells. And they just continue to do that until they find no cancerous cells. A lot of our patients, especially if you work in geriatrics, you're used to these types of surgeries, but you may not necessarily understand what it really means, right? And then, you know, the seven-syllable diagnosis for the other lesion, and it's gonna get excised, you know, just all these words. And just imagine what can happen, what runs through your mind in that situation. And it was fascinating for me because this was all laid out on me. without any context, without any prognosis, no understanding in the moment of what this actually meant. and they were trying to schedule a procedure. And I asked to speak to someone to kind of give me an idea of what this means. And it took about three minutes to get a PA on the phone to kind of give me an idea of what this actually meant, right? Basal cell carcinoma, very, it's the least aggressive out of any of the skin cancers. You take that out, you don't have to worry about it. We'll just follow up with regular skin checks. Not a big deal whatsoever. all this other piece that you have, it's basically just a mold that we're not necessarily sure if it could turn into something gnarly, so we're just gonna take it out just to be sure. That was not given to me, but that three minute gap, the stories that I told myself were fascinating. I was thinking about my life insurance policy. What are my kids gonna do if I'm not gonna be on this planet for much longer? What's Megan, my wife, gonna do? Just thinking about all the ripples that come with that getting that diagnosis and just realizing, you know, your mortality in that very short period of time. So I would say overall, this is, I would say a relatively minor interaction, right? Everything's all good. I had this Mohs surgery yesterday. It's bandaged up. You know, I've got a nice little scar. It's going to be fine, right? But think about what this is like for so many of our patients. When they go to that doctor's visit, that specialist, and they get that diagnosis, And sometimes it is hours, days, weeks, months, and even decades before they get that prognosis of what it actually means to have that name, that diagnosis on your medical chart. This is where we typically operate, right? This is where we are typically interacting with individuals. and this can be a very, very scary place for folks. It has huge implications in their day-to-day life. So let's go through some common examples that we're gonna see where we are kind of in the midst of the gap between that diagnosis and prognosis. Two of the most common ones that I've experienced working with older adults is degenerative joint disease and then osteoporosis. So degenerative joint disease, you know, you have someone that may have some back pain, whatever, maybe knee pain. They go and get the image, right? and they see the image report, especially nowadays with your access to MyChart, for example, where you can see a full-blown report without full context, right? You're reading, you know, radiologist's report verbatim, and you see degenerative joint disease. And oftentimes, how often are these folks actually given context of what that actually means? How often are they told? You know what? At this stage of the game, this is actually considered to be normal. If we were to take a hundred pictures of a hundred people, right, at least 75 of those individuals are going to have the same findings, right? But not all those people are going to be in pain. So yes, you have this on your image, but it's not necessarily abnormal or something to be that concerned about. How many folks are hearing that when they see that diagnosis on that report, right? so often is left untouched, unnoticed, unaddressed, and they can have this perspective that their joints are just absolutely disintegrating day by day by day. And you stretch that out over years and decades. Think about how they can learn to perceive their joints, their body, their ability to adapt, their ability to improve. Do they have a positive or negative perception of the days ahead, right? Oftentimes, it's going to contribute to a negative perception that it's just downhill from here. That is something that we can clear up. We can show, hey, we know you had this diagnosis. This is actually considered to be a relatively normal part of aging that a lot of folks have this on their imaging and they're doing awesome. They're doing things. similar to what you want to be able to do, I know that you can get to that point and I can help you get there, right? So DJD is one. The next one is osteoporosis. This is more common in the realm that I'm working in. I'm working in the context of fitness right now at Stronger Life in Lexington. So it's a gym for folks over 55 and we have so many folks that come to us that have a diagnosis of osteoporosis. And oftentimes that diagnosis is given based on a number of a certain area of the body that may be demonstrating low bone mineral density. And I always ask folks when they have that diagnosis, do you have your DEXA scans? Has anyone gone over your DEXA scan with you? And nine times out of 10, they say, no, no one's ever really walked me through this DEXA scan and what it actually means. So I had them bring it in. And when you talk through a DEXA scan, you'll see that they will run their bone marrow density at different parts of their body. And so you could, you know, have those numbers ran at, you know, their bilateral femurs, for example, the lumbar spine, thoracic spine. And so if someone shows below negative 2.5, for example, on that DEXA scan, in one of those areas, they're gonna be giving this diagnosis of osteoporosis. And oftentimes when you're looking at that DEXA scan, it may only be one one place it may be osteoporosis like a negative 2.6 in the right neck of the femur and then the left femur may be in an osteopenic range it may be kind of under that negative 2.5 maybe negative 2.3 negative 2.2 that's a different story right that when they are given that diagnosis of osteoporosis nine times out of ten they perceive that every bone in their body is brittle and is going to self-combust under any load, right? And that is just not the case whatsoever. Usually it's in a certain area that is a little more troublesome than others and we can give target interventions to build that area up and to show noticeable changes in that DEXA scan if we can work with these people over a longer period of time. And so osteoporosis diagnosis is another one. They're often not given what that prognosis actually means, and often not, they are given a message of hope that they can actually do something about this beyond taking a pill and crossing their fingers for that next DEXA scan for those numbers to change, right? There's a lot that we can do. So these are two of the dozens of situations that we often encounter, right, where people are given that diagnosis And then they may get a prognosis or they may not. And that is where we live. And I want us to just really consider and appreciate the negative implications of this. The fear, the lower physical activity. Increased fear will often encourage them to be more conservative with their physical activity because they're afraid to get hurt for example. We've had folks at Stronger Life that have gone to a doctor's visit and gotten a diagnosis, osteoporosis being one of the, I would say three, but one of them that if not given a clear prognosis and they will be scared to death and almost try to cancel their membership to say they can't exercise anymore. That this is a very, very delicate situation that we often find ourselves in. So now let's talk about what we can do about this, right? I think I like to think about this in three steps. Assess, inform, and advise. Assess, inform, and advise. When you're doing your chart review, when you're doing that evaluation, you see some of these diagnoses. Congestive heart failure is another one. The different categories of congestive heart failure, some are more serious than others, right? But man, that term alone will scare you to death, right? Assess what diagnosis do they may have and what's their knowledge of that? I would include surgeries in that as well. Knee replacements. Total hips, right? Assess their knowledge and perception of that particular diagnosis. Do they have an accurate perception of what it means to have osteoporosis? Do they have an accurate perception of what it means to have a total knee replacement and the implications that that actually has on your life after? Right? Because so many folks think they can't do X, Y, and Z and that's just not the case. We're learning that day in and day out with these folks challenging a lot of these perceptions. So assess. once you assess and you can inform. I feel like this is where this is something that I wish we would not have to do, right? I don't want to have to feel like I need to clear up someone given a medical diagnosis without an accurate prognosis, but sometimes we have to. But I think we do need to be very careful here that we don't kind of overstep our boundaries and really speak to this person's situation in the sense of where we probably don't have any right to do that, right? So this is where I'd like to speak in generalities. I don't, I'm not going to pull up someone's, you know, imaging and assess it myself per se and say, Oh, this is, you know, okay, this blah, blah, blah, and compare it to others. Like that, that's not my job. Right. But I can say I've had folks that have had that diagnosis that have responded really well to this treatment. I've had folks that had that diagnosis and they were able to do X, Y, and Z. We can inform them of what can happen with some of these diagnoses, but I would want to respect our medical colleagues there, so hear me out on that. So we assess and then we inform, all right? This is where, particularly with osteoporosis, this is where I will get their DEXA scan, And I will just say, hey, this area, this is where you have osteoporosis. This area over here, this is actually osteopenic. It's a little bit stronger, a little bit more dense than this area over here. Give them context and inform them of that particular diagnosis when we can, right? And then last but not least, we advise. What can they do about it? What can they do about it? We need to give them control to give them the ability to rewrite the script, to develop some of that self-efficacy of the confidence that they can do something about that diagnosis that they've been given. And that's going to look different for each person, right? But there's so much that we can do, especially with DJD, with osteoporosis, with congestive heart failure. These are not, not death sentences. They are not death sentences. There are a lot of things that we can do as clinicians to help maybe improve their situation, and ultimately, a lot of times, to prevent further decline. There's a lot that we can do with a lot of these 10-syllable, very scary medical diagnoses. So, we assess where they're at, their perception of their diagnosis and perception of their prognosis. Is it accurate, right? Then we inform them. We want to try and make it more accurate and realistic based on the evidence, but based also on what you've seen as well in your clinical practice, and then we want to advise. When we're able to do that with someone that has not been given a clear prognosis or context of their diagnosis, man, you've really given their life back. You've answered so many difficult questions they've been wrestling with for sometimes hours, but sometimes decades, and you can really change their life as a result of some of these conversations. All right, thank you all for listening so far. I appreciate y'all. Before I log off here, I want to mention a few of our MLA live courses coming up. So this is an awesome two-day, very practical weekend where we dive into a lot of exercise, application, prescription, but also a lot of these nuanced conversations about kind of the softer skills of implementing that fitness-forward approach in the context of geriatrics, where we may talk about diagnosis and prognosis and how we can bake that into an exercise regimen to get people to really push themselves at a level they probably haven't done before.

SUMMARY
Awesome weekend. So, I want you to check out, if you're around Madison, Wisconsin, we're going to be in your neck of the woods March 23rd, that weekend. Then April 5th and 6th, we've got four MOA Lives across the country going on at the same time. I'll be in Urbana, Illinois. We have one in Raleigh, North Carolina, Burlington, New Jersey, and then Gretna, Louisiana, just outside of New Orleans. All right, there's tons of other MLive courses across the country going on through the spring, summer, fall, so be sure to check on there if none of those are close to you, but we're grateful for y'all listening and watching wherever you consume this podcast. Y'all crush the rest of your Wednesday, and we'll see you soon.

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

Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity lead faculty Cody Gingerich explores the concept of "entertaining" patients by constantly introducing new & exciting exercises. Cody challenges listeners that just because they are bored, their patient may not be bored with PT, especially if they're seeing demonstrable progress with their rehab.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

CODY GINGERICH
All right, good morning everybody. My name is Cody Gingrich and I am one of the lead faculty in our extremity division. The big thing I want to come on and talk about today, it's going to be the title of today is called Are You Not Entertained? And really what today's conversation is going to be around is a bit of a blend between a couple of the lectures that we have in both of our extremity management division and then some of our spine division in our build a bike conversation. So if you've ever taken a course through the spine division we always talk about building the bike and then in extremity division the conversation is around dosage. Okay so the title of today called are you not entertained is really I want to focus in on are we as physical therapists, is our job to entertain our patients or is it to get them better, right?

HELPING PATIENTS RECOVER VS. ENTERTAINING PATIENTS
And so what we want to talk about is really our job is to get people better. We want people to improve health-wise, we want to improve their pain and all of those things, right? But where we see that tend to get a little bit lost in translation is when with our exercise dosage. Okay. We have so many, so many exercises at our disposal in physical therapy. We see things on Instagram, we see things all over the place. Right. And that leads to so many things swirling in our brain about like, Oh, let's do this exercise. Plus this exercise, plus this exercise, plus this exercise. Okay. And so what that does is that also clouds our judgment on what is actually bumping our patients forward. Okay. And when we talk about exercise dosage prescription, what that needs to be is a very methodical approach and then progressions over time. Of the same exercise, assuming that first exercise that you chose is showing benefit to your patient, right? And I think we veer from that too quickly, oftentimes. So let's take a shoulder pain, for instance, right? And we just give them a side, we've determined that it's coming from the posterior cuff and we really need to work on getting infraspinatus stronger, some of the teres group stronger, and that posterior shoulder really needs to build up some strength. So we start giving them side lying external rotation, okay? Now, is that the most fun exercise in the world? Potentially not, but we know that from EMG activity, that sideline external rotation is the best exercise that we could possibly give that person in front of us to build the capacity of their rotator cuff. And let's say up front, they can tolerate a two pound dumbbell for eight to seven to 10 reps somewhere in that neighborhood, which in extremity division, we would call that more in our rehab dosage. It falls in line with our rehab dosage and that's probably going to fall somewhere in there 70 to 80 percent of their one rep max shoulder external rotation. Now how does build the bike fall into that conversation? The building the bite comes the next visit when they show up and you have your subjective and objective asterisk signs. You have given them that one exercise and say, Hey, this is the best exercise for you. You need to do it seven to 10 reps, three sets, and you need to do that one time a day. You have a very specific rehab dosage laid out in front of them. and they come back in and your objective asterisk signs and subjectively, hey, they are sleeping better. They only woke up one time in the evening as opposed to three times. They were able to get through their workout, and they didn't have to stop or modify, or their pain was at a two out of 10 as opposed to a six out of 10. They were able to pick up their kid. Then, in your objective, they were able to raise their arm overhead, and they only had a very small window of a painful arc that was only a one or a two out of 10 as opposed to a five out of 10 the previous time. Now, your job at that point is saying, great, that exercise right there is working, We're going to go from a two pound dumbbell tip from that prescription to a three pound dumbbell.

STAY FOCUSED ON WHAT IS WORKING
That is not the time to decide, great, let me pull all of those other exercises that I have in the back of my brain that I've seen on Instagram and start giving them six to 10 different things or just like time to shift away. No, you have proven to that patient in front of you that that one thing that you gave them at the prescription and the dosage that you gave them was the right thing. Okay? So, Exercise and strength and conditioning principles tell us we need progressive overload. If you decide you wanted to get your back squat stronger, what is your back squat cycle look like? You are back squatting at least once, maybe twice a week, every week, and you add five pounds to that back squat and you do the exact same thing week over week. People don't get bored of that because they see progression. They see that they're getting stronger in that.

IS YOUR PATIENT BORED OR ARE YOU?
And I think we as physical therapists, I think sometimes it's us getting bored, not our patients. And we think that we, our job is to just be entertained or entertain them because we think the patients are getting bored of what they're doing. And so we need to give them the new fangled thing. Well, the reality becomes our patients are entertained by getting better and doing all of the things that they've told you that they haven't been able to do and now they can. Right. But, They will get bored and they will get frustrated if we don't also prove to them that they are getting better. It's not our patient's job to say, yes, I'm getting better. No, I'm not. Most of the time patients will feel they either have pain or they don't and you might get them that first time. Maybe they only could raise their arm to here and then the next time they're here and they're like, yeah, but it's still kind of bothering me. Your job then is to say, well, right, but last time you were able to get, you only were to hear, and now we're here. That's at least a 60 or 70% improvement. Now all of a sudden we're like, oh yeah, that is actually true. And I was able, I only woke up the one time last night. man, I am getting better. I need to keep doing that exercise. And you say, yeah, I wholeheartedly agree. But the thing is that seven to 10 reps for three sets now is getting too easy for you. So we need to bump that to the three pounder or the four pounder or whatever it is. Exactly the same thing, right? And that's where the patient gets entertained by seeing that they're getting stronger. improving all of their objective metrics that you're coming in to see, plus their subjective day-to-day life stuff. That's where the entertainment comes in. So don't get lost in the weeds of thinking, I need to give them the coolest brand new thing that I saw this week, right? Or I need to give them three, four, five different things. It is way, way, way more valuable for your patient, for you to know exactly right prescription, you've tested their one rep max, or you've tested a five rep max, or you have a very good understanding of their percentages of whatever movement that you're doing, that's going to challenge them appropriately, and that easily lets you determine whether or not that was the right prescription for them when they walked in, or that prescription needs to be adjusted. If they come in and they're a little bit worse, but it's the same symptoms, Great, that's not the wrong exercise still. That might be that you overdosed it up front and you can just pull that back. Maybe you handed them a five pound dumbbell and you said, okay, this is your exercise for the week. Maybe that needed to be a three pound dumbbell, not potentially a brand new exercise, right? And that's where the magic in rehab lives. Right? And that's where the entertainment factor comes in. Like you need to be entertained yourself because like I said, I think a lot of us as PTs, we're the ones that get bored before the actual patients do. Your entertainment needs to come from really figuring out the detailed prescription of what is going to be best for that patient, right? Use that as a puzzle each time they walk in and say, okay, well where, how can I dial this prescription in perfectly? And when they come in week over week, then you have to build that bike in front of them and say, okay, I'm proving to myself and to you that what I gave you previously worked and we can bump you forward with this same thing, but changing just the dosage. Don't go from, If you're trying to like, again, going back to that back squat, if you're trying to improve the back squat, how many different exercises can you do for your legs? You can do plenty. You can do back squat, you can do Bulgarian split squats, you can do hack squats, you can do leg press, you can do leg extensions, right? All of those things may get you stronger for sure. But if you want to improve your back squat, you are going to have to back squat and you're going to need to methodically and strategically bump that weight up time and time again. Once you feel like you have exhausted that thing and they come in and say, I have been getting better with this. You know, I followed exactly what you're doing. And this time, you know, we haven't seen as good of a bump. Maybe now we need to challenge that tissue in a different way, right? And that's when all of a sudden you can decide to switch exercises, okay? Find a new exercise, challenge the tissue in a different way, right? If that means that we need to go from really here and stop from this position here, maybe we raise it to a 90-90 here, or we do that wall slide that we talk about, that exercise is in the extremity management course, right? One of those two things, now we're challenging that through a little bit of a different range of motion. If we're doing a wall slide with a band, you start a light band, then you move to a medium band, then you move to a heavier band, right? And you dose that prescription the exact same way and we methodically take that approach to just adding resistance.

REHAB EXERCISES DO NOT NEED TO ALWAYS BE DIFFERENT
It does not need to be constantly shifting, constantly changing, constantly adjusting every single thing. that we're doing time and time again, right? So that's the big thing that I want to get on here and talk about that we see oftentimes throughout going around weekends is just that everyone wants all of the new things. And really they, it seems like the goal is trying to entertain our patients. We need to get our patients like they need to be able to like what they're doing. Absolutely. but they like when they get better. It's the same thing when people, this might be my own bias, but like if you're playing sports and everyone says like, Oh, I just, I want to be, I want to have fun. Well, you know what's really fun is when you're win, right? So like I have a lot more fun playing sports if I can also win at that sport. Right. And so that's the same thing. It's like, I might do some of the boring things because that's going to get me to win. which then therefore is fun. Same conversation here is like some of these boring activities or boring exercises, if you can prove to the patient that they're winning, now all of a sudden those boring exercises feel like fun because they can see the progress and they can see what's happening time and time again, week over week over week. And now they don't care about some monotony and some potential boring exercises if you have to prove that it is going in the right direction week over week over week. The second that you can't prove that to them, that's when all of a sudden compliance starts to dip. And once compliance starts to dip, now all of a sudden you're chasing yourself trying to figure out, well, what can I just do to get my patient to like do their exercises? Well, that's it. Prove to them that are getting better. Prove to yourself, right? Make sure every time they walk in, you're checking their subjective, you're checking their objective asterisk signs. So I want to challenge you this week, when your patients come in, give them the same exercises that if, assuming that things are getting better, don't abandon ship on that exercise. Add one pound, add the next band up, add three reps instead of it being a 10 rep, make it 13 or make it 12, same exact thing. at a set, right? These are the small details that we know bump people forward and actually progressively strength train. Okay, that's the podcast today. What I wanna talk about, are you not entertained, right? Entertain yourself by really dialing in that prescription dosage, right? Make sure that you have a good understanding and that's the fun part for you. It's like, well, last week we did 10, so this week we're gonna do 12, or it was two pounds or three pounds. That is the fun in rehab. Entertain your patients by proving to them that they're getting better, right? Using the dosage that you talk about and you're methodical over. Prove to them that they are getting better week over week over week. And now all of a sudden they're having a good time, right? Because they can do the things that they want to do. Catch us out on the road, extremity management. Myself, Mark, Lindsey, we're all over the country moving into the next couple weeks, so we appreciate you being on with me on this clinical Tuesday. Hope you all have a great day.

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic Division Leader Alexis Morgan discusses what a pelvic floor exam looks like in light of updated practice patterns & research,.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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

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

EPISODE TRANSCRIPTION

ALEXIS MORGAN
Good morning. Welcome to the PT on Ice daily show. My name is Dr. Alexis Morgan. I am one of the faculty with the pelvic division and happy Monday. I'm excited to be here this morning to talk to you all about the 2024 version of the pelvic floor assessment. We've been through so many iterations as a profession of the pelvic floor assessment. And I want to just take a few minutes today to talk with you all about the 2024 version, the updated version, the modern way to assess the pelvic floor. Thanks for joining me. Let's jump right in.

HISTORY OF THE PELVIC FLOOR EXAM
So when we think about the history of the pelvic floor exam, this goes way back, all the way to Dr. Kegel. I've actually done some podcast episodes on the history, and if history's not your jam, don't worry, I won't bore you with the history details today. But our pelvic floor exam does go way back decades, closing in on 100 years now. And over the last several decades, of course, we've had a lot more research come out and a lot more evidence, a lot more understanding of these muscles that are at the base of the pelvic floor. And so with, of course, new updates, new pieces of understanding, we're still gathering information, but of course, as we change in the way that we understand a group of muscles, of course we're gonna change in the way that we assess them clinically, right? We see this so frequently when we look at the evidence on strength. So strength is not necessarily indicative of problems or lack thereof problems. Yet we are so often talking about assessing strength and obsessing about what manual muscle test grade is there. And yes, if you're not familiar, we do have a manual muscle testing score for the pelvic floor. but realize that that is such a small piece of the entire picture. And we're starting to see this in the evidence as just described, and there's several studies that are making us go, hmm, maybe it's not all about strength. But how do we then take that into our clinical practice?

FOCUS ON RANGE OF MOTION & MUSCLE COORDINATION
First and foremost, we ourselves need to back off of obsessing about strength, right? We need to really get a full understanding of the person in front of us and really gather that information and not just talk about strength, but talk about the entire picture. So, here's the updated version of the way that we do our assessments. First, we're going to test their range of motion. I'll dive into each of these details, but I want to give you all the overall picture first. So first, we do a range of motion assessment. Then we go into coordination. And after coordination, then we might go into a strength assessment. We might go into a palpation assessment. or we might go into a prolapse assessment, depending on how that person shows up in front of us. We may take it a few different directions, our assessment, but we're going to start with the range of motion and coordination assessment. Range of motion and coordination are important for all people. No matter what we are assessing, no matter what problem, no matter what genitalia we are looking at, all of the people that we are assessing with the pelvic floor, we need to start with range of motion and coordination. So what is the range of motion of the pelvic floor? What do you mean by coordination? Well, range of motion of the pelvic floor, you've heard us talk about this a lot here at ICE, is squeezing up, we call it squeezing into the attic, going up towards the head, going to baseline, and then going into the basement. So in our A-frame analogy, we've got the attic, the first floor, and the basement. So we need to assess all of these areas. That is the range of motion. There are going to be problems if somebody can't raise it up. There's also gonna be problems if they can't push their pelvic floor down. There's problems when the full range of motion does not exist. So we need to A, assess it, and then B, help them find their full range of motion. That's beyond the scope of this podcast. Come to our live course where we talk more about this. But that is range of motion assessment. Very important as it is first. Then we go into coordination. So coordination is me assessing your pelvic floor with certain coordinated movements or certain movements that you do in the day. And I'm assessing to see what does your pelvic floor do and is it coordinated with the core muscles? How does that function? So we might would look at a cough We would definitely look at a brace, especially if the individual is having issues with some type of bracing mechanic. And you may do it in a lot of other different positions. I have clinically assessed pelvic floor coordination for a yogi who is having difficulty with downward facing dog. Yes, we got into that position to assess the coordination of her pelvic floor. That was where her primary complaints were. That's where we need to do that assessment. It's not a strength assessment at that point. It's a coordination. What is she doing with her core and pelvic floor in the problematic position? That is coordination. With these two important pieces of the assessment, There's a lot of different ways in which you might assess. Range of motion, coordination. That could be assessed just visually. Just externally, I am looking at maybe the rectum, maybe the vagina, male or female. Whatever it is, I might be just looking externally. Or I might do an internal assessment. vaginal or rectal. I might would do it in standing, a standing assessment. There's a lot of ways in which we're going to match the assessment with the problems that the person presents to us with. We're going to match them, but realize that they're going to start with a range of motion assessment and coordination. Then of course we can dive into our other three options, that strength assessment, that palpation assessment, and the pelvic organ prolapse assessment. So it's important for you to know that All of these options that exist, you may not use all of them in a client. You may not use them all in one day. It may take you several months or weeks, depending on the person in front of you, to go through all of these assessment tools. That doesn't matter as much as what matters is that you're testing the problems that they're presenting with, and of course, that you're making progress along the way. So that strength assessment is important. It is a piece of the puzzle. Someone needs to be able to generate enough force in their pelvic floor to squeeze off their holes. That way they do not have problems of a lack of force. That is important. But only when we know that they're coordinated enough to squeeze their pelvic floor. Right? Because if they can squeeze it on their own, but whenever they're bracing, they're not squeezing it, it doesn't really matter to work on strength. It matters to work on coordination. You see where I'm getting at? So once they get that, those first pieces, the range of motion and coordination, then we move on to strength.

WHAT NEXT AFTER RANGE OF MOTION & COORDINATION?
So with that strength assessment, we might do that in supine, we might do that in standing, testing their strength, their ability to squeeze the pelvic floor. With the palpation assessment, and again, we go into all the details. I'm skimming the surface here. We go into all the details in our live course. When we are doing a palpation assessment, that is purely to reproduce their pain. You hear us at ICE all the time talking about, and no matter which course you're taking, when we are doing a palpation exam, we are trying to reproduce their main complaint that they're coming in to see us for. So, same is true in the pelvic floor muscles, each of the layers, left side and right side. Does this reproduce their problem? Their problem might be urgency. When I gotta go pee or poop, I've got to go. Let's see if pressing on some of these muscles causes that urgency. or round ligament pain or adductor pain or might even look or sound like what the patient may come in with is sciatica, right? Or radicular pain. All of those could be caused by the pelvic floor muscles in which you would find in that palpatory exam. So that palpation exam is important to rule out the pelvic floor as a potential root cause of some of their symptoms that they are experiencing. And then lastly is pelvic organ prolapse. So we may not do this pelvic organ prolapse assessment. There's a lot of podcasts where we're talking about our thoughts on POP or prolapse, and I will have to guide you to those. I'm not gonna take all of your time talking about that this morning either, but it is a piece of the exam that you might would add in. We might would add in the prolapse exam if the person is coming in with their main complaint saying the word prolapse. Saying that I've been diagnosed with prolapse. Discussing some concerns about prolapse. Similar to the obsession about the strength scores, we can also see an obsession about a prolapse grade. Something about these numbers gives us this black and white, this very clear picture in our heads, but it's not exactly the full clinical picture. So really, do the pelvic floor assessment. If you need to do the prolapse assessment, absolutely do that. And again, you can do that in supine. You can also do it in standing and apply that to that individual. But just remember that 50% of individuals assessed objectively are going to have some sign of dissent, aka some sign of prolapse, so we don't need to be freaked out about it. Rather, what we need to do is focus on their range of motion, focus on their coordination. Those two pieces are so incredibly fundamental and important for everyone to be able to utilize their pelvic floor effectively. Whether that is in preparation for birth, whether that is performance under the barbell, or trying to reduce pain with sex, Whatever the topic is that the individual is coming to us for, we're going to start with that range of motion assessment. We're going to go into that coordination and we might hang out there for a while and work on the goals of pulling pelvic floor up, pushing down, feeling all of those differences of the pelvic floor, and then coordinating it. Coordinating it with diaphragmatic breathing, with bracing, with whatever problem they have, matching it to that. That right there added with it the three options of the strength, the palpation, and the prolapse assessment, that is the updated version of the pelvic floor assessment. That is what aligns with how we understand, as of today, the pelvic floor function. It matches what we see in the newest literature all the time, which is maybe it's not all about strength. Maybe there's some other aspect. And when you look at these studies, we recognize that individuals are assessing this, but it's not really been discussed about in this way. This is what we're doing. This is how you create change. This is how you have some organization in your assessment. This is how you get the patient on board. You tell them we're gonna do range of motion. We're gonna do coordination. We're gonna see how you do with each of these. This is gonna look a lot like this problem that you're experiencing. We're gonna match that up and we're gonna talk about what optimal is. Really focusing in on what matters to them helps them stay focused.

SUMMARY
So use this, let me know what you think, and if you are so excited to see us maybe in Greenville, South Carolina this coming weekend at the live course, we're excited too. Or we've got several courses coming up in Colorado, in Missouri, in Alaska, In New York, we're all over the place this year. So look for a course that's near you or near somewhere that you would like to travel to. We would love to have you at our course. We also are discussing these topics in a little bit different ways in our Online Level 1 and our Online Level 2. Our first cohort of the Level 2 is actually sold out. Our second cohort of the season of the year is in August. It will sell out. If you are interested in joining us, you should go ahead and purchase that ticket. We'll be talking about all of these aspects of what we just discussed today in both of those courses. head on over to PTOnIce.com, check us out, we would love to have you join us in the courses. Have a wonderful day, a wonderful week, and let me know what you think about the new way of doing the pelvic floor assessment.

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

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses research supporting the use of gait retraining for preventative rehab. She shares practical advice for coaching & cues to use with runners to improve their gait in a manner that has been shown to reduce likelihood of future injury. 

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog

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

EPISODE TRANSCRIPTION

RACHEL SELINA
Alright, good morning everyone and welcome back to the PT on Ice daily show. My name is Rachel Salina and I am a TA within our Endurance Athlete Division. So I help teach our Rehabilitation of the Injured Runner live and online courses. So hopefully today you are ready for a running topic because that's what we're going into. I will apologize now if it gets a tiny bit loud in a few minutes. I'm currently at our CrossFit gym, so we've got a group that's going to start doing 24.3 here in just a moment. So if you hear the music kick up a little bit in the background, that is what's going on. But otherwise, we'll keep this a bit brief into the point today. So we're going to talk about gait retraining and really addressing a question that comes up in our courses a lot. And that question is, do I address running mechanics if a runner isn't injured? So kind of asking that question, like, is there an ideal gait form, gait mechanics that we're trying to get to? Um, like if it's don't broke, don't fix it kind of thing. What do we do when someone is not injured? Should we still intervene?

WHAT IS THE GOAL OF GAIT RETRAINING DURING INJURY?
And I think first we need to break down a little bit what we're trying to do with gait retraining when someone is injured. So really what we're doing with most of our drills is we're taking a load that's overloading a particular structure, right? Say it's the knee. The knee is aggravated. running aggravates it. And we're going to use a drill to try and shift that load to a different structure, allowing the knee to have less load and therefore kind of recover and be able to tolerate the running. So all we're doing is shifting load from one structure to another. So we're not necessarily trying to make it perfect. We're just allowing that person to still be able to run because we've changed how their body has to absorb the forces of running. So for example, That same patient who's having maybe patellofemoral pain, we see that they land with an overstride, their foot is landing far in front of their center of mass. We might give that patient a forward leaning drill to try and bring the center of mass closer to where the foot is. By doing that, by getting that patient to lean forward more so than their preferred or kind of typical pattern, we decrease the stress at the patellofemoral joint, which is good. It decreases their pain. They're able to still run. But what we've done is we've shifted that load to the glutes and to the gastroxoleus. We've just moved the load. So that's the case where we'll use gait retraining. kind of in addressing injury shifting load.

WHAT ABOUT GAIT RETRAINING FOR SOMEONE WITHOUT AN INJURY?
But what about, like I said, if that runner's not injured, can we still use gait retraining in any form to either help that person run better, right? So we can talk about it from performance. That might be one time where we would use gait retraining in a non-injured runner. Or can we, do we have any evidence to show that we could use gait retraining to actually reduce the risk of injury. So that's where we're gonna talk a little bit more today. There's a really cool study that came out by Chan in 2018 and we dive into this some in our live course, but I really wanted to kind of deep dive today. So this study was looking at a group of non-injured runners and giving them a gait retraining drill. and then they followed these runners out over a year, which is a pretty long time to follow these runners, to see if there was any difference in the injury rates. So their only intervention, right, they were looking at addressing vertical loading to be able to reduce the vertical loading. So they had runners come in, okay, for eight sessions over two weeks, so four sessions each week. They increased their running time in that two week period from 15 minutes a session to 30 minutes a session. They gave the patients feedback, like they gave them visual feedback, which there's some systems we can use in a clinic to show like peak forces and rates. And we'll get into kind of how we can do this without having that visual. Anyways, they gave them lots of feedback initially. and then reduce that feedback over the eight sessions, which this is very typical of how you would see gait retraining carried out in a clinical setting or how we would like to prescribe it. So lots of feedback initially, kind of tapering that feedback off. And they actually didn't give them feedback in the last few sessions. And then they sent those runners off, right? That was just the first two weeks. And then followed them over a year. And they found, that the group that did the gait retraining had a 62% lower injury occurrence, which that's a huge deal to be able to, like that was the only intervention they did. They let the runners keep, you know, like their normal shoes, their normal running pace, speed, all that kind of thing. They just did the feedback. So given this is one study, but it's pretty hopeful or pretty helpful in thinking that if we can intervene and do some things to reduce the loading rate, we might be able to prevent some injuries. So like I said, in this study, they used like the, like they got visual feedback of their forces, but they also told the runners to run softer. And that's something that's very applicable to our runners that we can tell them to focus on, right? We can have them go, and spend those four or um sorry eight sessions on a treadmill inside like in a controlled setting trying to focus on making their gait um or their foot strikes softer and then send them out like they don't have to continue every single run to focus on that um but i think we can actually have an impact there um in how their body is having to accept load and hopefully be able to prevent some injuries. So like I said, I'll reference this study in the show notes if you want to read it all the way through. But again, a very promising way to start to look at still being able to provide something helpful to our runners when they're coming in, maybe from a performance or just a non-injury standpoint, we don't have to say like oh well you're not injured now so we don't do anything um but we also don't have to like pick apart every single tiny thing of their gait if not all of it um is something that we want to address so can we make them maybe run softer and then another instance where we can think of gait retraining from an injury perspective there was another study looking more at high school runners and again this was prospective as well so a bunch of runners that weren't injured, they measured their cadence and then followed them out. And the runners who had a cadence less than 164 steps per minute had a higher incidence that was associated with injury. Right, so that's another way where if someone comes in, they're not currently injured, maybe they don't have any complaints, they just want their gait looked at, they're curious what their gait looks at, they want to be able to do, like to run better or feel better running, we might be able to manipulate their cadence as well as a preventative type of intervention. So can they run softer? And can we make their cadence faster? So as I say, if you want to focus on two things for your non-injured runners that can be beneficial in the long term, that's where I would focus our attention. That's it. And some of these things are cues that you can very easily pick up when your runner is in the clinic for a gait analysis. If your runner is very loud, like you hear every foot strike really, really heavy, they might be someone that's good to give the cue to run softer and have them focus on that. If you measure their cadence and it's really low, like below that 164, have them start working on cadence retraining at 10% above that. These are some really simple, actionable ways to start helping your non-injured runners hopefully stay non-injured. All right, that's it today. Like I said, just want to keep it short and sweet.

SUMMARY
If you are interested in learning more about gait retraining, gait mechanics, gait analysis, we have two live courses scheduled for this year so far for Rehabilitation of the Injured Runner Live. Our first one is coming up in June, so that's June 1 and 2 in Milwaukee. And then we have September 7 and 8 out in Maryland. So we'd love to see you at one of those. If you can't make it live, Our next online cohort starts the beginning of June as well. So sweet. I hope you all have a great Friday. Get after 24.3 if that's your jam. Otherwise, get outside, go for a run, and we will see you soon. Bye.

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey demonstrates a manual therapy technique to mobilize the knee joint to improve knee flexion. She also discusses dosing the mobilization as well as demonstrating a home exercise follow-up for patients.

Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog.

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

EPISODE TRANSCRIPTION

LINDSEY HUGHEY
Good morning, PT on ICE Daily Show. How are you? I'm Dr. Lindsay Hughey from Extremity Management coming to you on a technique Thursday. This is my first technique Thursday, and I'm delighted to be with you today. I am going to show you a knee flexion gapping technique today. This is a technique that is really helpful for your folks with knee pain that are having any kind of mechanical knee sound. So maybe it's popping, maybe it's clicking, maybe it's even catching a little bit, or even just like crepitous sounds that maybe bother the patient. And they have some knee flexion deficits. So this gapping technique is one of our favorite in extremity management. So I'm going to show you on our demo model today is Paul. So first things first, we'll go over your position as the therapist, setting yourself up for good body mechanics. We'll chat a little bit about dosage. Then we'll actually talk about a follow-up mobilization to make this technique really effective. it happens what comes next. So this patient really needs to get after self-mobes to follow this up and for it to be its most efficacious in continuing to gain knee flexion and to reduce those mechanical knee sounds.

POSITIONING & SET-UP
So as the therapist, you are going to come alongside the patient. The table should be at about mid thigh height as the therapist. Your patient often will position themselves in the middle of the table. Tell them to scoot their hip to your hip. So go ahead and bring your hip to me, Paul, so that they're close, so that you get some really nice leverage here. The other thing is when you bend their knee into whatever flexion they have, their knee, the top of it, should sit about your chest height. If that's not the case, you might want to drop the table a little bit lower. So that will depend on therapist's torso side and then femur length of that patient. Next thing, you are going to come under that popliteal fossa with your elbow. And the patient's leg is just going to rest in your pubital fossa. So patient, you'll wait for them to just kind of relax. And then this hand is going to go somewhere along the tibia and fibula. in a cupped fashion, and then you're gonna sink in with your body. So it looks like so. So if I were to give you a little space here to see, my hand wraps around the tibia and fibula. And then I get back to that staggered PT stance, and I'm gonna lean in with my body and oscillate on off. I'm going to let Paul down for a second and do a little shadow mobilization body position. So I'm going to be staggered stance, midline is tight and active. That arm comes around, carries the limb, and we know we carry some big limbs here, right? If we're dealing with knee OA, meniscal injury, our big athlete legs, maybe they have some ACL stuff going on. Scoop here. Allow the leg to hang and then get that arm here and then it all becomes body. My body sinks so there's no break in the arms at all. This all stays tight and you'll oscillate.

DOSING KNEE FLEXION MOBILIZATIONS
Recommended dosage is 30 to 60-second oscillations, three to six reps, and then you'll retest that knee flexion. So we're looking for a change in either pain response, knee flexion, possibly even the mechanical sounds that they're having, but we try not to emphasize overall on the sound part. But we do want to do that test-retest. I'm going to show you one more time from the top, and then I'm going to show you the follow-up mobilization that we'll go to for this. So patient is close to you. I'm in staggered stance. I'm going to scoop that knee up, let it rest on my forearm so that I create a little gap in the knee joint. My hand is going to cup. I'm superior to medial and lateral malleolus. And then I'm just going to oscillate and sink for that 30 to 60 second oscillation. whatever the patient can tolerate, but really making sure I create that gap underneath the knee joint and sink in. And then you can get into progressive and more knee flexion. After that, we wanna follow up with a good mobilization. So right, we pretend we did those three to six reps, we've retested, he's feeling good.

HOME EXERCISE FOLLOW-UP
So now Paul needs the tools to own that autonomous access, right? To own the joint motion or range of motion that we just restored. So Paul, I'm gonna have you come sit on the floor and we're gonna actually use a band under his knee and a towel to create the gapping mechanism that my forearm created. So Paul's going to put that under, and then we're going to try to also get that band. So we'll put that in first. Beautiful. And then he's going to grab that lower tibia and fibula, lean back slightly. So lean on back, Paul, so that your foot's off the ground. And then he's going to oscillate his legs. So go ahead and lift your foot off the ground. And now he'll do that same, whatever oscillatory time, 30 to 60 seconds felt good. He can set a timer and he'll just kind of bounce on off. It should feel easy and feel very similar. And you can go ahead and relax to what we just did on the table. So again, try to match that dosage time. This technique is good for restoration of knee flexion, helping with pain, and kind of easing some of those mechanical joint sounds. It's one of our favorite go-tos for knee flexion restoration and extremity management.

SUMMARY
If you want to learn more from our team, from Mark and Cody, we would love to see you on the road. We are going to be in Spring, Texas this weekend, and then Aiken, South Carolina. Both of those locations have some spots left, so dive in. If you want to learn more about how we manage common knee conditions like knee OA, meniscal, patellofemoral pain syndrome, patellar tendinopathy, iliotibial band pain, we'd love to share what best practice looks like in that area. And we also cover the hip, ankle, foot, shoulder, elbow, wrist, hand, and best practices for dosage and tendinopathy. I will be on the road next weekend in Victor, New York. So if you'd love to join me, I would love to see you. And Alan will be there, our COO. So join us on the road. Check us out on ptonice.com. And if you're not on the app, we just launched our Ice Physio app. That is a wealth of connection. So join that as well. Have a happy rest of your Thursday. Thanks for joining me this morning.

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