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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock takes a deep dive into the jerk, discussing the importance of learning a strong leg drive, improving shoulder mobility, and committing to a strong finish with the movement.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

Good morning, everybody. Welcome to PT on ice Daily Show. I'm your host, Mitch Babcock from the Fitness Athlete Division. That means it's Fitness Athlete Friday, and I'm stoked to be back on the podcast, bringing to you another episode, this time going into some nuanced stuff around the jerk. So stay tuned for some more details around how to make your jerk a little bit better. Today's topic, don't be a jerk with your jerks. Before we get into that team, first of all, I'm wearing my Lions shirt. Did you watch the game last night? Of course you did. Thursday night football. Let's go Lions. It's been a long, hard existence being a Lions fan. So we're out here stoked that we got t01:27 MITCH BABCOCK

hree wins already on the season. Other news, non-football related, is that the fitness athlete team is going to be around the country coming up real fast here next weekend. Joe and myself are going to be out in Linwood, Washington, and we're rocking a big course out there. So if there's still time, if you want to slide in just under the cap of that course out in Linwood, if you're in the Seattle or greater Seattle area, we'd love to have you out at that course. We also have some courses coming up in the southern region. We've got San Antonio, Texas. And we've got Anna Maria Island in Florida. So if you're looking at Florida or a Texas course, we've got two of those in store for you coming up in the month of November. So otherwise, welcoming in the fall season here today.

01:43 MAKING YOUR JERK BETTER

And today's topic around don't be a jerk with your jerks. We just finished up a nice May cycle where we did a lot of snatching and clean and jerking for the last eight weeks. and giving my members of the gym as many helpful tools as I can as a coach and an athlete of what's helped me with my shoulder overhead, specifically the push jerk in this cycle, but all of these principles also apply for the split jerk as well. And I see this done wrong or at least thought about wrong a lot. I figured it was helpful to share with you guys, whether that's from a personal standpoint as an athlete, you're out there training in the gym yourself and you're like, hey, This is sweet. I hate jerks. I hate split jerks or push jerks. And I want to get better at those. Or if you want to be able to pass that on to your clients or members, hopefully this will be helpful. So the first thing I want to talk about is what not to do. Don't press your jerks.

03:37 THE JERK HAS LITTLE TO DO WITH ACTUAL PRESSING

The push jerk and the split jerk is not about how much you can press vertically. It has little to anything to do with actually pressing the bar vertically over your head. Think about what your one rep max strict press is. Ladies is usually somewhere in the ballpark of 60 to 100 pounds. Men, somewhere in the ballpark of 100 to 200 pounds of a strict press. And yet people are able to do almost twice as much as that when it comes to a jerk movement. It is not about your strength to move the bar off of your shoulder and press. So stop thinking of it like you need to push the bar up. The jerk is about pushing yourself under. That requires a couple things. One, specifically the legs. You need to start thinking about your legs way more than your shoulders on your jerks. It is all about your legs' ability to launch the bar off of your shoulders enough that you can then press your way under the jerk. Again, goes for the push jerk or the split jerk. So when you're in setup position, you've stood up that heavy clean and you're ready to make the jerk. Hopefully make the jerk. You need to be thinking about how much leg drive can I create vertically on this bar right now to launch this thing as far off my shoulders as possible. That means I need strong legs. I need to be better at my front squat. Specifically, when I stand up out of a heavy front squat, I need to be powerful in the finish as I'm standing and finishing that lift. So that's something that you can be training on days that you're not jerking at all, but be thinking about that last little third of the squat. Standing it up with a little power, with a little speed, and learning how to create really rapid short triple extension. Power cleans, same thing. Rapid triple extension at the top, but all we're trying to create here is more powerful legs. You can work on just dip and drives. It's a very common drill for Olympic lifters to work on. Get a bar in the front rack position. You just dip, hold, and just create a slight little bit of triple extension coming out. Dip, hold, create triple extension coming out. The focus point on the jerk needs to be on a strong leg drive. Now, once you get that to occur, then the press is actually you pushing your body under. It's just pushing myself down to a supported arm position. The shoulder is strong if it can meet the load in its locked out position. It's significantly less strong when it has to do any sort of motion to try to press out that kind of weight. So the quicker you are to press yourself down and support, the heavier of a jerk you'll be able to have, because it's just about supporting the load, not about pressing the load.

07:01 SHOULDER MOBILITY & THE JERK

That requires shoulder mobility. And this is the big downfall to your split jerk is likely either A, you've been thinking about trying to press it over your head this whole time instead of jumping over your head. And B, your shoulders are too dang tight to really get into that full 180 degrees of flexion lockout arm position. You're trying to press it out in front and that's killing you, right? So you gotta open up that shoulder mobility. And you guys are the experts at doing this. Mitch, what do you like to do to open up your shoulders right before I'm weightlifting. I'm not talking about a PT session. I'm talking about something members can do out in the gym, boom, in real time to open up that double arm overhead position. I want to use a green band, but I don't want to do a single arm. I want to do double arm. And so rather than looping the band and attaching it to the pull-up bar like we normally do, I want to drape the band around the bar in this fashion. This is a poor example, but you get what I'm trying to say. I just, I don't want to half hitch it at all. I want to just loop it over the bar and have the band hanging down. I'm going to put both my hands through the band and I'm going to spin around. If you're watching this, this is a great I hope you're having fun with this because I'm spinning right now. I'm going to do like three circles and what that's going to do is wind up that band. So I've got it looped over the bar and I wound it up by doing three circles in it. My hands are now held in this double overhead position and I'm going to kneel down on the ground from that position. I'm going to start to have the band pulling my shoulders, essentially both arms, right near my ears at this point. When I'm down there kneeling on the ground, hands overhead and hooked to the band, now I can start to add some side bending into this position, which really starts to peel on this lateral seam of my arm, coming down to thoracolumbar fascia, up into the tricep area. I can side bend left, side bend right, and even add in a little upper back T-spine extension to that drill. It is the best opener I have found recently to get my shoulders ready to push jerk. because I'm hanging out in the exact position, an exaggerated version of it, but the exact position I want to finish my jerk in, which is the head through, the T-spine up and extended, and the arms behind my ears. So when you're thinking about pushing yourself under the bar, make sure your shoulder mobility is opened up so that you can do that. Okay, so what do we got so far? Strong leg drive, Don't press your jerks. Instead, push yourself under your jerks and make sure your shoulder mobility is on board for you to do that really well.

10:47 IMPROVING JERK TECHNIQUE

And the last thing you need to think about, the only really cue I'm thinking after I think jump is I think head through. I think jump and I think head through. Too many people are scared to put their head through on a heavy jerk. They're committing to failing it and therefore they're committing to self-preservation. And so what they do is they jerk and they leave their head back behind the bar and they're like, if it works, cool, then I'll bring my head through. But if it doesn't, I can bail quickly and easy. That is just committing to failing the rep right from the start. You have to know that if this goes bad and I'm still pushing my head through and I can quickly get out and underneath the bar if I fail it. You're, trust me, you're athletic enough to move out of the way of the bar. I've seen it a number of hundreds and hundreds of times of athletes trying to get the head through, fail the rep and are still getting out from underneath the bar. You've got to commit to that head coming under and through the window. Because if not, the bar is going to be out in front of your center of mass. And it's way too heavy for you to hang on to out there. My max jerk is 350. There's no way if I don't get my head through that, that I can hold that kind of load overhead. I've got to bring the head through and I've got to bring the arms behind my head. And that's when I close my eyes and say a little prayer. Oh, I hope this goes good. But the head is forward. I'm not looking at the bar. The head's got to be forward and through. So the only two cues, if you're thinking about anything, it's jump as hard as I can and push my head through that window and pray for the best. Shoulder mobility needs to be on board. It's all about the legs. It's not about the shoulders. And it's about getting your head through the bar. And if you do those three things, you go out in the gym today, right now, and you start practicing those three things, I promise your jerks are going to feel faster, snappier. You're going to reach lockout a lot quicker, and you'll be able to PR that push jerk or that split jerk, whatever you're doing. And hopefully add 10 pounds on it. Don't forget to tip your caddy when you do. All right. I'll open, I'll share my Venmo below. Don't worry. That's how to not be a jerk with your jerks. I hope that stuff helps you. I hope that gives you some things to think about maybe for your athletes you're working with or cues that can help them and restore that overhead position. I think I should probably film a video of that shoulder mobility opener. I got a feeling I'm going to get some comments or questions about, Hey Mitch, I had no idea what you were trying to explain. Can you drop a video? So I'll walk right out in the gym. I'll film that and I'll do my best to drop a link to that video in the best place possible. Maybe over on my Instagram. Head over to my Instagram, Dr. Mitch TPT, follow that. And then, uh, I'll drop that video there for you guys, man. So glad you guys are here. Happy Friday. Go lions three and one and one and O in the NFC North. It's a good time to be a lion's fan for the first time in about seven years. Team. I hope you have a great weekend. If you're taking a nice course, let us know if you're taking a nice course next weekend, we'll see you out there. And if you want us to head down South, come find us in San Antonio or find us in Florida. and we'll be hanging out down there in the month of November. Have a great weekend, everybody.

01:27 MITCH BABCOCK

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

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore emphasizes emphasizes the importance of trusting a proven process for success, particularly in the later stages of a business or any endeavor when uncertainty arises. He cautions against blindly trusting any process and encourage listeners to thoroughly evaluate its merits before putting their trust in it.

Jeff acknowledges the prevalence of outrageous claims and self-proclaimed experts in today's era. He cautions against falling into this trap and emphasizes the need to dig deep and evaluate a process before trusting it. He suggests spending ample time observing and studying someone who has achieved desired outcomes through their process before fully committing to it.

This advice applies to various domains, including clinical practice. If someone is considering adopting a specific treatment approach or following a mentor's guidance, they should first spend a substantial amount of time observing the mentor's success with a wide range of patients. Only after extensive evaluation and proof of the process's effectiveness should one trust and implement it.

Overall, Jeff emphasizes the importance of trusting a proven process but stresses the need for thorough evaluation and proof. Blindly trusting any process without proper evaluation may not lead to the desired outcomes.

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

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

Okay team, what's up? Welcome to Thursday. Welcome to Leadership Thursday. And welcome back to the PT on Ice Daily Show. Thrilled to have you here. I am Dr. Jeff Moore, currently serving as a CEO of Ice, and always happy to be here on Leadership Thursday, which, as always, is Gut Check Thursday. Let's start off every Thursday how we always do. Let's talk about the workout of the week. Here's what we've got cooked up for you. We've got 21-15-9. Couldn't be a more classic rep scheme. We've got thrusters and bar-facing burpees. So hopefully the first thing you're thinking is it looks a lot like Fran, right? We've got two movements, we've got that classic rep scheme, but I'm going to argue it's going to be a bit worse. With Fran, we've got push-pull, right? So at least you're pushing that thruster and then you're pulling up on that rig. Now we've kind of got push-push, right? So we're going to go thruster and then hitting that push-up motion during that burpee. It's probably going to be a little more painful. Additionally, you're probably not going to be able to sprint through quite as fast, looking at how long a burpee takes compared to a pull-up. So in Fran, you might be able to out sprint the darkness, right? You might be able to get done with the workout before that darkness really catches up to you. Here, I think you might be living in it for a while. So just let us know how it goes. Make sure you tag us, Ice Physio, hashtag Ice Trained. Let's have some fun with the workout over the next couple of days. As far as upcoming courses, the thing I want to highlight this week, is that virtual ICE is open. So as you all know, our virtual mentorship, we only open it every quarter for a couple days, bring in a new group, add into the crew, and then launch, close those doors and launch for the next quarter. We are trying to hold that price steady. It's been 29 bucks a month forever. It's still 29 bucks a month. Yes, it's CEU eligible, but more importantly, it's a great way as you're going through ICE courses to be able to be in that group, hold you accountable. Every Tuesday we meet, going over case studies, new thoughts that aren't built into our courses. It's a way to deepen your knowledge and really make it more clinically implementable, if you will, by every week revisiting and expanding on some of our concepts. So if you want to jump in, go to Virtual Ice on the website. PTOnIce.com, as always, is where everything lives.

02:37 TRUSTING THE PROCESS

Let's talk about trusting the process. So trust the process, absolutely, right? You should totally trust the process. But I wanna unpack a couple things around this conversation that aren't talked about enough. So number one, trust the process. Everyone speaks of this in the early stages. Okay, so kind of a classic conversation around this topic is, hey, when you're just getting started, you might not see gains right away, don't worry, trust the process, it'll show up in time. That's clearly very relevant. And certainly when you think about areas like fitness where we often talk about this, yes, you're not gonna stack on a ton of muscle in the first couple weeks of training. You've gotta trust the process and those gains do show up down the road. There are certain areas where that early phase This concept is the most important, but I'm going to argue today that in the world of business, it's really in the later phases where I think this concept becomes significantly more important.

05:29 LOSING CLARITY ON CAUSE & EFFECT

So let me, let me build the argument. So early on in business. The connections are very, very clear, right? You don't need nearly as much trust that what you're doing is reaping a reward simply because cause and effect are much clearer early on. For example, If you're building a practice and you form a new relationship and you see an increase in customers, it's pretty obvious that those increased customers came from that relationship because you don't have a ton of relationships yet. And any increase in customers is really obvious because you don't have a ton of customers yet either. Additionally, it's really easy when you run an ad or something of that nature to see again that swell of business following that ad is quite noticeable and it's very clear where it came from. Following up with your customers is a lot easier. Number one, there aren't as many of them, so it's easier to dive in and figure out, hey, how did you wind up here? Where'd you come from? and there aren't as many people delivering your service. So you don't have to bring everyone together and try to kind of coagulate the data and see, hey, where's everybody coming from? The connections are simply clearer. There's not as much noise, little changes make very obvious results, and it's not as hard to collect or aggregate the data, because there aren't quite as many people delivering the service. Early on, you don't need as much trust. Five years down the road, it's much harder, right? It's much more challenging. You often find yourself saying things like, I have no idea where that person came from, right? There's so many more things going on. There's so much more noise that it's much, much harder to prove. Did this action result in a certain effect? Now we fight this valiantly, right? Everybody, and you should, is trying to track everything, right? Whether it's where a customer landed on your website, or if you're running an ad, you're putting a tag on there so you can see, hey, when that person came to the website, if we track them through to the commerce side, did they actually convert? You're doing your absolute best to track everything. But the larger you get, the more mature the organization, it becomes significantly more challenging to definitively prove that any individual action resulted in any significant outcome. There's simply too many variables. You don't know, did it come from word of mouth? You really can't track that all that well. There's so many things going on that it's tough to have that clarity that you had early on. The reality is growth results in necessarily losing some clarity on cause and effect. The more mature the business, the more true this is. So what's the answer? The answer is to very much embrace and trust the process. In the absence of proof, You're just gonna need to check the boxes of what's known to work. I would argue the earlier that you can do this, the earlier that you can stop wasting your time demanding proof of every single action that you did having a reward or a response, the more efficient you're gonna be and the faster you're gonna succeed. The earlier that you can say, I no longer need to see proof that this thing that I'm doing is reaping a reward, I'm just gonna do all of these things with absolutely ruthless consistency, and I'm going to trust that by doing so, the end result is going to be additional growth and more progress. The earlier you can trust the process, the more efficient and more successful you're gonna be. But there is a catch here. It's got to be a proven process. And this is what I want us to really think about this morning.

07:39 OUTRAGEOUS CLAIMS & TRUST

Team, we are living in an era of outrageous claims, right? We are living in an area where A huge amount of people that can't do are claiming to be able to teach, right? They're claiming to be able to get you unbelievable outcomes, even though they themselves don't really have a track record of being able to do so. That is the era in which we live. Heavily marketed, thinly veiled, outrageous claims. That is really where we are. Because of that reality, you need to dig deeper. The passion behind this topic is coming from having seen so many people over the years come to me and say, here's where I'm at. And me thinking, dude, how did you fall for that? Like that person, there was no reason to believe that those claims were being backed up by any significant track record of proof. The person simply did not dig deep enough. And that's what I wanna say to you today.

12:50 SHOULD YOU TRUST THE PROCESS?

Should you trust the process? Yes. after you have went through extensive lengths to prove that that process actually results in the real world, in the outcomes that you're seeking. This is across every domain. Clinically, if you're gonna choose a mentor, if you're gonna lock into somebody and say, I am going to treat the way that person treats, I'm gonna ask that person what the big rocks are, and darn it, I am gonna implement those in every patient that I see. If you're gonna do that, You better have spent a solid year around that person, watching them day in and day out succeed with patients. A wide variety of patients, a wide range of complexity of patients, until you get to a point where you're like, look, that person gets it done. Better than everybody else I've seen, almost regardless of who shows up in front of them, the methods that person's utilizing month after month after month after month consistently work. I buy it. That person can actually get it done. I am going to trust their process. In Con Ed, at ICE, I hope you never sign up for a certification until you've taken one of our courses and went back into the clinic and implemented and decided for yourself, do the tools that I learned in that weekend course or that online course when I went back in my clinic, was I demonstrably better? Was I more efficient? Was I having more fun? Did it actually work? Until we prove that to you, I don't want you to sign up for some long series of courses. I want you to test us, and I want you to go and see, does it actually work? That's the kind of level I want you digging in on everything. In business, you don't buy that someone can grow your business until you have talked to a bunch of people who aren't affiliated, who maybe have done some of their mentorship, but are not actively in their program, and you reach out in your private circle and say, hey, has anybody worked with so-and-so? I want to have some conversations. And you dive in and say, is it really as good as they say it is? Were the principles that they taught able to grow you? Anybody can put that on an Instagram ad. Did it actually work for you? Is your business three times bigger now than it was a year and a half ago like they said it would be? Dive deep and ask the hard questions. I love it when people reach out to me. And they're thinking about opening it onward, right? And they say, look, I want to talk to a couple other owners. I love it. They want to hear from the people. Did they actually deliver? I love when people who are getting coached up to become faculty at ICE, I hear them reaching out to other lead faculty. They're not offending division leaders by doing that. They're just going out and saying, hey, here's kind of what I'm being sold. Did it actually shake out like this? In looking for multiple sources. Business leaders, I hope you all are never offended by that. People are not second guessing you. Yeah, they are, but they're not disrespecting you. They're just doing the work. They're saying, look, I heard you, but now I'm gonna go see across multiple sources if what you're saying historically has added up. Are you actually able to get the job done? Have you proven that? Or are you just saying that because you want your business enterprise to grow? Do you have the goods? Team, in fitness, to me, with CrossFit, I had never heard of it before 2013, 14, but as I got into it, I looked around for proof. In the first thing I saw, in the second thing, in the third month, in the second year, is that everybody who just consistently did what was on the whiteboard and showed up five days a week had what I wanted, meaning tremendously well-rounded fitness. I was shocked by where they wound up. They had tremendous cardio engines. They were strong as all get-out. They had tremendous skills in gymnastics and mobility. The people who did the whiteboard, as written, five days a week, as hard as they could, and used that process, wound up exactly where I wanted to be. You can only watch that so many times until you're ready to say, okay, I believe it. I buy it and I'm all in. So yes, right, trust the process. And yes, put your head down and check the boxes. But after you've established certainty. Now I want to finish by saying here's why this is so critical. Here's why doing the legwork to prove to yourself to be fully committed that this person can actually get it done and that it should thus be transferable to your success. The reason it's so important is two things. Number one, once you do put your head down, and I am totally advocating for you to put your head down, right? Head down, stop looking for proof of every single thing, and just check the boxes with absolute rigor. I'm encouraging that. But once you do that, there aren't a lot of checkpoints. So once you've committed and you've said, I'm just gonna keep checking these boxes and I'm gonna trust the process, you're not really looking for proof, right? Because we've just established it gets harder and harder to gain any, so you've just simply gotta trust. The problem is if you're wrong, there aren't a lot of checkpoints to reveal to you that you're wrong. So you're gonna go a long ways down that trail. There is gonna be a tremendous investment until you realize, oh man, that system or that person or whatever didn't actually have the goods. I should have done more front-end homework. The second reason is because if you've done the work to truly prove it to yourself, if you've watched that clinician for a year and become absolutely certain their method works, if you've taken a couple courses and become absolutely certain that when you implement it, you're better for it, if you've done the work to be positive or as close to it as you can be, you're much less likely to quit. Once you put your head down and say, I'm just gonna check these boxes, I know what's gonna work, you are much more likely to go the distance to a point where you actually begin to reap very serious rewards because you won't be second guessing yourself because you've got certainty in your corner. But if you didn't do the work, you're gonna be saying much earlier than you should, am I sure this is the right path? And now you're gonna need proof and validation, which as we've just talked about, is hard to come by. So now you're gonna quit early, and if anything abbreviates success, it's early cessation of effort. Because there are a lot of checkboxes or checkpoints along the way to tell you whether or not you're on the right path, And because going the distance is so critical to success, you have to do the work to increase your certainty that that person's process or that system is gonna work for you. Do that work and then trust the process. Understand it's probably more important late in the game, at least in business, when things get cloudy and murky, than it is early on. I hope that spins the idea of trust the process, maybe a little bit different way in your brain, and certainly encourages you to go one step further on drilling down to be certain the process you're about to trust has actually proven merits historically. Have a wonderful Thursday, team. We'll see you next week. Enjoy that Gut Check Thursday workout. Cheers.

16:16 OUTRO

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses evidence based recommendations on shoe wear for older adults.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:43 DUSTIN JONES

Welcome folks to the PT on Ice daily show. My name is Dustin Jones and today is Wednesday where we're going to be talking about all things older adults in particular. shoe recommendations for the older adult population. Shoe wrecks, heel drop, doesn't matter, barefoot, minimal, conventional shoe, what the heck's the deal with the toe box, what in the world is a shoe last, we're gonna talk about all these things, what the evidence says, and then what we're kind of seeing out in the real world, right? Many of us are seeing in clinical practice or in the context of fitness. Before we get into the goods, just a few quick announcements. Our online MMOA Modern Management of the Older Adult courses are going to be striking up here within the next couple weeks. So Essential Foundations, that is our foundational online eight-week course, is going to be starting October 11th. And then our Advanced Concepts course is going to be starting on October 12th. That's just for folks that have taken Essential Foundations. We've got a bunch of live courses coming up through the fall across the country. The one that I really want to point your attention to is Falls Church, Virginia. That's going to be the weekend of October 7th.

02:51 SHOE RECOMMENDATIONS

All right, shoe recs. This is a topic that I really enjoy digging into. I've got a decent amount of experience around shoes. I used to sell shoes right out the gate of PT school. I was working in outpatient PT clinic and then working in the first kind of barefoot style shoe store in the country. Two of his treads out of Shepherdstown, West Virginia, currently in Charlestown. And just had a lot of, made a lot of mistakes, learned a ton, met a lot of interesting folks that were in this space that were really challenging a lot of conceptions. around shoes and what is good for individuals. And I was very dogmatic at one point and I've kind of come to the middle a little bit in terms of what I perceive to be beneficial and the evidence is starting to show that as well.

03:55 THE OLDER ADULT FOOT

So when we talk about recommending shoes for older adults, I think the first thing that we need to acknowledge is that the foot is different in an older adult than when you're younger, right? We see age-related changes typically in the older adult population that warrant us to really question the shoe that they're in, right? The reality with the footwear industry is that many of the shoe lasts, lasts being the shape of the foot where they basically create the shoe from. The shape of that shoe last largely mimics what you may see in a younger individual, not necessarily the common things that we will see in older adults. What do we see in older adults? Typically, you're going to see a larger circumference of their midfoot. larger circumference compared to when they were younger, you typically will see a lowering of that arch in many older adults. We often do see that the angle, the toe angles of that first and fifth toe typically do go in, which we're well aware of all the issues associated with that. And we see these changes yet 99% of the shoes out in the market are looking at a younger foot and creating the shoe around that as opposed to an older adult individual. So we need to acknowledge these changes because that is what's going to influence the current evidence-based recommendations. So what I'm going to go through is kind of what the current evidence says, the most recent systematic review looking at shoe recommendations for older adults, and then I want to dive into the whole minimal barefoot shoe versus conventional shoe debate, particularly for this population. So what do we know to be true in terms of some key characteristics of shoes that are gonna be helpful for older adults. One, and probably the biggest issue, is that it fits. I know it sounds super simple and silly, but if you check the fit of many of your patient's shoes or your client's shoes, you will see some very ill-fitting shoes. Whether it is the shoe is too big, there's a lot of wiggle room, their foot is moving a lot within that shoe, or it's the opposite, right? The shoe is way, way too tight for that individual, and that creates a whole host of issues related to skin breakdown related to performance breakdown as well. And so we want to be very aware that it fits well, all right? So that's the first thing. Next thing is that it has fixation. A shoelace system, for example, we could say Velcro as well, but laces are typically better, is that if that shoe is properly fit and it's fixated to that foot, that is going to allow them to do what they need to do when they need to do it, all right? The second thing, third thing is going to be a firm supportive heel counter. So I've got a shoe here. If you're listening on the podcast, you can come to YouTube or Instagram to see the video. So this is just a Reebok Nano. I can't remember the model of this one, but back here, you know, is a pretty solid heel counter. So it's this back portion of the shoe. And so you want this to be firm and supportive. and snug when people put this on so you don't want a ton of room around the heel with this heel counter you want to be nice and snug and that's why trying shoes on is super super important. Next thing is around a 10 millimeter heel drop and this is where some of y'all are going to say no Dustin it needs to be just a zero drop shoe Current evidence shows that 10 millimeters around that range that older adults do really well there. If you start to go above that, particularly above 15 millimeters, you see an objective change in their balance performance through different outcome measures and their postural stability as well. If you're not familiar with heel drop, it's the difference of the thickness of the heel to the forefoot. This information can be hard to find on most websites when you go to look up shoe specs. That's why you want to look up the reviews of that shoe. Typically, a running world, there's a bunch of running related sites that will do all kinds of shoe reviews and they will give you some of those specific specs. When we worked at Two Rivers Treads, we would literally get a demo product and then we would cut the shoe right down the middle and we would measure the heel drop because a lot of those numbers weren't being published. We found some really interesting things. What the trend in the heel drop realm You know, 20 years ago, it was very, very common to see heel drops north of 10. You know, you'd be going, you know, 14, 17, 18 range in a lot of running shoes in particular. And over the past 20 years, particularly the past 10 years, that that average has gone down and down and down to where it's pretty normal to see a four to five millimeter drop from the heel to the front. That was not the case 20 years ago. So that has changed tremendously in the footwear industry. So around 10, excuse me, around a 10 millimeter heel drop. Next is a firm midfoot. So when we're looking at kind of the sole that it is relatively firm, you will typically see firmness in the midfoot and the forefoot is going to, excuse me. All right now, the forefoot is going to be a little more flexible. That allows for, you know, terminal stance, that we have a lot of extension, big toe extension is a big one, but that midfoot, a kind of firm, medium thickness is a good thing for older adults. In terms of the traction, a slip resistant sole that's multi-directional and tread. There's not a lot of evidence to support, you know, super thick, aggressive tread like you would see in something like a trail shoe. but some tread that is going to allow them that slip resistance in several directions, not just anterior to posterior. The next thing that you are going to want to look at is the beveled heel and then a rocker angle. All right. So this is really important for older adults that you typically want to see around a 10 degree beveled heel. So towards the back of the shoe, when we're going towards the very back of the heel, there's kind of that upward curvature. So it's not completely flat, but there's a little upward tilt around 10 degrees is really great. This allows or decreases the amount of them kind of catching their heel, especially during that swing phase. On the other side of the shoe, the front of the shoe, we have our rocker angle. You also hear this referred to as a toe spring. Now, not the fact that there is a spring in the toe or the front of the shoe, it just references that upward slope that you will see towards the front of the shoe. around a 10 to 15 degree rocker angle or toe spring is really good for older adults. The reason being is that when you're going into that terminal stance, you need a good bit of big toe extension, right? Some more ankle dorsiflexion as well. Usually you need about 45 to 65 degrees of big toe extension. And if you don't have that or it is painful, then having that upward slope basically gives you some artificial big toe extension. It can be really helpful with walking, but particular activities that require a lot of big toe extension, think going uphill, think lunging or getting to and from the ground, that rocker angle is priceless. And then last but certainly not least, we want an anatomically shaped toe box and this has changed dramatically over the past 20 years as well that we typically saw the shoe last kind of curve inwards and now you're starting to see that wider toe box to where the widest part of the shoe is almost towards the very end of the shoe or the front of the shoe. Now don't mistake a wide toe box to be a loose fitting shoe, because you will have a little bit of room to wiggle your toes in a properly fitted toe box. But if you have good fixation, particularly around the waist or the middle of the shoe, it is not a problem to have some wiggle room in the toe box. So we're talking length, but we're also talking width as well. so that is really important so when you look at all these characteristics hopefully you're starting to say oh my gosh that's a lot to think about this is why it is so so important for two things one to have a good relationship with A local, particularly running stores are usually the best around town. If you have an awesome local running shop to where you can send your folks, they have a solid fit system and they have some solid recommendations that can meet some of these characteristics. you're going to refer your folks and they're going to be in good hands, right? But it's also important to encourage folks to not just go to Amazon, to not just go and buy the shoe online, but you need to try this on. These characteristics, but then also that shoe feeling comfortable is very, very important. All right, so those are kind of the current recommendations. That is based on a systematic review that was released in 2019. I'll drop the citation for that in particularly the Instagram post. I'll do that there.

12:39 MINIMALIST SHOES: PROS & CONS

All right, now let's shift gears a little bit and let's talk about the whole minimal shoe, barefoot shoe versus conventional shoe debate. Once again, I will say I was so dogmatic about this. I was the guy that ran half of a marathon without any shoes whatsoever. And the first half I wore Vivo barefoot because we were running on gravel, right? Like I was that guy. I drank the Kool-Aid hard, um, and then learn some valuable lessons along the way. And I've changed my stance a little bit. I'd say a lot actually on this, but let's talk about some of the pros and cons of particularly older adults wearing a barefoot style shoe. The first one is, there is evidence that a barefoot style shoe, when I say a barefoot style shoe, some of the key characteristics, typically it is a zero drop shoe. What I'm holding now is a Merrell Vapor Glove. I've bought three pairs a year of these things ever since they came out back in the day. I love these shoes. So it's typically a zero drop, a very flexible sole. So if you're not watching the video, I can roll it up like so. and it typically has a wide toe box. So the widest part of the shoe is going to be towards the front. That's kind of the typical characteristics of kind of a minimal barefoot style shoe. It also has a very low stack height in terms of how high it is off of the ground. So there are a couple studies, particularly with older adults, looking at how that's influenced some different parameters. And what they found is that when they wear a barefoot style shoe compared to a conventional style shoe, is that it does improve their postural sway. How does it do this, right? So think about the somatosensory input. You get a lot more input from that system whenever there's less stuff between your foot and the ground. You also have a lower center of mass, which can be very helpful for balance. And also, without that heel slope or heel drop, it doesn't shift your center of mass anteriorly. And so based on a couple studies, postural sway was improved significantly compared to conventional shoes when wearing those minimal shoes. So less sway, less postural deviation when folks were in static and dynamic situations.

15:07 CHANGES IN WALKING GAIT

The next thing is that when folks put on that barefoot style shoe, they adapt their walking gait, running gait as well, right? Like we'll have the endurance crew talk about that all day, but I'm mainly talking about older adults in particular with walking. Their ambulation parameters will typically change. What we typically see is that we see a shortened stride length, we see an increased cadence with their walking, and the big one is that they have a decreased stance time. So they're moving their feet a little bit quicker and their stance time is a little bit shorter. Now, this is really important because let's think of if you have some type of external perturbation, you lose your balance. You try that ankle strategy, that hip strategy, it ain't working. You got to do that step strategy. When you're taking short strides, you have that increased cadence. When you have a relatively lower stance time, you are much more agile and adaptive to be able to take whatever stepping strategy you want to take. That is a big one, so that is a big reason why these barefoot style shoes can be helpful for older adults. What are the cons to wearing these with these individuals? One is that there's hardly any rocker angle. If you look at the video, there's a slight upslope for these shoes, but if you wear Xero shoes, Vivo barefoots, for example, you don't see any upslope or rocker angle towards the toe. and very little support in that area. And if you have limited big toe extension, if you don't have at least 45 degrees, for example, terminal stance of your gait is gonna be pretty tough, especially if you're symptomatic at in-range big toe extension. So these rocker angles can be helpful for individuals, especially if they're on uneven terrain, going uphill, limited big toe extension, they want that rocker angle. It's helpful for them, get them in one, all right? Though also the cons are the zero drop for many individuals, that life requires some ankle dorsiflexion to navigate the world, especially if you are going uphill, stairs as well. If you don't have hardly any ankle dorsiflexion, zero drop shoes are very difficult and what ends up happening is you end up shortening your stride even more. increasing your cadence even more, and ambulation can become less efficient. What that also does, especially when you're going uphill, if you're wearing a zero-drop shoe and you have limited ankle dorsiflexion, when you're going uphill, you max out your dorsiflexion, you don't have anywhere to go, so you start to see different deviations, and you also start to see a lot of pressure on the forefoot and the ball of the foot. If you have skin breakdown issues, neuropathy for example, this could have a whole host of complications. So there's some drawbacks to having a zero drop shoe for particular individuals and we need to be very aware of that. Now with all that being said, I, this is me, Dustin, anecdotally speaking, I am definitely for most individuals to be in some type of minimal barefoot style shoe. I think by and large, for many of the things that we do throughout our lives, it's a really good thing, but there's a lot of times where you want a solid shoe, right? You want some stuff between your foot and the ground. You want some help with that big toe extension. You want some help with that ankle dorsiflexion. So when I'm thinking about recommending barefoot style shoes to older adults, I'm thinking about three main things. And this is kind of a checklist that I want you to think about.

18:28 PROTECTIVE SENSATION

One, and maybe the most important one, and this is probably one of the bigger mistakes that I've made in this realm, is that they need to have protective sensation. They need to have protective sensation. You need to get your monofilament out, your Seams 1C monofilament out. Check that protective sensation because if they do not have that, I highly recommend not recommending a barefoot style shoe because you will have lots of bumps, lots of bruises, stepping on gravel, you can create some trauma, if you will, and if they don't have that protective sensation, they may not be aware, and most individuals are not regularly checking the bottom of their foot to see if they're having any issues. I learned this one the hard way. I was treating someone that had type 2 diabetes and recommended, at the time, Altra, A-L-T-R-A, made a lot of barefoot style shoes, and I recommend the Altra Atom. You can look that up. It's one of my favorite shoes and basically gave this person a foot ulcer from some of the trauma that they received over several, several days. So learn from that mistake. Number two, you want at least 45 degrees of big toe extension. That's kind of the minimum for most individuals through ambulation, particularly through that terminal stance. So 45 degrees of big toe extension and also kind of symptom-free big toe extension. A lot of folks will have painful in-range big toe extension. So you need to be aware of that. If they don't have that, then you want a shoe that has some bit of a rocker angle. And I'm not saying you go to some like maximal style shoe, but even a relatively, I wouldn't call it nano, a minimal shoe, but the stack height isn't anything crazy. The heel drops three to four millimeters from the back to the front. And it has somewhat of a rocker angle. Something like that could be helpful for individuals and not putting too much between their foot and the ground. And then last but not least, their ankle dorsiflexion. At least 10 degrees of ankle dorsiflexion. That's kind of the minimum that we're looking through throughout gait. They need more than that when they're navigating uphill, when they're trying to do squatting, for example. But that's kind of the minimum. And I'd be very clear of when they want to wear these. When they're doing activities that don't require a lot of dorsiflexion or big toe extension, rock those barefoot shoes. But if you know you're going to be getting to and from the ground a bunch, if you're going to be guarding and kneeling, if you're going to be doing a bunch of squatting and lunging, then you probably want a solid heel drop. You probably want a nice rocker angle to support some of those deficits. So, I know that's a lot. I'm going to drop all these studies that I'm referencing in the comments of the Instagram post, but I think we need to be clear that we have evidence-based recommendations for older adults. I went through them at the beginning of this. I would say they're rather somewhat outdated, especially as the evidence is starting to evolve of looking at some of these different styles of shoes. But we're starting to see some early evidence supporting a minimal or barefoot style shoe in older adults. But we can't just do a blanket recommendation. Everybody gets Vivo barefoot. Everybody gets Xero shoes. That's not the case. We need to have that checklist, protective sensation, 45 degrees of big toe extension, 10 degrees of ankle dorsiflexion, and you're probably going to put someone in a good position. All right. Thank y'all. Y'all have a lovely Wednesday. I'll talk to you soon.

21:41 OUTRO

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses common myths related to the diagnosis & treatment of frozen shoulder presentations based on outdated & low powered research. Mark offers a newer, evidence-based approach which includes addressing diet & lifestyle factors, including judicious manual therapy, and load. 

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:18 MARK GALLANT

All right, what is up PT on ice crew we got Instagram over here we're getting YouTube Pulled up over here. Make sure I get everything set All right, we are live on both platforms now. Looking good. I'm Dr. Mark Gallant, lead faculty with the ice extremity management division alongside Lindsey Huey, Eric Chikones. Want to come at you today on clinical Tuesday talking about frozen shoulder. It's another one of those areas similar to IT band that we talked about a few weeks ago where there are a lot of things that based off research from almost 100 years ago, have stuck around for a long time. So we want to dive into where the problems lie and what we can do to solve those issues. Before we dive into that, few course opportunities coming up to catch us on the road. You can catch us. Cody is going to be in Rochester, Minnesota here in two weeks. So if you're if you're up in the Midwest or that North area and you've been looking to catch us, definitely look at Cody there. I'll be in Atlanta early November and then we've also got another course coming up in California. So we're so we're hitting the Midwest, the Southeast in California. If you're looking to catch us in the rest of 2023, if not, definitely look at those courses for 2024. There's a bunch of opportunities to catch us in 24 and those seats are filling up fast. So so jump on it right now.

02:46 DIFFICULTIES OF UNDERSTANDING FROZEN SHOULDER

So As far as frozen shoulder goes, it was said that frozen shoulder is difficult to treat, difficult to define, and difficult to explain. That was said by Ernest Codman in 1934. And we would argue that 90 years later, after Ernest Codman said that, it's unsure how much better we are in understanding frozen shoulder It's definitely a challenge to treat. And for any of you who have tried to explain it to patients, it's one of those ones where you feel like you're going around in circles as you're trying to explain it. We don't know really what the true mechanism is. We've got a lot of theories. We're narrowing the buoys, but we really haven't narrowed it all the way down. And we really don't know what the primary tissue areas are that are really creating this pathology. Again, it makes it difficult to treat, difficult to define, and certainly difficult to explain to patients. Who are the people that are going to come into your clinic that are going to have frozen shoulder or meet that presentation? Well, the main thing is oftentimes they're around 50 years old. It tends to be our 50-year-old folks that have this most often. And what you're going to see is active and passive range of motion are both going to be limited in their shoulder range of motion. At least one of those has to be external rotation. glenohumeral external rotation is the the area that we find to be most limited early in a frozen shoulder presentation so we're really looking at about a 50% reduction side to side of that active and passive external rotation early on in this presentation and then oftentimes you'll see other other motion areas start to be limited so 50 limited shoulder range of motion specifically external rotation the other thing that tends to be tied with frozen shoulder is It's often folks who have diabetes in their medical history as a comorbidity and thyroid disease, which matches that unhealthy tissues are oftentimes attached to unhealthy humans. So if they've got some serious significant comorbidities, especially those metabolic comorbidities, this is another group of folks you want to take a look at and think maybe this could be a frozen shoulder presentation. So what are some of the old myths or some of the problems that we've had with frozen shoulder over the years?

07:18 SUPERVISED NEGLECT

Well, the first one is going to be supervised neglect. So there was this idea that if you look at someone who had frozen shoulder early, you say to them, you know what? This is a presentation that runs its course in about 18 to 24 months. Here's some exercises. Go home, sit at the edge of a counter, spin your shoulder around a few times, and let us know how you're doing in 18 to 24 months. Unfortunately these were based on very limited studies so if you go back to again the 1930s 40s 50s with Ernest Codman a lot of his studies were based on on 6 to 12 people so a very limited cohort and he was giving wildly aggressive treatments like he would hospitalize these patients and basically pin their shoulder into end range rotation and flexion for up to 20 hours a day. And then he said, oh, almost all of these people get better. Well, certainly maybe with what he was doing with that aggressive treatment, but it would be, you'd be hard pressed to say like with a cohort of less than 10 folks that, that everyone with this presentation is getting better. If we go to the early 2000s, another popular study is Dirks et al that showed that folks who were just sent on their way with some basic exercises versus folks who were given physical therapy, that the folks who were given exercises and told to check back in at two years and four years, that they actually did better. Well, if you really dive into that study, from a quality perspective, it was not the most robust study. Only 77 people, very poor quality control, and it's really not demonstrated anywhere in that study exactly what the physical therapy group was doing. Again, based on limited research, we would be hard pressed to say that it's truly supervised neglect is the best method to just send these folks on. The other challenge that we run into is, like Codman said, 18 to 24 months, all these folks are going to get better. That does not seem to be true as we dive more into the literature. What we're looking at now is more that These folks can oftentimes have their presentation up to 48 months, so four years of dealing with this. And the only reason we say 48 months is because that is the longest that anyone has ever looked at it. That a large percentage of folks, when you look at them four years later, they are still having some pain or some limitation in their shoulder mobility at four years. And again, We say four years because that is the longest it has ever been looked at. And if you're really thinking about a presentation that is as uncomfortable as frozen shoulder is, especially early on, and we don't know how to define it, we don't know how to explain it well, and it can last up to four years, and potentially a lifetime of increased dysfunction of that shoulder, It's really hard to say to someone, hey, this is all we know. Good luck for the next four years. They're in a lot of discomfort. They've got a lot of shoulder limitation. This is another human being in front of you. We want to do our best to come alongside those people. We really want to walk the line with these folks to help them out. No one wants to be told, see you in two years. That's only going to increase fear and anxiety overall. and there's a new clinical practice guideline coming out for frozen shoulder it has not been published yet but hopefully sometime in the next you know six months to a year it'll come out one of the authors on that ellen shanley done a ton of research in the shoulder space and what their group is finding is that if we get them early physical therapist and we give them a good solid treatment during that first year most of those folks have a better overall prognosis and presentation as time goes out. So again, it does not seem that supervised neglect really helps because so many people really have this problem beyond four years. And we are starting to see new research that that if you get in there and you can help them calm symptoms down some, if you can restore whatever range of motion you're able to restore, that those folks are going to have a much better prognosis. So getting them in with you. And again, no human wants to have that vague of a presentation and be on their own. So us acting as a guide is always going to be very important. So that's the big one, supervised neglect based on poor research, we're showing that the outcomes of supervised neglect are not what we may have thought they once were. And we want to be good humans first and foremost, coming alongside those patients and really helping them out and guiding them along.

14:06 STAGING THE FROZEN SHOULDER

The second piece is the idea of staging for frozen shoulders. So historically it's been freezing, frozen, thawing. And a lot of times when the research, these were based on a timeline. So you would have a few months of the freezing phase, a long frozen phase and then coming out of it that last sometimes it was written as 18 to 24 months as their thawing phase. What we see now is those phases are very unreliable and it's rare that someone is going to fit into that nice bucket of freezing frozen thawing. what we're seeing more now is that we really to simplify things both for patients and for ourselves is as complex as frozen shoulder appears to be we want to have the simplest buckets possible so what we're going to look at is is this shoulder more pain dominant or is this shoulder more stiffness dominant and if we keep people into those two buckets it will really ease our mental burden and the patient's mental burden on how to treat those out effectively so So oftentimes early on, it's going to be more of a pain dominant presentation. You're going to be doing things that calm that person's symptoms down as much as possible. Sometimes that shoulder is so irritable that you're not actually going to get into the shoulder to do any direct tissue treatment. Things we like in that case are breath work is a wonderful way to calm the nervous system down. Specifically, if you can have the exhale slightly longer than the inhale has really been shown to calm the nervous system down. Can we get them doing some other sort of mindfulness practice other than breathing? Can we get their diet more dialed in? Again, unhealthy tissues are attached to unhealthy humans. Can we lower the sugar? Can we lower the processed foods, the alcohol? Can we get them doing some general fitness that does not involve the shoulders? So getting them on the bike to pump a lot of healthy blood flow to those tissues and doing our lighter exercises to the area so higher dose higher volume with low tensile load in their available range to pump a lot of good healing blood flow and fluid to those tissues and pump out whatever chemical irritants may be and then lower load isometric long hold lows to get some non-threatening stimulus to those tissues are some of our favorite things for that pain dominant presentation. Now the stiffness dominant presentation What we want to do then is now we're saying that their pain is below that 3 to 4 out of 10, their psychological irritability is down. Now we want to get into those end range tissues. We want to hit our end range mobilizations, followed up with eccentric exercise to really start to own that end range tissue. So oftentimes this is where you're going to do your really long hold stretches and mobilizations and follow them up with some decently loaded eccentric load so that they can learn to control that new range of motion and access new range of motion. Again, that would be once symptoms have significantly calmed down. Now, historically, looking at treatment for the frozen shoulder, this is one of those areas where we would often tell patients, well, hey, we're going to have you grit and bear it, Todd. You know, Tom, we're going to set you on the table and I'm going to crank on your shoulder for 45 minutes and we've got to get through this. And what we know now is that that was likely creating more irritability, both from a psychological perspective and a tissue perspective. The tissues were likely not really ready for that in-range, very vigorous stimulus and our patients, Tom, certainly was not ready. for that vigorous stimulus. And what that led to was not only tissue irritability and potentially delaying healing times, it also led to some psychological irritability. That's where folks like Tom would say, physical therapy, man, it's so painful. I needed to take 10 Advil before I went to physical therapy. They're afraid of physical therapy. They become apprehensive of loading. We were creating a lot of fear and apprehension. We want to meet these folks where they're at. We want to meet the tissue where it's at and get where we can out of it. This does not mean that we don't believe in intensity. We believe in intensity as the ultimate. It's intensity matching that patient's tissue tolerance and symptom profile. And once we can match that symptom profile and tolerance, then we want to maximize intensity when it's more that stiffness phase. Early on, we've got to respect that psychological irritability, the tissue irritability, do the things like breath work, light mobilizations, until we can progress them to those more vigorous exercises. In addition to that, the amount of force that it takes to move the shoulder capsule is absolutely ridiculous. It is almost 2000 pounds of pressure. to actually make changes to that capsule. So what we think we're doing with our manual therapy is unlikely true. We were likely often getting tissues like the subscapularis and other shoulder tissues to calm down and relax a bit with our mobilizations, not making true collagen changes, which would require much more vigorous load that could create injury to other tissues or really long sustained hold. So again, much more beneficial for us to lower symptoms, really manage their pain well early, get what we can out of the tissue, and then when symptoms are down, then really dial up the intensity, your long hold stretches, your eccentric loading, and really getting after those tissues overall. Love to discuss this more. Frozen Shoulder is such an interesting conversation. Again, to recap overall, supervise neglect, What we want to focus on more is coming alongside those patients, helping them calm their symptoms down, helping educate them for whatever stage they're at. When we're looking at staging, pain-dominant or is it stiffness-dominant? If it's pain-dominant, breathwork, diet, nutrition, general exercise, lifestyle, light load to create a pump to the shoulder, getting some light isometric load in, getting those tissues as healthy as we can. If it's stiffness-dominant, that's when we want to get more intense, get after those tissues, long and range hold with our mobilizations and eccentric exercises to get after this. Hope it helped. See you all in a couple of weeks. Hope to see you all out on the road. Have a great Tuesday getting after it in clinic. See you soon.

15:23 OUTRO

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett Addresses the fear of exercising during pregnancy and how it can hinder the care provided to pregnant individuals. Christina shares that she has received messages from pregnant individuals expressing their concerns and uncertainties about exercising while pregnant. The fear of exercise causing harm is often the primary concern that arises when someone discovers they are pregnant.

Christina emphasizes that this fear is not supported by scientific literature and believes that removing this barrier can lead to a significant shift in the way pregnant individuals are cared for. She argues that the medical system has contributed to this fear and stress the importance of reframing the conversation around exercise during pregnancy. Instead of focusing on the potential harm, Christina suggests highlighting the health-promoting aspects of exercise and removing any obstacles that may prevent pregnant individuals from engaging in physical activity.

Christina also points out that society does not have a movement problem, but rather a lack of movement problem, which is often observed during pregnancy. She highlights that the fear of harm is one of the factors contributing to the decrease in exercise during pregnancy.

Overall, Christina emphasizes the need to address and alleviate the fear of exercise during pregnancy in order to improve the care provided to pregnant individuals. By reframing the conversation and focusing on the health benefits of exercise, pregnant individuals can be empowered to continue exercising during pregnancy and set up for success.

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the faculty within our pelvic health division. If you did not see, we had an absolutely packed house in Arizona for our two-day live course, and we have a couple of live courses coming up through the end of the year. Importantly, we're taking the move up to Canada and we are trying to see if we can take some of these courses up there. So I am going to be in Ontario this next weekend, the 31st first or 30th first. in Hamilton, Ontario, which is close to Toronto. And then in December, I'm going to be in Halifax, Nova Scotia, in the east side of the country. So if you are a Canadian who keeps saying, why aren't we bringing these ice courses up to the north into Canada, we are trying to do that. So I hope that I will see some of you in our Canadian courses towards the end of this year and this weekend. Okay, so this is kind of a little bit of a punchy topic where, and I've been thinking about this a lot.

02:40  ETHICAL RESISTANCE TRAINING RESTRICTIONS

So to give context, so today we're going to be talking about, is it ethical to put resistance training restrictions on women that are pregnant? Where this comes from, so we are in this space of exercise, and to this day, very commonly, there is a restriction that can sometimes be placed on people that are pregnant that tell you that you should not lift more than 25 to 30 pounds during your pregnancy. And if you have seen me in the geriatric division, We've done a lot of pushback against putting restrictions on the amount of absolute load that is on an individual because of these preconceived notions that individuals of a certain age are not capable. I've had conversations before where people think that the two divisions that I'm a part of, the geriatric and the pelvic health division, are very different, but they both have one key concept that are kind of overlapping with them. that is under dosage of an under prescription of exercise. And so my PhD in geriatrics looked at high load resistance training for at risk older adults. I have since shifted some of my research into the pelvic health space looking at high load resistance training during pregnancy And that is where this conversation came up. So the motivation behind this episode was a conversation that I had with Margie Davenport, who I'm doing some postdoctoral research with, where we were talking about a systematic review that we are working on with Jess Gingrich, who's part of our pelvic team, on resistance training during pregnancy. And so part of the things that we are reporting on are things like what was the frequency, intensity, time, and type. exercise prescription principles for these randomized control trials or these exercise studies that were done in individuals who are pregnant. And I've talked about how understanding the context where these prescriptions come from, saying don't lift more than 20 or 25 pounds, have come from the fact that we do not have research in this area over a certain prescription, hence some of the cross-sectional data that we're doing, hence some of the follow-up studies that we are doing. So that's where this came from. But the reframe that really came into my mind over the last little bit was when Margie said, is it ethical to put restrictions on pregnant people for lifting? And so let's talk about that. So when it comes to these restrictions or when it comes to our recommendations, they come from the foundation of do no harm, right? no harm. We are trying to make sure that we are keeping our pregnant people safe and we are making our recommendations and they tend to be more conservative because this is a very protected time in a pregnant person's life. And so because we don't have any research in pregnant people, we say don't do it. But when it comes to the research, where we have to go is looking outside of the research, blending it with what we know in our current patient population, and then take the wants and desires of the person that is in front of us. We know that strength is protective at every single point in our life. We know that being stronger makes you more resilient. We know that it prevents chronic disease. that it keeps you with higher amounts of quality of life for longer. It helps protect you and give you reserve if you are sick. There are so many reasons why strength is protective. And it has been shown across almost every single patient population at every age. It is shown that strength is protective. When we have our pregnant population, we use these restrictions because we don't have anything above. But when we come down to the foundation of strength is protective, And we think about the lens of these restrictions, don't lift more than 25 pounds. We have to ask the question, are we going by do no harm? Because it's not that we have evidence that going above 25 pounds is harmful. It's that we don't have evidence at all. And so when we don't have evidence at all, we have to take a look at other areas or other amounts of the lifespan of the woman. And we have to think about, are there any harms that we can think of that are specific to pregnant physiology? And then kind of blend these two things together.

08:16 RESISTANCE TRAINING DURING PREGNANCY

And from a pregnant physiology perspective, the theoretical constructs that are driving some of these recommendations are things like the change to fetal heart rate and placental blood flow as a consequence of lifting heavy weight, and the shunting of blood away from the uterus that happens when we resistance train towards the working muscle. And we don't have any evidence from our acute studies that have looked at hemodynamics in the cardiovascular response to resistance training at a variety of loads to show that there is any adverse event that happens to mom or baby hemodynamically that would insinuate that there is some type of harm to fetal inflows and outflows as a consequence of resistance training. When we look at high load resistance training across the lifespan, we also have to think of what happens if we start to make women afraid of resistance training. What happens when we say don't lift more than 25 pounds or don't lift this heavy weight because you're going to prolapse or don't lift this heavy weight because it's going to cause incontinence. We don't have to just think about this snapshot in time where we're trying to maybe circumvent some leakage. We have to think what is the internal dialogue that starts to happen in that woman's life that is going to impact her at 65. where we think that we shouldn't be that resilient or we shouldn't be doing that much resistance training, we shouldn't put that muscle on us anymore because we are going to cause pelvic floor issues or we are going to harm our baby. What does that internal dialogue do to exercise selection in the postpartum period, in the midlife period, in the perimenopausal period, in the older adult period? Is me saying that you shouldn't be resistance training going to impact what I'm working with older adults down the line? and this may seem like a bit of a stretch but when we don't have evidence around fetal hemodynamics we don't have any case reports that have shown that an individual who's lifting heavy weight goes into a hypertensive emergency or that there's any type of pre-eclampsia that happens acutely or that after going to the gym an individual has had a fetal death which would be a case report that would come out in the literature as a special kind of This is something that happened that we should keep our eyes on that's how we start developing levels of evidence to start investigating different phenomena Because we don't have any of those things This reframe I think can be super important of Not what is the what is the harm of resistance training? it's how are we setting our moms back if they don't resistance train during their pregnancies? And you know I've talked to moms who've been placed on activity restriction or bed rest and they say like I had a complication that caused me to have to be in bed and let me tell you being weaker going into that postpartum period was painful for me. It was a lot harder for me. It was not something that I would wish on anyone to have to feel so weak and vulnerable in a time where you already feel weak and vulnerable. So instead of saying what is the risk of us doing resistance training during pregnancy, It's what is the risk if we decondition our moms to be and have them, are we setting them up for success in the postpartum period by purposefully deconditioning them? And you may think that that is a strong statement of purposely deconditioning, but when you are making a recommendation that they are not allowed to lift their toddler up or that it is somehow dangerous to do that, We don't want to acknowledge that while we are removing a stimulus, that we are actually promoting deconditioning. We are promoting deconditioning of the musculoskeletal system. And when we look at return to exercise postpartum and we look at persistent issues in the postpartum period, for example, diastasis recti, we know that those with diastasis recti are weaker across their abdominal musculature than those that aren't. We know that one of the biggest issues to returning to exercise is pelvic floor dysfunction, but it is also lower extremity musculoskeletal pain where our body has not had that type of stimulus or impact. It hasn't remained as strong as it was before pregnancy. And now when we're trying to return to activity. we're having lower extremity pain.

12:22 MOM WRIST & MOM KNEE

Why do we have so much mom wrist and mom knee, which we now have evidence are not actually physiological changes that occur within a female's body that are a consequence of the hormones of pregnancy. We see a weakness issue that comes into pregnancy, a certain amount of deconditioning that is expected as a consequence of pregnancy, but we do not promote, uh, blunting of some of that deconditioning by promoting resilience and resistance training. And so I feel like there is a paradigm shift that is happening, and it starts with reframing our questions. Instead of saying, what is the harm of resistance training? If we flip that and say, what is the risk of deconditioning a pregnant person? that changes the game. It changes the way that we frame exercise and what we consider to be bad. We don't have evidence at any levels of intensity in any modality of fitness that high intensity resistance training or aerobic training is bad for a developing fetus. or for a pregnant person. And in fact, it is creating a cardiovascular training effect to strengthen the fetal cardiac system when individuals are participating in aerobic training. And so how do we set moms up for success? Instead of saying, what is the fear? of exercising because that's the first … I literally had somebody message me yesterday saying, I'm four weeks pregnant and now I'm so scared. I have all these questions. I do all this strength training. I do all of this aerobic training and I don't know what I'm allowed to do. We have created that system where you get a positive pregnancy test and the first thing that you question and the first thing that you start to be fearful of is, is the exercise that I am currently doing going to cause harm? Our medical system has created that, and we need to work tirelessly to remove it, and instead say, what are the health-promoting factors, including exercise, that I enjoy, that I want to do, that I want to continue in order for me to feel strong, for me to feel healthy, for me to feel happy, for me to have strong mental health and resiliency, and that is going to trickle into the health of my baby. If we take that reframe, if we say instead of what is the things that are going to cause harm, it's how do we remove barriers to exercise, especially when we look at our society and we do not have a movement problem. We have a lack of movement problem. And dip in exercise occurs during pregnancy. And there is a lot of things that can contribute to that. But one of the things is fear that the exercise that they love to do, that they self-select to do is somehow harmful. And if we can remove that barrier, we are going to shift the way we take care of our pregnant people. And we are going to start to see our pregnant people be able to do all of these wonderful things without the fear that is unfounded in the literature of doing harm. All right, my rant for a Monday. I hope you all start to think about this. I have actually really been thinking about the do no harm piece of exercise and if it is founded and how to change the way that we frame exercise prescription. for our pregnant individuals. So I hope you found this helpful. If you have any thoughts around this, I would love to hear it. I'm definitely gonna be thinking about the way that I'm framing this up and seeing if there's any challenges that I can think of in my mind that would counter some of these arguments. So I would love to have these conversations with you all. If you wanna see some of the research coming out on exercise and pregnancy, I encourage you to sign up for our pelvic newsletter. It goes out every two weeks. We just had a letter go out last week. where any new research that's coming out, we try and stay on top of it. And this is where some of these podcasts come from. So if not, I hope to see you on the road. If you are Canadian, I hope to see you at one of our courses in Ontario or Nova Scotia. Otherwise, have a really wonderful beginning of your week, everyone, and we will talk to you all soon.

16:55 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. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko stresses the need to maximize preparation and recovery for a successful competition. He emphasizes the importance of preparing for the week before the competition, the competition day itself, and even the week after the competition. Joe encourages individuals to focus on their game plan, proper nutrition (including carbs, protein, and electrolytes), fluids, and electrolytes. Additionally, He highlights the importance of keeping the body moving between events to avoid stiffness and stagnation. The ability to warm up, maintain a good heart rate, and perform at a fast 100% effort is crucial for success.

On the day of the competition, Joe advises sticking to one's game plan and not letting others dictate it. He mentions that CrossFit is about being able to adapt on the fly, but it's important to trust one's strategy and see where it takes them. Joe also emphasizes the importance of nutrition during competition day, stating that eating is necessary and what one eats matters. He provides the example of an elite athlete who consumed multiple Snickers bars for fast carb and glucose intake to replenish muscles, but notes that this strategy may not be applicable to everyone.

After the competition, Joe discusses the importance of the follow-up week. He suggests focusing on recovery during this time and allowing the nervous system to recover and do what it needs to do. He highlights the significance of giving oneself time to recover, as it is an important part of the overall competition process.

Overall, the episode emphasizes the importance of preparation, execution, and recovery in the context of a competition. It highlights the need to have a game plan, trust one's strategy, focus on proper nutrition, and prioritize recovery to maximize success.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 JOE HANISKO

Good morning, everybody. It's PT on Ice, daily show live. It's Friday, I would say September 22nd, getting close to October already. It is Fitness Athlete Friday. I'm Joe Hanisko. I'll be your host today. One of the lead faculty of the clinical management of the Fitness Athlete crew. Today we want to chat about competition. So CrossFit competition prep 101. Just the basics. We get either personally ourselves or some of our clients who are signing up for local or online competitions and we want to make sure that we're preparing them and that they understand what their expectations are for getting into that competition. the week before, the actual date of, and then even that week after, like making sure they maximize their preparation and their recovery for a successful event, especially when really all that we typically have to see in comparison is these elite athletes who are going to be doing things similarly, but also different because of the amount of training they've put in and just the fortitude that they've built up in terms of an athlete and the resilience that they've earned in an athlete. We'll talk about that CrossFit Competition Prep 101. Before we get going, I want to make a couple of call outs to the CMFA Live agenda that's coming up for the rest of the year. Both of our Essentials and Advanced Concepts course took off online in the last week or so. So those are going to be going through until the end of the year and we'll get those going again at the beginning of 2024. But in terms of live courses, we have a handful coming up in the next few months to close out the year. So if you're looking to get into any Con Ed courses, we are going to be in California. Washington, Alabama, the state of Texas, down in Florida, New Orleans, and Colorado, all before Christmas. So from now until Christmas, we have six or seven CMFA Live courses that will be out there. So grab a seat if you're looking for that. Hop on to theptnis.com and you can find all of our courses there. All right, CrossFit Competition Prep 101.

03:45 PREPPING FOR COMPETITION WEEK 

Let's talk about the week of. So you're going into this weekend of competition. What do we do that week before? I would say that at this point, We're not talking about the prior weeks and months of training. That's a whole other conversation. But at this point, whatever you've done to earn your right to sign up for this competition, you've done it, you've earned it. You can't really gain a whole lot more in one week of training, but you can lose a lot in that one week. So we want to make sure that we take that week leading into competition pretty seriously. If we're assuming maybe competition day is on Saturday, which is most common for a lot of local events, I would say that those first two to three days of that week, Monday, Tuesday, Wednesday, per se, I would focus on training as normal. Keep things consistent. If you guys have specialized programming through your gym and or you're using some sort of online platform like Mayhem, Days one, two, and three can stay pretty consistent. We don't have to change a whole lot about that. It allows us to stay moving, feel good, test some things out, and it's not until day four and day five that we really start to maybe change some things there. Day four, I would say, is a great opportunity to just take a complete rest day, figure out how the body is feeling, let things calm down. Maybe we focus on just a nice walk outside, maybe we do some mobility work and some soft tissue work to kind of prep the body but I'm cool with day four-ish in that time frame being a complete rest day if that works out into your calendar. It gives us time for the body recover for the nervous system to recover and then it gets us to day five the day before competition. I would suggest that the day before competition you don't do absolute rest. I think it's kind of nice to low level prime the body for movement especially when you're about to do something at a pretty high intensity the following day. So this could be super easy, like moderate EMOM style work, where you're doing a lot of body weight or simple movements. This could be just a zone two kind of monostructural day where we hop on the erg, sorry about that light there, hop on the erg, get some of our heart rate into that zone two level and just do a nice 20, 30, 40 minute cruise control type of workout. But I like the idea of the day before competition, moving the body and taking that rest day, maybe a day or two before competition. opposed to resting right up until that point there. So in terms of our basic agenda, days 1, 2, and 3, you can stay pretty consistent. Day 4-ish, probably 3 or 4-ish, we're going to take a complete rest day and let the body completely recover, maybe focus on soft tissue mobility. And then day 5, we want something smooth and easy, get the body feeling good. If you have any you know problem areas we're doing a little bit of accessory work to tune those up but we're not hitting a hardcore CrossFit style event the day before that competition. A couple other things that I would maybe not do in that week before is I would not go above 75 80 percent of your maximum volume in terms of load so if your programming calls for deadlifts, squats, whatever it might be, some heavy loaded exercise, no matter what, keep that in that moderate, upper moderate range there. I feel like being in that 60, 65, 70, maybe 75% range at the most gives you an opportunity to load those tissues, feel like you're getting something out of it, but also not blasting the nervous system. Our nervous system is probably one of the most undervalued parts of our recovery because it's hard to sometimes assess until you go and perform. But when the nervous system is down, our actual performance will be down as well too. And typically what drops the nervous system is high volume training and high loaded training because we only have so much of the tank to give before we need to recover. So I would avoid hitting heavy, heavy weightlifting the week of. Keep those 75-ish percent or lower. That being said, too, another thing I've seen a lot and had a lot of education on is if your event calls for some sort of weightlifting complex, like a hang snatch to overhead squat to hang snatch complex, I'm just making something up, don't go out and test that thing at max capacity over and over and over again. One of the biggest flaws that I see with our novice CrossFit athletes is that it's something new. It's like, oh, I haven't done this exact complex. I don't know exactly what it's going to feel like. Well, go and test it at that 50%, 60%, 70% maybe. but I see so many people the week or two prior doing it three or four times and what they're doing is depleting their nervous system and when it matters on that Saturday when competition is there, you may in fact lose some by having tested that so often before. So I would, I'm not saying don't trial it to see what it feels like, but I'm saying you should have a good understanding now with all the training you've done before to earn your right to be in that competition, roughly what your capabilities are, and then testing that complex at lower to moderate weights will give you a little bit of an insight to where you think you can be, but you are not going to get stronger by practicing that over and over again in a week or two before that event. So get familiar, but don't blast yourself with those complexes. Yeah, and then the other thing I was gonna say is just don't, in terms of testing, going a little farther, don't test all those workouts that you're about to do at max capacity multiple times either. I'm on board for learning, for strategizing with team, if you have a team event, I think that is great, but do those several weeks in advance. Don't go and blast your body the week of testing an event that you're probably gonna do because that's where we'll see decreased performance and potentially injury risk that will increase when we're doing that stuff there so recap of the week of the week of you're going to train as usual for the most part days one two and three Day three and or four, we're going to take a rest day and let that body completely recover. Just focus on mobility, recovery style stuff. Day five, we want to move a little bit. Lightweights, bodyweight style exercises, throw that into an EMOM format. Get yourself on a ERG machine and do some zone two monostructural work. We want to avoid max effort loads throughout the week to keep our nervous system healthy. We don't want to test everything over and over again. Save yourself for Saturday. You will not lose by not training, but you can lose by overtraining in that week before. All right, so now you're in the day of. Day of competition. This looks a little bit different to everybody, but a few little pointers that I have, some of them will be obvious, but just reminders, is that just stick to your game plan. Hopefully you've thought your process through and trust it. You know yourself as an athlete, your team hopefully has connected, or your training partners, and you know each other fairly well. Don't let other people dictate your plan. Stick to your plan. CrossFit's all about being able to adapt on the fly, which you will have to do sometimes, but don't go in constantly thinking that you have to change your strategy. Trust your strategy and see where things take you.

10:37 NUTRITION ON COMPETITION DAY 

In terms of nutrition during competition day, I feel like we need to be eating. I think that's an obvious thing to say, but what we eat matters. We see people, Matt Frazier was a good example, who would just slam multiple Snickers bars in a day of competition because he was looking for fast carb glucose intake to replenish those muscles. It's actually not a terrible strategy, but we're not Matt Fraser either. There's got to be probably some moderation to that. I do believe having easily digestible carbohydrates, which may include some sugar and that's fine. A couple little gummy worms here or there, some fruit, maybe some of those protein bars or energy bars that have some carb in it, built in it. things that taste good and that are easy for you to digest are probably best. We need carbs to replenish our muscular glycogen system and just our overall metabolic system. I think getting some protein in is fair, but we don't need to heavily douse protein. We don't need to be eating like multiple burgers that will sluggishly kind of slow you down. So lean proteins, beef jerky, a little bit of pulled chicken, something like that can be a fairly easy type of protein to digest. And then I would say a third thing being fluids and electrolytes. So this is where getting salt waters of some kind, like a element for an example, or your own homemade version of that, getting that electrolyte balance into our body is crucial. You're going to be pumping fluids out, And you can get really scientific with this and weigh yourself before and after an event like some of these higher level athletes do. But I don't think that we have to be at that level. But do replenish your fluids. Be drinking water. Get some sort of electrolyte back into that system. And I think these are going to be two really crucial things in terms of adjusting fluids that are important there. Some of these sports drinks, just read the back. Get smart with these guys. Like read the back of some of these labels and you'll realize that you could make yourself a way better balanced electrolyte style drink than the marketed ones that have virtually nothing inside of them. So get online. figure out how you could dose in some table salt with some other electrolytes and just make something that is gonna help you retain fluids, especially if you're doing this in a hot, humid environment where you know you're gonna be sweating a lot. And then I think the other thing in between events is don't just sit and do absolutely nothing. Take some time, five, 10, 15, 20 minutes at the most to recover and chill, but as you're leading up into that hour before your next event, try to move. walk around, hop on a bike if they have one. This is where I will actually, in some circumstances, support things, simple things like massage guns. There is some anecdotal and potentially actual structural evidence that would say that the vibration and impulse is a good way to just kind of prep that nervous system and keep those tissues a little bit more aware of what they're about to be doing. I'm game for it. Whatever you gotta do to stay agile and feeling like you're at your best is what we need to be focusing on there. So day of, stick to your game plan, proper nutrition, including carbs and protein predominantly, and then electrolytes is big as well, fluids and electrolytes, and then find some way to keep that body moving in between events that you're not stiff, stagnant, going in. The ability to warm up, keep your heart rate at a good level, and then hit a fast 100% effort event is crucial to success. We don't wanna be going in cold. Even if you're feeling a little tired, you gotta find a way to keep that heart rate moving.

14:17 TAKING REST AFTER COMPETITION

All right, final thing is our final prep, I should say follow-up week, the week after your event. So you've done your week before, you've completed your event, congratulations. Sunday, Monday, Tuesday, leading into the next week, what do we do? Be okay, I'm gonna say this again, be okay taking more than one day of rest. I have an event coming up this weekend that has for sure three main events that all are at least 18 to 20 plus minutes in domain plus five like mini events. And then if you are lucky and fortunate enough to earn your right into the championship event, that would be four main events. So four main events plus five mini events. I don't train for that. Nope, not many novice athletes do. Elite athletes, yes, they are prepping with four to six hours of training on average per day in a week. We don't do that. Not many of us are doing that. So if we are going to go out and sell our soul in this event on a weekend, be okay taking Sunday, Monday, and maybe Tuesday and doing little to no major physical activity. It doesn't mean you have to be a couch potato. Maybe you are again going for hikes, walks, little bike rides, whatever it might be. Find some enjoyable sport that you like, like golf to get out and just stay active. I'm not asking you to be lazy, but I'm asking you to respect the amount of volume that goes into some of these CrossFit events. I see a lot of people who go and smash it on Saturday and then are at the gym on Sunday working out or Monday doing a, you know, high level, uh, online programming that is consisting of two plus hours of training. to each their own at the end of the day, but it's okay, I'm giving you permission to let your body recover. At the end of the day, for me, I'm reminding myself that this is not about today and tomorrow, this is about 20, 30, and 40 years from now. I am building my fitness to be a better, older adult. So be okay taking some time off. Use the next week to just sort of assess the body. Did anything tweak? Are you sore? Are you stiff? Focus on those areas. This is where getting your clients maybe back into your clinic that following week and just prepare for that. Say, hey Johnny, I know you got an event coming up on Saturday. Why don't we make sure that we have a day to meet on that following week just so we can talk about how it went and be sure that we're doing some good recovery things and I can help you better game plan that following week as well if I can see you early on that week. So take time to assess the body. And I would suggest again, similar to the week before, keeping loads in that 75, 80% or lower before we get back on track with your normal training. Just allow again that nervous system to recover and do what it needs to do, so. Hopefully that was helpful, guys. Again, either for yourself or for clients that you're having, but I love the fact that people are dedicating themselves to fitness and that they're willing to put their body, their soul, their personalities, their mentalities, their identities on the line and go sell it on a weekend or online competition. We are training for a purpose. We have short-term goals. We can go test those out. We have long-term goals. All this is leading to that direction. So preparing yourself for that competition is really important. Executing on the day of is really important and making sure you give yourself time to recover afterwards is also important. Hopefully it's helpful. If you have any questions, comment on the videos. Otherwise, take a look online and see if you have any interest in getting into our CMFA live courses coming up across the country. They are filling up. So let's get on those and enjoy the end of our year together. I will talk to you later. Have a great weekend.

17:46 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 // #LeadershipThursday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall delves into various lease terms, including flat rate leases, triple net leases, and percentage-based leases.

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

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

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Thanks for being here today on Thursdays. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty over in our fitness athlete division. Today, Thursdays, Leadership Thursdays, we talk all things business management, clinic, and practice leadership. Thursdays means it's Gut Check Thursday, so let's talk about this week's workout. We have a little couplet of power cleans and push jerks with a low to moderate weight barbell and some running. So we have 20, 15, 10, 5 power cleans at 95-65 and push jerks at 95-65. After each round you're going to run 200 meters. 20 power cleans, 20 push jerks, go for a run, 15-15 run, so on and so forth. When I sent this to our CEO, Jeff Moore, last night, he said, wow, that seems like a heavy, high-volume barbell workout. And I don't agree at all. This should feel about a 10-minute workout as usual on Gut Check Thursdays. You should be able to pick a weight on that barbell where you can really cycle big sets of power cleans. Maybe for some of you, even hang on to all of the power cleans and go right into your push jerks and really get a high intensity stimulus out of that workout and hit some quick 200 meter runs in between. So goal time, 10 minutes, scale to do big sets on that barbell. I love workouts like this because they're really easy to modify. This is the type of workout that I'll probably give to a patient in the clinic, right? If we can ditch the barbell entirely, we can do some dumbbell cleans and jerks, we can do some kettlebell swings and some landmine press, we can run, row, bike in between. It's a workout where you can take kind of the stimulus and manipulate it a number of different ways to achieve the same result based on the equipment you have and what your patient or athlete can do in front of you. So have fun with Gut Check Thursday. Course is coming your way. I want to highlight our pregnancy and postpartum division as we're rebranding to Ice Pelvic Health. So we have one live course and one online course with a second online course launching in 2024, a level two course, an advanced course. So you can catch that Level 1 course. The next chance to catch that will be January 9th. And then that Level 2 course, which will require the Level 1 course as a prereq, will be launching in 2024. And then some live courses are coming your way between now and the end of the year. This weekend, this weekend coming up, Alexis and Rachel will be down in Scottsdale, Arizona. The weekend, next weekend, September 30th and October 1st, Christina will be up in Hamilton, Ontario, up in Canada. The weekend of October 14th and 15th, Alexis will be in Milwaukee, Wisconsin at Onward  Milwaukee. Out in Bozeman, the weekend of November 4th and 5th, again, Alexis. The weekend of November 18th and 19th, again, Alexis will be on the road, this time in Bear, Delaware. That'll be out at CrossFit Bear. That's actually ICE faculty member Lindsey Huey's gym. And then your last chance to catch the ICE public live course this year will be the weekend of December 2nd and 3rd. Again, I'm in Canada with Christina. That'll be in Halifax, Nova Scotia. So check out that course. Our goal with that course, bringing on the second online course, is to have a three-course series that results in a certification and management of the pregnant and postpartum athletes. So that's what's coming your way from the Ice Pelvic Division.

04:31 IMPORTANCE OF LEASE NEGOTIATION

Today on Leadership Thursday, we're going to talk about negotiating your lease. And maybe for some of you, this is a thought you have in your mind as maybe you're thinking about beginning your practice of what does it look like cost-wise, what does it look like in practical application to buy or rent a space such as a clinic space where you can set up your practice. And maybe for some of you who are working for somebody else, or maybe already working for yourself, and you are maybe going through lease renegotiation, you're thinking about moving locations, of what are the essentials to look for in a good lease, what are the different options available to set up a lease, and what are some things that we look out for. So let's talk first about what and why this is so important. Of all the expenses that a business can have, your lease or your mortgage, the money you pay for your physical space, is going to be one of your highest expenses, but it's also probably the one that is the only one of all your fixed expenses that actually has room for manipulation. When we think about paying for internet or paying for maybe a fax service or something. Those are fixed costs, but they're unlikely to budge, right? You can't really call up the cable company. You can't call up Comcast and say, Hey, you know what? I think I paid too much for this. I'd like to pay half as much, right? They're just, they're going to hang up on you, right? They'll probably talk to you about bundling or try to give you a 5% discount for six more months or something, but you're really not going to be able to move the needle on that expense. Likewise, payroll, paying our folks is another big expense that's fixed. And that's also not an area where we can really budge the needle on expenses. If you don't believe me, go ask the folks that work for you if they would work for you for half as much money. Again, you're probably going to be met with maybe some laughter or maybe anger if they think you're serious. but that's an expense that we're unlikely to be able to significantly manipulate. It's very different with something like a lease. Based on the current commercial market for commercial real estate, based on even zip code, it may only be a five minute trip down the road to a new location, but based on zip code, based on a number of different factors, there tends to be more room here to hopefully reduce that expense a little bit. So I want to talk about ways to do that. and ways to set up your lease terms and maybe terms you have not even heard of yet. So let's start with there. Let's start our first point. Let's talk about what are the typical terms of a lease. So the most common, the one we're all probably very familiar with, even if you've never leased commercial real estate, you're familiar with this because you've probably done this with an apartment. It is a flat rate lease. This is paying X amount of dollars per month based on the lease terms. We're very familiar with renting apartments, maybe renting townhomes or condos of hey, it's $900 a month and it's a one year lease, right? And usually at the end of that lease, the price probably goes up a little bit and if you're still gonna live there, you renew that lease and you're kind of in that fixed rate lease cycle.

07:36 GRADUATED LEASES

The next is really kind of unheard of and very uncommon and falls on you, the person looking for a space to really inquire about it as if it can be an option for you. And that's a graduated lease, where you're eventually going to arrive at a fixed price per month that does not change, but you're not going to start out there. So an example might be you pay $500 a month for the first three months of your lease, Maybe the second three months of your lease, you pay $750, and maybe the last six months of your lease are built up to maybe $1,000 a month, as a quick example. So we're slowly graduating to the full terms of that lease. Why is this helpful? Obviously, it's less money over the 12 months. That's the number one reason. The other way is this is really helpful when you're first beginning your business. When you first hand your shingle, you probably don't have a full clinical caseload, which means the revenue coming into your business is probably not where you would want it to be to maybe even pay the full amount of that fixed rate lease. So negotiating for a graduation of the understanding of, hey, I'm not making 100% of the revenue I believe I can make currently. Can we kind of step up to that amount over time? This is a great idea, a great model to pitch, especially if you're not renting your own building or space. If you're thinking about starting up a side hustle in the corner of a gym, and you're literally just getting a portable treatment table in the corner, you're not getting a lot for your money, so the idea of spending maybe $1,000 a month to have 20 square feet in a corner is less than ideal, especially when you're first starting, of hey, can we just see where this goes? Can we do $200 a month for the first three months? Can we do 400 for months four to six? can we do 600 months six through nine and then maybe months nine through 12 we're at 800 a month and then we can revisit at the end of the year what changing to a fixed rate amount might look like. So this gives you some breathing room that you don't have to rush out and think about stressing and worrying about maximizing your revenue from day one. It gives you that kind of room and time to go out and market your clinic and not just thinking about maybe I need to be working in home health or something to even pay for this lease and I don't actually even have time. to see patients at my own clinic because my lease is so high. So graduated lease is a really great option that's often not really thought about, not really offered, something you may have to ask about, but something that a lot of business owners, especially if you're subleasing a space, might be very open to because for most of those folks, that space is empty anyways and they'd rather have you paying more and more and more over time than paying nothing at all for that space.

11:01 TRIPLE NET LEASES

The next type of lease is something that almost no one is familiar with unless you live in a really big city or you deal with really serious commercial real estate, and that's called a triple net lease. How a triple net lease works is you pay a little bit of money for the actual principal on your lease, but a lot of the cost of your monthly payment is a shared split of usually the insurance for the building, the maintenance costs for the building, and the taxes for the building. So this is very common in bigger cities where you have multiple businesses inside of the same building, where you have a shared entryway. When I think of a triple net lease, I think of the flagship Onward and Onward Charlotte, where there are, I think, 12 businesses in a three story building, a couple businesses per each floor. That is usually where you will see a triple net lease of the taxes, the insurance, the maintenance costs for that building, are all kind of added together and then divided among the number of leases inside of the property. So this can be a great way to get a cheaper lease, especially the bigger the building. Yes, more maintenance costs, more taxes, more insurance, but more people to spread the cost across. So overall, a pro to this approach is we tend to see cheaper rent and overall a cheaper lease payment because those costs are shared. Now there are some downsides here that we need to be aware of. If you're the first tenant in a brand new building, you have no one else to share your costs with, right? So asking if that does happen to be you and the lease is a triple net term of how does that work with the sharing of this cost? Am I expected to pay 100% of it because I'm the only business in this building currently? That's not ideal. Or is the landlord going to assume the majority of that as more and more businesses open up inside of the common building? The other concern there is that overall physical therapy is really low maintenance. When we look at actual property wear and tear, maintenance, that sort of thing, we don't tend to damage a lot of the buildings we're in. We might have some scuff marks on the door frame from maybe folks coming in and out with with walkers and wheelchairs and things like that. But you don't tend to see a lot of big property wear and tear in a physical therapy clinic, which means in a triple net lease, you could make the argument that we're probably paying more than we need to because we use such a small amount of the shared spaces, especially in something like the bathroom as well. physical therapy clinics are not nearly as business busy as a business like a gym or a restaurant where maybe hundreds of people per hour are coming and going and if they're using maybe shared bathroom spaces they're really causing the majority of the maintenance costs for that compared to your clinic. So just being aware of how many tenants are in the building and also what are their business types. Is there a lot of foot traffic? If so, that's going to jack up the overall maintenance cost of the building, which is then gonna be passed on to you as one of the tenants in the building. So be aware of those factors if you're thinking about a triple net lease or you're being offered a triple net lease. The last type of lease type available is something we should never do, which is a percentage-based lease. We should never do this, first of all, because it's illegal for us to do this as healthcare providers. Getting into a negotiation where you pay 10% of your monthly revenue as your lease, what that looks like, how that functions, is essentially kickbacks. We are not allowed to be involved in any sort of kickback system as healthcare providers. Does it happen? Yes, but part of being a business owner is managing risk and one of the biggest things you get in trouble for. is something like that. So knowing that you should not do this, this also just becomes weird of now if your rent is based on a percent of your revenue. First of all, the payment is different every month. It's not going to be exactly the same. It's going to fluctuate up and down. So that's always a little bit awkward. The other awkward part is now you have to sit down. You either have to give complete access to your landlord, to your financials so that they can look and say, I will be the one that calculates how much you owe me. Or you need to sit down monthly and give that information to your landlord. And that just doesn't feel good for one business owner to just be laying open how they do their operations and financials to another business owner. The issue with this, aside from it being illegal, why it's not good for business, is that in general, a physical therapy clinic can expect linear growth. As my caseload gets more full, I see more patients, my revenue increases. When I reach the point at which I have no more time, in my week to see patients, I hire another therapist. And the process just keeps repeating. Their caseload gets full, their revenue increases in a linear fashion, so on and so forth over time. That does not happen in other businesses. For example, with a gym, especially a gym that maybe has an unlimited membership model, they're going to reach the point at which they can have no more members, and there's no more way for them to increase their revenue at all. So as your Revenue at the clinic continues to increase as you hire a second, a third, a fourth, maybe a fifth therapist. Your revenue grows and grows and grows. In a percentage model, your rent is going up, up, up, up, up, up, up in a way that it starts to become unfair for you as the PT clinic owner to be expected to always pay 5%, 10%, 20% of your revenue of your monthly lease payment is going to increase linear alongside your revenue as a clinic. And it's going to become very quickly an out of control expense. So that's never something we want to get involved in. The last thing we never want to do is not a type of lease that is official is any sort of quid pro quo, any sort of this for that arrangement of if you treat me 10 times a month for physical therapy, you can rent the back room of my gym or my spin studio or my yoga studio or whatever. That's just not really good business for a number of reasons. First of all, we have, I would argue, a lot more to offer as physical therapists. At any given time, 87% of the American population has some sort of pain, which means When you give up time on your schedule in exchange for something, you can expect those times to be almost always booked, right? Imagine that same situation with a massage therapist. Hey, you can have this back room if you give me two massages a week. Guess who's never missing those two massages that week, right? The landlord, right? They're always gonna be using those in a manner where, again, very similar to a percentage lease, you're gonna find yourself having the feeling that you're giving more than you're getting. The other main reason to never do this is that if you trade lease payments or really any other sort of expense in exchange for physical therapy treatment or programming or something like that, that is now an expense you cannot show on your taxes. Part of being a business owner is yes, making money, but also being able to justify all the expenses related to running your business that you possibly can to reduce your tax liability so that you pay less taxes over time and overall the clinic has more profit. If you are exchanging your lease and it has a $2,000 value a year, you cannot write off that $24,000 as rent payments on your taxes to reduce the tax liability of the income that the clinic generates. And the more you do quid pro quo stuff, the less expenses you show, and to the government that looks like more revenue with less expenses, it looks like more profit, it looks like more taxable income. We never want to be in a situation where we're paying Anywhere close to the amount of taxes is actual profit that the clinic makes. It doesn't feel good to go to work and run a business and then pay almost all of your money in taxes at the end of the year and not have a lot left to show for it. So that's really why we want to avoid quid pro quo type arrangements, trading expenses in exchange for physical therapy treatment or other physical therapy services that you may offer at your clinic. So I hope this was helpful. We talked about different lease terms, about why leases are maybe the one area of running a business where we have a lot of room, wiggle room. to hopefully reduce the price, or at least keep the price as capped as we can. We talked about different types of lease terms, a typical flat rate lease, a graduated flat rate lease, a triple net lease, quid pro quo, and percentage based leases. So, I hope this was helpful. I hope you have a fantastic Thursday. Have fun with Gut Check Thursday. I'm literally getting ready to go next door and do it right now. If you're gonna be at a live course this weekend, I hope you have a fantastic time with our instructors. Have a great Thursday. Have a great weekend. Bye everybody.

18:37 OUTRO 

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses masters athletes who challenge negative age paradigms and serve as role models for younger generations. 

According to the episode, the decline in physiological systems can be attributed to both aging and other factors such as inactivity, sedentary behavior, obesity, and chronic diseases. It can be challenging to distinguish between changes in physiological systems solely due to the natural aging process and those influenced by these other factors. However, Christina suggests that psychosocial factors also play a role in positive aging. Factors like loneliness, connectedness, sense of purpose, and the ability to make healthcare decisions not only for oneself but also for others contribute to positive aging. These psychosocial factors are independent of physical capacity and can help individuals maintain a positive aging experience.

Christina emphasizes the importance of building and maintaining relationships, connectedness, and the capacity to learn, grow, and contribute in the context of healthy aging. These aspects are relevant not only for older adults but also for all generations, including Gen X, Gen Z, millennials, boomers, and masters athletes.

Loneliness is a significant issue in society, affecting people of all age groups, as highlighted in the episode. Building and maintaining connections and relationships are crucial for sustaining healthy lifestyle factors and combating the loneliness epidemic. This is particularly relevant for older adults, who may struggle to maintain relationships as they age. Christina mentions the challenges of making new friends as an adult, as expressed by her grandmother.

The masters athletes discussed in the episode serve as examples of individuals who demonstrate the importance of these aspects in healthy aging. They not only prioritize their physical performance but also value psychosocial considerations. Masters athletes have the opportunity to build relationships with individuals across different age groups who share similar mindsets regarding health promotion. This allows for the exchange of knowledge and the adoption of healthy lifestyle factors.

Furthermore, masters athletes have the capacity to learn, grow, and make decisions. They challenge negative age paradigms and combat belief systems around aging through their athleticism. They set goals not only for their own performance but also for serving as role models to younger generations within their family and sport. Masters athletes also contribute positively to their sport by creating mentorship opportunities for younger athletes. They serve as examples of successful aging and contribute to the overall belief in the ideology of successful aging.

Overall, this episode emphasizes that building and maintaining relationships, connectedness, and the capacity to learn, grow, and contribute are essential aspects of healthy aging for all generations, including older adults and masters athletes. These aspects not only contribute to physical well-being but also to psychosocial well-being and the overall belief in successful aging.

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:43 CHRISTINA PREVETT

Good morning, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our modern management of the older adult division. We have three courses in our geriatric curriculum that encompass CERT MMOA. We have our eight week online essential foundations course with our next course starting October 11th. We have our eight week online advanced concepts course, which if you have taken our essential foundations, you are eligible for advanced concepts that starts October 12th. And then we have our two day live course that we still have quite a few courses for the remainder of 2023 if you were looking to get involved. So we are in Falls Church, Virginia, October 7th and 8th. I am in Fountain Valley, California on the 14th and 15th. And then we are in Mattawa, New Jersey on the 21st and 22nd. And if you did not see that we are currently in what I call revamp season, we just updated our live content for MMA Live. And if you are in advanced concepts coming up in October, you are going to be getting brand new material. And I am so, so excited about that.

00:00 THE MASTERS ATHLETE

And what we are going to talk about today is some of that content relating to the master's athlete. When we think about our geriatric curriculum, let's be honest, we are not talking about master's athletes most of the time, right? We often will talk about this sickness, wellness, fitness continuum. And when we talk to our geriatric clinicians who are on our calls or taking our courses, and we say, you know, what percentage of individuals are in the sickness or the completely sedentary side of the spectrum, We're talking about the majority, right? We're talking about the majority. We're getting individuals who are saying 80, 90% of their caseload is completely sedentary or is struggling with the chronic disease burden from multimorbidity. And very few of our clinicians are working with the master's athlete. So why do we care about this group? Well, one, we want to cover the full spectrum of geriatrics. But secondly, there is this really neat kind of underpinning that we are gaining from a research perspective when we are evaluating the master's athlete. When we talk about aging physiology, it can be really tough to tease apart what is what we would call the natural history of getting older, what are things that we can expect to change across our physiological systems as a consequence of getting older, and what are the contributions of other things to that aging process. We talk about how we have accelerators and brakes to the aging process, and we can stack the deck in our favor, and then we're just talking about risks and statistics. And one of those things is that as we get older, we tend to move less. We tend to be more sedentary. Obesity rates can go up. And chronic disease, one of the biggest risk factors across all categories, is age. And so we have this hard time teasing apart what is from the aging process and what is from the inactivity, the compounding effect of sedentary behavior, kind of what are those influences? And so the masters athlete has, especially for our lifelong exercisers, those who are veterans, who have never really stepped away from the sport for very long, we're starting to get some ideas and tease apart, you know, what is an aging process and what is accelerated because of changes related to inactivity, obesity, chronic disease. And so I kind of want to tie this in. So we have this physiological change.

06:05 CARDIOVASCULAR FITNESS IN AGING

And when we look at, for example, in the cardiovascular system, our masters endurance athletes maintain their VO2 max by about 57%. And our endurance athletes, when we compare our masters endurance athletes in their 70s, have a lower VO2 max than our endurance athletes in their 20s, but a similar VO2 max to our younger individuals in their 20s who are completely sedentary. And so that is showing that while yes, there is a change to our cardiovascular output, our max heart rate is going to go down, our stroke output, our stroke volume, our cardiac output is going to decrease. Our amount of deconditioning in our VO2 max as a marker of cardiovascular fitness is a slower blunting than maybe we had previously thought. And things like our ejection fraction and our resting heart rate actually do not change with age in a healthy, cardiovascularly conditioned older adult. And to me, that's fascinating. So we're looking at that from the endurance side. When we flip to the strength side, we see that our raw strength in our power lifters is relatively maintained and up until about the fifth decade of life. So an individual squat bench deadlift, as long as they stay injury free and training volume remains pretty consistent, we're going to maintain those numbers for quite some time.

08:50 TYPE 2 FIBER REDISTRIBUTION

And then as we go into different age groups over the age of 40, we're going to start to see some blunting down of that strength effect as a consequence of age. We talk about in the musculoskeletal system though, that there is this change in this redistribution of our muscular fibers, where we see a shift from this composition that has a bias towards type two fibers in certain muscle groups. And we see this shift towards more of a type one slow twitch fiber archetype in many of our muscles. And we seem to see that this is true in our strength athletes as well. And the way we're starting to gain insight into this information is by comparing our power lifters and our weight lifters. So our power lifters are slow strength movements. We have the squat, the bench, the deadlift. For our weightlifters, we are working on speed strength. So we are going to get those type two fibers at high percentages of our one rep max, but we're also gonna try and preferentially activate them with some of these fast twitch movements, such as the clean and jerk and the snatch. And we start to see that the open records for weightlifting in age groups decline much steeper. That means that we are still seeing this switch of type 2 fibers. That does not mean that we don't train power and we're going to try and have this use it or lose it principle that holds true for everything. But we know that that type 2 fiber redistribution is part of this aging physiology that we can expect to see in many of our older adults. Taking a step back from that, it's super interesting to see that we are getting this heightened or slower rate of cardiovascular aging in our endurance athletes. And we're getting this relatively slower change in the musculoskeletal system in our strength athletes. And that specificity principle appears to hold true. And it's something that we see very consistently in our rehabilitation efforts, right? We are trying to train the person's body to not experience pain, dysfunction, or loss of physical function in the exercises, in the movements, in the day-to-day tasks that are important to our individuals. And so when I step back and think about myself as a person in my 30s who's going to try to hold on to my physical function for as long as possible, somebody who maybe isn't in the highest level of competition, but would still consider myself to be very much an athlete, this idea of training both systems I think is extremely important and extremely relevant in our messaging for maintaining physical function. We see oftentimes that we focus in strength training for very good reason. Oftentimes our older adults, unless there's a significant amount of cardiovascular compromise, are losing the strength to complete activities of daily living, like getting off the floor or being able to get up from a chair without using their hands before their cardiovascular system. In our kind of community dwelling older adults, not our individuals with pulmonary pathologies like congestive heart failure or COPD, that cardiovascular system isn't being the limiting factor as often. But what we want to be thinking about is how do we optimize the reserve in both of these systems and how do we slow down the slope of the line? In I'm MMOA, we talk about how we do not want to think that successful aging is just related to physical function. Physical function is a really important part of aging frameworks. and successful aging frameworks, but it is not the only thing. And so I kind of want to take this conversation and then take it a step further. So while yes, we see that our masters athletes are able to have a blunting of the changes in physical function that we see with aging, as a consequence of optimizing their physical reserve earlier in life and then maintaining that optimized physical function into later decades. Where we want to also bridge this is towards some of the frameworks that we're seeing with healthy aging. So the World Health Organization put out a healthy aging framework with the idea of having this decade-long initiative that internationally we are going to try to be encouraging healthy aging initiatives because our global population is aging and that is going to put a massive burden on our healthcare system. And there's a lot of things that we need to think about. And so their framework is really brilliant in that they talk about the ability to meet basic needs and the ability to maintain mobility, like their ability to be mobile around their community. And I think our Masters athletes are good examples of what this might look like in order to try and maintain this type of physical function.

14:58 BUILDING RELATIONSHIPS IN AGING

But the other three things are important considerations as well and do not relate directly to physical function, but there are some kind of extensions or indirect relationships that we can make. And those are the ability to build and maintain relationships, so that connection, the ability to learn, grow, and make decisions, so autonomy in some ways and purpose, and the ability to contribute, which really kind of ties into that purpose conversation. And if you listen to the MMOA podcast, Ellen and I were just on that platform, if you want to take a look, talking about the blue zones. And this was a series that was done on Netflix that talked about these areas around the world that have a higher percentage of individuals living over 100 compared to global norms. And where they were talking about this was not only related to physical function, where physical function was something that we were considering, but they also talked about some of these biopsychosocial considerations like building and maintaining relationships and that contribution to that other aspect of a person's soul and a person's being. When we look at the Masters athletes and we look at qualitative systematic protocols or systematic studies that are looking at some of the other indirect indicators of what a Masters athlete values outside of their physical performance, they kind of touch on these other aspects of the healthy aging framework. where the ability to maintain relationships, one of the things that can be a big struggle for our older adults, and my grandmother who was in her 90s said this beautifully, she said, everybody I know is dying. And Having, building new friends as a grownup is extremely hard. And so one of the other things that our master's athlete literature is really demonstrating is some of these other bio, or these psychosocial considerations that are just so important when an individual is aging. So what they're showing is that our older adults who are master's athletes continuing to compete have this avenue to build relationships with individuals across different age cohorts that have similar mindsets related to health promotion. And that's so important, right? We see that we tend to take on a lot of the lifestyle factors of the individuals who are closest to us. Our literature shows that if we are around individuals who are in the overweight or obese categories, we are more likely to be overweight or obese. The business sentence is, if you are the smartest person in the room, you are in the wrong room. And that's around this building and maintaining of connections and relationships that also have this trickling effect of helping to sustain healthy lifestyle factors. And this loneliness epidemic is so relevant now for all generations, Gen X, Gen Z, millennials, boomers, and some of our older adults. Like all of this connectedness is such an important part of healthy aging. And we're seeing this in our masters athletes as well. And then finally, this capacity to learn, grow and make decisions and the ability to contribute. Our masters athletes are also demonstrating this because they talk about this capacity with athleticism to combat belief systems around aging, to start tackling some of these negative age paradigms, to be able to have goals related to not only what their performance is, but role modeling their athleticism to younger generations within their family and within their sport. and their capacity to be able to create this mentorship for some of their younger athletes that allows them to contribute very positively to their sport. And so not only are we seeing that physiologically within our systems, our masters athletes are blunting some of the slopes of the line across different organ systems, but we're also seeing some of these indirect psychosocial positive contributions of individuals in the Masters Athlete space that are contributing to this overall belief around Masters Athletes having an ideology around successful aging.

17:23 MASTERS ATHLETES & CHRONIC DISEASE

Some of our masters athletes, we kind of consider them to be completely free of chronic disease. And while we do see a lower incidence of chronic disease, like cardiovascular disease and diabetes, for example, in our masters athletes who have continued being active throughout their life, that does not mean that they are immune, but it does mean that when they are diagnosed with things like chronic conditions, that they are better able to manage those disease processes because they have these healthy lifestyle factors that are going to slow down the disease process. So all of these things kind of coming full circle, where we are looking at the master's athlete that while yes, in many of our older adults that we are teaching for clinicians, they are not going to be primarily focused in the master's athlete category. They do give us a lot of insight into the rates of loss in physiological systems and what we can attribute truly to aging versus other confounding variables such as inactivity, sedentary behavior, obesity, chronic disease burden. And then we can also see how some of the influence of these other psychosocial factors, this loneliness epidemic that we are seeing, this connectedness that is needed, this sense of purpose and the capacity to take risk and be a contributing factor to not only their own healthcare decisions, but those of their family and the people around them that are trusting them with their wisdom and knowledge and experience is a way for us to see this positive aging cohort that is also independent of their physical capacity that they are able to maintain. All right, I ended up going a little bit long, but I think this is such an important conversation. And not just for our older adults who are already in these age cohorts, but anybody who is listening, who is thinking about themselves as an athlete. Because we see in the literature that the Masters athlete is defined as anybody who is kind of reasonably beyond the open retirement age, but is continuing to train and compete in sport for the purpose of physical fitness. But in MMA, we think about it as anyone who wants to intentionally move their body towards a goal. And that may be all of you that are listening to this. It's like, how can you put in that master's athlete mindset into your own life to connect with other people with like-minded goals, to be able to optimize your physical function if you are listening and you are 30 or 40 or 50? to maintain that when you are 80? And then how can we do this to help drive purpose in our lives, to allow for that feeling of fulfillment that is just so important to maintain as we get older? All right, if you are looking for more information about research coming out in the geriatric space, I encourage you to go to pti.nice.com slash resources and sign up for MMOA Digest. Otherwise, I hope you have an amazing week and we will talk to you soon.

20:26 OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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. Zac Morgan // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Spine Division division leader Zac Morgan discusses a mobilization technique specifically designed for patients with unilateral symptoms. These patients experience tightness primarily on one side of their body and often feel the need to be stretched out, especially in the morning.

To address these issues, Zac introduces the concept of mobilization with movement. This technique involves actively moving the affected area while applying a mobilization force, with the goal of improving symptoms and increasing range of motion. Zac then demonstrates a mobilization technique using cups. He explains that the cups will be placed on the region of the patient's back that is most tight or painful. The patient is then instructed to keep the cups on for about a minute, allowing them to acclimate to the sensation.

It is important to note that this mobilization technique may not be suitable for all cases of back pain. Back pain can manifest in various ways, and it is crucial to have the right patient in front of you for this technique to be effective. However, if the patient experiences improvement when they forward bend and their symptoms feel better during this movement, the mobilization with movement technique can be beneficial.

Zac  suggests starting with easy active range of motion exercises and gradually adding more stimulus, such as overpressure or the use of weights. He highlights the versatility of this technique and mention that he frequently uses it in the clinic for patients with similar presentations.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRO

Good morning PT on Ice Daily Show. Zac Morgan here. I'm a division lead with the spine division, so you can find me on the road teaching either the cervical spine management course or the lumbar spine management course alongside of Jordan Berry and now Brian Melrose. Speaking on that spine topic before we jump into this morning's Technique Tuesday, I wanted to just point out the next handful of courses that we have. So we actually have three different lumbar course offerings this weekend. So last minute you want to jump in, we'll be in Richmond, Virginia. Baton Rouge, Louisiana, and then Denver, Colorado. So if you're looking for a last second seat there for lumbar spine, jump into those. If none of those work, we have a few more offerings this year. So in October, the 21st and 22nd will be Frederick, Maryland. So right outside of the DC area there at Onward Frederick. Also have Fort Worth, Texas, the November 4th, 5th weekend, and then December 2nd and 3rd at Onward Charlotte. I have a lumbar course as well. Quickly, just pointing out the cervical ones, and then we'll jump into the content. Greenville, South Carolina, October 14th and 15th. Bridgewater, Massachusetts, that's November 11th and 12th. And then here in Hendersonville, December 2nd and 3rd. So those are the cervical and lumbar offerings left this year. But without further ado, let's kind of jump into the topic this morning.

01:21 TECHNIQUE TUESDAY

So this morning I want to kind of bring back Technique Tuesday in the Spine Division. If you've been around forever, like myself, you remember those days way back in the day where Jeff was in his clinic there in Upper Michigan showing some different techniques each Tuesday morning. And those were always really fun to consume because it just gave you some new ideas and things to play with. in the clinic and this morning I wanted to cover a technique that doesn't live in our lumbar course but it is one that I find myself using from time to time. But before we actually jump in and do the technique I'd like to kind of describe who I would do this to because in particular this is a technique that you want to have the right patient selection for. If you've been to the lumbar course, you've heard the stories of derangement and dysfunction. If you're McKenzie trained, you may be really familiar with those terms as well. If you're not familiar, go back a few months to where I did a PT on ice kind of covering these topics about the lumbar spine needs to flex, and that'll kind of refresh you or jump in the live course if it's all completely blank to you. But essentially, technique selection for the right patient is huge here. So what we're looking for is the patient who does have their symptom onset when they flex forward or when they bend forward, they feel their symptoms, but the response to that flexion is the important part. So we're looking for that dysfunction patient or soft tissue extensibility dysfunction, however you like to think of that. McKenzie coined that term dysfunction and essentially the idea being that the soft tissues living on the backside of the spine are not extensible enough and then when the person bends forward and they reach the limit of that extensibility they receive their symptoms. So the real key in diagnosing this person is their response to the flexion. Because if you've been around for a while, if you've seen patients presenting with low back pain, you know that for some folks, when they move into their symptoms, they get tremendously worse. If that is your person in front of you, each time you have them flex, they feel worse, or they lose range of motion, or perhaps even peripheralize symptoms down their limb, that is not who you would do this technique to. Rather, the inverse should be true. So on your active range of motion exam, this patient's gonna come in, and they're gonna present with back pain, Sometimes they might have some leg symptoms, but more commonly back, buttock pain. And you're gonna have them bend forward, and when they bend forward, they'll say, oh Zach, that's my symptoms, I can feel it right there. And often if you observe their lumbar curve while they're forward bending, you'll notice this person does not have that nice reversal of the lumbar lordosis. As a matter of fact, they'll often hold their lumbar spine very rigid as they move forward. So their back will stay completely flat, and they'll just move into hip flexion. Now the key is that you have to have them do that multiple times. So if you have them go ahead and follow up with another rep, what you should see if the patient's a dysfunction patient would be definitely no worsening, but probably more often a bit of improvement. Whereas the derangement patient worsens every time they flex. This person feels a bit better each time you move them into the provocative motion. So for that, we want to treat that with repetitive flexion. So this person needs to restore their lumbar flexion and we're here to help them. So homework often is going to be simple flexion, like just get in a position, flex your back regularly. You can go with a typical McKenzie dosage of 10 reps an hour. You know here at ICE we make those decisions based off of that person's irritability, both psychological and physical. And so dosage is going to play a lot into their irritability. But one technique that I love for this patient is a mobilization with movement into lumbar flexion. Now we see this patient a ton at our clinic because this, you'll see this presentation show up quite a bit with weightlifters. So weightlifters will often have some sort of a flexion injury at some point and then they'll quit flexing their back. So they'll maintain neutral and often they'll even hyperextend a bit to maintain neutral in their back. But one thing's for sure, they will not allow their back to flex. And as with anything in the body, if you don't use it, you lose it. And so over time, this person develops a lot of stiffness and tightness in their back. They have a lot of complaints like that, and they have a really hard time forward bending. The odd part is the solution again is to forward bend. So in homework, I'm going to have them do that in life. Whether that looks like a cannonball position, repetitive standing flexion, it doesn't really matter so much. But one thing I love doing in the clinic is this mobilization with movement. So shout out to Brian Mulligan who kind of conceptualized mobilizations with movements, snags, nags, huge kind of founder in the manual therapy world and really responsible for kind of giving us some of these techniques. But this is one in particular that I find myself using quite a bit. And I actually have a really good patient here in front of you. So I'm gonna have Alexis step in. If you don't know Alexis, she's my wife, better half, and then also faculty in our pregnancy and postpartum course. So Alexis has this problem. She has a really hard time flexing her back. It's typically pretty bad here in the morning, so now is a pretty good time for us to be doing this.

06:06 MOBILIZATION WITH MOVEMENT

But essentially what you want to do for this mobilization with movement, confirm it's on the right patient, then have them sit on a table. In general, I would probably bring up the table up a little bit, but this will work. It really doesn't matter if you have a massage table or a high-low. This one's super easy to do. The only item you need is a mobilization belt. and it doesn't really matter so much which one, but I kind of like this blue one for a couple reasons. It's cheap. Um, so this is the Mulligan belt and then it doesn't have that big leather piece that sort of gets in the way for this mobilization and it costs extra that you don't need. So what you're going to do is form a big loop with that mobilization band. So make sure it's in a big loop and it's going to go around you and the patient. So put it around your back first. And then you're going to reach around the patient, clip, make sure that buckle's not contacting them. And then the belt should live right at their ASIS. So you want that belt to be essentially where like the waist part of a seat belt would be on an airplane or in the car, right at the ASIS. Then I'm going to tighten that up to where I've, right now I've got way too much slack in the belt. So I'm going to put, this to where we now have it taut, so it is nice and firm. And essentially what I'm thinking about with the belt is fixing her pelvis to this table. So you can see it's at a little bit of a downward angle. not completely parallel. If I was completely parallel, I'd be pulling Alexis back towards me. I want this downward angle with the belt to kind of fix the pelvis down to the table. From here, the mobilization is super easy and simple. Sometimes I'll start out without even mobilizing, but just fix the pelvis and then have the patient move through some active range of motion and deflection. So what Alexis is doing is she's just reaching her fingertips towards her toe here, trying to allow this part of her low back to really relax. and just move forward. So typically this is how I would start someone out here. Rather than cranking on them immediately, I'll just allow them to access whatever flexion they feel comfortable with and just move forward. And you know at ICE we like to pump. So we're usually going pressure on, pressure off. We're hitting that in range position and then coming out. Let's say 10 or so reps have gone by and she's continuing to improve each time we do this. She likes the feeling of the stretch. That's where I'm going to add my pressure or my mobilization force. Now I've seen this technique taught segmentally specific where you find the exact segment that you feel is reproducing the patient's symptoms and drive on that. But I'll be honest with you all. I'm typically not the guy that's in there with my thumbs on a specific segment. Rather, I use my whole hand to give nice broad force. If the problem's in their thoracolumbar junction, my hands are typically right here around the bottom of the ribcage, pushing forward. But, go ahead and come on up. If the problem's a little bit lower in the lumbar spine, my hands are just gonna live a little bit lower. So I'm not putting any segmental pressure here. What I am doing is just essentially pushing into flexion in the region of the back that I feel is provoking the symptoms. So don't overthink your mobilization force. Just very gently add pressure all the way to in range and then come off. Super, super simple. I find just as much success being very regional as I do being very segmentally specific. So don't overthink this one. This is just repetitive motions with overpressure. Very nice way to loosen up the lumbar spine. typically this patient loves it.

10:08 LOOSENING UP THE LUMBAR SPINE

Now a couple little nuances here with this technique before we finish up. Sometimes you're going to have a patient who is more of a unilateral restriction. So they're going to mostly complain of right-sided back pain and it's going to be mostly tight on their right side but not so much on their left side. For that person, you want them to forward bend and reach to the left. You want all of these tissues to open up. So Alexis is now forward bending and grabbing her left ankle, and you can see that that would open up this side, and it gives you the really nice ability to just kind of push and open up kind of that QL, all of the lumbar extensors, everything sort of living on this side of the back. So for those more unilateral restrictions, come on out, She's liking that position, that's why she's hanging out there so long. For that unilateral presentation, sometimes I'll do this mobilization a bit unilaterally as well, but just some nuances that you can play with.

13:33 MOVEMENT WITH CUPPING

The last piece that I wanted to show you all is just a way to increase the vigor a little bit, and kind of give the patient that perceived stretch, because often this person is gonna tell you, when they wake up in the morning, I feel really tight, and I feel like I need to be stretched out. And so we want to kind of match that feeling So for that I want to expose their back a little bit and I'm going to add some cupping. So what I'll do with cupping is I'll kind of take my cups, find the region that seems the most tight or painful to the patient, and then I'll fix these cups on them, have them hang out with the cups on. I'm not gonna do that on the video, but for a minute or so, just to sort of acclimate to having these on their back. And then after a minute or so goes by, they're gonna move through those same flexions with the cups on. So I'll show you real briefly just a couple of those. Always use a little cream when you're using cups. It's much friendlier. to your patient. But essentially what we're going to do is fix that cup on her back. That already gives her a bit of a sensation of stretch. These are over the lumbar extensors and they're in the region that's been provoking her symptoms, the region she feels the most tight. Now again, a minute or so would go by. We would make sure she felt relatively comfortable here. with the cups on before we moved, but let's say that minute has passed and I'm ready to go ahead and move through some more range of motion. The cups are still on. Now my belt is in the exact same position and Alexis is doing the very same thing. So she's just forward bending. I can even add some more pressure if I like, or I could slide these cups around and see if I could isolate the exact area that feels the most stiff. appreciate that this is definitely a higher vigor than where we started with. So you want that person to have lower irritability at this point. You want to have seen some good symptom response prior to progressing to this much vigor. But if you're seeing good success and you want to up the vigor here, cups are a really nice way to increase the stretch to that region. So in summary, No one technique is good for all back pain. Back pain presents a bunch of different ways, and you've got to have the right person in front of you if you expect it to work. So for this technique, if the person improves each time they forward bend, their symptoms feel a bit better when they move into them. you want to move into those symptoms with your treatment, and that's where this mobilization with movement is really helpful. You can start out really easy with just active range of motion. You can then add some overpressure. If you want even more stimulus, you could add some cups, or better yet, even have them hold a weight in front of them and have that weight drag them down. Lots of creative options here with this mobilization with movement, and just one that I find myself using quite a bit as we see an awful lot of folks who have this dysfunction presentation. Team, hope to see you on the road at some point. We are out and about a bunch throughout the rest of this year. Jump on ptonice.com and jump into any of the live courses that are in your area or ones that are on your list. Keep your eyes peeled for future announcements with ICE. Lots of cool things on the docket coming out here in October. So I will see you again here soon in a month. Until next time, hit that mobilization with movement.

14:29 OUTRO

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan emphasizes emphasizes the significance of comprehending your own body and the process involved in utilizing the pelvic floor. Without this understanding, it can be challenging to educate and support others in this area.

To better understand and utilize your pelvic floor, Alexis suggests a five-step process. The first step is to "tell" the actions of the pelvic floor, which involves becoming familiar with its location and functions. Alexis uses the analogy of an A-frame house to explain the contraction and relaxation of the pelvic floor.

The second step is to "demo" the actions of the pelvic floor. This can be done through videos or using a pelvic model to visually demonstrate the movements. The purpose of this step is to help individuals visualize and better comprehend what was explained in the first step.

The third step is to "practice" contracting and relaxing the pelvic floor. Alexis encourages listeners to pay attention to any sensations they feel when they contract their pelvic floor. During virtual sessions, she advises being mindful of any additional body movements that may occur during the contraction.

The fourth step is to "ensure" that the individual is correctly performing the pelvic floor movements. This step involves confirming if the person felt the intended movements and if they understood the instructions. If there is any uncertainty or confusion, Alexis emphasizes the importance of not progressing to the next phases until both the individual and the instructor are confident in their understanding.

Lastly, the fifth step is to "progress" in using the pelvic floor. Alexis mentions that this five-step process may not occur in one session and that it may take time before individuals can confidently progress. However, by understanding their own body and going through these steps, individuals can develop the knowledge and skills necessary to effectively assist others in utilizing their pelvic floor.

Overall, the episode highlights the significance of understanding one's own body and the steps involved in using the pelvic floor in order to effectively educate and assist others in this area, as well as provide meaningful care virtually.

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

Hey everyone, Alan here. Before we get into today's episode, I'd like to take a moment to introduce our show sponsor, Jane. If you don't know about Jane, Jane is an all in one practice management software with features like online booking, scheduling, documentation, and a PCI compliant payment solution. The time that you spend with your patients and clients is very valuable and filling out forms during their appointment time can quickly take away from the time that you all have together. That's why the team at Jane has designed online intake forms, that your patients can complete from the comfort of their own homes. And to help them remember to fill out their forms, Jane has your back with a friendly email reminder sent 24 hours before their appointment. This means they arrive ready to start their appointment and you can arrive ready to help. Jane's online intake forms are fully customizable to ensure you're collecting everything you need ahead of time, whether that's getting a credit card on file, insurance billing details, or a signed consent form. You can build out your intake forms from scratch or use templates from Jane's template library and customize it further to meet your practice needs. If you're interested in learning more, head on over to jane.app slash guide. Use the code IcePT1MO at sign up to receive a one month grace period on your new account. Thanks, everyone. Enjoy today's episode of the PT on Ice daily show.

01:26 ALEXIS MORGAN

Good morning, PT on Ice daily show. My name is Dr. Alexis Morgan, and I am here today representing the pelvic division. Happy Monday. I hope you all had a wonderful weekend. Let's discuss a huge topic that is virtual care this morning. Virtual care is something that really grew a lot during COVID. and we all kind of had to pivot, right, and try to figure out, okay, how exactly is this done? One of the areas that I feel like is potentially the most surprising about doing virtual care in is pelvic floor health, pelvic floor assessment, pelvic floor physical therapy. A few weeks ago, I did a PT on ice, about the virtual care and the subjective exam. And did a whole entire podcast on that, did not have time to discuss the objective assessment. So today I'm hopping back on to discuss how we do the virtual objective assessment. If you missed last time's podcast, go ahead and rewind back about a month and look for that. that virtual subjective care, because that's gonna be important and of course it's gonna lay the foundation for this pelvic floor assessment in the objective category. So, let's go ahead and just dive right in to exactly what we teach and what we do for that objective exam. We talked last time, and we talk all the time in pelvic health, that we are educators, that we really teach people how their body works and we teach them the truth about their bodies when in fact they've read unfortunately online and in magazines and on YouTube and in various forms they've heard lies. They've heard myths and they've heard misconceptions. It's very confusing. It's a confusing area of our body. And we get the opportunity to be educators. Part of this objective exam, when we are virtual, is education. So here's how it goes. It's really a five-step process. Number one, tell. Number two, demo. Three, practice, four, ensure, and five is progress. So let's dive into each of those categories.

04:47 ACTIONS OF THE PELVIC FLOOR

So with tell, number one, first you're gonna tell them the actions of the pelvic floor. You're gonna essentially get them oriented with where the pelvic floor is and what it does. You're teaching, you're telling. So you're gonna tell them the actions of the pelvic floor, right? So when it contracts, it goes up. We use the analogy attic, first floor, and basement of the A-frame house here at ICE. So tell them that. So when it squeezes, it goes up into the attic. When you're just chilling, you're hanging out at first floor. We're just at rest at that first floor. That's where life is. happens when we're just chilling. Then we go into the basement. And that basement is the downward movement towards the feet. The holes expand, they enlarge. That analogy is helpful for someone to understand, helpful for them to kind of visualize that. But generally, that analogy isn't quite enough. And because in this objective exam, you know you're not gonna get to give them direct feedback, direct visual or tactile feedback, you've gotta go that extra step. So step number two, so step one was tell. Step two is demo. So you're gonna demo with maybe a video or your pelvic model that you have. Help them visualize what it is that you just said with that analogy. So looking at the pelvic floor, when it squeezes, it goes up towards your head. When it relaxes or an effortful relaxation, it opens up and goes away from your body. That's demo. So they can actually see. So tell and demo these two work hand in hand together. Step number three is practice. So you're gonna ask the client, okay, I want you to practice that. Go ahead and contract your pelvic floor. Do you feel anything? When they are contracting, you're looking for on this virtual call, you're looking for any kind of extra little body movements that they may have. If they're holding their breath, if their entire musculoskeletal system rises, they're doing too much. They're putting way too much into that. And so you can cue them and have them, okay, can you, can you do a similar thing? Can you still raise your pelvic floor? But can you do it with your entire body? relaxed. Just move your pelvic floor, even if it's a little bit less of a muscular engagement practice. You also want to have them do the opposite. So you had them go into that attic. Now you want to have them go into that basement. If they had trouble going into the attic, we definitely want to just move on and go to the basement because maybe they'll feel that a little bit better. So we go into the basement and we say, okay, I want you to bear down. I want you to push towards your feet. I want you to open up those holes, whatever language they need, and you wait for them to feel that. So we're talking them through this practice, but that's not really all. We've got to go on to step number four, which is ensure. So, you've got to ensure that they're doing what you both think that they are doing, what you both want them to be doing. You've got to ensure. So you're gonna ask them some questions, like, okay, so we talked about how it contracts, it closes up, and it goes, your pelvic floor, when you squeeze, raises up, like towards your head. Did you feel any of that movement? Are you sure that you felt it go up? Can you feel the difference between up and down, between that attic and that basement? Can you feel a distinct difference? If they can, I'm still reading their answers, and if they're saying, yeah, yeah, I think I felt that, I'm not convinced with that. I'm not convinced with a little question mark sounding. Yeah, I think I felt that. What we want to hear is, yes. Yes, I felt it. It wasn't strong. I didn't feel much, but I definitely felt a difference in that direction. We want to hear that. Because from that, we can then progress them. Number five. progress them to teaching what the pelvic floor should be doing in their problematic movements. Whether that is double unders, squatting heavy, catching a clean, whatever that might be. We want to teach them what their pelvic floor should be doing. That's again beyond the scope of this of this podcast this morning and please come on to our courses where we can really dive into that. But realize that that five-step process does not always occur in one session. So tell, demo, practice, and ensure absolutely will go hand-in-hand together. But it might be a while before you can progress. because if that person who's like, I think so, I think I felt that, or maybe they're saying like, I didn't feel it at all. I really don't know what you're talking about, Alexis. I didn't feel that. If neither one of you are sure that they felt those movements, you can't go on. You can't go on to the next phases because they have no idea. This little area of their pelvis is like a black box. They can't feel it. They can't move it. How are we supposed to rehab it? We've got to give them homework. We've got to give them projects to work on to be able to feel that. Some examples that I use is I'll send them with a mirror. to look at their pelvic floor to see if they see that movement. Or they can use their finger. They can use a finger and insert it vaginally and feel those differences. They can feel that pelvic floor move. Just getting to the point where they can feel that mobility is a really big improvement and can get them to where they can feel that elevation and that depression of the pelvic floor. So a visual tool for them or maybe a tactile tool for them with their finger. That's kind of a double tactile cue, right? They can feel it with their finger. They can also feel it in their pelvic floor. You might go with just a third option, a single tactile cue. So rolling up a washcloth and sitting on top of that. or straddling over the top of a bouncy ball to be able to feel a little bit of the difference. One of my most commonly used ones for the single tactile is actually tell them to sit in a bathtub where it's super, super still and work on feeling those movements.

13:15 USING WATER AS A TACTILE CUE

Because of the pressure of the water, and the stillness of the water, they can actually feel any slight movement, particularly if it's still and if it's quiet in there. So that's one of my favorite ways to send them home with Homework, to try to get to where they can feel that movement, they can actually engage their pelvic floor, and they can discern the difference between a contraction and that effortful relaxation, or the attic and the basement. You send them home, you repeat all of this on the next visit in about a week or 10 days. Give them that practice to do and follow up with them soon on this, and you're gonna go through that same thing. tell, demo, practice, ensure, see how their confidence is, and then potentially at that point, then we progress. Then we move on to their positions that challenge them or their movements that challenge them, and we educate accordingly. I hope that was helpful for you all to utilize in your own practice and realize that It is challenging to do this if you don't understand your own body and if you don't understand all of these steps. So if you're listening to me today and you're like, I don't really understand how to use my pelvic floor, then you go through these steps. And I guarantee you that when you flip to the other side and you're talking others through this, you being able to relate to them is really going to be able to help. and you can understand that client so much better. Thank you all so much for joining today. I hope this was helpful. I hope you all have a wonderful week. This weekend, I'm gonna be in Scottsdale, Arizona with a whole lot of you all. We are so excited to join you all for the two-day live course. We're gonna have a blast down in Arizona. We've got several upcoming courses. So be sure to take a look on ptonice.com and be sure to register for our newsletter. Everyone always asks us, how do I find out more information? How do I stay up to date on the research? How, how, how in this fitness forward pelvic health world that is ice pelvic, The way to do it is to register for the newsletter. It comes out every other week, every other Thursday, and we give you all the goods there. So be sure to sign up for that, it's absolutely free. And of course, come on over to our courses, our live courses, and we're rolling out our last online course of the year right now, and we're gonna start fresh in the new year. So we are really looking forward to seeing you all out on the road or online. Thanks for being here.

16:42 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. Megan Peach // #FitnessAthleteFriday // www.ptonice.com 

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 MEGAN PEACH

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

03:59 IMPACT VARIABLES

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

10:41 GROUND REACTION FORCE & RUNNING RELATED INJURIES

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

14:39 OUTRO

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

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 JEFF MOORE

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

02:16 YOU HAVE TO CHOOSE

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

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

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

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

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

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

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

15:28 OUTRO

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:43 JEFF MUSGRAVE

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

02:55 RADICAL CANDOR IN PATIENT CARE

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

04:05 RADICAL CANDOR & FEEDBACK

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

10:53 CARING PERSONALLY FOR PATIENTS

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

12:01 SETTING REALISTIC EXPECTATIONS

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

14:29 OUTRO

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

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

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

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

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

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

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

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

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

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

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

1:01 LATERAL KNEE PAIN

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

04:01 OPEN CHAIN CLAMSHELL MODIFICATIONS

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

09:28 PLYOMETRIC TRAINING

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

12:01 RUNNING PROGRESSIONS FOR IT BAND PAIN

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

14:14 OUTRO

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

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

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 APRIL DOMINICK

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

06:34 POSTPARTUM DEPRESSION

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

09:06 EFFECTS OF POSTPARTUM DEPRESSION

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

15:06 THE ROLE OF THE HPA AXIS

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

18:39 IDENTIFYING POSTPARTUM DEPRESSION

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

19:53 OUTRO

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

02:14 ALAN FREDENDALL

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

04:18 WHAT IS A CARBOHYDRATE?

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

09:13 MUSCLE GLYCOGEN 

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

11:17 GLYCOGEN DEPLETION DURING EXERCISE

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

13:58 CARBOHYDRATE CONSUMPTION

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

22:08 CARBOHYDRATE CONSUMPTION & TIMING

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

24:46 OUTRO

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 ALAN FREDENDALL

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

04:15 FILTERING CANDIDATES

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

08:30 THE RESUME

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

10:14 THE INTERVIEW

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

14:52 EVALUATING SWEAT EQUITY

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

18:36 GET IT IN WRITING

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

20:35 OUTRO

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:33 JULIE BRAUER

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

07:18 ENDING RELATIONSHIPS WITH PATIENTS

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

09:52 STARTING RELATIONSHIPS WITH PATIENTS & SETTING EXPECTATIONS

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

13:23 PUNCTUALITY IN HOME HEALTH

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

23:47 OUTRO

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

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

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

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 ERIC CHACONAS

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

01:31 WEIGHTLIFTING & KIDS

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

04:52 BARBELL WEIGHTLIFTING FOR YOUTH

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

08:45 LIFELONG LOVE FOR PHYSICAL DEVELOPMENT

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

09:25 OUTRO

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

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:22 JESS GINGERICH

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

02:17 SOCIAL MEDIA & PELVIC HEALTH

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

04:08 BREAKING DOWN CONTENT CREATION

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

08:00 JUST POST IT

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

09:33 OUTRO

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

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

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

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

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

EPISODE TRANSCRIPTION

00:00 INTRO

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

01:26 MATT KOESTER

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

04:07 EVOLUTION OF PEDAL TECHNOLOGY

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

07:31 THE CLIPLESS PEDAL

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

09:45 SOLID FOOT POSITION WITH FLAT PEDALS

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

14:43 SAFETY & EFFICIENCY OF CLIPLESS PEDALS

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

16:23 OUTRO

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