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 significant issue regarding the lack of individualization and care for older adults with cognitive impairments. Jeff points out that many older adults on their caseloads are at different stages of cognitive impairment, but this often goes unnoticed until it progresses to advanced dementia. The problem lies in the one-size-fits-all approach to treating cognitive impairments, where individuals with mild impairments are grouped together with those with severe impairments, or they are treated the same as the general population without screening for cognitive impairments.

This lack of individualization and care for older adults with cognitive impairments is also evident in nursing homes. Jeff mentions a study from Germany that examined a population of nursing home residents. The residents were grouped based on their cognitive and physical impairments. However, the study found that there was a lack of personalized care, as a more diverse group was randomly assembled with varying levels of cognitive and physical function, and they all received the same basic intervention.

Jeff emphasizes the need to tailor care to the individual's cognitive capacity, just as their physical capacity is considered. He uses the analogy of coaching a peewee football league, where practice would not be taken to the local NFL team if the capacity is not appropriate. Similarly, individuals with cognitive impairments should not receive interventions that are beyond their cognitive abilities. However, in the current state of rehabilitation for those with cognitive impairments, interventions are often not matched to their cognitive abilities. This lack of individualization and care for older adults with cognitive impairments is a significant problem that needs to be addressed.

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 - JEFF MUSGRAVE

Welcome to the PT on Ice Daily Show. Good morning, my name is Dr. Jeff Musgrave. Super excited to be with you this morning, talking about a topic that's really important to me, but also reviewing a research article eight days off the press, a new technique called clustering to give better care to those with dementia on our caseloads. But before we get into that, if you're looking to up your Geri game, we are available. We've got some extra seats in our New Jersey course in Matawan, New Jersey this weekend. If you want to hop on that train, we'd love to have you. We've got space for just a few more. Next weekend, if you want to join us for live, we'll be in Annapolis, Maryland or in Central South Carolina. Last cohort of Essential Foundations just kicked off. We've got our first live meetup, so sorry if you missed it. We will be up in full force in January 2024. There is still time to catch advanced concepts if you want to sign up for that. The last cohort is about to begin, so grab those seats.

02:42 - JEFF MUSGRAVE

So team, man, I'm so excited to get to talk to you about this topic. There are so many older adults on our caseloads in various stages of cognitive impairment. And this oftentimes goes unrecognized until it becomes advanced dementia. when things are a bit harder to turn the tide, but also there's a severe lack of individualization and care for those that have cognitive impairments. A big problem in general practice is this one size fits all. In geriatrics in general, whether we're talking about physical impairments, but unfortunately we see the same problem when it comes to cognitive impairments. We see those with cognitive impairments get treated the same regardless of how advanced those symptoms are. So we see one of two big problems here. We either see those with very mild cognitive impairments grouped with those with very severe impairments, Or we just see them treated the same because no one's screened or picked up on the fact that there's a cognitive impairment on board and they're treated just like the general population which is also not appropriate. So neither of those are a good look. So this study out of Germany was looking at a population of residents in nursing homes and what they did is they clustered them based on their cognitive as well as their physical impairment. So they used a clustering approach to try to get homogeneous groups of people based on not only their physical function but their cognitive function. So all these residents were 65 and up. They had mild to moderate dementia and were living in a skilled nursing facility. The physical measures that they used were the six minute walk test, the timed up and go, 30 seconds sit to stand. But the biggest place where they saw variation that dictated their function was on their mini mental state exam. So their cognitive impairment did a lot to dictate their function. So what they found at the end of this was that those that had more advanced cognitive impairments were not able, even if they had the physical function, to participate in as high level balance training as those that had more severe cognitive impairments. So those with more mild cognitive impairment were not able to participate at the same level, in particular when it came to balance challenges.

04:56 - COGNITIVE IMPAIRMENTS & TRAINING

The interventions for this study unfortunately the link did not go through that I could see all the details but what they what they were doing was some form of strength training either seated if there was lower physical function versus standing or dynamic movement in standing if they had higher physical function. So lower to higher physical function and then they gave also a cognitive layer to their interventions while they were doing balance or strength training. So that allowed them to scale the intervention to those who, to make it more appropriate. So they had a higher and lower physical function, higher and lower cognitive function group, and they scaled the cognitive load as well as the instructions So one big thing that's missing is the environment and the type of cues that we give typically in clinical practice for those with cognitive impairments also need to be scaled. They can't be as complex of cues with multiple sentences in the same duration of time. We've got to really scale that to the person in front of us and individualize that care based on their cognitive capacity, just like we would their physical capacity. The way I kind of think about this is if you were coaching a peewee football league and practice is going really well, you would not march them over to the local NFL team for practice. Their capacity is not appropriate. But we do the same thing with cognitive impairments where we've got someone who has more advanced cognitive impairments, getting a much higher level of training than what they should be and it's no surprise when the results aren't as good and that's also what was found in this study was the experimental group had the matched physical and cognitive and then there was a more heterogeneous group that was just kind of randomly put together with higher and lower cognitive and physical function, and they all got this lowest common denominator intervention, which we commonly see, especially because this was looking at group training in skilled nursing facilities. What typically happens is we've got this big group of people, and we find the person with the lowest cognitive and physical function, and we give everyone that. So the person that has the lowest physical and cognitive function gets an appropriate challenge. Everyone else has lots more ability that is not tapped into and is not being challenged. So it's no surprise once you hear that's what's happening, which unfortunately is the state of rehab for those that have cognitive impairments in general, is it's not being matched to their cognitive ability. So those that were not matched based on their cognitive and physical function showed decline in their mental function by the time the study was complete. So those with matched physical and cognitive challenge to their actual, their functional level, They did great. They were able to maintain their cognitive level in this skilled setting. And those that were not matched showed cognitive decline in even a short period of time. This is pretty wild.

08:09 - SCREENING FOR COGNITIVE IMPAIRMENTS

So some big takeaways here. Are we screening? Are we screening cognition in our older adults? The research says that the sooner we can screen people, the better chance we have to change their life and help them maintain their cognitive function and sometimes actually improve their cognitive function. There is a mountain of research that shows exercise is beneficial for cognition, especially if we're pushing into the fitness realm. and we're pushing people at high intensity and we're asking them to lift heavy things, we're asking them to learn new novel tasks. So we want to make sure we're doing that with older adults, not only for their physical function, but for their cognitive function. But we need to get a baseline of where they are to make sure that we're scaling these things appropriately. The tool that was used in this study was a mini mental state exam, which unfortunately is not great at screening for mild cognitive impairment, which is kind of that first phase before there is problems with activities of daily living, like once we get into more advanced forms of dementia. Tools like the MOCA, the Montreal Cognitive assessment may be more appropriate for catching signs of mild cognitive impairment. Also the SLUMS, the St. Louis University Mental State Exam. However, with that one, it's good to be aware that that can trigger automatically a local referral once it is complete. So you want to make sure that your patient, if there's any family members involved with care, that they're all aware that that will happen. And if this is like, man, I am not comfortable with this cognition stuff, this feels like way out of my depth, that's fine. You don't have to be the expert on everything, but you do need to be accountable to having resources in your area. Who is the SLPs, maybe outpatient, Or on your team if you are in a skilled environment that you can send for a cog referral. Or OTs, we have lots of OTs that are great at screening and intervening cognition and giving you an idea how many step commands, what type of environment, what type of cues are appropriate for this patient. but we have got to meet them where they are for cognition, just like we do for our physical interventions. So if you're not screening, start there. We've got to do more than alert and oriented times three. We've got to be getting these screening tools in use, or we've got to start making those referrals to people that are able to help get a baseline and make sure that our interventions are appropriate. So if you are screening, awesome, you are ahead of the curve. So now your job is to make sure that these interventions are appropriate, just like we're outlined in this study.

14:09 - SCALING UP OR DOWN BASED ON COGNITIVE PROCESSING DELAYS

So what we want to make sure that we're doing is we want to know that there are things like cognitive processing delays, where it may take someone with more advanced dementia symptoms two minutes to process our commands. That was just five seconds of silence from me. If you can imagine two minutes of silence after your cues made this mistake so many times with this population. In two minutes, we've said a thousand things. and they're still processing the first thing that we said. So want to be mindful as we pick up on these symptoms. Cognitive processing delays can be up to two minutes. More mild forms, it could be five, 10, 15 seconds. It may feel a little more natural. Likely your skin's going to crawl, but it may be a very appropriate communication. It's going to look way different in this population. We want to make sure that the more advanced the cognitive impairment is, the more familiar the tools and the exercise interventions that we're using. We can't give a 40 point intervention and biomechanical explanation on a beautiful trap bar deadlift with an older adult. who has advanced dementia, we may be better off to use their purse and add some stuff to it, or add just grocery bags with food in it, and just ask them, pick this up. Once they do that, let's walk, walk 20 feet, or walk over to this area of the gym. No more cues, no more instruction, set it down. That may be a very skilled, very appropriate set of cues for an older adult with advanced dementia. So we want to keep in mind the tools. We also want to keep in mind the scenario. Can we control the environment? That is a skilled scaling tool. How loud is it? How busy is the environment? Is there lots of interaction? Are we at prime time in the clinic, out in a busy clinic where there's people throwing balls on a rebounder or the music's blaring? There's lots of laughter and fun. That may be a completely overstimulating environment for someone who has more advanced dementia. So the complexity… of the environment, the amount of noise, background noise, all those things are scaling options. So if we start in that quiet environment, we may eventually scale in to more advanced and complex environments where there are more distractions, where it is more like real life. But that's gotta be an intentional choice. That doesn't need to be an accident. We need to be very skilled with our interventions and that is part of it. How we choose to practice is also very important. Are we going to do random practice where we're jumping between tasks to task? That's going to be way less on the ability for someone with more advanced cognitive impairments. We may need to do block practice where we spend a big chunk of time, maybe 15 minutes, working just on a sit to stand. We may never get to a squat with a bar. That's fine. But if we can make it practical, we can meet people where we are, that may be where we need to stay. 15 minutes here, 15 minutes on the next thing, that may be our whole session. Or maybe it's something like a simple obstacle course. Pick this up, carry this, and follow me. That could be it. So I wanna keep these things in mind. If we are screening, we are getting a sense of what the cognitive ability level is of our clients, then our job is to scale it appropriately, and then you guessed it, then progress it as we're able. So we wanna use all those leveraging tools. So my advice to you, we're gonna switch gears, so that should be relevant to everyone. Now, if you are training in a group setting, kind of like this study outlines, where you're in a skilled facility, and you're doing group training, you can start with this lowest common denominator approach, but what you have to add in are easy scaling options. You've got to think about, we've kept everyone safe, but then for those that have the cognitive ability to do more advanced balance, or they're safe to do more advanced strength training, What can we do to scale it up for those individuals? So we've got everyone moving, everyone's safe. Now, how do we scale it up? Go heavier. Have heavier weight options available. Maybe instead of sitting, those people that have more advanced functional and cognitive impairments, they're going to be standing. Or maybe they're doing a dynamic movement. Maybe we're going to add some type of vestibular component where we're going to ask them to fixate and move their head side to side or up and down with the fixation point or maybe without a fixation point. Maybe we're having them close their eyes and head turn side to side or up and down. We can add that vestibular layer. We can add a cognitive component as well where we can ask preference questions like everyone, someone shout out, you can think to yourself or shout out loud some of your favorite foods. or name as many states as you can, or name things that are green. We can go very simple up to more complex counting tasks where maybe we're subtracting by 7 from 300 for someone that has a very mild cognitive impairment. Those things may still be on the docket. Those still may be very appropriate. But if we're doing group training, we can start with that lowest common denominator and then just offer scale up options. Another easy one that was even outlined in this study that they found to be beneficial was even just having a little piece of compliant foam for those that were already doing standing. Everyone in the group was mostly doing standing. They added the compliant foam in and that was a great option to scale up balance training. Everyone's getting instruction on the same movement, but there's not really a whole lot of extra instruction to change the surface. All right team, I got super fired up about this. Treated lots of people with cognitive impairments. If you're treating this population, I would love to hear any tips and tricks. Drop those in the comments. Thoughts? I will be dropping the article citation for you. The study was a new approach to individualized physical activity interventions for individuals with dementia. Cluster analysis based on physical and cognitive performance. I hope you enjoyed it. I hope you have a wonderful rest of your day and we will catch you next time.

OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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 the importance of working with patients to dispel negatives beliefs & fear concerning movement aggravating symptoms. Zac describes different strategies to discuss with patients how not moving after surgery or while in pain is probably the riskiest decision. 

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 - ZAC MORGAN

Good morning PT on Ice Daily Show crew. I'm Zac Morgan, so I'm lead faculty with the spine division. I teach lumbar and cervical spine management, so you can find me on the road doing those things. Shout out to that crew in Hartford, Connecticut or Waterford, Connecticut this last week. We had a good time learning about cervical spine over there in Waterford. Few more courses on that note coming up this year that if you're trying to jump into either cervical or lumbar, just wanted to point you in the direction of. So November 11th and 12th, we'll be back in that Northeast region up in Bridgewater, Massachusetts for cervical spine. December 2nd and 3rd, Hendersonville, Tennessee for cervical spine. And then if neither one of those work for you, the next chance will be at the turn of the year on February 3rd and 4th over in Wichita, Kansas. If you're looking for lumbar spine management, we've got three different courses this year that are all still have tickets available. Frederick, Maryland, that's next week or this upcoming weekend, October 21st and 22nd. Then we've got November 4th and 5th. That'll be over in Fort Worth, Texas. And then lastly, Charlotte, North Carolina on December 2nd and 3rd. So still several Good offerings if you're looking for cervical or lumbar spine management. We've already got quite a few booked for next year as well, so if this year the calendar doesn't work out or if the Con Ed budget resets at the beginning of the year, Take a look at the 2024 course offerings as well and more to book there.

01:36 - CATASTROPHIZING REST

So team, this morning I wanted to talk to you all a little bit about rest and why I think we need to catastrophize rest. I think we need to make a bigger deal out of it when our clients come in and we find out that they've been resting. So let me talk a little bit about this. I've been chewing on this idea for a while and I think it's important for us to sort of understand that when someone's in pain, their risk meter is broken. Like they don't have the ability to conceptualize what's actually risky for them often when they're in pain. And so let me unpack what I mean with maybe a clinical scenario that we're all really familiar with. Let's think about something like a knee replacement. I think most of us in our career will interact with patients who have had a knee replacement. Usually we have interacted with those people on the days right after they have had a knee replacement or maybe you're the one that's getting them out of the bed in the hospital and you're the first person that's getting that person moving. I think we understand the risks to this person pretty well, and as a profession, we respond to them pretty well. We understand what this person's actual risk is when it comes to the knee replacement, and their risk would be being too sedentary or resting too much. And what would come alongside of that risk would be a lot of problems that we'll cover in a bit. You think about what that person's concerned about when you talk to that person in the subjective exam on day one, or maybe you just went into their hospital room and you're talking to them. That person's usually concerned about things that are unwarranted. They're worried that their knee is gonna pop out when you start to flex it. The first time you have that person do active range of motion, that person's like, oh my gosh, is my knee gonna fly out? Is the implement actually gonna pop out? They're worried about things like that, but we as PTs, we know that's not very common. We tend to mobilize knees really early and get them moving really, really rapidly and get as much range of motion as possible as quickly as possible in something like a knee replacement because we know that it's crucial that that happens at short term. So a large part of our job early on in managing this person who has just had a knee replacement is convincing them that their risk meter is off. Again, they're afraid to move. They walked through the door that day with a lot of blood in their amygdala. They were very concerned. They were worried, what if something's going wrong? I didn't know it was going to hurt this bad. I didn't think it was going to be quite like this. And they have typically not been moving as a response to all that pain.

03:22 - CONVINCING PATIENTS TO MOVE

And our job is to help them understand that, hey, if you don't move, that's where the risk lives. The risk lives in being sedentary after a knee replacement. Like what's actually risky is if we don't move, the blood will pool, right? And we will wind up with things like a blood clot. Very risky. If a blood clot ends up dislodging and we end up with a pulmonary embolism, that's life-threatening. So that's real risk. That's something that we have to help those people understand is like, hey, if you're too still, we could wind up with something like a blood clot. And maybe we don't fear-monger that to patients, but we do help them understand that risk. You think about some of the other risks that that person has if they don't get moving. What about long-term mobility? If a knee replacement patient does not get their knee moving, you think about what that person's long-term mobility is gonna look like, and it's gonna be quite poor. That first 12 weeks after knee replacement is the most important time for us to restore full extension and get as close to full flexion as we can. We're really trying hard to push range of motion early because we know that person's long-term risk is having a stiff knee. and then not being able to participate in some of their ADLs because of the immobility in their knee. We get the risk so we help unfold that to the people in front of us. I mean the last big ones that happen if someone rests are things like atrophy or loss of cardiovascular endurance and we know this happens very very rapidly. when someone's on bed rest, when someone's immobilized, when somebody's truly sedentary or even sedated, things like that. We know the body responds and we see wasting of all those systems. The same thing's happening if someone doesn't move when they've had knee replacement. maybe not as rapidly as true rest, but we know that they're losing muscle mass, we know their muscle girth is going down, we know their endurance is getting worse. All of these things are truly risky for that person. And for that reason, I think we as PTs do a really good job of helping that person understand, hey, I know it hurts, but the risk of you moving through pain is much less than the risk of you not moving through pain. So I need you to move. And I think we do a really good job with patients like knee replacement patients or patients with a knee replacement. I think we do a really good job with those folks, getting them moving, even though it hurts, getting them back to their ADLs, getting them progressively loaded back to where they're out of sort of disability. I want to shift gears now. And I want to talk a little bit more about my expertise area, which is cervical spine and lumbar spine. So patients with neck pain and patients with back pain. That's typically who I'm seeing the most of in the clinic these days. And I think our response to these folks is a bit different than it is with the knee replacement patients, which is sort of understandable, because with a knee replacement, you understand exactly what happened to that person, where with back pain and neck pain, we never know what the tissue driving their symptom is.

06:57 - FEAR & OUTCOMES WITH BACK PAIN

But I think we often respond with fear, and I think that influences the person's outcome. So let me unpack what I mean. So when someone acutely strains their back, they do something, they were lifting their kid and something happens and now their back is really strained and they're in high, high levels of pain and usually high levels of disability as well. Like a lot of patients will tell me, Zach, I can't even tie my shoes. I have to have my wife help me tie my shoes. I can't get my pants on. I can't get on and off the toilet. The activities of daily living are really influenced by these high pain levels. And a lot of these people, when you start to talk to them, they're terrified to move. Especially a forward bending, but really just to A lot of people in general with acute back pain, they're so scared to move their back around. And they're afraid that what will happen if they move their back around, is that they'll worsen their scenario. They're concerned that if they move too much, and maybe some of this is valid, but if they move too much, they'll worsen whatever's wrong with their back, and then they'll have long-term problems. But team, as you're hearing that unfold, you and I both know that's not the case, right? Like it's actually the people who choose not to move who usually wind up with worse recurrence of their back pain. It's why, I mean, you look at the Olivera study in 2018, where they compared all the lumbar clinical practice guidelines around the globe that they could get their hands on. And there's really only two things, all CPGs, not profession specific, um, not region specific, just all the CPGs that they looked at in that study, they agreed on two things. One of them, don't image. The second one, get moving, right? Don't rest, some sort of exercise. We know people with back pain need to get moving. It is clear, no one argues about that anymore. There's no studies, no big studies that have looked into, hey, rest is actually the successful recipe for back pain. It's not that. We gotta get them moving. But I think sometimes we let our fear of allowing that person to move hold them back. But we need to conceptualize those risk factors. Like you think about what it was like for your knee replacement patient. Maybe we don't have the same concern of like a blood clot or an infection, but think about this person's other risks.

06:57 - THE IMPORTANCE OF MOVEMENT

Like, what about long-term mobility? If someone doesn't restore their ability to forward bend, they often end up with a loss of long-term lumbar flexion. And how does that usually wind up? Maybe sometimes they're fine and they're asymptomatic throughout the rest of their life, but often when I see recurrent back pain patients, They have had episodes throughout life and they've chosen to avoid a certain range of motion and part of our job is to do some graded exposure back to that to help them conceptualize the risk. To help them realize actually being still is where the risk is. We've got to get moving. You think about atrophy. You think about what happens to that person's muscular system. If they have severe back pain and they're not doing the things that they normally do, perhaps they're laying in bed a little bit more, sometimes they're laying on the couch a bit more, a lot of times their spouse is helping them out, their partner is helping them out with a lot of their ADLs. Team, when people have acute back pain, they often get very still because their fear level is really high, and part of our job is to help them understand that where their head is at, what they're concerned about, is actually much less risky than being still right now. Being still is where the risk lies. If we don't get back to movement, you're going to lose that long-term mobility. You're going to lose a lot of your muscular system. You're going to end up losing quite a bit of your cardiovascular endurance. That's where the risk lies. Because what do we all know about people who tend to lose muscle mass, who tend to lose cardiovascular endurance? Most of those people will struggle to get that back. And I think the longer they live, the more challenging that climb back to fitness is going to be. So our older adult clients are definitely in this boat. We've got to keep these people moving. We've got to get them afraid of resting. That's where the fear should be because what happens when you rest is the long-term stuff. That's what causes recurrent back pain. If a person hurts their back and they're now afraid to move in that range of motion and they don't restore capacity, whether that's cardiovascular capacity or the actual strength of the tissues because of fear, now that area is more fragile. It's more susceptible to injury. They're usually careful with that area and being careful with that area often is not a solution for getting rid of a recurrent back pain. As a matter of fact, we want to move more towards things like graded exposure, graded exercise, building that engine, building the tissues, how robust that underlying tissue is. That comes with movement. It doesn't come with rest. So team, I think just putting this whole thing into perspective, what I want to get across this morning is that when someone comes in to see you in pain, their brain is not in the right decision making area to understand risk. Their amygdala has all the blood in it. They're really concerned. they don't know if they're going to be okay. It is our job to use our prefrontal cortex because we can use that in that state because we're not anxious because we see this all the time. We use our prefrontal cortex to say, you know what, actually we need to develop a plan that gets you back to X, Y, and Z. And that's what we do with rehab. And that's how we try to bring down that recurrence, is we avoid all these catastrophes that happen when people sort of follow their natural instinct, which is to rest. So that's all I've got for you this morning. I want us all catastrophizing rest a lot more on our patients, helping them understand that that is not necessarily the safe choice. A lot of times people's risk meter is broken there and it's actually the unsafe choice. So let's catastrophize rest, get out there this Tuesday team, meet us on the road if you're looking for anything. Please feel free if you want to have a big conversation here, jot it into the thread and I'll be on here all day answering any questions. Thanks team.

OUTRO

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

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore takes a deep dive into the Valsalva Maneuver from 3 different lenses: the scholarly research, the pregnancy & postpartum patient, and the strength & conditioning world.

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 - RACHEL MOORE

Good morning PT on ice daily show. My name is dr. Rachel Moore. I am here with Representing the ice pelvic division. I'm on faculty with ice pelvic division. Whoo. Sorry. I need to drink my coffee um i just got back in last night super late night flying from a course this weekend our pelvic live course in um wisconsin it was so much fun we got to see some leaves change which is exciting for me because in houston we don't really have that happen um so really awesome super great weekend awesome and engaged group that we had. If you are looking to join us on the road to catch our live course, our live pelvic course, there are still so many opportunities this year. In that course, we are doing so many things. We are talking about pelvic floor considerations. We're talking about the internal assessment and actually going over and practicing it on your back and in standing. We're talking about pelvic girdle pain which is such a huge topic in the pregnancy and postpartum and just pelvic world in general and then day two we're diving into the actual fitness side of things where we're doing squats and we're learning how to brace and we're using weightlifting belts and we're getting up on the rig and doing gymnastics moves it is a blast every time I come home from a course I'm hyped and there are four more chances of in 2023 to catch this course on the road. So October 21st, we've got a course in Corvallis, Oregon. November 4th, we've got one coming up in Bozeman, Montana. November 18th, we've got one coming up in Bear, Delaware. And then December 2nd, we've got one in Nova Scotia, Canada. So tons of opportunities to catch this course live on the road. Our online course will pick up again in January. So if you're interested in joining us in the ice pelvic division, that's what we got coming up.

02:08 - THE HISTORY OF VALSALVA

This morning we are here to talk about Valsalva. So the word Valsalva is kind of a term that nobody really knows what it means or everybody thinks they know what it means and they all have their own separate camps of what it could mean because it's described so many different ways in the literature. So what we're going to do this morning is clarify what the different definitions of this one word are, talk about the history of it a little bit more, where this term really even came from in the first place. So this topic is really near and dear to my heart. Recently, Christina Prevett and I recently just wrote a clinical commentary on Valsalva and on the nuances of Valsalva. and how as clinicians we can take this term and how we need to take this term and understand the lens, especially when we're looking at research, but when we're talking to patients about what this term even means and what we're actually looking for in our strength training fitness world when we say the word Valsalva. So let's kick it off with the history of Valsalva. The term Valsalva is actually named after a physician from the 18th century. So he was an otolaryngologist. Anyway, he worked in ears and throat, ear, nose and throat doctor. And he created this maneuver essentially as a way to push infection out of the ears. So, the maneuver that Dr. Valsalva described actually doesn't even look like the Valsalva that a lot of people talk about today. His maneuver was plugging your nose and blowing out, but not against a closed glottis. And when he created this maneuver, the purpose of it was to flush infection out of the ear by having that tympanic membrane push outwards to, in theory, push pus out of the ear. That is where this term was created. So when we look at Valsalva in the research lens, when we talk about diving into the specifics of research on this topic, if we're looking in the ENT world, autolaryngological world, we're thinking about this maneuver as a plugged nose, closed glottis, now push out in order to push that tympanic membrane out. When we're looking at this word in the urogynecologic world, it has a very different emphasis or purpose. So when we think about pelvic organ prolapse and the diagnosis of pelvic organ prolapse, that's where we see the Valsalva, quote unquote, being useful, I would say. So the Valsalva in a urogynecologic world is an intentional bear down and strain with a closed glottis. in order to measure the descent of the pelvic organs, particularly during that POPQ or that assessment for pelvic organ prolapse. So on the ENT side, we have the focus of plugging nose, blowing out, pushing tympanic membranes out. In the urogynecologic world, we've got this strain down through the pelvic floor in order to descend the pelvic organs and measure what that descent is.

06:04 - VALSALVA IN STRENGTH TRAINING

In the strength and conditioning world, the term Valsalva means something completely different. In the strength and conditioning world, the Valsalva is a maneuver that is advantageous, particularly if you're a competing athlete in the strength training world, where we need a little bit extra spinal stiffness in order to hit a lift to PR. so in the strength training world this is an inhale into the belly and then a brace of those core muscles that anterior abdominal wall and all of those muscles within the core in general in order to increase that intra-abdominal pressure and spinal stiffness to be able to lift heavier. So when we do the Valsalva, we have a 10% increase in that spinal stiffness and that carries over or translates into pounds on the barbell. So when we're again thinking about our competitive athletes who are maybe trying to like edge somebody out, the Valsalva is an incredibly useful and productive maneuver. Even if we're not a competing athlete, if we're talking about just getting stronger and we're pushing ourselves to the capacity that we want to push ourselves to in order to make those strength gains, the Valsalva is likely utilized in order to increase that capacity to lift heavier. The confusion here comes from that one word having many different definitions. And when we look at the urogynecologic world versus the strength training world, they really are truly opposite. When we're thinking about straining and bearing down, we're pushing down with our abdominal wall muscles, we're pushing down with our pelvic floor, and we expect to see that descent. I 100% agree that we shouldn't put a heavy barbell on our back and then strain and push down through our pelvic floor. That is not beneficial and it is going to put a lot of strain through the pelvic floor. Absolutely. However, when we talk about Valsalva in a strength training capacity, that's not what the Valsalva is. The Valsalva in a strength and conditioning world is that intentional inhale into the belly and brace of that anterior abdominal wall muscles. When we do that brace of those anterior abdominal wall muscles, we don't want to see a descent of the pelvic floor. That would be an improper brace that would need training to improve that coordination. What we expect to see with a valsalva in the pelvic floor world is a matched degree of contraction for the demand that's placed on that system. So if we're thinking about somebody who's lifting a heavy lift, a one rep max, We expect that pelvic floor to kick on, but we're not necessarily volitionally thinking about lifting pelvic floor and doing that pelvic floor contraction. As that core canister is engaged and we engage that proper brace, the entire core canister should kick on to a relatively equal degree. So in the strength and conditioning world, that Valsalva is advantageous. In the urogynecologic world, if we're taking that concept and applying it to lifting, it is the opposite of advantageous. So when we're looking at recommendations for our strength training athletes and our patients, we need to understand the language that is being used and what the definition of that language is. So from the standpoint of our OBs who are telling our patients, don't ever do a Valsalva, in their mind, they're saying, don't ever strain and push your pelvic floor down when you're lifting. Totally. We agree. 100%. Don't do that. It's not going to be great. But the disconnect is that this one word has so many different definitions. So we really have to dive in and break down what was that recommendation specifically. So when we're with our patients, that looks like breaking down the definition for them.

09:01 - VALSALVA MANUVEUR IN THE LITERATURE

But if we're looking in the research world and we're trying to read literature, read the newest evidence about what recommendations are for our pregnant and postpartum athletes, we need to go into the article itself and look at how they define Valsalva. Because we can easily read the abstract and the conclusion of an article that says Valsalva is not recommended, but if we're, looking at this article and it's actually meaning the bearing down, then we're not getting, we're not able to extrapolate that to the strength and conditioning side. So really with this term, it's one word named after a man who the original maneuver isn't even what we're talking about anymore anyway. Across the board, we have to either figure out different words or different ways to describe this, or it really falls on us as providers to break down what it is we're talking about. So rather than just telling your patients, do a Valsalva, maybe we don't use that language at all, and we just talk about bracing. When we do a brace, we can manipulate breath. If we're gonna take that intentional inhale and then brace, that is a Valsalva, But in order to eliminate the confusion across the board, we can just call it a brace. This makes a lot more sense to patients than being told by one person to never valsalva and then by another person to valsalva. And when we lay it all out and explain what all of these differences are and how it's all one term, but it has different meanings, and none of these meanings necessarily are the same. And in fact, in the urogynecologic world, in the strength and conditioning world, they're literally the opposite. It starts to click with patients, why it's okay that my physician told me not to do this Valsalva, but you're telling me that I can, because I understand that these are two very different physiologic mechanisms. Our clinical commentary over this that dives into all of this and so much more comes out in the spring. So keep an eye out. We'll be sending it out in the ice pelvic newsletter. So if you are not signed up for that newsletter, head to PT on ice.com, go to the resources tab, sign up for that newsletter, not only for our clinical commentary in the spring, but for all kinds of resources. in the pelvic floor world. Stay up to date on the newest evidence and also just check out some cool stuff that we find along the way. I hope you guys have an awesome Monday and I hope we see you on the road soon.

OUTRO

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses hip shifting in the squat. Zach emphasizes the need to ensure first and foremost, pain is in the hip or elsewhere in the body is not the cause of the shift. Second, Zach urges listeners to determine if the shift occurs under increasing loads or not. Finally, Zach discusses that if the squat is pain-free and that the movement pattern does not change under load, hip or ankle mobility is the final culprit.

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 - ZACH LONG

Hey everybody, welcome to the PT on Ice daily show. It is the best day of the week here on the podcast, and that is Fitness Athlete Friday. I am your host today, Dr. Zach Long. I'm lead faculty inside of the clinical management of the fitness athlete curriculum, teaching in our live weekend seminar, as well as our advanced concepts course. And today we're going to be chatting about assessing the individual that has a hip shift when they squat. what are the questions you should be asking, and what are the things that you should be looking at and programming for them to help address that hip shift in the squat before we dive into that topic. Upcoming courses that we have in the Fitness Athlete Live arena here. November 4th and 5th, I'll be in Hoover, Alabama, and Mitch will be in San Antonio, Texas. November 18th and 19th, we'll be in Holmes Beach, Florida, and in December, Colorado Springs, Colorado. If you can't make it to any of those courses, we are already filling up the 2024 calendar as well. And we have Portland, Charlotte, North Carolina, Boise, Idaho, Renton, Washington, Raleigh, North Carolina, and Fenton, Michigan on the map. So check out all of those courses, as always, at PTOnIce.com. If you want to get registered, learn how to better assess, treat, and help fitness athletes do the movements that they love, as well as how do we get those people that are not already getting their daily dose of physical activity, how do we start to get them involved in that sort of stuff as part of their plan of care when they come to see us for pain? So PTONICE.com there.

02:32 - ASSESSING THE HIP SHIFT

All right, today's topic, the hip shift in the squat. What I mean by that is you watch somebody squat, and instead of their weight staying even side to side, you see them shift some of their weight more towards one side than the other. Why does that happen? What are the questions you need to be asking? And then what are the things that you need to be doing as part of their treatment? So I think there are two big questions to ask subjectively when somebody comes to see you for a hip shift or you notice that when you're watching videos or watching somebody actually lift in the clinic. Question number one is, does that individual currently have pain in regions of the body that are impacted by the squat? Question number two is, does that change under load? When you ask and answer those two questions, you'll have a much better idea of what interventions you need to do to help improve that squat pattern. 3 Different Pieces to That 1. If someone is having pain, That's kind of the end of the discussion on the hip shift in the squat. So if somebody comes in and they're dealing with really nasty patellar tendinopathy or they're dealing with an ankle that was just sprained and is very, very sensitive as we dorsiflex the ankle. or someone has really irritable hip impingement. As they squat down and those tissues start to get loaded more as we go through range of motion, if those tissues are really sensitive, the body is understandably going to want to unload those tissues and try to avoid further aggravating them. So, when pain is on board and I notice a hip shift, I don't really worry too much about the hip shift right now in terms of trying to correct that. Instead, my main focus is on doing everything I can to calm down that irritability, because until we calm down that pain, we're probably not gonna make a whole lot of progress on the hip shift. So if pain's on board, take care of the pain. Now, there are definitely things that you can do that might assist this a little bit, but to me, those are secondary to the pain portion of this. So you could have somebody do box squats where they limit their depth to where they don't hip shift. or some other variations of lifts that maybe load that tissue a little bit less so that they demonstrate less of that hip shift. I think that's a fine intervention to do so that maybe that hip shift doesn't become, you know, as much of an ingrained movement pattern to them. But overall, when pain's on board, just take care of the pain and don't worry quite as much about the hip shift.

04:29 - HIP SHIFTING UNDER LOAD

The second component to that, the second question was, does this change under load? And this is the big one that I see missed quite a bit. So I've had a couple of these show up in the last few months in the clinic, which is why I decided to do this podcast. And of those that I've seen lately, most of them, I was a second opinion. So they'd already seen another physical therapist or a chiropractor. And they had already had a lot of mobility drills that they were working on to try to improve the hip shift but they weren't noticing a change with the mobility drills. And what was missed by that previous practitioner was the fact that the hip shift worsened with load. And if we think about like the mobility demands of a squat, those demands don't change drastically when they go from an air squat to a 45-pound barbell squat up to a 400-pound squat. What does change is the demands that we're putting on the muscles. And actually, it's a little different than that. It's a little opposite. When you put load on a bar, if you're a little stiff, that load will often help you move a little bit better. It'll help push you through a little bit of that stiffness. So the key thing here is that if you notice the hip shift gets worse under fatigue or under load, then it is probably not a mobility issue. It is much more likely to be a tissue capacity issue, a strength issue. That's the big turning point here. So two examples of this that I've seen lately. Number one, super high level power lifter. He started noticing when he looked at videos of his squat that his bar would get uneven, but that wouldn't happen until he got to weight over 400 pounds. Prior to that, it didn't happen. And if you watch a set of him squatting over 400 pounds for say a set of five, what you notice is rep one was a little bad, rep two a little worse, rep three worse, rep five was really, really bad in terms of that bar being uneven. And what I noticed when I started analyzing that was that as he came out of the bottom of the hole, you would see his one side of his leg, if you're watching that Instagram, I have no idea why fireworks just popped up on my background, but You saw one of his legs really extend rapidly and the other one slowly extend. And what that's called is a good morning squat fault. If you've taken the Fitness Athlete Live course, you've heard us discuss that squat fault, but he was doing it only on one leg. And that leg had previously had an ACL reconstruction. And when we went and measured his limb circumference on that leg, he had a significant quad muscle mass difference on that side compared to the other side. So it was a strength deficit. And what we ended up doing with him was we loaded up his quads, doing a lot of unilateral work. We'll talk about a few drills for that in just a second. And what we noticed is the more we built up that unilateral quad strength, the less that hip shift was present. Another example I saw was recently in a… very high level CrossFit athlete, like top 200 in the world. When he deadlifted, he lost a major competition because his deadlift was relatively weak compared to his level of fitness. And when we watched his deadlift, he kind of did the same thing. So he starts pressing off the ground and the side that he had previously had an ACL reconstruction on about a year and a half prior to this, he hyper extended that knee as soon as he started pressing off the ground because he was still had a little bit of top end quad weakness relative to the other side. So he locked that knee out and he tried to, on that surgical side, make it almost a straight leg deadlift and rely on his posterior chain rather than his quads. So if it changes under load, it is a strength issue, not a mobility issue.

09:26 - ANKLE & HIP MOBILITY

If it doesn't change under load, then you're gonna shift your thinking towards it possibly being more likely to be a mobility issue. And so from a mobility perspective, a few things that we like to look at, Number one, I'd say the most common are ankle and foot limitations. So lack of ankle dorsiflexion, lateral tibial glide, or the ability of the midfoot to move as somebody drops down into a squat. In our Fitness Athlete Live course, we talk you through a couple different tests that we think really help you screen out the foot and ankle, and if that's the impacting factor on somebody's squat technique. The second one to that is going to be somebody's hip mobility. And then the third to that is sometimes you'll see knee flexion limitations, but typically you don't see knee flexion limitations unless somebody's had some really significant trauma to that knee or a recent surgery. Outside of that, it's typically the ankle or the hip from a mobility perspective that will be impacting somebody's squat, causing them to have a hip shift in the squat. So once you answer that, you kind of know what to do. If it's pain, take care of the pain. If it's mobility, work on mobility. If it's strength, then let's do some unilateral strength loading of whatever tissue it is that you identified was a little weaker on one side versus the other. Take care of that. But I also think that it's worthwhile to spend a little bit of time working on some drills that might help reinforce a better movement pattern. So that as you build up maybe that unilateral strength or as you open up that ankle mobility, now you start teaching them a little bit more of where they want to go. And there are two drills that I really frequently use for that. My favorite to use is what's called a sit squat. So what I do there is I get an individual sitting on a box, a bench, a chair, a medicine ball, whatever the lowest surface they can perform this drill on, and they're sitting on it. We pull their feet back underneath them. We lean over. I get them positioned exactly how I think they should look in the bottom of the squat. And then they're sitting there, and I've got everything lined up so that it's symmetrical or as close to symmetrical as I feel like we're gonna get or we need to get. And then what I do is I tell them, imagine that there's a scale underneath your butt. Right now it says 100% of your weight. I want you to make it say 50% of your weight. So they just unload that medicine ball a little bit. Now I say, I want you to lift up one inch and only one inch. So they barely lift off the medicine ball or chair. They go back down to 50% weight and they just cycle up and down. And if you do a set of five to 10 reps of that, it is gonna actually burn really, really good because most people don't spend a whole lot of time under tension down the bottom of the squat. because there's no load on it. It's not going to be very fatiguing or really eating to their recovery a lot. So I use this a ton as a warmup drill, but that is deceptively hard and is really good for getting people to evenly drive and press into the ground and get an even lift off. And then when they sit back down, what they should feel if they're on something like a medicine ball is that they have the same amount of butt cheek touching the ball. Like if they sit down and it's only left butt on the medicine ball and right butt is floating off the side, then they're not squatting evenly. They're demonstrating that hip shift so they also get some tactile feedback in terms of their positioning. The other thing that I really like to do at times with individuals is get them to do some tempo box squats. So we squat down to a medicine ball, a bench, a low box, whatever it is, and we're basically doing the same thing there. We're going down nice and slow and we're making sure when we touch that surface that we're squatting to that we feel an even amount of weight on both butts. so that we, again, know if we're hip shifting or not. Those can be two good drills to drill in moving a little bit away from that hip shift. So, again, your two questions to ask when you see a hip shift. Are they having pain? Does it change under load? When you answer those two questions, you'll have a much better idea of what to go to to get rid of the squat hip shift a little bit faster. So, hope that helps. Look forward to being back on here again in a few weeks with you all. Hope you all have a great Friday and a great weekend, and we'll see you on the road.

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 discusses the three pillars of evidence-based medicine: clinical expertise, current best peer-reviewed evidence, and patient input. He gives suggestions on how clinicians can better incorporate all 3 pillars to improve practice.

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. I hope your morning is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and a faculty member in our Fitness Athlete Division. We’re here on YouTube, Instagram, the podcast on Thursday. It’s Leadership Thursday, that also means it is Gut Check Thursday. Gut Check Thursday this week, four rounds for time, some interval work. Four rounds, 10 handstand pushups. Those can be strict or kipping. Read the caption on Instagram for some help with modifications if you’re still working on those. 10 handstand pushups right into a 50 foot double kettlebell front rack walking lunge. Kettlebells in front of the body, working the thoracic spine, working the legs, 50 feet of a front rack lunge, and then out the door for a 200 meter run on the treadmill, whatever. The goal there is one to one work to rest. That means we’re looking to finish that round in about two minutes. Work two minutes, rest two minutes, complete for four rounds. you’ll be done in ideally about 16 minutes. So read the caption, check for modifications, scaling is needed to try to get your round time as close to two minutes as possible, modify the handstand pushups as needed, reduce the load on the lunge as needed, and then sub out the run for a row or bike as needed. So hope you have fun with that one. That’s a great one that really facilitates intensity. You’ve got some upper body with the handstand pushups, some lower body with the running and some monostructural, with the lunging, sorry, and then some monostructural with the running. So a great workout to really drop the hammer, rest, repeat a couple times, really working on that anaerobic glycolysis system. Before we get started, just some quick courses coming your way. Today I want to highlight our cervical and lumbar spine courses. A couple chances left towards the end of the year as we get near the holidays to catch cervical spine management. This weekend you can join Zach Morgan up in Waterford, Connecticut. The weekend of November 11th and 12th, you can join Jordan Berry up in Bridgewater, Massachusetts. That’s kind of the greater Boston area. And then December 2nd and 3rd, you can join Zach Morgan at his home base at Onward Tennessee in Hendersonville, Tennessee. Lumbar management, also a couple chances left before the end of the year. Next weekend, October 21st and 22nd, Jordan will be in Frederick, Maryland. That’s kind of west of the Baltimore area. He will also be in Fort Worth, Texas the weekend of November 4th and 5th. And then you have two chances the weekend of December 2nd and 3rd. You can catch our newest spine faculty member, Brian Melrose. He’ll be up in Helena, Montana. And then you can catch Jordan Berry at his home base in Onward, Charlotte, also the weekend of December 2nd and 3rd.

02:55 – EVIDENCE-BASED MEDICINE

Today’s topic, evidence-based medicine. A couple different ways to frame this. Are you doing it right? Are you doing it wrong? Or it takes a village of really drilling down and better understanding what comprises evidence-based practice. For many folks, they think it’s the research. For others, they think it’s many, many, many years of clinical expertise, pattern recognition, and others believe none of that matters. What matters the most is actually what the patient believes is happening, what they believe will help them, and matching our treatments, our interventions, our education as best as possible to essentially the patient input side of the equation. And if you’re on the podcast, I’m gonna show a Venn diagram. You’re not missing much, if I’m being honest. I’ve got it right here on the whiteboard. What we know with evidence-based medicine is that it’s actually all of that stuff, right? It is three different spheres, three stools, whatever analogy or metaphor you’ve heard to refer to these before is correct. When we look at evidence-based medicine, is it an overlapping of, yes, scholarly evidence, peer-reviewed research, Yes, clinician experience, practice and pattern recognition. And yes, also patient expectations and beliefs, and that the point at which these three areas overlap is the middle where we have evidence-based medicine, evidence-based practice. But what you’ll find is because of this overlap, none of these areas can be evidence-based on their own. So our goal today is not to show you this Venn diagram, but to show you when evidence-based medicine goes wrong, how it goes wrong, and how we can all get a little bit sharper at evidence-based practice in our clinic with our patients. So, let’s tackle these points one by one. The first, the one we’re all most comfortable with as clinicians is our own clinical expertise. Probably more important than anything else with expertise and experience is the pattern recognition, the dose response relationship that begins to form in our brain The more patience we see, the longer we’ve been seeing patience. This is, you could call this the 10,000 hour rule, whatever you want to call it, but the belief that the more work, the more time you put in, the more you will maybe, theoretically, begin to master your craft. And there’s some truth to that and there’s some non-truth to that as well.

05:06 – AVOIDING DOGMA IN PRACTICE

The biggest issue, as I have it written out here on the whiteboard, is that just focusing on this area in your practice, the bias here is that you become really prone to dogmas, becoming a dogmatic person, becoming almost a guru. We see this, of course, and we’re going to mention it a lot on social media, of the approach on one side of the continuum or other. It doesn’t really matter if manual therapy sucks. physical therapy doesn’t do anything to the far end of that same continuum of, I believe that I’m putting people’s bones back into place with things like spinal mobilization manipulation. So it doesn’t really matter where people fall in the continuum, they fall somewhere on some sort of dogmatic continuum line, which is not great because it tends to the further they get into their own dogma and guru like behavior, the less they tend to incorporate research evidence from peer-reviewed sources and also the patient input. These people over time you may have heard phrases of I use what works with most people and the key there is that it works with most people not all people of the true person practicing evidence-based medicine the true clinical expert is the person that gets all almost every single person better. It’s not enough to get 50% of your patients better, or 60, or 70. You should, or we hope you would be pursuing excellence in such a manner that you’re thinking, how can I help 99.99% of people? And again, just focusing so much on one of the three aspects of evidence-based medicine with your clinical expertise is not gonna cut it. I often think of how much pattern recognition informs practice, but that doesn’t mean that that’s what we do with every person. I often think of when people come into the clinic, they present with anterior shoulder pain, what we might call instability, the feeling of looseness in the joint or otherwise just pain or maybe even stiffness on the front of the shoulder. I look at it as something wrong with the relationship between the deltoid and the lat. I understand the need to treat the rotator cuff, load the rotator cuff, but I also understand that the rotator cuff is ultimately paying the price for what the deltoid and the lat are not doing for the shoulder complex itself. That when these folks present with limited range of motion overhead, that getting in and treating, particularly the internal rotators, subscapularis can have a lot of value in restoring that range of motion and increasing tolerance to load long-term. However, that pattern recognition in my head is yes, where I’m going to go to first, but again, I can’t get caught up too much in thinking this is what works with most people, this is what I’m gonna do no matter what. I have to be aware, I have to be humble that if it’s not working for that patient in front of me, I need to go back and say what does the evidence say, what other treatments could I pursue, and also what input does the patient have into the equation of Are we maybe, yes, identifying the right cause, using the right treatment, but the patient expectation is that they can continue to do three to five hours a day of elite level CrossFit training on top of trying to move through the rehab of their shoulder. Those two things are always going to be at odds, and until I can start to incorporate more of the other arms of evidence-based medicine, I’m going to have a limited effect of how many people I can potentially help rather than most, I’m thinking again, how can I help that 99% of people?

10:40 – CURRENT BEST EVIDENCE

That moves really nice into making sure that we understand that yes, evidence-based medicine does include evidence. It includes what we would call and what’s labeled as current best evidence. That’s the second aspect of evidence-based medicine. I think we can be really hard on ourselves and social media here can make you feel like you’re not doing a good job at keeping up with the research. Because the truth here, if we’re being really intellectually honest, is no one can keep up with the research. There are 1.8 million scientific journal articles published every year. There are 35,000 articles being published every single week. It is impossible for any individual practitioner to read all of those. Ever. It doesn’t matter if that was your full-time job. You would not be able to keep up with it. So what we tend to see is that we tend to focus on specialty areas in practice. And I think that’s okay. I think that helps narrow our lens. And as long as we are finding a source bias here is I think we do a good job with hump day hustling. There are other great sources as well that do a good job of taking a bunch of research and condensing it in a way that can be absorbed, especially that is then kind of classified by specialty area. But understanding, it’s really impossible here to always be up to date on the current best evidence. And just being up to date and reading new articles doesn’t mean that that evidence necessarily has any value. We need to be mindful of that fact as well, that just because something new has been published doesn’t mean it has value. This is a great example. This is an article. You may have seen this make the rounds on social media. The title is, One and Done, The Effectiveness of a Single Session of Physiotherapy Compared to Multiple Sessions to Reduce Pain and Improve Function in Patients with Musculoskeletal Disorders, a Systematic Review and Med Analysis. This paper was published just a couple days ago, so brand new off the press, right? We tend to associate newer with better in research, which is not always the case. And we tend to try to immediately incorporate articles like this into practice and make giant conclusions that often the paper does not support. Already there are people on social media posting this article and saying, look, physical therapy doesn’t work. You should not go to physical therapy. There are folks posting this and saying, see, I told you manual therapy does suck. In some of these studies, in a systematic review, they did manual therapy. I told you it was worthless. Dry dealing does nothing. Spinal manipulation does nothing. Cupping does nothing. People who practice that are committing malpractice. They should be fined or lose their license or be in prison for doing dry needling. And all of those giant conclusions are being made from just this one article. They’re being made in such a manner too that tells a lot of us who read a lot of research that they probably haven’t actually read the full paper, right? They probably have just read the abstract. Because if we read the full paper, what this paper is really saying is that more physical therapy doesn’t seem to help as long as all we care about measuring is pain. No information was given about any other outcome measure, strength, changes in vital signs, did people’s blood pressure get better, did stuff like depression, anxiety get better, kinesiophobia, all these other different things that we can measure about a patient that we would expect to change with physical therapy intervention were not measured in any of these studies. And probably the most important thing that’s missing from this study all the studies that it analyzes and pretty much every piece of physical therapy research is there’s absolutely no information on what was actually done to these people in a way not only that the study could be replicated in the future and possibly validated, or that we have any idea of what was done. It’s entirely possible that folks in some of these studies only got manual therapy, that some folks maybe, yes, got exercise, but how was it dosed? Did they test the sub-max lift? Did they train at or above 60% of that sub-max number to ensure that strength was actually happening? And the answer to all those questions usually is no. So it’s really important we don’t get deep down the evidence-based hole, knowing that for the most part, a lot of the research that comes out, even though there’s a high volume of it, it’s all quite weak and doesn’t necessarily get incorporated into practice because it doesn’t really help change and inform practice pretty significantly. Also from this study, Most of these patients had a spinal fracture, they had diagnosed osteoarthritis of the knee, or they had some sort of whiplash disorder of the neck. So kind of specialty populations that can’t just really be extrapolated to the general population to say that physical therapy doesn’t work. Nonetheless, people grab this article and they cite it. That kind of shows us an overlap between the sphere of clinical expertise and pattern recognition and evidence. I’ve written it right here on the whiteboard. That person, we would call that person a cherry picker. That person has a very shallow knowledge of the research and they’re basically using the research to better inform their own dogma, right? That is not evidence-based medicine. That is just cherry picking research that supports your bias and ignoring the rest and not really taking a deep dive in the research. We have to remember as well that it is evidence based not evidence only that we have to act in the absence of evidence we actually have to do something with people and that we don’t always have the best research to inform what we’re currently doing in the practice that if we are treating a patient we’re doing certain interventions they are making progress both according to their own input, their own goals, their subjective input, and also what we’re measuring objectively, then by every way we can measure it to both us and to the patient, the patient is making satisfactory progress. And sometimes we don’t always have research to support that. And that’s okay. We need to also be intellectually honest, that some of the research we would like to see happen can’t happen. A lot of research is either done on folks who are already healthy or it’s done in a manner that whatever intervention is given can’t potentially make that person either less healthy or more injured. We often see people in low back pain get some sort of treatment and then another group gets some sort of what we call usual care. Either way, somebody is getting some sort of intervention that is designed to improve their symptoms, not maybe theoretically worsen their symptoms. I would love to see research of folks lifting near or at their maximal one rep max potential with a deadlift, and I would love to see the outcomes of what happens with a group of people who lift with a focus on a brace neutral spine, what happens to people who intentionally flex their spine throughout the deadlift, what happens to people who intentionally extend their spine without a deadlift. Is that research ever likely to happen? No. Why? Because it would be really unethical to take a group of people who have nothing wrong with them and potentially cause them maybe a lifetime of debilitating injury just to try to prove a point from the research, and that is not the point of research. We have to be mindful that we’re conducting research on human beings who have lives, who have families, who have jobs, and as much as we would like to see some specific lines of research come to fruition, we’ll probably never see some of that because of the interventions the risk is simply too high, it probably won’t pass review from something like an institutional review board at a university. So we need to be mindful as well of, yes, we’re always trying to keep up with the current best evidence, but that doesn’t mean it’s actually the best, even if it is current, and it doesn’t actually mean that it’s research we would actually like to see happen, because it can be limited, again, by the ethical nature of actually conducting that research on living human beings. The bias here is being prone to being so far in this camp, and I’ve written here on the Venn diagram of being up in the ivory tower, of only doing things that has a lot of evidence to support it. Again, in the absence of evidence, we still need to do something with that patient. We still need to understand their condition. We still need to at least try some other evidence-based interventions to help that patient out. What many of you can’t do is have a patient come in for evaluation and say, I don’t have the current best evidence way to treat you, you’ll need to leave now. That usually doesn’t go very well. And we need to recognize as well, that patient is probably just gonna go see another provider anyways. Even if you were being very, very intellectually honest with them, that there was no evidence on treatment for their current condition, they’re probably just gonna go somewhere else and get less evidence informed care there anyways. So for the best, it’s probably that they stick with you for the long term.

19:14 – MATCHING PATIENT EXPECTATIONS & BELIEFS

Our final aspect is including patient expectations, values, input. I think this is the weakest area for all of us, of the thing we probably consider last, when maybe it should be what we consider first. This is forgotten far too often that the patient, again, is a living human being with thoughts, feelings, beliefs in front of us, and doing our best to match our interventions to their expectations, beliefs, values, is really, really important, and kind of tying in to the current best evidence, we have really good evidence to show that as well. If that patient comes in and says, hey, you know what, you may not remember, but you saw my husband about six months ago for some really bad low back pain. he was in so much pain, he was off work, and you did something with some needles and electricity or something, and anyways, he felt so much better, he was able to go back to work, he’s back, he has no issues anymore, that’s fantastic, and I was hoping, with my back pain, that we could try something like that. Now, of course, what that patient did not get from their husband is all the other stuff you probably, hopefully, did with that patient. But what they took away from it was that dry needling appeared to cure that person. And so, it’s really helpful, I think, if you can match that expectation as much as possible. Yes, you could give that patient a 45 minute lecture on how dry needling for low back pain doesn’t have as much evidence to support it as strengthening the spine and increasing cardiorespiratory fitness and reducing inflammatory diet and getting more sleep and managing your stress and you can go all the way down that pain neuroscience rabbit hole to the point at which maybe that patient doesn’t come back to see you anymore Or if your long-term goal is to help that person and you know what is the most evidence-based way to help that person is to have their back get stronger, to help them with their current lifestyle habits, then probably the shortest point there, the shortest line between two points is a straight line between points A and B. It means that if you can just offer the dry needling, that’s probably going to be the most beneficial thing, right? You’re matching that patient expectation, belief, and value. Does it take time? Yes. It doesn’t take a lot of time. Does it take a lot of resources? No, it doesn’t. It costs a couple cents for the needles, right? And it lets us get to what we ultimately want to get to that person which is addressing their lifestyle, getting them loading, getting them moving if they’re not currently moving, and overall changing their life for the better from both a physical fitness but also overall health and lifestyle perspective. And I think far too often We have an agenda, we have a bias with certain treatments where it doesn’t matter who comes in the door. We can be on either side of the dogmatic perspective of everybody gets spinal manipulation, everybody gets dry needling without actually consulting the patient, do they want this or not? Are they open to another treatment? And what will ultimately get us to what we know works the best for most people, which is to get them moving more, get them stronger, get their heart rate up, address their lifestyle. So you can have many sessions of education only. You would think you’re practicing in the most current evidence-based way, but we know we can’t talk patients better. We actually need to do some stuff. And at the end of the day, I would challenge you that it’s probably better if they do that stuff with you versus leaving your care and going to see another healthcare provider. That’s another thing that articles like this do not address, of how much follow-up care did patients receive after they leave the study. Overwhelmingly, that is something that is not addressed. of if you do not provide the treatments that the patient wants, whether they want manual therapy, whether they want strengthening and you don’t have the time or equipment to provide that, whatever they want, if you do not match those expectations and values, they’re probably gonna go somewhere else. They’re gonna spend healthcare dollars somewhere else. And that might be with a healthcare provider that’s not as evidence-based as you are. So challenge yourself. Are you actually practicing within all of these three different spheres? Are you trying your best to keep up on the scholarly research, at least as it relates to the areas of practice that you’re passionate about? Are you honest with yourself that you do have clinical pattern recognition that has value, but knowing that it does have its limitations and you’re willing to adjust your treatment when things don’t work? And are you combining your practice expertise and the current best evidence with patient expectations and values to ensure that the treatment you’re offering is actually the treatment that the patient wants. So check yourself. Evidence-based medicine, are you actually doing it? I hope this was helpful. I hope you all have a fantastic weekend. Have fun with Gut Check Thursday. If you’re gonna be at a live course, I hope you have a fantastic time. We’ll see you next week. Bye, everybody.

OUTRO

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant delves into the various phases of rehabilitation for shoulder instability, providing valuable insights and recommendations. One key phase highlighted is centered around core stability, with Mark emphasizing the significance of incorporating core-related exercises into the rehabilitation program. Specifically, exercises like plank and plank rotations are mentioned as effective ways to engage the core muscles.

Furthermore, Mark discusses the importance of tailoring functional exercises to the individual's capabilities. He explains that if certain exercises, such as overhead press or full bench press, are too challenging, alternative exercises can be introduced. Examples provided include the landmine press, bottoms-up press, and push-up variations. The goal is to find a level of functional activity that the person can comfortably perform and then scale it accordingly. This approach not only helps to keep the individual motivated, but also allows them to track their progress towards their goals.

In addition to core stability, Mark discusses the significance of incorporating speed work into the rehabilitation program. As the patient progresses through the program, Mark suggests gradually introducing speed training. This involves training the tissues to tolerate different velocities of force through a full range of motion. Specific speed work exercises, such as concentric-eccentrics at different beats per minute (30, 50, 70, 90, 120), are mentioned. Additionally, activities like Turkish Get-Ups are highlighted for their ability to improve core resilience while working on shoulder stability.

Overall, Mark underscores the importance of integrating core stability exercises and speed work into the rehabilitation program for shoulder instability. These phases of rehabilitation play a crucial role in enhancing overall function and resilience of the shoulder joint.

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 - MARK GALLANT

Alright, what is up PT on ICE crew? Dr. Mark Gallant here, lead faculty for the Ice Extremity Management Division. alongside Eric Chaconas and Lindsey Hughey. Coming at you, sorry, Lindsey, messing up that last name. Happened to me for years, now it's happening to you. Lindsey Huey, the other extremity management lead faculty. Coming at you here on Clinical Tuesday, wanna talk about atraumatic shoulder instability and traumatic shoulder instability, and what a good plan is if we're gonna treat these folks non-operatively. Before we get into that, I want to update on a few courses coming up. So I'll be in Woodstock, Georgia, November 11th. Cody Gingrich will be in Newark, California, December 2nd. And Lindsey Huey will be in Windsor, Colorado on December 9th. So a lot of opportunities, different regions of the country to check out ice extremity management. over the next couple months if you need to get in those CEUs for the year. So again, that's November 11th, Woodstock, Georgia. December 2nd will be in Newark, California, and December 9th will be in Windsor, Colorado. So definitely come meet us out on the road.

02:58 - CONSERVATIVE CARE FOR SHOULDER INSTABILITY

So when we're looking at shoulder instability, it used to be that if someone had a traumatic shoulder instability, it was an automatic do not pass go, you're required to have surgery. And then the folks that had atraumatic shoulder instability, the people who were either born loose or worn loose, those folks, it was a maybe depending on how many dislocations, what was going on. But oftentimes a lot of these folks were getting filtered into surgical procedures. What we've now seen over the last couple of years, now that we're getting better with our rehab programs, is that conservative care and physical therapy can do quite well with both the traumatic shoulder instability and the atraumatic shoulder instability. So Anju Jaggi, who's been researching shoulder instability for years, came out with a trial this past year that recently released that showed in folks who had atraumatic shoulder instability, if they had conservative care versus if they had an inferior capsular shift, if they had an inferior capsular shift or an inferior capsular shift placebo procedure where they actually did nothing, that the folks who had the placebo treatment did just as well with physical therapy. So placebo surgery versus actual surgery, the placebo surgery with physical therapy did wonderful. We also have Ellen Shanley in 2019 who looked at what happens if people do have a traumatic shoulder instability event and they go through a full course of physical therapy and found that a majority of those folks were able to return to their sport the next year. So 85% of the individuals who had an instability event had good physical therapy and they were able to return to their sport. We do want to have some humility as physical therapists and allied health professionals that These folks were all individuals who did not have bony damage, so no bony bank hearts and no Hill Sachs lesions in these studies. If those things are not present, we can do quite well. So what is this actually going to look like? Margie Olds, who's another researcher who does a lot with shoulder instability, recently came out with a clinical commentary of how do we best do how do we best work with these folks? And we've been using it in clinic and seeing some really nice results. What the overall theme is, is we really want to get some of the local rotator cuff muscles really functioning well so that the lats, the pecs, the big movers don't have to take over.

04:13 - MUSCLE FIRING PATTERNS & PRIME MOVERS

What we used to see is everyone would try to disinhibit the prime movers, the pecs, the lats. We saw this a lot in FAI treatment where we would try to disinhibit the TFL. What we realize now is this is very challenging, and what we actually wanna do is get the muscles that aren't firing as well to be more robust, more resilient, and fire well, and that will calm down the prime movers. So what we see is if we get the posterior cuff functioning well, if we get the subscapularis functioning well, that we will see the tone of the pecs and the lats calm down. The issue traditionally in physical therapy has been once we get to that stage, we don't move them on to more functional fitness, to more global resilience, to more general preparedness of the system. So what is this gonna look like in clinic? It's actually gonna look quite a bit like our tendinopathy progressions for rehabbing folks. So we're gonna start folks out with more isometric contractions, really getting the cortex and those muscles firing, progressing them more into a rehab dose with concentric eccentrics, then we're gonna focus on speed training, getting those tissues to tolerate speed and different velocities of force through a full range of motion, and then getting them back to their overall functional fitness. So what we specifically like to do in clinic is early on, first phase, they're first coming in to see you, they may or may not have been in a sling for a few weeks, Recommendation for slings and these folks now, if it's first time instability event, or if they've had that atraumatic shoulder instability and they had an instability event, is you can put them in a sling short term. There's no research that says it benefits them. There's no research that says it harms them. Put them in the sling. We don't want them in a sling for more than three weeks. If they feel like they need that to calm down, it is okay for a short period of time. We're going to get them in clinic and we're going to start with our isometrics. Two things that we specifically want to hit with our isometrics, if they can get into a 90-90 external rotation position, we want to hold that three sets, 30 seconds. If that person's willing to perform more, five sets of 45 seconds is even better. Whatever range of that external rotation they can get in, without pain going over a mild and whatever range they have access to, that's where we're going to perform that exercise. The other exercise we're going to perform to go after that subscapularis is a prone liftoff. So they're going to be on their stomach, they're going to put their hand behind their back as far as they can, and they're going to rotate into internal rotation to lift the wrist and hand off the back. If they can only get to the glute day one or just barely to their side, that's totally fine. When you're looking at this one, we want to be really careful that that person is actually internally rotating the shoulder. So this is not the time to turn around and type your notes. We want to be focused that they're getting true shoulder internal rotation. what a lot of people are going to do is they're going to wind up trying to extend their shoulder more or really dump through that scapula. So making sure that when they're doing that isometric, they're getting a pure shoulder internal rotation. We also want to start working on co-contraction of the shoulder. So where the delts, all the muscles are going. Oftentimes these people, although weight-bearing, closed-chain exercise is beneficial, early on it may be too much for the system. We're gonna start them out with a side-lying arm bar. So our big three exercises that we've found to be very beneficial are 90-90 ER, three sets to 30 seconds, if they can tolerate five for 45, that's even better, that prone lift-off isometric, and then a side-lying arm bar for that same period of time. Once they're able to demonstrate that they can do these exercises well, then we're going to, that they can do them well with pain less than a, than a three out of 10 or keeping it in that mild symptoms, they can tolerate the entire timeline. Then we're going to move them into a more of our rehab dose program where we're going to start getting some, some resistance through the system and getting, getting into some actual concentric eccentric repetitions. we really like to do the same motions. So we're going to stand them up, have a, have either a meter band, or if you have a cable pulley system, their hand is going to be behind their back. The cable will be to the opposite side, and they're going to have to do that lift off with resistance. We want them to hit somewhere in the 15 to 20 rep, keeping those symptoms mild for three sets. that will get their subscap, their internal rotation, again, making sure they're not solely substituting extension in that motion. Then we're gonna get them back, either on the table or in quadruped, hitting their 90-90 ER. This time we're gonna hit a light weight, two and a half to five pounds, and then we're gonna do, again, 15 to 20 reps. Can they tolerate that high volume, 15 to 20 reps? keeping their symptoms mild, that would be good for that motion. Then we're going to progress them now instead of doing their open chain arm bar, we're going to see how they can tolerate planks. So getting them into that plank position and having them do plank taps. We can modify this depending on the person by either widening their feet to get a better base of support or putting them onto a box. So for phase two, again, we want to hit that lift off, this time with either a band or a cable resistance, 15 to 20 reps, three sets. We're going to hit our 90-90 ER, two and a half to five pounds, if they can tolerate that, keeping symptoms mild. Again, higher on those repetitions. And then we're going to start working towards our plank taps. As they progress through this phase, then we're gonna start working on speed.

10:30 - SPEED & METRONOME TRAINING

What we wanna look at with the speed is how much can that person tolerate velocity? The metronome is one of the best tools we can use to get this going. We've seen this a lot in the tendinopathy research. Margie Old is the first person that we're aware of that really laid out in a peer-edited journal article, clinical commentary, how exactly they're doing this with shoulder instability patients in clinic and what they're doing is they're starting them out 30 beats per minute on the metronome and they're going to do neutral internal rotation with a band or a cable column at that 30 beats per minute then as they can tolerate that well they're going to progress to 50 beats per minute then to 70 beats per minute, 90 into 120, which is moving pretty fast. If they're doing internal rotation at 120 beats per minute, it's pretty rapid. As they can tolerate that better, they're going to go out, put a towel under their arm, 45 degree angle of abduction, hitting those same 30, 50, 70, 90, 120 beats per minute, and then progressing to a 90-90 position, hitting that 30, 50, 70, 90, 120 beats per minute. Same with external rotation for that posterior cuff, 30 beats per minute in the neutral, progressing to 50, to 70, to 90, to 120. Then looking at can they do it at 90 degrees of external rotation or 90 degrees of front plane external rotation, 30, 50, 70, 90, 120. and then progressing up to 135 similar to that face pull type of motion. Again, 30, 50, 70, 90, 120. So really systematically progressing the speed training the same way you would with your loaded resistance exercise. Now, the other thing that we're gonna do during that phase three, we're gonna start progressing the plank taps. Can they now do a plank with a rotation going on to their side. So they've got to get a little bit movement through that closed chain exercise. And we love to add Turkish get up variations. So one thing that we see with a lot of, especially atraumatic shoulder instability folks, is that they're going to have a, their core is not going to be as resilient as it could be. So we often see a lot of that anterior and posterior trunk dysfunction leading to maybe the lats and the pecs having more myofascial tone and if we can work on that while we're getting the shoulder more resilient that can be a nice beneficial step. So what we'd like to do is do the first part of the Turkish get up or doing a whole Turkish get up so that we're getting some shoulder stability and we're getting a big massive core engagement. And then the final phase, phase four, where historically A lot of PTs have stopped. Oftentimes these folks are out of pain now, so compliance becomes more challenging. Really encouraging these folks that we want to get them fully back to everything that we're doing and build as much resilience to their shoulder. This is where you're going to really work on your vertical pulls, your horizontal pulls, so your pull-ups, your rows, your vertical presses, your overhead press, your horizontal press, your bench press, and then really getting into dynamic speed work or sports training. So snatches, push jerks, push press, burpees, things that are going to be more functional and have some velocity to them are really good here. Your kipping pull-ups. What we want to encourage is we're not going to only start the functional phase after they've gone through phase one, phase two, phase three. So phase one, again, being more of your isometrics, phase two being your slow concentric eccentrics, oftentimes starting at a higher volume, those 15 to 20 reps and progressing to more load. Phase three, working on your speed work, 30 beats per minute, 50 beats per minute, 70, 90, 120 beats per minute. Working on your core related exercises, with shoulder stability. We're not going to only do functional exercise after that's all done. We're going to find what is the level of that functional exercise that they can do. So if they can't overhead press, can they landmine press? If they can't do a full bench press with the barbell, can they do a bottoms-up press? Can they do a push-up variation? What is the level of functional activity that they can do? We're gonna scale it down to that level so that the person is, they've got that goal in mind. They are always aware of what they're getting back to. They're doing something that's getting all of the tissues moving. Oftentimes it's a little more fun for them. So we're keeping that as part of the program. as early as irritability allows us. So again, overall for shoulder instability, what we now know is for both traumatic and atraumatic, as long as there's not a Hill Sachs or a bony bank heart or severe trauma related changes that we do quite well in conservative care and physical therapy, we want to have a systematic program starting out with your isometric exercises that give both the posterior cuff and the anterior cuff really going.

16:01 - PROGRESSING TO CONCENTRIC-ECCENTRICS

Progressing those to our concentric eccentrics, typically starting out with a higher volume. When they can do that, then we're going to progress to our speed work with our concentric eccentrics, 30 beats per minute, 50 beats per minute, 70, 90, 120, making sure we've got some activities that also engage the core, like our Turkish get ups, our closed chain exercises with those plank and plank rotations, and then getting into our more functional fitness or whatever their sport related activity is. Hope this helped overall. Love to hear anything in the comments. We would love to chat and engage about this. Hope you all have a great Tuesday in clinic and hope to see you on the road soon.

OUTRO

Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning 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  continues with part 2 of her series on postpartum depression. In this episode, she discusses how rehab providers can screen for postpartum depression. She also offers tips for communicating with clients who we suspect have postpartum depression with scripted suggestions and responses to support a client in the moment.

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 - APRIL DOMINICK

What's up PT on Ice Daily Show fam? My name is Dr. April Dominick, and today I'll discuss how to screen for postpartum depression and share tips and scripted phrases that you can practice saying to get comfortable supporting someone you suspect has postpartum depression. In the ice pelvic division, updates and course offerings are going to be that we are on the road October 13th and 14th in Milwaukee, Wisconsin. And your next opportunity after that will be with myself and Dr. Christina Previtt. We will be tackling all things pelvic health in the Pacific Northwest in Corvallis, Oregon, and that's gonna be October 21st and 22nd. So head over to PTOnIce.com and grab your seat. Our final courses for the fall are still listed, and you still have a few chances to catch us live. So in episode 1553, that was the last episode I did of this postpartum series, depression series, we talked about prevalence rates, we defined postpartum depression, and we talked about risk factors for postpartum depression. Since then, I ran across another systematic review from 2017 that cited worldwide greater than 10% of pregnant and immediate postpartum women are having depressive episodes, greater than 10%. That number is still astounding to me. While screening for PPD or postpartum depression is one thing, if someone is sharing that they're struggling and you sense they have some signs and symptoms of postpartum depression, we as providers may feel empathy for the person in front of us, but we may be at a loss of words for how to communicate that with another individual. So in the second half of today's episode, I'll go through a few key phrases that you can build off of in response to someone you suspect having postpartum depression, with the ultimate goal, of course, being referring them to the appropriate mental health provider and or medical provider.

00:00 - SCREENING FOR POSTPARTUM DEPRESSION

But first, let's chat about how we can screen for postpartum depression. Just a quick definition of postpartum depression, it is going to be someone with moderate to severe depressive symptoms. That can arise around post childbirth whenever that occurs, all the way up to four weeks post childbirth. And then that can also last for up to a year or more postpartum. Postpartum depression, it affects daily functions. So someone has some struggles with chores or daily childcare tasks compared to the baby blues, which is a more mild form of depression. Postpartum depression does require medical intervention as well. So pregnancy and postpartum, as we all know, is a time of psychological vulnerability, especially in those first few weeks when there's so much transition happening after delivery, which is why early identification and screening for treatment is key. So we want to ask the questions, whether that's verbally or in a paper or outcome measure form. So ACOG recommends that patients be screened for postpartum depression at a few certain timeframes. At the first OB visit, at 24 to 28 weeks gestation, and there was a study in 2013 by Wisner et al that suggested for a majority, depression begins prior to delivery. So this is why we have those checkpoints during pregnancy. And then the other times that they suggest that we screen for postpartum depression is at the comprehensive postpartum visit, whether that's at six weeks, four weeks, eight weeks. And then also I loved this at pediatric visits well into the first postpartum year, because pretty much after that six week visit, um, most women are not seen by their OB until the next year for their annual. So those are some timeframes that we as PTs are likely seeing these individuals maybe during pregnancy, postpartum, so we can also help with this screening process. In terms of outcome measures, there are a number of outcome measures out there that are used to screen for postpartum depression. We are going to go over two of the most common evidence-based tools. The first is the Edinburgh Postpartum or Postnatal Depression Scale, and then the Patient Health Questionnaire. They're both two scales that are recommended by ACOG and by the Postpartum Support International Group, which is a really cool resource, and we'll talk about it more in my next episode, but it's going to be a resource available for those in that perinatal mental health space period kind of combines those two things. So the two outcome measures, the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire, we love them because they are available in many languages and they are quick to administer and they're free. Who doesn't love free stuff? They are validated also for the perinatal population. which I think is something important that while we can give someone a major outcome measure that's for general depression, it's even really more helpful to have someone go through an outcome measure that is specific to the time and space that they're in. And then scoring, the lower the score for both of the outcome measures is going to indicate lower or more mild depressive symptoms. The cutoff value of 11 or higher out of 30 for the Edinburgh scale is going to maximize the combined sensitivity and specificity.

07:21 - THE EDINBURGH POSTNATAL DEPRESSION SCALE (EPDS)

Let's go through a couple of differences, though, between what we'll call the EPDS for the Edinburgh Postnatal Depression Scale. So for the EPDS, it's got 10 questions. And not only does it address the depressive symptoms and suicidal thoughts, but it also has an anxiety component of perinatal mood disorders. And that anxiety piece is likely what contributes to it being the most widely used screening tool. The other interesting thing I came across is that the EPDS is actually reliable and a valid measure of mood in the supporting partner, whether it is a male or a female, which I think is great. Example of items from the EPDS. are as follows. The person is going to be answering whether or not they have been so unhappy that they have been crying, the thought of harming myself has occurred to me, or I have felt scared or panicky for no good reason. Moving to the patient health questionnaire, that's going to be nine questions that assess for the depression component. It does include an item about suicidal ideation, but it doesn't have an anxiety component that the EPDS does. Instead, it includes some of the somatic symptoms of major depressive disorders, such as fatigue, sleep disturbance, changes in weight, and these reflect what is also on the DSM categories. Here's an aside for all these outcome measures. So in my research, I ran across a study from 2017 by Ukatu et al, reviewing about 36 articles that used PPD screening tools, and they investigated the outcome measures and their ability to detect maternal depression. So two of the conclusions from this review that looked at a bunch of articles that use PPD were, one, is that they found no recommendation could be made about the most effective tool for detecting PPD, which is, I guess the good side of that is you can use, there are a lot of tools out there and they will likely be capturing the depression component.

10:28 - WHEN IS THE ONSET OF POSTPARTUM DEPRESSION?

The other thing that they mentioned was there's no recommended time duration in which to screen patients, again, from all of those reviews that they studied. So one of the reasons they suggest that the timing can be difficult to recommend is that For certain outcome measures that are administered at the two-week mark, the outcome measure may not be able to differentiate symptoms of baby blues, which commonly ends after about two weeks post-birth, versus postpartum depression that can have a much later onset. And that can be anywhere from post-birth up to three to four weeks for onset. So I just thought that was an interesting find from the screening side of things. But the two that we talked about are the EPDS and the patient health questionnaire. So outside of administering those two outcome measures, when it comes to screening, you'll want to also use the power of your ears and your voice to catch anything that may have been missed in those outcome measures. Remember, some people won't necessarily be honest on the outcome measures. They may be less likely to share that they're struggling due to the feelings of shame, abandonment, maybe they have a lot of guilt about not being enough for their baby, or they may not even realize their current emotional state, even when asked right on the outcome measure. So be an active listener. Ask the person How are you doing? But don't stop there. If you get a general response that's like, I'm good or I'm okay, I think you should ask it again. Say, I'm going to ask you again, how are you doing? Then you should also be on the lookout for words or phrases that the person may use in their conversation, like dark, heavy, blue. And then we certainly also want to have screening out postpartum psychosis in the back of our minds. So hearing voices that tell me to drop my baby, if you hear that, that is very serious. It is a medical emergency. This postpartum psychosis is going to affect about one to 3% of moms. So that's how to screen postpartum depression. How do we have the difficult conversation? How do we navigate the intricacies? when we suspect the person in front of us may be suffering from some postpartum depression. A few general tips. You'll want to listen with compassion and empathy, particularly to the non-physical symptoms. As neuroscientist, Dr. Andrew Huberman said, says, use your body to shift the mind. An individual that's not functioning at their usual physical capacity, or is in pain, or I don't know, recovering from a human body coming out of their body, or they're lacking sleep, right? This does not only affect the physical body, but it's also going to affect the brain and the soul. So it is within our scope to chat about this as their mental status is linked to their physical healing and recovery and management of their condition. As a provider, ignoring their mental status is not an option. You'll also want to avoid being dismissive. So someone may have been very vulnerable with you and they shared that, you know, they're just struggling. They're struggling to find the energy. They're struggling to feed themselves. And then you as a provider, like, okay, moving on to range of motion of your leg, like absolutely not. That is not acceptable. So avoid being dismissive, hear them out. Then remind them that addressing their mental health now will be so much more beneficial than months or a year down the line. And then mentioning that you'd like to take an integrative approach and refer them to a medication provider or their OB or a PCP or a psychiatrist, right? We'll talk in the upcoming podcast, but medications like antidepressants are also a good treatment option for them. So what are some specific responses that you can practice or just have in the back of your head when you suspect someone may be experiencing postpartum depression? I don't know about you, but especially in the public health space, I tend to get, you know, we talk about intimate subjects and there are some times that someone will share something with me. And I mean, I am feeling so much for them, but I have a hard time putting into words the quote right thing to say. And I'm not saying that these things, these scripting phrases that I'm going to give you are the right thing, but it's something to go off of if you're just struggling in that way.

16:43 - HIGHLIGHT & CELEBRATE

So the first phrase, and I think it's probably one of the most impactful, your feelings are validated. I'm in a group text with a few moms and one of them, they've all been recently pregnant and recently postpartum. Some of them have been going through some tough times when it comes to emotions. And one of them said, my OB put her hand on my arm and told me how brave I am for asking for help and really realizing that I need to be my best self for my family. And she told me I could call her office anytime to talk to her. And that meant so much. So just letting the person in front of you know your feelings are validated. Number two, early identification. So if you've got someone who is pregnant and you suspect that they're going through some tough times from an emotional standpoint, you can say, you don't have to feel this way for the next eight months of your pregnancy. There are resources available. Number three, highlight and celebrate the person's abilities. Say, look at what you're doing. All of this is very impressive given the circumstances and all the stress that you've been under. Bring it back to a potential or current bond with the baby. And you know, if the baby's in the room with you, even better, have a little side conversation before the appointment starts with the baby. When I point to you, look at your mother with loving eyes. I'm just kidding. But definitely show the person or show the mother, look at how you're learning what your baby needs, right? For comfort, for snuggles, for food, for diaper changes. So remind her of the role she's playing. And then number four, remind her your health is a priority just as much as the baby's is. So often, as soon as labor and delivery is over, maybe we have that six week, postpartum visit, the rest of the visits are not for the mother, they're for the child. So just reminding her that her health is definitely linked and just as important to her baby's health. And then number five, say this happens. There's a fine line though between normalizing that this happens a lot, but also it's not so normal that you don't need to address, that we can't have you not address it. So there was a resource that is, was in the deep dive realms of the ACOG website and the title, the title just gives me chills. It says, how do you talk about mental health conditions in a strength-based way? Love that. Here were their suggestions. Say mental health conditions are common. Mental health conditions are like medical conditions or like diabetes. They need to be treated. Medical conditions are, or mental health conditions are treatable. And that reminding the client that the aim is that every woman who is pregnant or postpartum or every person who's pregnant and postpartum is screened for mood disorders. They also recommended that their clinical support office staff needs to be skilled in talking to patients in a strength-based way, as they may be the first to encounter a postpartum person. And I wholeheartedly believe that because the face of the first person you encounter can really and truly change the trajectory of your care. So let's sum things up. If you're a healthcare provider, interacting with someone In the pregnant and postpartum period, you are in a unique position to be screening for postpartum depression. We covered using two outcome measures such as the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire. If we suspect PPD, we as rehab providers can be confident in having these early conversations early on and during the client's pregnancy and then again in the early postpartum period. Using tips and verbal responses, the scripting phrases that I mentioned, can help support and validate the client's concerns in a strength-based way. Reminding them that their health is equally as important as their baby's. Reminding them of what they've accomplished under these incredible circumstances. And telling them, hey, this condition is treatable, just like we would treat a shoulder injury. This awareness can decrease stigma, it can normalize screening and detection, and encourage women to discuss any mental health concerns with you. Join us next time for specific treatments, resources, and ways to support a person with postpartum depression. Cheers, y'all.

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. Paul Killoren // #LeadershipThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren emphasizes the importance of using e-stim in conjunction with dry needling. This combination provides validation and helps the practitioner determine if the needle is in the muscle. Furthermore, using e-stim with needles can reduce post-treatment soreness, making it more approachable for patients. Paul also highlights research supporting the use of e-stim in various treatment goals, such as pain modulation, neuromuscular changes, tissue nourishment, nervous system accommodation, and somatosensory reorganization. Paul always recommends using e-stim after inserting the needle, as it offers multiple benefits for both the practitioner and the patient.

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 PAUL KILLOREN

Good morning. PT on Ice daily show streaming worldwide on Instagram and YouTube. I'm your host for the day, Paul Killoren, of the dry needling division for ice, and I'm hijacking the mic. Normally on Thursday for the PT on ICE Daily Show, we have practice management, we have leadership stuff, really inspiring messages from Jeff Moore, from Alan himself. I'm hijacking the mic and calling this Technique Thursday. We're talking needles on a Thursday. dry needling division. Before I dive in, some pretty exciting updates. Our very first advanced dry needling course is going down January 12th to 14th. And we actually have a registration page up and live that has a little work to do. But the course is going to be ready and the very first advanced dry needling course for ice will be in Washington in Bellingham in January. And then having the upper, lower, and advanced course that will form the ICE dry needling certification. So again, our division's not even a year old. We have had our upper and lower dry needling courses running across the country for almost 12 months. And this will be that final piece. So really exciting stuff coming out of the dry needling division. But I'm going to dive in, dive right in today.

01:58 - THE NEEDLE IS IN, NOW WHAT?

And the title of today's episode is my needle is in, now what? And honestly, when I framed this topic, when I started to prep and form this discussion, in my mind, I pictured that novice clinician, I mean, you're on your first dry needling course, you're doing vastus medialis, vastus lateralis, glute medius multifidus, you learn the technique, the palpation, the anatomy, you're looking for a bony contact, you get super excited, just like, oh, sweet. There's the bone. That's what I was looking for. Now what? So really, this is a question I've answered consistently on level one or kind of first dry needling courses for the last decade. But again, when I started to prep for this episode, there's layers to this. And really, whether you're a novice, an intermediate, or even an experienced dry needler, Sometimes it's worth having this discussion of, our needle is in. Like first we learn how to do it safely, how to do it specifically, but our needle is in, now what? And to fully acknowledge, depending on who you listen to, how you were trained, the answer of, now what, will be very different. Because first of all, there's that technical spectrum of, well, now we piston the needle, or now we twist the needle. Now we use e-stim. But even there, let's say there's a dosage spectrum of, okay, if I piston how many times? If I twist it for how long? If I just leave it there, what duration? If I use e-stim, what parameters? So again, I thought this would be a pretty easy, a pretty short, quick-hitting topic, but there's layers to it. And first of all, let's say that there is significant value to my needle is in a very specific target. Again, safety always comes first when you learn dry needling, but I think we also can acknowledge one of the benefits, one of the advantages of the needle as a clinical tool is we can be sniper precise. We can put a needle in semi-membranosis, in multifidus. You know, this is not necessarily a technique of broad stroking manual therapy of like, we're doing the lateral hip, we're doing the low back, we're doing the SI region. To some degree, even a manipulation, we're saying, you know, we're not joint specific necessarily. We're kind of giving input neurophysiologically to joint receptors and there's more of a regional and global response to that. With a needle, I think we can just say, first of all, I have a needle in semimembranosus.

04:46 - THE BLESSING & THE CURSE OF NEEDLING

I mean, The blessing and the curse of needling is it keeps us honest, especially if we use e-stim. When you get that motor response, the needle's telling you, it's like, you know what, Paul? You're not in semi-membranosis. You missed. You're either like, you drifted subcutaneously or you missed superficially in tendinosis, you missed deep in adductor magnus. So first of all, I don't wanna just like completely glaze over the fact that your needle is in a very specific target is a big part of the equation. I mean, for ice, for our dry needling, we teach safety for sure, but you as like highly educated, skilled clinicians, teaching you all how to be safe with a needle happens pretty quick. So our, our goals, our mantra with dry needling are be safe, be specific. Again, that's, that's a big part of using this needle as a tool and then be strategic. And that's what I want to go to today, because again, the topic here is, my needle is in, now what? And again, let's acknowledge that it depends, not just on how you're trained, it depends on that patient on the table, on what is your goal for that session, what is the acuteness or the chronicity of the condition. So by no means do I want to make this sound easy, but I am going to give a very specific answer to this question. And again, I have previous training, I know the narratives out there of the needle is in, now we twist it for two minutes. Or the needle is in, now we just let it sit there. Or we pissed in it. And again, there are narratives, there is research, and there is benefit to each of those approaches. But I'm telling you that those aren't the answers. Again, I have a pretty specific answer that I'm going to get to But I think I'll torture you just a little bit longer by setting the stage. And really, I'm going to flashback, not even talking needling, I'm going to flashback to my DPT education. I went to Regis University, graduated in 2010. So what attracted me to Regist was Dr. Tim Flynn, Julie Whitman, Jim Elliott. I mean, big manual therapy specialists, but researchers of our day. So we finally, you know, you're year one, year two, you finally get to that musculoskeletal management, you finally get to learn some manipulations from Tim Flynn and Julie Whitman. And you know, if you don't remember how you started with manipulations, it wasn't good. The hands were not skilled, like it wasn't crispy right out of the gate. So you spend a half day, you practice on your classmates at home, and finally you're like, man, I'm starting to feel like my hands have some skill. So imagine you are there, you're learning manipulations, your hands are feeling more skilled. Imagine how disheartening it was for me, and I remember this day, when Dr. Tim Flynn stands up and says, you know what, you can teach a monkey how to manip. And I mean, He's overgeneralizing, but the point is still true. He's like, you can teach a monkey how to manipulate. It's really how, like when to manipulate. Um, I guess how to apply it. There is skill there. We'll acknowledge that. But then it's what you do afterwards. So, I mean, that, that hit for me. And first of all, it's like, Oh man, there are manipulating chimps out there that are doing this better than I am. And again, that wasn't his point, but. But the point remains knowing when to use it, how to use it to some degree, but then the dosage and the follow through, the aftermath is really the true magic. That applies for dry needling as well. Again, can we teach a monkey how to put a needle randomly into tissue? For sure. Like there is not much needle skill to getting a needle interstitially, into muscle tissue. There is a skill to being more specific, and there is a skill to answering the dosage question, now what? And I'll tell you now, without further ado, we have our needle or needles in. The answer to now what is e-stim. And you know, I don't, you know, I kind of do the, you know, I was trained previously, I know the research, the narrative and the benefit to all the other approaches, but the answer today is eSTEM. And honestly, what makes me so confident in that is first of all, I have my own empirical anecdotal, like I was not using eSTEM, now I am. I have that sample size to make me confident. But what makes me more confident And it's not even just the research, I'll touch on that in a minute. But what makes me more confident is knowing or hearing that some of the other dry needling educators or other dry needling institutions in the US and worldwide that previously were saying there's no additional value to e-stim with dry needling, or we're essentially just doing tens through a needle, they're now starting to use e-stim. And whether they use it the same way we do with ice, whether they explain it the same way, what they're saying is there's value to e-stim. And here's what the research says, is our needles are in, now what? E-stim is the answer for almost any treatment intent. First of all, I mean, if you haven't taken one of our upper or lower courses, we teach e-stim right out of the gate. I mean, day one, we learn how to use the unit, we get muscles to pump, Again, there's high value when you first learn dry needling to using e-stim because it keeps you honest. Are you in that muscle? Are you not? But that immediately gives you some, I guess some validation, like I'm saying, but some grace. Because first of all, what we know is that if we use e-stim with our needles versus not, any sort of post-treatment, post-needle soreness will be much less. So there's a very, um, a very real like patient approachability aspect to using e-stim. And there's research to support that.

12:33 - E-STIM DOES IT BETTER

But beyond that, what if our treatment goal is not pain modulation? What if it's neuromuscular changes? E-stim does it better. What if our goal is, tissue nourishment, blood flow, maybe venous return, lymphatic activation, edema evacuation. What if our goal is that? ESTIM does it better. What if our goal is nervous system accommodation? Or what if it's getting the biggest, baddest neuropeptide or enkephalin, endorphin, but our pain modulating up top cortical response. What if that's our goal? eSTIM does it better. What if we're talking pain science and there's some somatosensory reorganization, there's some homuncular smudging that we would like to remap. We'd like to give a very profound and precise input to that homunculus, to that somatosensory cortex. eSTIM does it better. So again, these are, these are research based answers. Very real research that says group A just got needles, whether that was pistoning or placing or what have you, and then group B got e-stim. What was the difference? At this point, e-stim does it better. And really, that is the long and short of this episode. And again, I think to not minimize the impact of you have to learn how to put a needle in safely, There is significant value, especially with the needle, to say, my needle is in, very precisely, fill in the blank. My needle is in peroneus brevis. My needle is in extensor hallucis longus. My needle's in glute minimus. There is significant value to the precision of that tool. But that's only half the battle. My needle is in, excellent. That took some training, that took some some skill honestly that took some three years of doctorate level like anatomical training and education and awareness that took a lot to say my needle just contacted I guess the external ileum like we are at the depth and the location of glute minimus that's awesome that you checked the box that is step one but if we don't fill in the then what you're leaving a lot on the table clinically And if you just logged on, the answer is eSTEM. So again, I know I see some of the names jumping on. Thanks for joining. I'm preaching to the choir, to some of you, because you've taken our upper or lower courses. We immediately talk about how to use eSTEM, the research behind eSTEM, and then we use it all weekend on the course. And it's a different experience. I think eSTEM makes dry needling a little bit classier. We can be a little bit more classy with our needles when we use E-Stim. We can also be a little bit more dialed, a little more tactical with our treatment intent. Again, is your goal pain modulation? Is it neuromuscular changes? Is it blood flow? Is it just fluid dynamics of moving fluid? Excuse me. So that's the answer for today. Again, jumping on on a Thursday for a Technique Thursday. We're talking dry needling. And the question was, needle is in, now what? And the answer was Easton. Excuse me. So if that prompts any questions, again, this is a big piece of our curriculum. Drop some comments in the thread. Hit us up on Instagram. This is on YouTube as well, so you can throw some comments there. Again, my name is Paul Killoren of the dry kneeling division for ice. If you hopped on late, We are launching our advanced dry needling course in January. That'll be the final piece of our upper dry needling, lower dry needling, and then advanced for the certification. If you're in Washington State, that'll be the third course of the series to allow us to dry needle as far as getting 75 hours. But if there's anyone out there who is trained in needling, who is uncertain about using eStim or the benefit of eStim, first of all, I'll just encourage you to try it. Like, there's value there to hearing your patients explain the difference of using eStim or not. Otherwise, we have an online course if you already have the needle skills, you know how to put your needle in, but then what? If you don't know how to use the eStim, there is an online course through ICE as well, eStim plus needles. That's all I've got for today. Thanks for logging on. I'm incredibly proud of myself. This is my most concise, my most brief podcast topic, but it's an easy one for me. So if you're out there saying, what do we do after we put the needle in? I'm not saying there's not value in twisting or pistoning or just static needling. There's blood flow changes. There's neuromuscular changes. There's tissue disruptive like inflammatory cascade responses to all of that but the answer is e-stim and With that I'm logging off folks. Thanks for joining PT on ice daily show. See you next time

OUTRO

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

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult faculty member Julie Brauer emphasizes the importance of executing obstacle courses in a specific, dynamic, objective, and progressive manner. The purpose of these obstacle courses is to prepare patients for the chaos of their daily lives and help them confidently overcome these challenges.

To make obstacle courses specific, Julie suggests replicating the functional demands of the patient's specific goals. This means creating exercises and challenges that directly mimic the movements and tasks the patient needs to perform in their daily life. By doing so, the patient can develop the skills and confidence necessary to navigate these challenges effectively.

In addition to being specific, obstacle courses should also be dynamic. This involves incorporating a combination of exercises and layering dynamic challenges. By introducing variability and unpredictability into the obstacle course, patients can improve their ability to adapt and respond to different situations. This dynamic nature of the obstacle course helps simulate real-life scenarios and prepares patients for the unexpected.

Objectivity is another crucial aspect of executing obstacle courses effectively. Julie suggests leveraging subjective and objective outcome measures to make the obstacle course objective. This means using measurable criteria to assess the patient's progress and performance. By having clear and measurable goals, both the therapist and the patient can track improvement and make necessary adjustments to the obstacle course.

Lastly, obstacle courses should be progressive. This involves gradually increasing the difficulty and complexity of the challenges as the patient improves. Progression ensures that patients are continually challenged and can continue to develop their skills and abilities. It also helps to keep the obstacle course engaging and motivating for the patient.

Overall, executing obstacle courses in a specific, dynamic, objective, and progressive way is essential for helping patients develop the confidence and competence to effectively navigate the challenges in their daily lives.

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 - JULIE BRAUER

Welcome to the Geri on Ice segment of the PT on Ice daily show. My name is Julie Brauer. I am a member of the Older Adult Division, and we are going to be talking this morning about obstacle courses and leveling up our dynamic gait training. So I've been really passionate about creating meaningful obstacle courses for a really long time, and I've become even more excited about this topic since our live course has gotten this massive revamp where we spend an entire lab focusing on dynamic gait challenges and how to layer. So I'm so excited to dive into this today because obstacle courses can be a really challenging, fun, creative way to implement dynamic gait training into our plans of care. With the purpose of preparing our patients for the chaos that is their daily lives, right? We want them to be able to move confidently through the chaos of their lives. And if we really think about it, What better exercise could we give our patients than a combination of exercises, a combination and layering of dynamic challenges that exactly replicate the functional demands of their specific goal, right? However, I think we many times really missed the mark here on executing this in an effective way. And when I say executing in an effective way, I mean in a way that is specific and dynamic, objective and progressive. So when I reflect back on the past eight years of my practice,

02:37 OBSTACLE COURSE LIMITATIONS

When I think about all the obstacle courses that I have seen throughout various settings, most of them are variations of stepping over cones, or stepping over hurdles, or many times it's stepping over canes. Many times it's one rep, the patient goes through that obstacle course forwards, and then the next time they go through it sideways. Many times it's weaving around cones as well as stepping over them or maybe stepping in and out of an agility ladder. And when we think about that, we have to realize it's pretty unidimensional, right? It doesn't exactly look like real life. Most of these patients are not on a clock. We aren't often capturing our PE while the patient is going through the obstacle course, right? Like I could go on and on about a list of things that are wrong with our typical obstacle courses that we see in our clinics, in our profession. And while stepping over cones and navigating around them is a really solid place to start, we really have to start thinking about moving beyond that, right? I consider stepping over cones and navigating around cones very similarly to our other underdosed exercise. I will go as far as to say that I think that cone stepping is the ankle pump of dynamic gait training. Stepping over cones is the ankle pump of dynamic gait training. And so why? So let's unpack that. Because many of you would probably say, like, what do you mean stepping over cones is challenging for my patients? And I'm going to respond with, well, yeah, I mean, tandem standing is challenging for a lot of my patients, but I'm sure as hell not going to waste multiple weeks of a plan of care with my patient in tandem stance, right? The question becomes, is it the right challenge? Is it the right challenge? Similarly to tandem stance, Do the demands of stepping over cones match the entirety of the chaos and the dynamic demands that comprise our patients' lives? We have to realize that stepping over cones only hits one aspect of dynamic gait and balance, right? It only hits on anticipatory balance. And we know that balance can break down in multiple different areas. And there's so many other components of balance and dynamic gait that we want to pay attention to. we have to realize that stepping over cones is not super specific, right? It doesn't look like real life. Our older adults are not moving around in an environment where these very bright orange cones are sticking out to alert them they need to step over that thing, right? And then also, you know, just thinking about If I am able to get my patient really competent and confident in stepping over cones or weaving around cones, does that actually translate to our patients feeling incredibly confident to take on the adventures in their world?

06:08 ROOM TO GROW WITH OBSTACLE COURSES

So we have to first reflect on why there's just a lot of room to grow when it comes to our typical obstacle courses, all right? So now that we've set that framework, let's talk about how to level up our dynamic gait training from assessment to implementation and creating in dialed in workouts, focusing on how to make these obstacle courses specific, objective, dynamic, and progressive. All right. And we're going to put this in the framework of focusing on two different types of goals. And these were goals and dynamic eight challenges that students who were part of our MMOA live course a couple weeks ago in Oklahoma came up with. absolutely stellar students who came up with really awesome dynamic challenges. So I'm going to share some of these with you. So these two goals that we'll be talking about back and forth, um, that many of you can relate to with your patients are the goals of one, being able to independently navigate through the airport and board an airplane independently to be able to go on vacation. And then two, to be able to independently tend to a garden. All right. So two goals that are very common among older adults. And we'll talk about how to make it specific, dynamic, objective and progressive. All right.

10:21 SPECIFIC OUTCOME MEASURES

So starting out with making our obstacle courses really specific. This is where we need to dig deep. So if you're part of our MMA crew, you hear us talk about our formula, make it meaningful, load it, dose it all the time. So this is that make it meaningful part, right? So we need to dig deep into what that goal actually looks like. I want to peel back all the onion layers. So if my patient is telling me, well, I want to be able to go on vacation. I am having my patient take me through from start to finish. I want to know exactly what that looks like for her or for him to go from getting out of that car into the airport through the airport onto the plane into into their seats right so I am asking question after question after question because I want to visualize what that goal looks like, right? If it's gardening, I want to know exactly what the functional movements are that comprise that goal because there is where I'm starting to create my obstacle course. I am in my head taking mental notes about what are all the pieces and parts that are going to comprise this obstacle course to make it very specific for the patient. Now, sometimes going seven layers deep with our patients is really, really difficult, right? They just, they have a hard time answering these questions or having that conversation with us. This is where we can leverage our outcome measures such as the PSFS or the FES and the ABC, right? Those are going to give us some insight into some components of their daily lives that are really scary or they feel like they're going to lose their balance or fall or components that they're actually really confident in. So you can use those outcome measures when perhaps the conversational part and you're asking a million questions and digging deep, is a little bit difficult for your patient. And then we want to really leverage our objective outcome measures, right? So our mini-best and our DGI, because that's going to give us very, very, very specific information. If our patient is telling us that, yeah, I'm having a difficult time because I'm afraid people are going to knock into me at the airport, well, I'm sure as heck gonna want to look at their reactive balance with their mini best, right? So we wanna use both digging deep, asking the questions, using those subjective outcome measures, and then definitely using those specific objective outcome measures to see where perhaps the balance is breaking down, right? So to give a couple of specific examples, If our patient, maybe in their PSFS, are saying that lifting that suitcase over their head is really the part that is limiting them from feeling confident and being able to go on that trip, maybe it's a strength component that we really want to focus on. So maybe I'm going to look at a press or a push press and see what that looks like in isolation and maybe coach that up, right? But then I know that I'm going to add a push press or a press into my obstacle course, because maybe it's not that the strength component of that push press is the big issue, but more that they are so fatigued after going through the entire airport that they just don't have the energy to get that suitcase up into that overhead bin, right? And so, again, to bring it back to the balance component, if they're telling us, I am so scared of getting bumped by someone at the airport, because I'm afraid it might fall, I want to know, hmm, what does their reactive balance look like? I want to look at forward. I want to look at backwards. I want to look at lateral. And then to put that into the obstacle course, maybe I can do something like our stellar students did a couple of weeks ago, where they use TRX straps. And as the patient's walking, they swing those TRX straps at spontaneous times, to see how the patient reacts to that, right? Or you could do something like as your patient is walking, you offer an external perturbation and see what their stepping strategy is. All right, so that's how to make your obstacle course as you're figuring out what the pieces and parts are very, very specific to what they're telling you and what you're finding throughout your assessments. Next, we have to talk about how to make it dynamic. And what I mean by dynamic is not just the patient is moving, right? Like, you know, I can see a lot of you being like, well, yeah, well, you know, stepping over cones or hurdles like that is dynamic. But we have to think more about just the patient moving, right? Yes, that is dynamic, but we have to remember that we need to mimic a dynamic environment, not just our patient being dynamic and our patient moving, right? And in addition to that, what I mean by dynamic is layering.

14:21 MIMICKING REAL LIFE CHALLENGES

We want to combine anticipatory balance, reactive balance, vestibular fitness, strength, power. We want to combine all of those things together in our obstacle course, because that's real life. And that's when balance breaks down, when we were trying to navigate through all these different components. Remember that older adults are not waking up in the morning. And for the first two hours of their day, they're only doing a single task. And then the next two hours of their day, they're doing a dual task in reactive balance, right? Like they are constantly moving in and out of forward gate, sideways gate, making 360 degree turns, reactive balance, anticipatory balance, cognitive tasks, motor dual tasking. All that stuff is happening constantly. So we want to mimic that type of chaotic environment. We want to layer all of those challenges on. So what would that look like? Let's think about our gardening example. So if we're thinking, and our patient is telling us, okay, so I have to pull the hose, right? And I have to pull the hose and walk along the grass. And so you're thinking about this, hmm, how can I mimic that? Could I have my patient pull a rope? Could I also then have them do head turns where they're looking behind their shoulder to make sure that their hose isn't totally annihilating all of their flowers, right? You're making it that specific, but you're layering on challenges. What about for the individual who wants to go on vacation, they're really scared about stepping onto the escalator with their suitcase, right? So how do I replicate that? Can I step onto a variable terrain, like stepping onto a BOSU ball, while I'm lifting a weight or doing a suitcase deadlift, right? So now we have that sensory orientation, we're adding in that vestibular fitness, we're adding in the strength to step on and get stability on a moving object while also having the strength to lift an object. If we think about our gardening example, think about the act of pulling weeds. Maybe we're getting our patient down into a half kneel and we're doing a rowing exercise for strength. Or maybe it's more of the balance component our patient is worried about when they go to pull those weeds. So we do something like utilize squigs or we get a really heavy dumbbell and we tie a TheraBand around it and we have them pull the TheraBand and release. or we put a resistance band around them in half kneeling, and we go ahead and give them perturbations. So we layer on all different types of challenges, anticipatory, reactive, vestibular fitness, strength, power. That is how we layer. And we want to layer and layer and layer because that is what real life is like. Next, we have to find a way to make this objective, right? We have to dose it appropriately. We have to find a way to progress our obstacle courses. So we got to think about our goal, right? If we think about gardening or the airport example, if the goal is to be able to continuously move through, let's say 20 minutes, because let's say it takes 20 minutes to get through the airport. Gardening usually takes 20 minutes of time to do all those tasks. Okay, that's our long-term goal. So maybe we start out by, we want to see how many rounds you can get through when you continuously move for six minutes. That's more of the short-term goal. And we're recording how many rounds did they get through? How many breaks were required? Or if you have someone who, for example, gets to the airport really, really, really last minute, which just, like, my anxiety goes up even thinking about it, and you know they're going to be racing through the airport, maybe you want to design the workout so that that intensity is really, really high. And maybe you're doing something like three rounds of that obstacle course for time. We also want to be tracking our PE and using that to progress our goal. So if our patients, you know, capacity is really struggling, for example, you know, within three minutes of the obstacle course, it feels like an RPE of seven or eight, then maybe one of our goals is that it takes eight minutes of doing that obstacle course until that RPE of seven to eight come up. If we're focusing on balance capacity, are we using something like the balance stability scale to ensure that the variable terrain that you have mimicked, right, by perhaps having them walk on foam is enough? Or do we need to progress that by maybe underneath the foam, putting in some ankle weights or some other objects or having stepping stones to increase that balance challenge. So it actually elicits a step reaction, which maybe we saw in our mini best that we want to improve. If our patient more has a strength deficit, right? So that push press to get that suitcase in the overhead bin or the deadlift, maybe to get that mulch up from the ground or like a clean up from the ground to the shoulder and up overhead. Are we looking at our patient's estimated one rep max and making sure that we're working them at least 60% of that so that we can elicit positive strength adaptations? We have to make sure that we are dosing appropriately and that we have ways to progress this. Putting a patient on a clock is the easiest, easiest way to do it. Getting that RPE, really making what you're measuring be specific to what their goal is. And then the last part here is we can really utilize part practice of this big obstacle course to even more specifically dial in where our patient is having trouble, right? And it allows us to be very efficient because to create a big obstacle course can take a lot of space and a lot of time. So what we can do is as we're assessing and looking at this patient going through an obstacle course, we can see the pieces and parts that they have the most difficulty with. We can be asking them again from our questions and our subjective measures, like where are they having the most difficulty or where do they feel the most confident? And then we can pick out those pieces that we see and that they tell us and create like an EMOM or an AMRA. right? Making it very, very, very dialed in. So this is where I would take like three to four functional movements that comprise the goal, that comprise that entire obstacle course. So if we look at our gardening example, minute one, we, for an EMOM, we could do a sled push, or that could be a walker or resistance band, right? And we could be trying to mimic pulling that hose. Minute two, we could have our patient do some quadruped rows. So thinking about being down on the ground and doing some weed pulling or picking up different gardening tools. Minute three, we could be doing some external perturbations while they are in half kneeling. That could be mimicking pulling that weed and having to really catch themselves as they move backwards. Minute four, we could do something like a clean and press that could mimic trying to get that heavy bag of mulch from the ground up to the shoulder or up overhead. So that's how you can take your entire big obstacle course, pick out the important parts and create a workout that is much more succinct and easier to set up and doesn't require a whole bunch of space. Okay. That is what I got for you all today to come back around and wrap that up. When it comes to our dynamic gait training and creating obstacle courses, think about how you have to dig really, really deep. Leverage your subjective and objective outcome measures to focus on making your obstacle course specific, objective, dynamic, progressive, and then utilize EMOMs and AMRAPs to dial in the components that they are specifically having difficulty with. Now, talking about all this obstacle course stuff, I know it's getting some of you excited to think about dynamic gait training and all the different things you can do. You've got to come see us on the road to one of our live courses and check out our new revamp where, like I said, we spend an entire lab just on dynamic gait training and showing you all how to add in a lot of these layers. So on the road, there are tons of opportunities in October. My gosh, yes, it's October already. We will be in Virginia, California, and New Jersey. And then in November, we are in Maryland, South Carolina, New York, and Illinois. Plenty of options across the country to catch us out on the road and check out that super cool fun lab. On the flip side, our online courses, both Essential Foundations and Advanced Concepts are starting, gosh, next week. So October 11th and October 12th. Head to ptinice.com, message any of us. We'll be happy to answer any questions for you. We hope to see you on the road or online next week. Have a good day, guys.

OUTRO 

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

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey explains that patients with frozen shoulder often struggle to manage their condition and experience fear of the unknown, which can significantly impact their cognitive and emotional well-being. Lindsey emphasizes the importance of understanding the patient perspective and their emotional stories. She highlights that patients may fear the future and the unfamiliar territory of living with a frozen shoulder, which can have a profound effect on their psychological well-being. Lindsey also emphasizes the need for healthcare professionals to appreciate the expectations and experiences of patients with frozen shoulder, acknowledging that their pain is not an exaggeration. She suggests providing controllable solutions and empowering patients to advocate for themselves in order to receive timely care and diagnosis. Lindsey underscores the challenges faced by patients with frozen shoulder in managing their condition and the significance of addressing their emotional and cognitive well-being.

Lindsey reinforces the importance of healthcare professionals assisting patients with frozen shoulder in finding ways to continue engaging in activities they love. This involves helping them adapt their activities or modify their movements so that they can still experience joy and maintain a sense of autonomy and independence.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 LINDSEY HUGHEY

Good morning PT on Ice Daily Show. How's it going? I am Dr. Lindsay Hughey. I will be your host today on Clinical Tuesday. It's so good to be with you all. It's been a little while. Today I am going to chat with you about frozen shoulder and helping your patients navigate no man's land. But before I unpack this episode, I'd love to tell you a little bit about courses that Mark, Cody, and I have coming up. Cody actually was just promoted to lead faculty. We are so excited. And he will be teaching his first class this weekend solo in Minnesota so Rochester and there are still tickets left if you want to join him he would love that and you're sure to have a blast with him this weekend so October 7th and 8th can you believe we're already in October so wild other courses coming up in November on November 11th 12th we'll be in Woodstock Georgia and then our final courses of the year are in December. So you have two opportunities on December 2nd, 3rd. Cody will be in California, Newark, California. And then December 9th, 10th, I will be at CrossFit Endure again. That's always a blast of a spot. So Fort Collins, Windsor, Colorado area would love you to join. Those are our last of 2023. And then we'll be in 2024, which is super wild. So please join us. Thanks for letting me share courses coming up.

03:37 LIVING WITH FROZEN SHOULDER

So last week, if you tuned in to clinical Tuesday, Mark hopped on here and he chatted about frozen shoulder, just the challenges associated with treating folks with frozen shoulder. And he really highlighted not only best treatment as we know it, but the importance of coming alongside the patient. And we need to do that better because this is an area, and if you think about any patient you've ever seen with frozen shoulder, it's always challenging, right? Because they are suffering and there are just so many unknowns. But we do have more knowns in regards to the patient perspective that just came out this past May. William King and Claire Hebron out of the Physiotherapy Theory and Practice Journal published a qualitative review of frozen shoulder. So specifically giving us the vantage point from the patient. So this study involves six folks, two were females, four were males. Their age range between 35 and 66. So a varied mix of sexes and then age ranges. They all were British and there was a mix of right and left and even bilateral frozen shoulders. So these interviews were done with these six folks and the question that was asked of them was can you describe in as much detail as possible what was important and meaningful to you in your experience of living with frozen shoulder? They used hermeneutic feminology methodology for those research nerds that want to know and they found the following five themes And so today I'm going to tell you what those themes are, and then I want to unpack some of the participant details from each theme. And I'm sure you'll be able to relate with some of your patient care experiences. And then kind of end the show with suggesting a rewrite of the title, plus some key takeaways for us going forward in caring for these folks with frozen shoulder. So the five themes illuminated from this article, and again, that's title, and I'll drop the link, is Frozen Shoulder, Living with Uncertainty and Being in No Man's Land. The five themes that were found were, number one, patients felt an incredible pain experience that they described as dropping me to my knees. Two, a struggle for normality in life. Three, an emotional change of self four the challenges of traversing the health care journey and then five coping and adapting and learning how to do that. So I want to unpack each one of these just a couple examples to help you appreciate that patient perspective. So dropping me to my knees that incredible pain experience All of the patients that were interviewed described multiple experiences where if they move their shoulder quickly or hit up against an object unexpectedly or involuntarily kind of reached and forgot about their shoulder for a second, that this pain would literally drop them to their knees. That when they would go to like stretch in the morning, they would scream and writhe out of pain. And this not only affected their body and their discomfort but like their family. Some of the participants described kind of scaring their partner because of like sudden outbursts or yelled. So an experience that's not just personal but affecting those around them.

07:28 EMOTIONAL CHANGE OF SELF

Number two, the struggle for normality. So a lot of the folks describe multiple daily activities just being very limited and I'm sure your patients have had the same right just getting dressed, just rolling over in bed, unable to sleep, just that constant ache that's with them always kind of being in their mind and then challenging just normal daily activities. Not just ADLs and IADLs, but starting to lose work function, missing work and or recreational function. So one participant actually had to sell their fishing boat or chose to because they said just transporting the boat became so cumbersome and a reminder of their shoulder limitation. One of the participants described being unable to throw the ball. They're at a family gathering and their kid is watching other people throw the ball with their parent and the parent that has frozen shoulders just sitting there thinking, oh I can't even like throw the ball with my kid so this normalcy doesn't only impact them personally again in their daily life but it's impacting their family relations around them their work right their ability to actually provide for their family and then the recreation like enjoyment in life people that love to fish that was my dad's like favorite pastime if there's an emotional psychological peace here that is huge then that is challenged when someone has frozen shoulder that they can't do that one activity that brings them peace or joy and they can't um help provide for their family because they're suffering Which leads us to that third theme found, an emotional change of self. So all of the participants described overall just low mood from being in constant pain, having low self-esteem and starting to feel less worth in their family unit. Just kind of feelings of uselessness because not being able to reach overhead or being limited in the ability to just help out with daily chores. this was a really challenging thing to read, but one of the patients described that emotional change as if you were an animal, you would be put down because you're miserable. So basically like lack of thriving and like that was heartbreaking to read, but like this is how low emotions get when you're in, when patients have that frozen shoulder state. And a lot of them said not just the emotional drain is challenging, but like you're physically drained because of that emotional taxation. So multiple participants reported poor sleep, which I already mentioned earlier from a normalcy perspective, but they linked that to how this led to fluctuating mood because you never know when you're gonna get a good night's sleep. And so overall mood was very cantankerous and unpredictable. which patients even again mention that they're not able to even sleep in the same bed as their partner because they're so disturbed and uncomfortable in their sleep. And so they're sleeping in a separate room, again, that's that intertwining like emotional change of self being affected. and when this happens right you start seeing sleep being affected it makes you want to prompt for health care help right and so this leads to that fourth theme where patients are traversing the challenge of the health care journey going to a health care professional hoping they can help them sleep better helping they can take away the pain.

09:28 IMPACT OF DELAYED DIAGNOSIS ON TREATMENT

But what most of the participants really highlighted is that this delayed diagnosis happened consistently where they saw multiple healthcare professionals prior to actually getting a solid diagnosis that this is in fact frozen shoulder. And so there was this, there's this period of not knowing and switching back and forth, like what's wrong with my shoulder? And then you finally know. And, um, even the treatments they were getting were challenging because patients said they didn't actually see solid results. So they would ask for a pain medication and then some of the healthcare professionals would be afraid of addiction. So they wouldn't give them stronger medications to help. And so there was this balance of figuring out what's that pain medication that's right for the patient. A lot of the patients, said that injections were life-changing. So getting a corticosteroid injection was helpful, but it didn't always happen right away. And some of them had to really advocate for that to occur. And that some, even the patients that were finally recommended to get the injection mentioned they were afraid of the needle. So we have to understand it might be a delay to get to the treatment that's effective, And then they might even have a fear of actually using that treatment that's recommended from the healthcare provider. So they're dealing with a lot of challenges in the healthcare journal. And disappointingly enough, as for most of our audience that are PTs, a lot of the folks said that PT wasn't the greatest. They didn't have initial great experiences because the PT would give them stretches that were super painful and not working. And the patient would have to wait a whole week to tell the therapist that, and then the therapist would give them something new, and then the stretches would hurt and not really work, and they'd come back again. We can do better here, right? If you test, retest in that session, you'll know whether that's working. So some kind of disappointing healthcare journeys for most of these folks. But there was some hope along the journey. So the fifth theme found was coping and adapting. Once patients did finally get to the healthcare provider or the PT that started providing effective care, they did have hope. Once they saw it start working or when they got that injection and the pain started going away, they could move their shoulder a little bit more. So when pain's down and range is better, they were super jazzed about it and finally had some hope. Various participants did say that it requires that coping and adapting, it requires you to shift your mindset, that press on attitude in the face of adversity. So helping our patients get there quicker, I think is something that we have an opportunity for. Another part of that, some coping strategies was people just learning, some of the participants mentioning that learning to work around the disability, right? If they were right-handed, starting to use their left arm, to keep functioning in kind of a pushing through mentality. The final binding theme of all of these, so we've unpacked examples of dropping me to my knees, an incredible pain experience, the struggle for normality, three, an emotional change of self, four, the challenges of the healthcare journey, and then five, coping and adapting. That theme that they found binding them all together was uncertainty. Or as the authors of the study titled No Man's Land. One thing I said that I was going to unpack was a suggestion for a rewrite. So we are dealing with humans, not just men. So I'd love to suggest that we call this No Human's Land. But this does come from a phrase, right, that was used to describe unowned land or unoccupied land or land that's not officially owned or inhabited by someone. but we are dealing with multiple humans, right? Not just males. So that rewrite I think is important here.

13:58 FROZEN SHOULDER & THE FEAR OF THE UNKNOWN

But ultimately the main thing I want you to appreciate is with the unknown of how this disease may progress or regress, we have to do better for our patients here. They will not be able to manage their present living with frozen shoulder if they're fearful of the future. They don't read it. Oh, hopefully you're all still there. Give me a wave or like a thumbs up. If you are a little alarm went off. Sorry about that. Um, but patients will not be able, um, to manage living with their frozen shoulder. If they don't know how to manage it in the present, if they're fearful of the future, sorry for the folks that had to hear this twice on YouTube, but That fear of the unknown, right, or no humans land territory, this affects cognitive and emotional well-being. So what can we do with these themes, knowing patient perspective a little bit more deeply here? And I know it was only from six folks, but I'm sure you can relate and think back and reflect on patients you've seen, and they've had similar tough experiences. There are powerful takeaways here. appreciate that expectations from your patient they're always tied to a real human with an emotional story and we have to know that and appreciate that. We have to know that this pain is not an exaggeration. We need to give stabilization to that human story. with some of the facts of the do's and don'ts about frozen shoulders. See Mark's podcast last clinical Tuesday because he dove into best treatment and about what we know, what we thought we knew, and where we are presently. We have to provide controllable solutions. Some solutions. Help your patients advocate for themselves early. and with tenacity with their specialist, right? Help them get to that corticosteroid injection. You don't usually hear us saying that, right? That medicalization, we try to avoid that here at ICE, but here's a condition where we see, especially in the United Kingdom, this being a helpful pathway in combination with physical therapy. So help them get to the proper care and diagnosis faster. Make it so they don't have to see three healthcare professionals before they start feeling better. USPTs test retest the value of your treatment in session. Don't send someone home in writhing pain that worsens their range. Send them home with something that is helpful, right? That's easing and know that before they leave so they don't have a whole week of time of ineffective self-care. Let's not forget the human behind the painful and stiff shoulder. Those with frozen shoulder, let's help them feel direction at a really destabilizing time in their life. Help them figure out a way to do what they love, to keep working, help them be autonomous, to navigate their pain, their setbacks, and then their interactions with the healthcare team. We have a really cool opportunity to make living with frozen shoulder a little bit more endurable and making the patient feel more known. Thank you for being with me this clinical Tuesday and sorry about that little blip in the middle. Happy Tuesday. Cheers.

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich challenges the notion of associating the word "safe" with breath and movement, particularly during pregnancy. She questions why breath suddenly becomes a determining factor for safety in this context. While she acknowledges that the pelvic floor experiences increased demand as the fetus grows, she also affirms that it is a muscle that can strengthen with appropriate exercise.

Jess encourages weightlifting as a means to strengthen the pelvic floor during pregnancy. She explains that stronger muscle fibers are more resilient, sharing this information with her clients in the clinic. She also highlights the fact that individuals are not instructed on how to manipulate their breath when coughing or sneezing, which exerts similar force on the pelvic floor as lifting 35 pounds. Since this natural phenomenon is beyond our control, it is unreasonable to expect individuals to exhale on exertion for every activity.

Jess also address the misconception that breath holding is detrimental to the pelvic floor. She explains that breath holding actually increases spinal stiffness, enabling individuals to lift more weight and become stronger. However, She clarifies that breath holding with a bear down to the pelvic floor is not recommended. She differentiates between different positions of the pelvic floor, referring to the basement (during bathroom use or childbirth) and the first floor or attic for other tasks.

Overall, the episode aims to alleviate fear and promote understanding of the pelvic floor. Jess emphasizes the importance of educating individuals about their pelvic floor and its functions, highlighting its potential for strength and dispelling myths and misconceptions surrounding breath and pelvic floor function.

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 JESSICA GINGERICH

Good morning and welcome to PT on Ice daily show. My name is Dr. Jessica Gingerich. And I am on faculty here with the pelvic division here at ICE, which means it's the beginning of the week. So happy Monday. We are going to talk about breathing in the pelvic floor. This is a hot topic in the pelvic space. often referred to specific breathing strategies that are like safe or protective to the pelvic floor. And in reality, it's just not that simple. So let's start with a few housekeeping items. We are currently in our last cohort of the year for the online course. So if this is something that you've been wanting to get on, we're about to put the pedal down starting January 9th. So head over to the website to sign up for that online course. In the month of October, we will be in Brookfield, Wisconsin on the 14th and 15th in Corvallis, Oregon, October 21st and 22nd. So again, those courses are all on the website, so head over there and snag your spot. They are filling up fast.

01:50 BREATHING DURING EXERCISE

Okay, let's talk about breathing during exercise and how it stresses the pelvic floor. How many of you, as moms, clinicians, or just someone with a pelvic floor, hint, all of you, have been told to exhale on a lift or exhale on exertion? My bet is behind your phone, you are silently raising your hand because you've heard that. Whether it's for yourself or for your clients, wherever you are in the exercise space, you've probably heard that. When we think about this, so there's a lot of information from fitness professionals or medical professionals in the exercise space saying a lot of different things and boy is it confusing. This is especially true in the pregnant and the postpartum population. These clients typically come in having some kind of, have done some kind of research around breathing and lifting, and they're worried about their pelvic floor. So how do we help them understand how to manipulate their breath with exercise? So firstly, let's take the word safe out of it. If I am a non-pregnant female versus I get pregnant, Why is my breath all of a sudden making something safe or unsafe with a particular movement? There is more demand placed on the pelvic floor, especially as the fetus grows. Sure, yeah, that happens. Is the pelvic floor a muscle? Yes, it is. Do muscles get stronger as we place appropriate demand on them? Also, yes. We need to encourage weightlifting to some capacity during pregnancy so the muscle gets stronger. Stronger muscle fibers are harder to break. I love telling clients this in the clinic. We don't ask someone to manipulate their breath when they cough or they sneeze. which by the way is the equivalent of lifting 35 pounds or putting 35 pounds of force through the pelvic floor because it is a natural phenomenon that we cannot control. We don't tell them how to manipulate their breath there. So having someone exhale on exertion for everything is unreasonable. There are times where that can be helpful, especially early postpartum or if there are symptoms. But have you tried to exhale an exertion with double unders or box jumps or lifting 80% of a one rep max? You can't control your breath, like during movements where your heart rate's up. It's virtually impossible because your heart rate's up, your respiration rate's up. And as for the 80%, your body is just going to do what it's going to do, which is probably gonna include a brief breath hold or maybe even one that's longer so you can get through that movement well. Secondly, breath manipulation should be initiated one of two ways. Are they symptomatic? No. Continue what you're doing. Are they symptomatic? Yes. Let's change a bracing strategy or breath manipulation to see if we can continue that volume and that weight without symptoms. From there, we continue to scale as needed. And lastly, Breath holding during exercise. And what I mean by this is someone is lifting a heavy barbell or let's say both of their wiggly children at once from the ground. And Oh, by the way, one is screaming their head off. They're going to brace their core, hold their breath and lift the weight or their babies. Have they just ruined their pelvic floor or has their body just done what it's going to do naturally? My answer is the latter. We cannot always manipulate the breath, especially in life, especially life as a mom. We need to stop scaring moms and over-medicalizing breathing when in reality, our bodies are going to just do what it needs to do to get through a task. We believe in this so heavily that we teach bracing mechanics in detail, in depth, in our live course. So I mentioned those live courses at the beginning. Get on that. Like you, whether you're treating this population or not, you're going to see it. So to recap, there are no safe and unsafe exercises. It's simply, are we ready for that particular demand, whether that's weight or volume. We modify due to symptoms. We aren't ruining the pelvic floor by holding our breath. Breath holding increases spinal stiffness, which allows us to lift more weight, which also allows us to get stronger. And that's huge. Now, I do wanna be clear. Breath holding with a bear down to the pelvic floor is not what we want to do. When our pelvic floor goes down, and what we like to refer to that as in the basement, that's when we're going to the bathroom, right? That's when we are actually having a baby. any other time our pelvic floor is likely going to be on that first floor or in the attic and somewhere in between depending on the task at hand. So let's start taking the fear out of this. Let's start encouraging moms, really anybody, to do what their body's meant to do, and let's help teach them. It's something that we can do, we can teach them. Your pelvic floor, we can't see it, right? We can see how our shoulders move and how our neck moves and head moves. We can see that. We can't see how our pelvic floor moves unless we're laying down with a mirror between our legs doing an active Kegel, and that's not realistic. Also, knees go over toes when squatting. I hope everyone has a great Monday.

08:13 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. 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.

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

00:18 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.