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The #PTonICE Daily Show

The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com
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Mar 18, 2024

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

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

Mar 15, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

Mar 14, 2024

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

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

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

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

EPISODE TRANSCRIPTION

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

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

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

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

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

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

Mar 13, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult Division Leader Christina Prevett discusses 4 important reasons for older adults to lift heavy: improving strength outcomes quickly, reducing fear, improving confidence, and translating heavy lifting to real-life function.

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

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

EPISODE TRANSCRIPTION

CHRISTINA PREVETT
Hello everyone and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our division leads in the modern management of the older adult division. Today I am going to talk about a question that I got from one of the physiotherapy students that I was working with last week. So last week I had the pleasure of going down to McMaster University to teach movement analysis. So basically to create the foundation of some of our big movements, including the squat, deadlift, press and pull. Talking to our students about all this normal movement variation and what that means for our foundational knowledge before before we kind of start building in these additional layers around aging and different diseases and all these types of things. And we started talking about exercise principles and we talked about you know that strength versus hypertrophy versus endurance And I made the argument, as you know, that we have within our older adult division, how we need to be less afraid to make our older adults lift heavy. And I love that this student was really like thinking through, and he said to me, well, does it really matter? Because we see that our people, if we use lightweights and high repetitions, they're going to get some hypertrophy as well, right? So then why do I need to do this if I can just get them doing three sets of 10 at the right intensity and they get better? And so I loved this question. You could tell that he was really thinking about the literature and trying to bring it into where he wants to go with his clinical practice. And I always love the challenge. I love having a meaningful conversation around our thought processes when it comes to certain principles that we are teaching. And this is no exception. So I thought that I would do a podcast episode on this around what we know in the literature, where we are going from a PT perspective and an OT perspective, rehab perspective in general, around this type of thought process. and then kind of take our four takeaways about why we do this within MMOA. So let's talk about the research first. So this student was not wrong in that if you take an individual who is not doing anything and you get them doing something, even low repetition work, at a moderate intensity, they will see initial improvements, right? They will. Stu Phillips group out of McMaster actually did a Bayesian network meta-analysis that was looking at the comparisons between high load and low load and high volume and low volume. And he showed that all groups did get a little bit better. especially with hypertrophy, which is building muscular bulk, that high load, low volume training is not necessary or sometimes maybe even ideal because of the amount of load that's required for muscles to get bigger if that is your goal. However, what we did see is that individuals got stronger faster when exposed to higher loads versus lower loads.

NO TIME FOR A SLOW BURN
And so this is our first principle that we really hold true to within MMA. We do not have time for the slow burn. When our older adults are one slip, trip, or stumble away from losing their independence, when it comes to their aging experience and where they want to be in the next five years, yes, they will get stronger a little bit with low load training, but they will get stronger faster by making them lift heavy. And so I have what I feel like an unbelievable amount of urgency when it comes to working with a lot of my older adults who are at this cusp of losing their independence. And I don't have a ton of visits with them. I want to get the biggest bang for my buck. But he was absolutely right in that what we used to consider really tangible buckets around like, you know, less than six is this and six to twelve is that and twelve to twenty is this. It's more blurry than that. And as rehab professionals, that's OK. We embrace the land of the gray. But where I'm going to prioritize the heavy lifting piece is because I know that they're going to get better faster. So that's number one.

LIFTING HEAVY REDUCES FEAR OF LIFTING
The second reason why we get individuals lifting heavy in rehab is because it reduces fear. So many of our older adults are afraid. They have been told by our medical system that they shouldn't lift more than 20 pounds, that they shouldn't do this, that they shouldn't do that. They're being told by their family members, oh mom, like let me get that for you. Like basically you are too old to lift this on your own, let me do it. And I'm not saying that this is coming across as something that is disrespectful. It's meant to be helpful, but over time and with reps, it creates a ton of fear. And so many of our older adults are afraid over a certain threshold and require graded exposure in order for individuals to feel okay and feel confident about going and approaching a load that was making them uncomfortable before. And what we know is that when individuals lack or have a high amount of fear or lack self-efficacy in a movement, they avoid that movement. And so if they are afraid to lift over a certain threshold, then that might mean that they have relinquished their independence with certain tasks around the home. And again, that can be a threat to their capacity to stay up to date with their activities of daily living, right? So number one is we get people to lift heavy because it gets them stronger faster. The number two is that it reduces fear.

LIFTING HEAVY IMPROVES CONFIDENCE
And two is very closely linked with number three, which is it increases confidence, right? I say to my older adults all the time, if you are lifting this 50 pound weight with me, you are never going to be afraid to lift something in your day-to-day life. And I hold true to that. I will say, you know, if you are able to lift a hundred pounds, then you know that that kitty litter that is 30 is something that you're going to be able to handle. And so exposing to supra physiological loads compared to what their activities of daily living are gives confidence. It reduces fear and subsequently increases confidence and self-efficacy. And that is a really important narrative for so many of our older adults where their interactions with our healthcare system make them afraid, make them feel fragile, and therefore make them lack confidence with their capacity to do activities of daily living. Now, I'm not saying that we are going to ignore risk, right? We're going to have individuals who have balance impairments or things like that that do make them have a risk for falls, slips, and trips. But a person with more physiological reserve with respect to musculoskeletal reserve kind of in the bank. is going to always do better with a fall than somebody who isn't, right? Because that sedentary behavior, that lack of musculoskeletal resiliency from the muscle, the tendon, and the bone is more likely to give you an injury as a consequence of a fall. So we want to take into account all of their other variables within their medical history, but we want to increase confidence when it comes to a lot of our tasks. So that's one, two, and three, right? So people get better faster if you get them to lift heavy weights versus low weights for high repetitions. It reduces fear. It increases confidence.

PEOPLE LIFT HEAVIER IN REAL LIFE THAN THEY THINK THEY DO
And my last one is that people lift heavier than we give them credit for in their day-to-day life, right? When we're handing them five-pound dumbbells or we're handing them pink three-pound dumbbells, they are lifting their 25-pound dog. They are bringing their 40 pound grandchild onto their lap. So they are doing a seated hip hinge with 40 pounds. They are making sure and doing a very forceful pull if their dog is pulling on their leash because they see a squirrel and their dog is 40 pounds. Like they are doing so much more in their activities of daily living. And if we are truly trying to do a rehab program that is work hardening and This is true not just for our outpatient community dwelling older adults, this is our home health older adults. This is our, you know, even the plate full of food that individuals are taking from their walker from their kitchen into their living room, that plate weighs two or three pounds. has a load to it. And so individuals lift so much more than they even think that they do. And I'm not like, when I think about my so many of my clients, like they forget how much load things are, or they like push a couch that's 50 pounds, and they don't think that they do a 50 pound, if I get them to a 50 pound sled push, they think that that's too much. I was like, you just told me you moved your couch. Like that is exactly what you did, right? So they lift so much more. And when they have more resiliency, the percentage of strain on their body with those tasks changes, right? So going back to that, can you lift a hundred pounds versus the 30 pounds of kitty litter, right? If they are working at 30%, that is a repeatable effort. If I got them to do a set of 10 at 30 pounds, yes, that would be a lower strain. But then if I gave them 35 or 40 pounds and they're afraid to lift it and they think that they can't lift that anymore, then they're topping out at 80% of what they believe their max capacity is to move that kitty litter. And that is a much harder reproducible task, even with some of the exposure and higher repetitions. than if they believed that they could lift 100 pounds and this was only a 30% effort. And it makes me really kind of think to even the state of our research and how much are we missing because of this inertia that we've created that this is the repetition range that we have always done so this is the repetition range that we are going to replicate and that is where we get into a lot of 3x10 repetitions right like we have always gone in that moderate intensity range and now we have this inertia in research as well where We have so much evidence that is accumulated in this area that our studies that are on the fringes in the 20 plus repetitions looking at muscular fatigue rates in our our rep ranges that are in the five minus or five or less ranges are so small that the bulk of our evidence is in the middle. And so then we think that this is where all of our exercise programs need to be. And I'm not against three by 10. I absolutely am not. But it is recognizing that there is a lot that can be done by exposing individuals to higher loads and then allowing their confidence to thrive. So where we go with this is not to say that our older adults don't gain anything from the three by ten repetitions. That's actually not true at all. And oftentimes what we will do is we will have individuals lifting heavier with us in a supervised setting where we can monitor irritability, especially when irritability is high. And then a lot of our at home repetitions are in that endurance hypertrophy range, because we bring the load down, we bring the intensity up to a moderate range with a less amount of load, load that tends to be more readily available in the home. And then we get this beautiful combination of getting that exposure to high loads, but also getting some of that hypertrophy resiliency in those higher repetition ranges. So where are we kind of going from here? One, we need so much more research that is comparing different types of exercise programs, right? When we are thinking about high load paradigms, so much, the bulk of the decisions that we make in rehab, and this is so true in our older adult divisions, and actually it's everywhere, but a lot of our health intervention research is comparing doing something to doing nothing. And they say that it's not doing nothing because they give a home exercise program, but then they don't tell us how often people actually did set a home exercise program that you gave them at the beginning of your 12 week intervention and then never checked in on them again until the end. And we are always going to see at least initial newbie gains when we compare doing something to doing nothing. It is a lot harder as a researcher to do doing moderate intensity to doing high intensity and making those comparisons, hence why we are using indirect Bayesia network meta-analyses to try and gain insights into some of those comparisons. Because it takes a lot longer for us to see differences between individuals who are doing nothing to doing something in both groups, but the intensity is slightly different, but still hitting thresholds for adaptation potentially. So we have so much work that we need to do in this space, but until then, I have the four reasons that our division uses and why we try and expose our individuals to intensity and know that the main biggest take home that you can see in your older adults, and that is important for driving physiological adaptation to resistance training at any rep range, is effort. Effort is the important part, and so often in MMOA Live, we see that people don't wait for effort to show up in our older adults. They don't wait for the grunts, they don't wait for the redness, they don't wait for the sweating across their brow. And that is always one of my markers of effort. And so when I have my people in the gym, and I would say that probably 70% of my time in rehab is spent in the gym, the rest of the 30% is education and manual therapy, they're sweating. they're working hard, their muscles are feeling tired. I always say I love the shakes. I get the shakes and some of the core work, you know, like those are the things that effortfulness across the lifespan that I am looking for. So how can you get some ideas around exercise prescription and effort?

SUMMARY
Well, I'm so glad that you asked. We start our next cohort of MMA level one this week, actually today. Today is the 13th. We have some big things coming at us. One is that our MMOA level one starts today. So if you were hoping to get in and dive into some of this research on exercise prescription, we have three weeks that focus on where our mindset is with respect to loading the older adult. And we also are seeing big changes around moving to an app. So if you guys have been seeing, jump into the iStudents group. We are going to be migrating over to Circle, so all of our courses are gonna be moving in that direction. So if you are interested in getting, thanks Taylor, we are going to be going in that direction. So if you guys are looking for where some of our slides and things from the courses are gonna live, they are going to be on the Circle app, which we are really excited for, that platform migration. All right, I hope you all are having a great week. We will see you all. If you are at our MMOA Digest, please get on there. Otherwise, we'll see you in a couple weeks.

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

Mar 12, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose makes his debut on the Daily Show to discuss how to come alongside powerlifters, the differences between raw & equipped powerlifting, the sport-specific demands of powerlifting, and how to keep powerlifters competing. 

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

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

EPISODE TRANSCRIPTION

BRIAN MELROSE
Good morning, PT on ICE Daily Show. My name is Brian Melrose. I'm one of the lead faculty in the spying division, teaching both cervical and lumbar courses. I'm stoked to be here on clinical Tuesday to talk about all things barbell isometric with a very particular population. That population that I want to talk about is with the power lifting athlete. And if you haven't had the chance to work with one of these guys before, then again, you don't know that when you lift 600 to 800 pounds of load, you tend to end up with some neck and some back pain. And so that's where this sport has crescendoed well with my clinical practice. And so I treat a lot of recreational, national, and even world-level powerlifters here in northern Colorado. And the story for me really begins about two years ago when Natalie Hanson walked into our clinic. And Natalie's a world-level powerlifter. She's won worlds multiple times and was in a new weight class and looking at returning to the sport. And so as I begin to work with her, as well as other powerlifting athletes, we can begin to understand, number one, why they have so much spine pain, but number two, how we can help them in the clinic to mitigate some of those symptoms, both leading up to competition and on competition day.

COMMON SYMPTOMS OF THE POWERLIFTER
And so the first thing I want to do is just provide a little bit of background as to why these folks end up running into some symptoms during competition. And so a typical powerlifting competition is going to consist of three different lifts. You get three attempts to get your highest lift total for the end cumulative sum. And so the powerlifting competition is always done in fleets or groups, and it begins with the squat. So everyone comes out going from the lowest weight to the highest weight, and they get three attempts to throw down the heaviest squat possible. After that, all of the athletes will transition to benching. Again, same style there. Three lifts to get the highest bench possible. And then they end the day with a deadlift. And to put this in context, right, in smaller events, like in Worlds, so last year I got the opportunity to go to Lithuania with Natalie and check out the World Competition. And there's only six other athletes that are throwing down similar weights. And so the entire competition takes about an hour and a half. So in 90 minutes, you are One rep max loads, again, either just below your one rep max or trying to hit the new PR. And so nine different lifts of, again, compound movements tends to really tax this system. And so both athletes are pretty gassed, usually by the time they get to the deadlift and then again at the end of the day. But when we begin to take a deeper look as a physical therapist at what's happening at the spine, we begin to see why things can kind of, again, become problematic. First, we have the squat, where again, there's a large compressive load through the spine. And then the athletes have to transition to benching. And if you've never watched powerlifting before, then you probably are unfamiliar with their unique benching position, which is extremely arched. And so the feet have to stay on the ground. The hips have to be in contact with the bench. all arch to end range, their end range in the lumbar spine. And what that allows them to do is typically decrease the distance the bar has to travel to their chest to complete the lift. It also helps pin the shoulder blades down. On the flip side, it makes it extremely difficult to maintain that arched position. The lumbar extensors are working incredibly hard to be able to maintain the hip contact down on the bench. And so they're in that lumbar extended position. The extensors are very shortened, but they have to be extremely active. All of the athletes, after benching, then have to switch gears and go out for the deadlift in an opposite position, where the lumbar spine is much more flexed, and those extensors have to then elongate. And so you can see why that can be challenging for a lot of those powerlifting athletes. But for someone like Natalie, it's even more challenging. And so Natalie, it's mostly because she has such a strong bench. So Natalie was just down in Austin, Texas a couple weeks ago and broke another world record. And because her bench is so high, she's typically one of the last people to go within that fleet. So she'll be the last person doing her third bench attempt. And then all the athletes switch gears, and they start doing the deadlifting. And so because of her geometry and history of back bend, she tends to be lower down in the pack when it comes to the deadlift. And so sometimes she has about 10 or 15 minutes to come off of the stage from the bench and then go ahead and switch gears and get ready for one of her first attempts warming up in the back with deadlifting and then coming out on stage and hitting a deadlift. And so for her in particular, that kind of, again, high bench, lower deadlift really decreases the time that her system can kind of switch. And so that's one of the reasons why we like using the barbell isometric.

RAW VS. EQUIPPED POWERLIFTING
But the other thing that I want to describe real quick is the difference between raw powerlifting, which I think a lot of us are imagining at this point, and what's called equipped powerlifting. And so raw powerlifting is a little bit more popular now, typically just done with a weight belt. Equipped powerlifting is what's done a little bit more historically. In equipped powerlifting, in the squat, you're allowed to use knee wraps as well as a squat suit. In the bench, you're allowed to use a benching shirt. And then in the deadlift, you can also rock a deadlift suit. And so these are single ply materials that are a little stretchy, but fairly rigid. And what they do is assist the athletes in some of the most difficult positions of the lift. And superficially, you might think, well, that probably makes things a lot easier for the athlete. And if they stayed at the same weights, that would be true. The thing is, though, is that these athletes tend to load the barbell way more aggressively and lift loads that physiologically they would not be able to do if they didn't have, again, the assistance of the equipment. And so the equipment becomes this other variable within competition or within the equation in the sense that they can They also have to almost fight the equipment to get into position. So with the bench, again, they're lowering down, have to balance the weight, and still have to touch their chest, but they're fighting the stretch of the shirt to get there. In the same way, when they end the day down in the deadlift, not only have they just taken those extensors from end range extension and activation of the bench, and now they're asking to kind of elongate for the deadlift, They have to fight the shirt to even get down and get into position.

COMING ALONGSIDE POWERLIFTERS
And so the answer to helping these athletes, either on competition day or in training, is really twofold. The first thing that we need to fix is, how can we get those tissues to be a little bit more pliable or extensible after benching in preparation for the deadlift? And so to do that, I'd like, again, referring to one of the things that we talk a lot about in our lumbar course, And we're talking about repeated motions, particularly folks that are recovering from a derangement and are reintroducing flexion. When we reintroduce flexion, we tend to start in non-weight bearing. And I do the same thing for my powerlifting athletes mid-competition. I like them to lay flat on the ground, on their back, and pretty much just rock their knees to their chest. postural tone, we already decreased some of the activation in those muscles. And then as the athlete brings their knees up, again, usually about 20 repetitions or about a minute, they flex the lumbar spine from the bottom up. So instead of reaching forward, they're kind of, again, coming at it a different way. And so usually that can help relax some of those muscles. Next, is what we typically like here. So again, looping a band behind the back, getting it down here, and then sticking in the first 50% of the range to begin to get a little bit more motion at the joint, as well as some muscular activation. Last, we end up going to the Jefferson Curl. So now in a weight-bearing position with a lighter load, but segmentally flexing that athlete all the way down to end range, and then coming back. And so what that can do is, again, take those tissues from a very guarded, shortened position, and gradually tease them in the right direction. In a powerlifting competition, especially for someone who's stacked like Natalie, that might be three or four minutes that we have. In the clinic, we can leverage things like manipulation, dry needling to mitigate those symptoms. But in the competition, it's going to be much more movement-based.

BARBELL RACK PULLS TO PRIME THE DEADLIFT
So now that we have the tissues relaxed, the next question becomes is how do we prepare them for the deadlift? And again, these athletes warm up a lot backstage, and they go out and pull something pretty heavy. And this is where the barbell isometric comes in. It's my favorite exercise to give as a primer in this situation, because we can control the environment and give them the work in the position where they feel most vulnerable, where the lift is the most difficult, and not have any movement of the bar. And so for most athletes, that is going to be right when it's coming off the ground. So they're fighting the suit to get down, but they're also trying to pull these extremely heavy loads from the floor. And so typically in the back, during a competition, we would bottom out the J-hooks or the arms and kind of standardize it at the height of where the Olympic plates would rest. And so what the athlete is able to do is get into their conventional or sumo position, get into the bar and then just hold and just maintain some good activation at the rig where they get maximal effort in terms of the extensors, but there's no change in the joints or the muscular position. And so our dosage on competition day is typically going to be something a little bit lower in reps and lower in terms of duration. And so if you've ever watched powerlifting, sometimes those folks are grinding a lift out for anywhere from 5 to 10 seconds. And so I tend to dose the isometric at 3 to 4 reps of around 10 seconds. And so that tends to, again, get some good primers on board during competition day. But you better believe that we've been leveraging these throughout the training leading up to the competition or event. And so the day I like to select for that, for a lot of these power lifting athletes, is on a day when they've done a lot of high volume or heavy benching in that arch position. Their back should be kind of locked up as much as it is. We run through that flexion progression, going from non-weight bearing to across gravity to standing. And then I have them end with some barbell isometrics at the rig. Now we can cook things a little bit longer. And so what we'll typically dose on a training day would be longer holds, anywhere from 10 to 25 seconds for four to five repetitions. And we really, again, want to tax those muscles all the way to work on the endurance and the positional tolerance where they have the most difficulty. And so that's how we really like to leverage the barbell isometric with powerlifting and athletes, both on competition day and in some of the training leading up to the event. It is helpful as this is for both powerlifting athletes. You may be able to transition this to other folks in the clinic. If they have some back spasms or issues at a particular part in the lift, you just match the isometric to where they need it. For a lot of folks, that's in the bottom. But if they were having trouble at mid-range, we would just move the J-hooks up and have them perform the isometric where they're having the most difficulty. And so this has been an incredible way to help these athletes train. Why are these folks having some pain and dysfunction in this area? We guys love the deadlift. The deadlift is king. If there's one exercise below the spine, you know that's what we're going to choose. But what do you do when you get an athlete that rolls into the clinic and they're already deadlifting? Or they're not only already deadlifting, they're doing it multiple times a week, and they're doing it We're going to be answering that question over the next couple of podcasts I'll be throwing down in the coming weeks. And I'm going to give you some seeds of things to kind of marinate on as we get there. But when it comes to loading the spine for folks that are already deadlifting, we need to consider things like planes of motion, as well as speed and fatigue. If we can get our athletes kind of oriented to some of those things, I think we help them create the most robust and resilient spine. So that'll be coming down in the future.

SUMMARY
Thank you for hanging out with us here on clinical Tuesday. I just want to plug a couple of courses we have coming up next. If you guys are looking to hop to any of our cervical courses, I'll be teaching down in Longmont, Colorado here in just two weeks. There's a couple of seats left, so go ahead and hop on that if you'd like a ticket. For lumbar, We're going to be kind of active April 6th and 7th. I will be out in Carson City, Nevada. Zach Morgan will be on his home turf in Hendersonville, Tennessee. And again, you can grab us on the road for both those surfable and lombar courses. Hope you guys have a great Tuesday. Thanks for hanging out and talking about barbell isometrics with the power lifters.

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.

Mar 11, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses a story of usual patient care when experiencing menopause in the American healthcare system.

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

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

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

EPISODE TRANSCRIPTION

RACHEL MOORE
Alright up and running on Instagram and YouTube. What is up guys? My name is Dr. Rachel Moore I am on faculty with the pelvic division here at ice Pollen has been wild in my area of Houston and I have a sinus infection. So I Sorry about the congestion that you're likely going to hear throughout this episode. This morning we are here to talk about menopausal women and how they deserve better and how they have been kind of set aside and really isolated in the type of pelvic care that we are starting to see normalized. I really want to kick this off this morning with a story that inspired me to even pick this topic. So Last weekend I was teaching in California with Alexis for our pelvic live course and on the plane I ended up sitting next to this older couple. It was a husband and a wife and they were having a hard time like connecting to the Wi-Fi. I didn't really know how to get the United app up and running so I leaned over and I helped him kind of figure that out and I had my iPad with all my slides next to it because I was going to prep for my lectures on the plane. So I always like to work on the plane on the way there. And the lady leaned over and she was like, oh, like, thanks so much for your help. And just kind of started making small talk. Asked what I was traveling to California for. And I told her that I was actually going to work. I was going to go teach other physical therapists because I was a physical therapist. And so this kind of kick started a whole conversation where she was telling me she was flying out to California to run a marathon and she had been rehabbing a hamstring injury for like two years and she had gone to in-network PT and then she had gone to out-of-network PT and all along the way like her hamstring would get better and then it would come back and it would get better and it would come back and so we kind of chit-chatted about that a little bit talked about her running volume and things like that and then I kind of alluded or something I said I don't even remember exactly what it was but told her like I'm actually a pelvic floor PT and that's a big part of what I treat And she was like, oh my goodness, I can't believe this. Like I just had a pelvic floor evaluation and her husband leaned over and he was like, oh boy, you have no idea the can of worms you just opened. And we, she really just dove into her story. And so she had had surgery or not surgery. She'd had a bladder pacemaker put in because she was struggling with urgency and frequency of urination. So she had been at this point to a gynecologist, to a urogynecologist, to an orthopedic doctor for her hamstring, and on the MRI that was done for her hamstring, the report also said that she'd had some issues with her bladder, and she asked her ortho doctor about it, and he was like, I don't know, all I know is about the hamstring, I'm not here to treat your bladder. and she was really feeling hopeless about her pelvic floor and about whether or not she could get help for her pelvic floor. She'd gone to a pelvic floor evaluation and she said it was really helpful and she learned a lot but it was an out-of-network provider and she'd already spent a lot of money on out-of-network care for her hamstring and she didn't want to dive into this area at that point. And so in this conversation we really kind of got into the weeds a little bit. So through this conversation, it's like those conversations on the plane, you never know where they're gonna go. We ended up chatting about cycles and menopause, and she was menopausal at this point. And ever since she had been in menopause, that's when her hamstring symptoms started. That's when she started noticing issues with the pain in her hamstring, and we started talking about fueling especially with her running volume and we started talking about how there's estrogen receptors in other parts of your body aside from in your ovaries and all of the ways that being in menopause can potentially set you up for issues with your musculoskeletal system And in this conversation, she was shocked because nobody had ever really talked to her about what menopause consists of, all of the different ways that menopause can cause issues aside from just you don't have a period anymore, you may have hot flashes, and it was really upsetting to her. And we kind of continued talking over the course of the flight, it was a four, three and a half, four hour flight, and it kind of dawned on me in that in this moment in this conversation because she had a son and we were talking about how when she had her son pelvic floor pt was not done nobody talked about it nobody uh it was just normal that you pee on yourself and i know these days we like to feel like that is still a thing but if we think about perspective shifts like 20 30 years ago It was even less common than it is now, right? Like it was not a thing that was really prescribed at all. So many women were getting surgeries right out the gate after having had their kids. And so this group of women that are now going through menopause were really kind of, I don't want to say shafted, but shafted in their prenatal and postpartum pelvic floor care. And I think that that means that we as pelvic floor PTs need to put it out there that we can help them because they have lived their entire lives up until this point, believing that it's normal to pee when they sneeze, believing that it's normal to leak when they exercise, maybe not exercising at all because this has been something that they've dealt with since they delivered their kids 20 or 30 years ago. And now is the time that their symptoms are potentially flaring back up. We see an increase in pelvic symptoms as we transition into this stage of life. And so if we are not addressing these issues and we're not putting it out there that we can address these issues, women aren't getting the care that they deserve. And not only did they not get the care that they deserve initially, when they first got into this pelvic floor space after having had a baby, they're not getting it now. I think as pelvic floor PTs some of us may really lean into the prenatal and postpartum space and it makes sense because a lot of us are maybe in that time stage of life where either we are having kiddos or people that we know are having kiddos or maybe thinking about it in the future. And so it really feels like this easy transition as we're entering into the pelvic space to lean into the prenatal and postpartum space. And it is needed. I'm not saying we shouldn't do that, but I think as pelvic PTs, we really need to get comfortable with explaining menopause and explaining the changes that happen in menopause. And more importantly, talking to women and talking to providers like, gynecologists like urogynecologists getting together with these people and letting them know like we can help mitigate these symptoms. We can help be an adjunct to care on top of things like HRT or hormone replacement therapy which absolutely should be talked about especially now that we're seeing the shift away from like absolutely don't do HRT because it can increase your breast cancer risk We're seeing that language changing. And so it's exciting to see these women start getting the care that they need in the realm of HRT. But as pelvic PTs, we can step up to the plate and help layer on even more in terms of helping them manage their pelvic floor symptoms, the genitourinary syndromes that they're experiencing. We can really talk to them about building up strength and building up muscular support for their bones as everything changes with their bone mineral density. We can maybe teach them how to exercise for the first time if they're people that have been avoiding exercise for the majority of their life because of symptoms that they have been experiencing since they first had their babies. So really, my whole point of this episode this morning is if you are not in this menopausal space, If you're a pelvic PT and you're not comfortable talking to people about menopause, or you really don't feel like you know enough about menopause to really truly serve this population, I truly feel like it's time for us to step up to the plate and get comfortable with it. We have a lot of resources out there. A few resources, I'm just going to list a couple because otherwise it kind of sounds like a rambly list. The North American Menopause Society actually has like a provider list that you can go in and search for menopause-informed urogynecologists and providers. Letstalkmenopause.org is a website that you can take a peek at, you can also direct your patients to, has resources for patients, really kind of breaks things down into patient-friendly language. The Menopause Manifesto by Dr. Jen Gunter. And then in our live course, we actually dive into menopause in week five. And we talk in more depth about how, sorry, our online course, not live course. We talk in depth about how we can help as PTs serve this group of women. I really feel like it is time for us to do this y'all. I think that this group of women and maybe it's my heart going out because I'm thinking about like moms and grandmothers and all of all of these women in our lives that have just been told that this is something they have to deal with. And now they're being told this again. It's time for us to help change this. It's time for us to bring fitness forward PT to this group of women, especially this group of women. They deserve it. I don't want to say more than anybody else because absolutely we all deserve it, but they deserve to get this quality of care.

SUMMARY
If you're interested in jumping into our online course to learn about menopause in that week five, our next cohort opens up April 29th. We have two live courses coming up, April 6th and 7th in Windsor, Colorado, April 13th and 14th in Spring, Texas. That's where you can catch us on the road in April. We've got some more courses coming up in May as well, so if you're looking into summer, hop on the website, sign up for a live course, and catch us on the road. Thanks for tuning in this morning. If you guys have any questions about menopause, reach out to all of us on the ice pelvic faculty and we'd be happy to answer. Thanks. Have a great Monday.

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.

Mar 8, 2024

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses helping patients return to running following ACL reconstruction (ACLR). Jason describes healing & strength benchmarks to use to initiate running, strengthening needed to facilitate return to running, and biomechanical changes that need to be addressed to improve performance.

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

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

EPISODE TRANSCRIPTION

JASON LUNDEN
Hey, good morning, everyone. Welcome to another edition of PT on ice daily show. My name is Jason London. I am the endurance or the endurance athlete division lead. And I am happy to be chatting with you all today. We'll be talking about return to run following ACL reconstruction. Sorry that I'm on a little late. I just wanted to avoid my dogs going crazy when my daughter was getting picked up. So for those of you who are patiently waiting since seven, thanks for your wait. So we're going to be talking about return to run following ACL reconstruction, covering, you know, why do we care? when that happens and why do we need to be thoughtful about that, what do we look for as our athletes are returning to run, and then how do we address it. So one, why do we care? Well, several different reasons. First and foremost, performance. We want to set our athletes up for success with when they're returning to run and being able to demonstrate good mechanics for performance, but also We do want to be thoughtful of that healing ACL graft and as it is going through the ligamentization phase, we want that to have basically been gone through that full phase before return to run just because of the stresses placed on the ACL with plyometrics, even though running itself in healthy adults should have very low stress on the ACL. And then third, probably the most important piece with really being cognizant of what's going on with their gait mechanics is a high rate of early onset osteoarthritis following ACL reconstruction. And with that, there's been studies looking that have shown that It really comes down to one of the risk factors is patients who under load the operative side seems to be one of the driving factors for early onset arthritis. So it's going to be something that you want to look for.

CHANGES IN MECHANICS FOLLOWING ACLR
So what do we look for in these patients who are returning to run following ACL reconstruction? Well, the main things that we see in the literature and then I would say I see in the clinic as well is, um, I'm jumping ahead here a little bit. But what we want to look for is those patients that are underloading the knee, so decreased knee flexion on the operative side in the sagittal plane at mid stance compared to the on operative side. So any difference greater than two degrees of knee flexion at mid stance is something that we need to address. That patient is underloading that knee. And then the second thing, particularly for patients following a hamstring autograft, semi-T, semi-membranosis autograft, is increased tibial external rotation during stance, which has been shown to be in the literature. Now, I jumped ahead there a little bit.

WHEN CAN WE RETURN TO RUNNING?
You know, when are we actually allowing these patients to return to run? Again, we want the graft to have gone through the ligamentization phase. So that is going to be at four months, anywhere between three and four months. But to be on the conservative side, you would want to wait till to the four month mark. And in addition to that, we don't want to just be timeline based because, you know, assuming that the graft has gone through the ligamentization phase is all done on you know, benchtop research. So we do want to have our objective criterion as well for when these patients are ready to return to run. And so we want, first and foremost, you know, full passive range of motion, minimal to no swelling, and normal walking gait. Those three things, in my mind, should almost always have been achieved by the six-week mark, so it gives you plenty of time before you're even thinking about returning to run. In addition to that, objectively we want them to have a certain level of strength. So we want 90% limb symmetry index, so 90% of what they can do on the non-operative side for hip strength, particularly hip abductor, adductor, and extension strength. And we want 80 to 85% LSI of knee strength, so quad and hamstring strength. Ideally testing all of these with, isometrically using a dynamometer. If not, you know, coming up with other ways with one rep maxes, planks, et cetera, to try to get a little bit of a better sense rather than just your hand doing that isometric hold and rating it a, you know, five out of five. In addition to 80-85% LSI with isometric strength testing for the knee, we want there to be some objective testing too. So we want the athletes to be able to perform single leg squat to 60 degrees with really good form without having to put their contralateral leg down and then do a two minute timed single leg squat max reps in two minutes and comparing that to the contralateral side and wanting that to be at 80 to 85% of what they can do on the non-operative limb. So this is, of course, going to take them some time to achieve. And so generally when that is going to happen is between the three and four month mark. So again, 90% hip strength, 80 to 85% knee strength, both isometrically and objectively.

INITIATING RETURN TO RUNNING
And then when they are returning to run, we're going to start with a walk jog program. where they're going to be jogging for a certain number of minutes and then having a walking interval with that. And gradually ramping up, depending on their experience, to where they are running continuously for 30 minutes. Once they've hit that, then you can have them do a threshold test. And basically, after they've had two successful bouts of running at 30 minutes without pain, having them on that third run of that week going to run as long as they can without pain during the run and for 24 hours after and that would set their threshold in terms of where they're going to be starting out at and then you're going to increase their running volume off of that.

LOADING TO FACILITATE RETURN TO RUNNING
I got a little bit ahead of myself earlier on but what we do want to look for is decreased knee flexion or underloading in mid stance on that operative side or excessive external rotation on that operative side as well of the tibia. And so how do we address that is mainly making sure that for the loading that one that they do have adequate quad strength to accept the load so really working on a lot of eccentric quad strengthening using the extension machine, leg press or or weighted wall sits, and then also doing focused loading patterns. So I really like having them do crouched carries with the knees flexed to approximately 60 degrees. I'm really teaching them to load through that knee that way, as well as doing some supported hopping with a monster band, a pull-up assist band, to really get them to load through that knee.

ADDRESSING GAIT MECHANICS
And as we know from a lot of the literature is, you know, strengthening alone is not going to carry over to the gait mechanics, unfortunately. And so we need to give them some cues while they're running to increase loading and knee flexion at mid stance. Probably the best cue to give them is to try to hit the ground hard when they're running. It's a nice external cue that seems to work better. Otherwise, other things you could try is telling them to try to sink into their stance more when they're running too. And, you know, having them do that in block training. So, you know, a lot of verbal feedback for them or auditory feedback based on how they're they're striking and titrating that over time. For the increased tibial external rotation that really again goes back to hamstring strength particularly medial hamstring strength since that's where the graft was taken for those hamstring autografts and in the study by absorted kick in 2017, they found that those athletes who had less than 85% hamstring strength compared to the contralateral side were more likely to have that tibial external rotation. So again, focusing back to that strengthening of the hamstring, but having to get that carry over for gait too. And what I found is I don't have really good external cue for them, but just having them thinking about when they're coming into flight phase is having them pick their foot up and internally rotating their foot to overcompensate initially, and then gradually that works itself out. So return to run for ACL reconstruction, you know, we're probably getting in the time right now where this has been happening for a lot of you for those athletes who tore their ACL in fall sports. Winter sports, we're probably not quite there yet unless they tore it in early season, but really be thoughtful about the timing of that. Again, thinking of wanting the graft to have gone through that ligamentization phase, so generally around four months, and generally they're not going to be ready until that point anyways if we look at our objective criteria, particularly of the 85% isometric strength of quadriceps and hamstring and being able to get 85% of what they can do on the control at all time with that two minute timed squat to 60 degrees. Again, this is important for performance. important for good outcomes following that ACL reconstruction and most importantly important for trying to decrease that rate of early onset arthritis at the knee following ACL reconstruction. So hope you gained a few pearls here. Working with ACL reconstruction patients is very rewarding and a lot of fun and don't just fall into the habit of When it's time to return a run, just sending them off with a walk jog program. Make sure you're looking at their gait mechanics and addressing that and thinking also about what is that athlete's history of running and what are their goals for running too.

SUMMARY
If you're looking to join us for any of the endurance athlete courses, we are just starting up the second cohort of online and unfortunately that is full for any of those that would want to join. So your next option there is May 7th, I believe. The first professional bike fit cert is coming up here in April, April 20th in Asheville. This is a little bit of a special one. as that the other lead faculty, Matt Keister, and myself will both be teaching that, so it should be a lot of fun. And we're really looking forward to hitting the trails around Asheville for some great biking. And then the first rehabilitation of the injured runner live course is going to be in June in Milwaukee. That one is filling fast, so if you're thinking or sitting on the fence on that, Make sure you sign up for that quickly. We do only have two live courses this year for Rehabilitation of the Injured Runner live, but we will be offering more next year as Megan Peach is moving back stateside and we'll be able to teach with that. I hope you all have a wonderful day. Get outside and do something fun with friends and family over the weekend, and we will catch you all later. Bye. Did you see him? I need to go get ready.

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.

Mar 7, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses the concept of a lateral shift when addressing low back pain, as well as three objective & 1 subjective ways to assess the potential presentation of a shift.

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

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

EPISODE TRANSCRIPTION

JORDAN BERRY
All right, what is up PT on Ice daily show? This is Dr. Jordan Berry coming at you live on a technique Thursday or an assessment Thursday for today. So I'm lead faculty for cervical management, lumbar spine management. And today we're talking about the lateral shift and how in the clinic we can pick up on the lateral shift so that we're not going to miss it. So we're going to talk about just a few ways from an objective and a subjective standpoint that we can pick up on the shift so that we don't miss it. And so one thing that I commonly see in the clinic, whether it's a client who is not getting better, or it's a client who's not progressing like we think they should be, or if I'm doing a case review with another clinician or watching that clinician evaluate the lumbar spine, one thing that we commonly see is the lateral shift is not on that person's radar, or they don't know all of the different ways that a lateral shift can present. We're going to unpack that over the next few minutes here.

WHAT IS A LATERAL SHIFT?
When we talk about a lateral shift, what we're really talking about is when someone has an acute episode of low back pain, oftentimes it's back and back related leg symptoms as well. they will oftentimes have what we call a lateral shift. And so that is when, quite literally, the body is shifted in a direction where the hips go one way and the shoulders go the other way. And there's a bunch of different theories on why this can happen, but really the person is going to inherently avoid this side of pain. So almost always the shift is going to be in the opposite direction of the side of symptoms. And so when we talk about a lateral shift, we name it based on the shoulder position, not the hip position. So for example, if I had pain on the left side and I was shifted this way, away from the side of symptoms, then we would name the shift based on where the shoulders are heading. So in this case, it would be a right lateral shift if I am going towards the right with my shoulders and towards the opposite side with my hips. And so again, there's a bunch of different theories on why this can happen, but one thing for sure that we see very consistently in the clinic is if someone presents with a lateral shift and it's not corrected or that treatment does not respect the lateral shift, you will typically not make very much progress. But it's not just a visible shift. There are other ways that we can sometimes pick that up. And so we're going to spend just a few minutes unpacking that. So I've got Jenna here to help me with a couple of demos. So if you're listening on the on the podcast right now, jump over to YouTube or Instagram if you want to see an actual visual of what we're talking about. So I've got four ways that you can pick up a lateral shift in the clinic.

FINDING A LATERAL SHIFT: USE YOUR EYES
So starting with number one, number one is the most obvious. It's actually visible. So when someone has really significant back and or back related leg symptoms, you'll quite often see a visible, a literal shift when you're looking at them square on. And so if I have Jenna stand right here facing the camera. So let's say that Jenna had symptoms in the left part of her low back and then going down the left leg. almost always what you will see is the shift would be towards the opposite side of symptoms. So we would see Jenna's shoulders going towards the right away from the symptoms on the left. And the best spot to look when you're staring square on at the client would be at the forearms. And so we're looking at a difference in space between the forearms. So sometimes you might have to snug up the shirt a little bit or ask the client to relax the arms, but you will see a difference, more space on the side that the person would be shifting towards. It can be very obvious sometimes or it can be really subtle, but I'm always starting just getting a good visual of looking at the person square on. So number one is an actual visible shift. Okay.

FINDING A LATERAL SHIFT: LATERAL FLEXION RANGE OF  MOTION OR SYMPTOM ASYMMETRIES
Number two is an asymmetry in side bend or an asymmetry and lateral flexion. So when we're going through active range of motion, we will typically see that side bending towards the side that they're already shifted towards is gonna be much better than going towards the opposite side. So using this same example here, if Jenna is shifted towards the right, right, her shoulders are going towards the right side, what we will typically see is that she side bends towards that side, right, towards the right side, that it's pretty solid because that's the direction her body's already wanting to go to. And then when you go to the opposite side, it's gonna be, yep, very limited and oftentimes painful. And so anytime I see an asymmetry in lateral flexion or an asymmetry in side bend, I'm for sure gonna test out a lateral shift correction to see if it makes a difference. And when we say asymmetry in side bending, it's not always just an asymmetry in range of motion, can also be an asymmetry in symptoms. So even if the side bending is relatively similar from a range of motion standpoint with how far the person can side bend, if one side is dramatically different from a symptom, from a pain standpoint, that's also sometimes indicative of a lateral shift. Okay, so number two is an asymmetry in side bend.

FINDING A LATERAL SHIFT: HIP RANGE OF MOTON ASYMMETRIES
Number three, an asymmetry in rotation of the hip. Specifically, internal rotation is usually the one where you're going to pick up on it. So if I have Jenna sit right here on the table and she just does internal rotation while she's sitting right here. So we're just assessing how much internal rotation we have. And then if I had Jenna fake a lateral shift, so let's go in the same direction, right? She's shifted towards that right side because she's off when her shoulders go to the right, she's offloading the left side. And so now it's going to present like she has much better internal rotation on the left versus the right. Now, it might not be true internal rotation that is different. It might just be of the position of the hips that it presents as if it's different. So picking up on internal rotation again, either because of symptoms or because of range of motion, can be a third way to differentiate between someone having a lateral shift. You can test it in sitting like what we're doing here. You could also test it in supine, but Very commonly it is the side opposite of the shift that actually might have a bit more internal rotation. Again, because of the position of the torso or the position of the trunk.

FINDING A LATERAL SHIFT: THE SUBJECTIVE HISTORY
And then lastly, the fourth way that we can pick up on a lateral shift is in the subjective. So the first three are going to be more in the objective exam, right? The last one, the subjective, is going to be a preference for sleeping or lying on one side versus the other. So that could be, again, sleeping, that could be laying on the couch, it could be any time the person's non-weight bearing, they prefer to go in one side versus the other. And again, because they're offloading the painful side.

SUMMARY
So if I hear any of those four things, whether it's in the subjective or the objective exam, I'm for sure going to test the lateral shift correction because I can't afford to miss it. So again, as you're going through this week and you're seeing someone that has acute low back pain, back-related leg symptoms, and you're trying to pick up on the lateral shift, what are those four things that might indicate that? Well, number one, the most obvious, it's visible. So you're gonna look at the person square on, and you're gonna look at the forearms to see if there's a difference in space side to side with their arms relaxed. Number two, an asymmetry in side bend. That asymmetry could be range of motion, being asymmetrical or symptoms being asymmetrical side to side. Number three is a difference in hip rotation, more specifically internal rotation. And then lastly, the subjective exam is a preference for sleeping and or lying on one side versus the other. All right, that's all that I got for you today. This is part one of two. So we're going to come back in a few weeks and jump on again and go over different ways that we can actually correct the lateral shift. The one that we know most commonly, right, when you're standing on the side and you're shearing the person or shifting the person in the opposite direction, that is by far the most common. But we've got a lot of other cool variations when the person might not tolerate that position. So as always, if you want to learn more about this, hit us up at one of our live lumbar management courses. And we've got a bunch coming up from the spine division over the next few months. I know we've got two coming up this weekend to next weekend as well. Cervical and lumbar spine management. Have an awesome day in the clinic. 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.

Mar 6, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the theory of selective optimization & customization, including how to help patients select goals, optimizing treatment around goals, and being OK with compensation as needed.

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

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

EPISODE TRANSCRIPTION

JEFF MUSGRAVE
Welcome to the PT on Ice Daily Show. I'm going to be your host today, Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday. That means it is all things geriatrics today. So excited to be sharing with you a topic fresh off a really exciting trip, Preparing for Adventure and the SOC Model. Now, don't get sick to your stomach if you're a home health clinician. We're not talking about start of care, okay? We're talking about a theory for successful aging.

THE STRONGER LIFE RETREAT
So I'm gonna give you a little bit of background on how I got to this topic and why I'm excited to share it with you. just came off a trip out of the country with 20 members that are 55 and older. So we took an adventure retreat. Stronger Life members joined us out of the country to seek adventure and this was a really incredible experience. If I was preparing one of these members from a formal PT standpoint, what would I want to be thinking about? How would I select the goal? How would I optimize? When do we compensate for these patients? So if you're preparing someone for adventure, we need to be thinking about all these things. BALT's successful theory on aging has been a really helpful framework we use very frequently in our division, the older adult division. And what we want to do is, Adventure is relative, right? So we're taking 20 members from Stronger Life to the Dominican Republic where they're going to go snorkeling, where they're going to go horseback riding, where they're going to be walking or running on the beach, they're going to be swimming in the ocean, they're going to be kayaking in the ocean, all these exciting things. But adventure is relative. So maybe the patient in front of you, adventure for them is going to their grandson's baseball game. that may be a big overwhelming task that you need to break down. Or maybe it's just going for a walk outside. Maybe you've got a primarily homebound population and going outside feels like a big adventure. So I am going to use this higher level adventure example because it's fun, interesting, and fresh for me coming off this trip, which was so much fun. But for you, know that all of these things are scalable and this framework is going to be relative regardless. of the functional level of the client in front of you.

SELECTIVE OPTIMIZATION AND COMPENSATION
So just a little bit more on this SOC model. So Selection Optimization and Compensation. So this has been a tenet of Lifespan Psychology and the process of development that entails Losses and gains of our patients over time. We know that in general, our patients who are not seeking fitness, who are going through this period of time where they're in a decline, if we can't interact with some fitness and get them active, we know it's gonna look like this. But for many of our clients that we're taking this fitness forward approach, there's gonna be gains and losses over time. And what we wanna do is we wanna learn how to partner with them in this aging process, knowing that there are some changes, despite our best efforts, things we can't change. We're really comfortable with things we know we can change, but we have a little more trouble when we bump into barriers and things we can't move forward. So this model, SOC, Selection, Optimization, Compensation, looking at the full lifespan and learning how to use these three tools.

SELECTION
So the first tool is selection. So when we're talking about selection and we're thinking about older adults and their goals and successful aging for them, we're talking about goals that matter to them, not these BS goals like get better, get out of the hospital, feel better. Those things are things our patients may report to us, but it's our job to dig deeper and figure out why and why they feel that way and what specifically that means to them. So finding that meaningful goal and what they want to accomplish, we've got to break it down and get as specific as possible. The more effort we can put on the front end with selecting a meaningful goal and really understanding what that means, it makes the rest of our job so much easier. When it's time to select exercises, we're trying to figure out what tests and measures we need to be looking at. It becomes so much more clear. So a good start, I'll give you an example. We had lots of members who were planning to go horseback riding for the first time, or first time since they were in their teens. And if I had that client in the clinic, I'm seeing them in the fitness realm currently, but if I was seeing them in the clinic, the questions I would ask based on this framework of selection are, when is this gonna occur? When's our goal need to be accomplished? I would also want to know what's amounting, you know, excuse me. So when's this going to occur? How long are you going to ride? How big is the horse you're getting on? How frequently do you want to ride while you're gone? What gate is this horse going to going to experience? Is this member going to just be doing a slow walk? Are they going to be trotting where they're going to be oscillating up and down which may stimulate the vestibular system? Are they going to be cantering? How much dynamic balance do they need? How much strength do they need to be able to hold their position on the horse? So based on the frequency, the duration, the size of the horse, how often they want to do this, this is really going to help us break down what our patient needs specifically to reach this goal. And reminder, we're going to go through this same process if someone needs to carry their groceries in. We want to select a meaningful goal for them, then we need to break it down. We need to have all the specifics possible at our fingertips. So we want to know the strength, the range of motion requirements, the endurance requirements, the balance requirements, the vestibular requirements, which in this case are very relevant. When you think about the movement of someone on a horse, they're going to be going up and down. That's going to be stimulating the inner ear system, the utricle and the saccule as they accelerate, decelerate. There's going to be head turning. They're on a beautiful beach riding a horse. They're going to be turning their head, looking at stuff or trying to talk to their friends or get some selfies going. during that time. So we want to be as specific as possible to figure out what in the world they are going to need to be able to accomplish this goal. So selection is the first piece. We want to select a meaningful goal to them and we want to get as much information as possible.

OPTIMIZATION
Once we have all the specifics nailed down, We're going to go on to the next step. And this is where most of us shine is optimization. So the first piece is selection. The second is optimization. Based on where this patient is starting, And the goal, we now have a start and a finish line. We've got to get accurate measurements at the beginning. Our CEO, Jeff Moore, is very famous for saying you can't make good decisions with bad data. We want to be specific of the conditions we're testing. We want to be accurate so we can actually see if we're making change in the future. Otherwise, we might as well not measure, by and large. So we want to be very specific with those measurements. But now we know This person wants to go horseback riding once. It's going to last about 45 minutes. They want to walk. They don't care if they canter or trot. They're going to be on the beach, so they're going to have to walk across the beach to be able to get there. So we now, we're going to say those are the specifics that the patient gave us. So now we're going to be looking at the range of motion of their hips. We're going to say, oh, these are going to be small island horses. There's not as much hip abduction required. We know that we don't have to get them stable in a seated position for a canter or a gallop. We just got to be steady in this seated position for 30, 45 minutes one time. And then we're going to, you know, hopefully the mounting situation we've asked about as well. Are they going to be able to go up steps unsupported to get on this horse? Or are they going to need, in the equestrian world, a leg up? Is someone going to come over and help boost them into position? So once we've got all that information, we've checked the range of motion, strength, balance, vestibular requirements, then we're going to go to work, right? We're going to challenge all of these different systems to reach this big, meaningful goal. range of motion that they need to really make this happen. We want to make sure that we're, you know, not laying on the table, kicking our legs, sitting, or outside of these positions that aren't relative to the goal. We want to make sure that these are big functional movements. We want to make sure that it mimics this movement and this activity as much as possible. Being in a seated position, can they go up and down, accelerate back and forth? There are lots of creative ways to do this on Swiss falls or if you're on, on a rolling chair going back and forth and adding some head turns. There's lots of ways we can replicate this. Even the mounting situation where we can use a high-low table and get really creative and maybe we're getting them onto a bolster or a Bosu ball, something like that. But during this optimization, we've got to make it as much like the actual goal as possible, as quickly as possible. That's going to help us with buy-in, And we know from motor learning, just in general, the more it replicates the actual activity and the conditions. I mean, heck, we can play some seagulls and some ocean music. We could do these things outside with distractions. There's lots of ways to layer in all the specifics that we gained from the first piece of selecting the goal. But once we know the optimization period, we've got to replicate that as much as possible.

COMPENSATION
Once it's time for the third piece is compensation. This is the part that we get really uncomfortable. Most of us in the rehab world, we want to restore function as much as possible, and that's not a bad thing. We want to do that, but sometimes we don't have enough runway. The patient doesn't come to us in enough time. We can't help them change quickly enough to meet that goal on time. And if we want the goal to be accomplished, we're going to have to compensate. Oftentimes, our OT colleagues are much better at this. They're like, hey, just use the tool. Let's make this thing happen. Most of us that are physical therapists, fitness pros, we want to see people get stronger and we get really uncomfortable when it's time to compensate. but there are simple ways, little on-ramps, like getting a leg up, practicing having someone help them get on the horse, versus saying, you know what, you just can't mount on your own, so I don't think it's a good idea for you to do this, or you don't have quite enough range of motion to be able to throw your leg up behind the horse, for example, so this is really out of the question, versus saying, hey, can we have someone support you? Is someone else going on this trip? Can you bring someone into the office and we can replicate this mounting situation to give them a leg up, swing their leg around the horse, and help them be stable. Heck, even sometimes we can have someone walk alongside them to help keep them steady. If the goal is meaningful enough, we can accomplish it with some compensation. So whether it's an adventure retreat, whether it's a patient that needs to walk outside, get thrown groceries, go to a kid's baseball game for the first time, adventure is relative to the person in front of you. Regardless of that, a great framework, keeping in mind that compensation and changes in capacity happen over time, our BALT's theory of successful aging. So we wanna make sure that we're selecting meaningful goals to the patient, We're optimizing all the systems, getting good baseline data, and then if all else fails, we need to compensate to make those goals happen.

SUMMARY
Team, I hope this was interesting. I hope this was helpful for you. If you're looking to catch us out on the road, We're gonna be in Newton, Kansas. I'll be there on the 16th and 17th, and then Madison, Wisconsin, we'll be there March 23rd and 24th. If you're trying to hop into one of our online courses, lucky for you, level one course is going to open up on March 13th, and then not long after that, we'll have level two. So I hope you enjoyed this. If you have any questions, comments, please drop them for me. I hope you have a wonderful day, and that's it for now, 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 CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you’re there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Mar 5, 2024

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 concept of viewing the human body as a vehicle or mechanical system versus recognizing the underlying physiological systems in place that make the human body adaptable & changeable. Zac encourages listeners to adopt loading a primary intervention as a way to cause physiological change in the body in a manner that could not be done with a vehicle.

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

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

EPISODE TRANSCRIPTION

ZAC MORGAN
Good morning, PT on Ice Daily Show. I'm Zac Morgan. I'm a lead faculty here at the Institute with Cervical and Lumbar Spine Management, bringing to you all this morning some concepts on physiology versus physics. And I would say physiology greater than physics is the title of this episode. Before we dive into the actual episode, I kind of wanted to talk through some of the definitions of these two sciences. Do you think it'd be helpful to frame our conversation this morning? And before we even do that, I want to start out by saying that really using physics to describe why someone develops symptoms or why someone gets hurt, I think it could be maybe one of the most unhelpful things we've ever done as a profession. So let's start out with definitions, and then I want to unpack that big statement that I just gave you. So from the physics perspective, let's start there. Physics is a natural science. Its studies matter. It's foundational constituents. and its motion and behavior through space and time. So that's the definition of physics. When you think about physiology, it has a different definition. Physiology's definition, it's a branch of biology. It deals with the normal functions of living organisms and their parts. It's the science of how the body and its parts work and function. Physiology covers a multitude of systems within the living organism, how cells, organs, and tissues work together and interact. The point here isn't that physics are completely irrelevant when it comes to why someone develops symptoms. There is certainly a part of the puzzle. But the unipolar commitment to physics from whether it's us as therapists actually understanding why someone develops symptoms or when we're actually describing to someone why they develop symptoms, that unipolar commitment to physics, it's devastating in the clinic.

AN OVERCOMMITMENT TO PHYSICS
So let's start with why I think as therapists we tend to overcommit to physics. Physics, while on the particle level, are very challenging to understand, when you think of physics on the big picture level, they're actually not all that challenging to understand. Humans, we tend to believe the things that we can actually lay our eyes on. When we can see something happen, when we can interact with it, we tend to believe those things as humans, and it makes sense because we can actually see them. And when things happen right there in front of us, it's just so much easier to believe them. We can observe the physical universe. We can test these things on ourselves. You think about things like gravity. Gravity is a physics concept. It's really easy to test gravity. You can take basically any object, drop it, and you can observe that object fall towards the center of the earth at a specific time or a specific speed. It doesn't really matter the object. They all move towards the center of the earth at that same speed. we can observe that, we can interact with it. So it's really easy to believe in gravity and it's really rare that you would interact with someone who doesn't believe in gravity. From a physics perspective that's easy to observe. Now let's extrapolate that more towards what we see clinically. I think a lot of times people will use these examples of things like vehicles. That's a very common example for the body. People will compare the body to a vehicle or tires to joints. And you think about like tires, that's a physical object and every mile that you drive on your tires, that tread wears out a little bit more over time. You can watch that happen. You look at the tread on your tires and you can see that it's wearing out with each mile that you drive. Really the only way to avoid your tires wearing out is to not drive as much. So we know that that stuff happens because we can watch it happen, and so we tend to believe in that. So it's so tempting clinically when you look at something like an imaging study that one of our clients comes to us with, and you can look at whether it's an x-ray, CT, MRI, ultrasound, you name it, really any type of imaging, and we can observe those tissue shapes on that image. And when we look at those shapes, we can attribute pathology to the shape of those tissues. It's really easy for us to observe that and say, hey, I bet if that gnarly looking intervertebral frame and that gnarly looking joint were to move through space, it would be painful because it looks really, you know, disrupted. It's not smooth. There's a lot of pressure or a lot of compression in that area. We can observe these things on imaging and then kind of extrapolate that out to the symptom presentation in front of us. And this is what's so devastating in the clinic. While it is a piece of the pie in a lot of our clinical cases, it's certainly not the whole pie. It's only one small slice.

PHYSIOLOGY IS THE TICKET
When you think about what the rest of that pie is, it's physiology. What environment that those tissues are living in. That's really where the ticket is. I think because it is so easy to wrap our heads around this concept of physics, it's so easy for us to observe it. We have tools that make it easy to observe. It's easy to make a lot of attribution of symptoms to those concepts. And so this is really challenging to our patients. Like you think about what that does to a patient's psychology, like it's devastating. for those people. People don't understand much about their bodies and so when we give them these descriptions they often catastrophize the symptoms or they catastrophize the physics. They worry that it's going to be like what they've seen in their tires where every mile they run their knee ends up with a little bit more osteoarthritis but yet we know that recreational runners have less prevalence of knee osteoarthritis than sedentary folks. So it's clearly not the same as our tires. That's not a physical object, it's a physiological object. It's much, much different. So again, physiology deals more with the ecosystem that these tissues live in and that's where we want to put our attention moving forward as a profession if we really want to have a chance at helping people conceptualize their body and and helping people feel stronger within their body and helping people understand the benefits of exercise.

OUR BODY IS AN ECOSYSTEM
So let's talk a little bit about that. When you think of those examples like a tire or a vehicle, the big thing that those things lack that our body has are things like a vascular system. Like your vehicle doesn't have a vascular system. It's simply just built by engineers. And like I said, each mile that you drive is one less mile that you can drive in that vehicle. Sure, you can maintain the vehicle. You can rotate your tires, and that will make them last longer. You can change your oil, and that will make your engine last longer. But at the end of the day, shy of not doing anything in that vehicle, it's going to break down over time. Our body is completely different. It has a vascular system. It has intra and extracellular fluid that are full of nutrients that are built to help your body adapt to the stimulus in front of it. It has an immune system that creates specific responses to stimuli that create a more robust underlying system. That can't be said for a vehicle. So when we compare our body to a vehicle, our clients often don't have that understanding that our body is actually full of a lot of adaptations that we've developed over a long period of time that are inherently built within us that help us continue to move forward. They help us build a more robust vehicle. That would be awesome if when you bought a car and you used it and you maintained it well, if it actually It actually lasted longer for every mile that you drove. That would be great. We would all want that car. But over time, cars break down. Over time, if our body has the right ecosystem underlying it, it builds more resilience. You think about like our MMOA crew, so Modern Management of the Older Adult, and you see some of these stories that they share where older adults start to put on so much capacity, so much strength, so much cardiovascular endurance over time. It doesn't make sense. If our vehicle was an actual vehicle made of physical objects that we could interact with, it should break down over time, but we know the physiology drives function. And so when we put it in the right ecosystem, and when we allow it to adapt over time, we get way more out of it. I mean, think about it. Your tire, it doesn't get nutrients from the fenders. The rims don't provide it nutrients. The air within those tires don't allow it to build more tread over time. Again, I would love it if that was the case, because we wouldn't have to replace these things, But our bodies, they do have those things. The vascular system is built for that. The immune system is built for that. Our bodies are so much different than vehicles and when our clients leave our interactions and they have in their head that they're going to break down over time, they end up opting out of activity and that's exactly what we want to avoid. Like you think about if someone feels the that every mile that they run is one less mile that they can run on their knees, or every deadlift that they do is one less time they could pick their grandkid up, think about what that does to them psychologically. It makes them avoid those activities, and so they wind up missing out on all these physiological adaptations that would extend their quality of life and lifespan. That's a huge mistake as a profession, and we need to move dramatically away from that over time. It's easy to observe problems in people's bodies. We can make attributions of the way someone moves with pain. You can look at those imaging studies and say, well, if that nerve root's that compressed, then this person's probably gonna be in a tough spot. But team, it's not like that in the body. The body is so well built to adapt over time. I'll never forget the first time I heard Jeff Moore say, back pain is not a tissue shape issue, it's a tissue health issue. And it just hit so hard in my head when I heard him say that for the first time, because it is that. I mean, you can look at the Brzezinski study, you can look at the Nakashima study, that's lumbar and neck kind of respectively, and you can see that people with no symptoms whatsoever have all sorts of physical deformities in their spines and yet they have no symptoms whatsoever. Over time, we're seeing the same concept throughout the rest of the body. Like I said, the extremity crew does a great job of pointing out the inadequacies often of imaging studies throughout the rest of the body. And team, seeing that over time, it is becoming more and more clear that these physics examples, while they're easy to understand both for us as clinicians, but also for our clients that we're teaching these concepts to, while they're easy to understand, they're such a small piece of the pie, but they have catastrophic responses within people's psychology. People tend to catastrophize those things. So we have to focus on physiology.

LOADING CHANGES THE UNDERLYING PHYSIOLOGY
And team, I think our treatments, what we choose to do with clients reflect this. When you think about, if you haven't taken the extremity course, you have to because they do such a wonderful job of framing things like tendinopathy. From a physics perspective, sure, you could look at a painful tendon, you could look at a histological study, you could look at an ultrasound sometimes, and you can see that those collagen fibers are disrupted from a physics perspective. But going in and physically stimulating those things isn't what creates adaptation. It's not cross friction massage, it's not those things, it's load. And why does load work? You take a relatively poor vascular supply, but still a vascular supply, and you force angiogenesis to that region, you get that tendon to adapt over time. You change that underlying physics. Vehicles don't do that. So we have to get our heads wrapped around how these things are different so that we can start to push our patients forward and help them work through a little bit of discomfort, which is a big part of tendinopathy management. People need to know that they're going to be okay and that their body is built for these stimuli and it responds in a way that is tremendously different from a lot of the other things that we can observe in the universe. It's so cool that our body is built for that. You think about spine management. We talk a lot about this on the weekend. Often a nerve root is in a really unhelpful environment. There's a lot of concentrated inflammation in the region and the person's reporting a lot of distal symptoms when that's going on. We do things like repeated motions or spinal manipulation or some sort of treatment to intervene on that region and we draw a lot of fluid in there and drop that concentration. Team, that is so amazing that our body can do that and that the person can leave feeling centralized and feeling so much better. But we didn't push the jelly back in the donut. It wasn't a physics issue. It was a chemical soup bathing that region. And when we draw fluid into that region, it feels better. The person feels dramatically better.

ENGINEERING VS. BIOLOGY
Team, We have to change our perspective. We can't keep comparing our body to a vehicle. Vehicles are built by engineers, and they're really well built, and they're built out of physical materials that we can all observe in the universe put together, and they all have specific wear rates. There are things you can do that might slow that wear rate down, but at the end of the day, they do wear out over time. Our bodies are biological. They're physiological vehicles, and within those, they are well built. They've been built over thousands of years. to heal, to move forward. They've been built for the one specific purpose of survival. It's what makes us so different from everything else in the universe and it's why a huge part of what we do is address this underlying physiology. It's about the ecosystem that the tissues live in. We have to move forward as a profession and this is why things like fitness forward care make so much sense. Because it goes so much far beyond that local tissue, like you think of the environment and you think of when you do address this fitness forward method of care, now you're improving metabolic systems, cardiorespiratory systems, you're improving all systems team. And at the end of the day, that is a huge deal for us.

SUMMARY
I just want to point you all in the closing moments here towards a couple of upcoming lumbar and cervical spine courses if you are looking for them. A few here in March for cervical, we've got Kuna, Idaho. That one's filling up pretty quick. And then same deal for so that one's March 9th and 10th over and that's close to Boise, Idaho. March 23rd and 24th Longmont Colorado also filling up so if those are on your list make sure you jump in those pretty soon. Casper Wyoming has a few seats left as well. If you're looking for lumbar spine management Brookfield Wisconsin that's right outside of Milwaukee at Onward Milwaukee. to see you on the road. We love having these conversations in a lot more depth on the road, a lot built into those spine courses, but have a good rest of your Tuesday. We'd love to interact with you all here on this thread if you have any questions or thoughts to add to today's podcast. Thanks.

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.

Mar 4, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses female fertility, including what physical therapy interventions are not currently supported by research for use in assisting with conception but also offers some key ideas to come alongside this vulnerable population to assist them within the limits of our scope of practice.

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

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

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

EPISODE TRANSCRIPTION

CHRISTINA PREVETT
Hello everyone and welcome to the PT on Ice daily show. I'm trying to get YouTube up and running. I don't know why it's telling me that this isn't available, but I am gonna give it another go. If you don't know me, my name is Christina Prevett. I am one of our division leads for our pelvic division as well as our geriatric division. And today I wanted to talk to you all a little bit about our role in fertility. So we are working on our level two, finishing up our level two course content. And one of the areas, our level two course is talking about how to create a fitness forward approach to pelvic health in a variety of different conditions. And so one of those conditions is around fertility, infertility, birth control, that type of space. And I have thought, an astronomical amount about where our role is in fertility, fertility management, and infertility. And so to kind of give context to this, like it really has been in the last five or ten years where we have started to advocate for ourselves as a member of the obstetrical team, right? So we really advocate in pelvic health, especially with rates of pelvic floor dysfunction and pelvic injury that happen around the pregnancy and postpartum period, that we have a role to play from a rehab perspective when it comes to female health and male health in the fertility space potentially. And so we have kind of made this jump where we are now very well known for being in the obstetrical space, helping with birth prep, helping with reducing perennial trauma, rehabbing from perennial or abdominal trauma as a consequence of a C-section or a vaginal delivery. And so we really have etched our role in a wonderful way in the obstetrical space. And so it doesn't really seem like that big of a leap for us to think about coming into the fertility space, right? Because it's all kind of centered around the pelvis. It's an area where there is a lot of misunderstanding. There's a lot of grief. There's a lot of trauma that happens. And so we are seeing more and more of our physical therapists and other allied health providers start advertising services in fertility.

FERTILITY GONE WRONG
And so Before I go into some of the research in this space and where we at ICE stand in this space, I want to tell you all a story about where this can go terribly wrong. So I owned a physiotherapy clinic and a gym up in Kingston, Ontario for five years. And I had a woman come in to see me and she was looking for a consult for the gym. Her husband was in the military. He had done multiple tours and they were having trouble conceiving. So they had done multiple rounds of IVF, neither of which had been successful. I think they had done two rounds and he was currently deployed and he was struggling with mental health stuff. He was struggling with PTSD. She was, as a consequence of the healing process, was also struggling with a lot of mental health and anxiety, trying to be that person for him. So it was a really complicated situation, their fertility journey. And so they were, she was coming in saying, you know, well, if I can get in better shape, then maybe it's going to help this next round of IVF. And so I was talking about her history with exercise, and then I was talking about her history with rehab, just trying to get to see if, you know, she would want to come into one of our programs and what that program may be. And she told me that she was seeing another provider and was getting adjusted three times a week for fertility. And so I kind of asked her the situations and circumstances around that. And she said that, you know, I am willing to try anything to get pregnant. It's what I want more than anything else. And so she's like, I went to this provider and they did a x-ray of my entire back. And I was starting to have low back pain, which like infertility, trauma, mental health, baby that they want that they cannot have. Like her pain was focusing around her pelvis and her low back. And provider x-rayed the entire spine and said, oh, here it is. Here's your infertility. It is at your neck and you have a issue at C5, C6, and there's an innervation right there, right to the uterus. You're going to get adjusted by me three times a week for six months. And I guarantee you the next time you have IVF, it's going to be successful. And I have never raged internally in a conversation so much in my entire life. It was a really tough spot for me to be because I was a person that she had never met before. Then she was asking about gym-based services, did not even know that I was a physical therapist because that was not the role that I was playing in this interaction. And she was in such a vulnerable space that if I came in super hot and was like, that is not true, then I would have potentially severed a line of hope for her that she had developed, but oh my goodness, how unethical is it for you to make promises that you cannot keep? And so I tell this story to give the frame of reference that I think about when I make statements about where we lie with respect to our role in rehab.

FERTILITY: A VULNERABLE POPULATION
So the first thing that we always have to think with this, and this is in any space where we are trying to kind of go into new markets, and I am not against being in new markets, but this population in particular is a very vulnerable population. This is a population where individuals are feeling like their body is failing, The emotional and mental load of fertility is high. The shame and guilt and spiraling and social context and people asking you if you're gonna be having babies soon even though it is something you want more than anything else in the world and it is not happening. The feeling of your body failing you at something that you quote unquote should be able to do. These are all things that make us need to think very clearly about the statements and promises that we make as we consider niching into this space. The second filter of this is from a manual therapy perspective. We have no evidence that our manual therapy increases chances of conceiving. So we cannot say that we are changing the orientation of the uterus to make for a more hospitable environment. We cannot say that. It is not ethical for us to say that. One, because we have no evidence that there's going to be any movement of really strong really anchored organs in our body where we are placing hands on people right like our evidence is that we are horrible at landmarking exactly what what muscle we are on we are not doing a hip flexor release and and changing trigger points in our muscles We are not able to really localize our manifs and we're really interacting with the nervous system. So if we can't even do that at the superficial musculoskeletal system, why do we think that our manual therapy is going to impact our organs? So we need to be very mindful about what we are doing. And so the first thing we have to filter is the ethics.

THERE IS NO EVIDENCE FOR THE USE OF MANUAL THERAPY TO IMPROVE FERTILITY
The second thing we have to recognize is that we are currently going into a space that does not have evidence for our manual therapy techniques to change our fertility. That is number two. That is not to say that this evidence will not develop. It is a new area, but we cannot say, if you come to see me, you're more likely to get pregnant. We cannot say that. We can say that we are exploring different modalities and we can have lots of conversations about fertility. We are educated providers in the fertility space, but we need to be very clear with our communication about what we can promise to individuals because it is unethical for us to say that this is gonna happen. Three, there is a placebo effect of somebody taking care of you when you are in such a vulnerable space, right? There is one of the biggest and best things that we can do as rehab providers is that we are able to have space, have time to listen to our people and cater to and speak toward the emotional side of what they are going through. A lot of the interactions with our medical space when it comes to fertility are very much focused on the physiology of it, right? Because that is what they are trying to remove barriers for from a physiological perspective, whether it's on the male or female side, and allow fertilization to occur in successful implantation. But we need to be very, very mindful. So to finish off this episode, what can we do? Where do we have evidence around a potential role in rehab. Okay, so in order for conception to happen, right, we need to have, on the female side, we have to have an egg that is released on a monthly basis, right, so we have to be ovulating. That egg has to travel into the fallopian tube. Sex needs to occur with ejaculation so that the sperm is meeting the egg in the fallopian tube. And then the fertilized egg needs to travel through the fallopian tube and embed into the uterus and have the hormonal environment, have the enrichment of the uterine walls in order for that implantation to be successful and maintained. Okay. So the first piece in our fertility is the ovulation space. And if you've been following our pelvic crew for a long period of time, you know that one of the areas around ovulation, and we are not medical providers, so we are not looking at their hormone levels. We are not seeing if luteinizing hormone is creating a estrogen surge that allows ovulation to take place. But we are one of those providers that oftentimes can catch relative energy deficiency in sport. So We can have conversations that individuals are amenorrheic to be a resource dealer and a primary care provider to refer on if we think that something is going on with their menstrual cycle that has to do with their nutrition or that they are not ovulating as a consequence of low energy availability. So from that perspective, if they're not getting their period, like we may be that resource dealer to a registered dietitian or nutritionist that has a scope of practice that works with potential disordered eating, potential issues with fertility, and that has a more broad scope of practice to be able to speak to those levels, right? We could be referring to our obstetrician if individuals are thinking of conceiving in the next six months and they don't have their period, let's get them to get their doc to do blood work or let's like get earlier on that process and then send that letter and say, you know, I've been treating this person for musculoskeletal issues. Like I am a little bit worried about relative energy deficiency in sport and we can make that connection. We can also educate on the menstrual cycle and what is required for fertility to take place, right? We can be talking about when our fertility windows are, right? We are not reproductively positive or we're not able to have a fertilized egg at all parts of our cycle, right? Ovulation occurs between day 12 and day 14. So that window, usually between 11 and 15 days of your cycle is like your chance window of getting pregnant. So we can be educating on that. We have evidence for that. Medically, in our scope of practice, we can absolutely be talking about that physiology. We have a role in that space and we have the time to sit down with our people and talk about tracking your menstrual cycle and recognizing some of the signs that you might be ovulating, like changes in cervical mucus and body temperature and those types of things. The second piece where we have a role is that sex needs to be successful in that women are able to have penetrative intercourse and ejaculation needs to occur. And so I'm going to do an entire second episode on male fertility and male fertility factors and our role in male fertility, because fun fact, 30 to 50% of infertility cases are male factors. And yet all of our information is on female related fertility factors. And so in order for sex to be able to happen, individuals have to not have pain. and they need to be able to have penetrative intercourse. So here's another area where our role can be quite massive, right? In really extreme cases of pelvic pain or vaginismus or vulvodynia, there are circumstances where the pain is so severe that individuals do artificial insemination or other assisted reproductive technologies because they are unable, without significant severe pain, to be able to have penetrative intercourse in order for ovulation or fertilization rather to occur. So we have a role in that space as well. And this is where our evidence is, right? So if individuals are having pain with intercourse or on that guarded high nervous system response, right? Parasympathetic tone is a very important part of our arousal response. then we can be interacting with that nervous system and we can be working on pain-centered modalities in order to try and allow individuals to be able to participate in intercourse in order for individuals to be able to successfully, hopefully conceive. Where some individuals, and this is gonna be long, so I'm gonna try not to rant too much, where we're taking a bit too much of a stretch for where we are at in our opinion, is around the hypertonicity and what the hypertonicity of the pelvic floor is doing from a hospitable environment for fertility and saying, well, your body might not be ready. Let's talk about our vagina and our pelvic floor muscles and our cervix. Our pelvic floor muscles are here. Our cervix is here at the top. So once sperm has passed your cervix or has gotten through that, and you, I'm not saying that your penis goes past your cervix, but what I'm saying is when you are having that ejaculation, that the sperm is going to go up towards the cervix. Once you have passed that pelvic floor layer, the pelvic floor has nothing to do with our fertility, right? So that hypertonicity piece, likely has no impact outside of pain responses on successful fertilization of an egg, right? Because that sperm is gonna go up towards the cervix and sneak through to try and be able to ovulate that egg or to be able to fertilize that egg like really quickly and the muscles of the pelvic floor are not impeding sperm from getting there. So again, kind of coming full circle, like our role is in education and pain management from where our evidence stands right now. And if we are going into these areas of gray, we need to be mindful of our language. And then we need to really think critically about what do we truly think is going on? And is some of my manual therapy interacting with that nervous system, bringing that stress response down, getting us into more parasympathetic tone, or am I moving an organ? That's where we need to be critical and we need to be honest with our people. We talk about all the time with diastasis recti rehab that I cannot make any promises about what your belly looks like at rest because all of our interventions are when your belly is contracted. I can get you stronger. I'm going to be able to have more function. I'm going to be able to say this, this, and this, but I cannot promise you that your belly is going to look different or that it is going to look the way it did before pregnancy, nor would I really expect it to. I am very clear with that communication. We need to be mindful and do the same thing when we are thinking about our role in fertility. All right. That was a bit of a rant. I'm so sorry. I went a little bit long, but… This is really important.

SUMMARY
If you want to talk more about fertility, that is in our level two course, which means that you'll have to take our level one online course. Our next cohort, which sold out a couple of weeks ago, it starts today, which means that our next cohort is starting the week of April 30th. So if you are interested, let us know. Our next cohort of level two that's gonna dive into all this literature is in August. So take that level one, get into that level two, and I am so excited to be able to deep dive into these spaces a little bit more. All right, have a great week, everybody. Talk 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.

Mar 1, 2024

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


In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the strategy behind helping athletes & patients consider adding extra training volume on top of their normal exercise routine. Why should we add it, when should we add it, how should we integrate it into our normal training, and who is appropriate for extra volume?

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

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
Welcome in, folks. Good morning. Welcome to the P-Town Ice Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday. It's the best darn day of the week, we would argue here, from the Fitness Athlete Division. Those of you working with crossfitters, Olympic weightlifters, powerlifters, endurance athletes, anybody who is recreationally active, part of that 10% minority of the human race that exercises on a regular basis enough to produce a meaningful health and fitness effect. We're here to help you help those folks.

INCREASING TRAINING VOLUME
So here on Fitness Athlete Friday, today we're gonna be talking about increasing training volume. A hot topic, especially this time of the year, the CrossFit Open has begun as of yesterday. This is often the time of year as people go through the Open, maybe they did not perform as they thought they would, and they begin to ask questions about how can I make my performance look more like someone else's, right? So 24.1 was released, a couplet of dumbbell snatches and burpees over the dumbbell. I just finished it this morning, just finished judging a few hours as well. First workout, usually very approachable. People maybe have questions of how can I get faster as we get into the later weeks of the Open. Heavy barbell comes out, high skill gymnastics comes out, people begin to have more questions. What else could I be doing besides coming to CrossFit class? This relates to other athletes as well. Endurance athletes who maybe want to get faster in their mile time, faster in their race times, stronger to have less injuries. All of those questions tend to come up of what else could I be doing? So today we want to focus on asking in the concept, in answering the question of increasing our training volume. Why should we do that? When should we do it? Who is the person that's appropriate for it? And then how should we actually begin to introduce increasing training volume?

WHY SHOULD WE INCREASE VOLUME?
So let's start from the top. Why should we increase training volume? I think this is really important and that's why I have it as the first point today. often folks are maybe disappointed with their performance in the open or a recent road race or competition or something like that and they want to do more training and just adding in more training without understanding why we're doing that training or having a goal for that training can be a very rocky foundation to build upon and can really ultimately maybe set us up for an unsuccessful addition of volume that doesn't meaningfully improve our performance and maybe leads to an increased risk of injury for no reason. because we don't really know why we're training for more volume, right? Just doing more CrossFit metabolic conditioning workouts or just doing more accessory weightlifting or just running or biking more miles without a goal is really just adding meaningless volume to the equation. We need to understand why should we do this. So when folks come to you with that question of What should I be doing extra outside of my running or outside of CrossFit class? We should be asking back, why do you feel the need to add more training volume in? What specific deficit are you understanding or do you feel has been recently exposed that we need to add more training volume in? To just improve general fitness, with those folks we would say, Be patient, right? Continue going to CrossFit class. Continue if you've only been running for a year or two, continue your normal running training, right? Understand that high level performance often comes with most folks. When you look at them, they have a large training age, which means they have been doing whatever they're doing for a long period of time. And so expecting to close that fitness gap in just a couple of years by just adding in more volume is not really an intelligent way to approach that. But if we have identified some specific deficits, then that can be an argument to maybe add in some extra volume. So, folks who are maybe long endurance athletes who are noticing the longer my runs, the slower I become. I perceive that I maybe need to add in some speed work. Folks may be doing CrossFit that say, you know what, I'm great when the weight is body weight or when it's a low to moderate weight, dumbbell, kettlebell, barbell, whatever, I'm okay. But as we get heavier, I perceive that my strength, my upper limits of strength is limiting me from moving the weights around. In CrossFit class, where I'm perceiving that if I added in some more resistance training to whatever I'm doing, Maybe my tissues would be healthier or I don't have some of the skills and I would like to begin to practice them, right? I would like to practice double unders outside of class. I would like to practice pull-ups or muscle-ups or handstand push-ups outside of class or maybe add in an extra day of running if I'm a CrossFit athlete. So understanding why we're adding volume in is very, very, very, very important and it should be to address a specific perceived deficit and all the better if we can actually objectively test that so that we know if we're starting to make up ground on that deficit or not with the extra volume that we're being asked to add into our programming. So starting with why is very important.

WHEN SHOULD WE INCREASE VOLUME?
The next question is, when should we do this? I would argue that we should really only add in extra training on top of what we're already doing when we feel like our current training has plateaued. Of that person who says, I have been going to CrossFit six days a week for 10 years, and I feel like my ring muscle ups are not getting any better. I feel like I have literally not added a pound to my max, clean and jerk, whatever. When a perceived plateau is there, That can be a good argument to begin to add in some extra volume, especially those folks, uh, endurance athletes as well. Like, Hey man, I have been running for a decade and my marathon pace got faster, faster, faster the first couple of years, but it's been pretty much the same pace for the past two or three years of races. I feel like something needs to change. Or, again, those folks who do not have a skill. So that's when we begin to action that extra volume. For me, over the past year, my extra volume looked like adding in some more running. Doing pretty well, pretty happy with my CrossFit performance, but when runs showed up, especially in workouts where the runs were longer, 800s, miles, workouts like Murph Hero workouts with a lot of running, really, really, really impacted my performance despite doing pretty well on the other stuff that wasn't running. So beginning to add in extra running outside of CrossFit class.

HOW DO WE INCREASE TRAINING VOLUME?
Now, how do we do this? This is as important as why. How do we add in volume in a very intelligent manner? The key is with anything else, just like when somebody first began an exercise program, we need to start low. We need to go slow. We need to stair step this volume. A lot of folks perceive a deficit or otherwise feel like they want to add in more volume and they just do more of what they're already doing. And sometimes they do it every day, right? The person who leaves CrossFit and goes to Planet Fitness and does an hour on the stair stepper. or does an hour of machine weights, whatever. Adding in a big chunk of volume, again, if we don't have the foundation of why and when we should be doing this, can be a really unintelligent decision. So we should do this carefully. For me, this looked like one extra day of running for a couple of weeks, two extra days of running for a couple of weeks, so on and so forth. Using a running coach to very carefully and controlled add running volume in on top of working with a nutrition coach to make sure that I was fueling appropriately. So making sure that if we do come to the decision that we could benefit from extra training aside from what we're already doing, that we do it very, very, very, very carefully. What we're trying to do adding in extra exercise pieces is we are trying to push ourselves maybe into a short period of what we would call overreaching, functional overreaching. We're pushing the margins just a little bit, but we also need to be mindful of all the other training that we're doing, and we have to be careful that this functional overreach does not become overtraining, right? We need to make sure that if we're adding an extra stuff, we respect this new volume. We do it carefully. This extra volume should come with a progression in a deload. So for example, my running coach always had me on four week cycles. where every fourth week was a deload, added a little bit of miles every week for three weeks, and then a deload, add, deload. That deload week is a chance to give my body a break, go back to essentially my pre-running amount of volume, but it's also a great week to assess how did my body respond to the previous three weeks of training. Should we continue with the next block of extra volume? Or should we stay where I was at? Or should we maybe even regress a little bit because it was a little bit too much of an overtraining feeling rather than that functional overreach? And again, being objective with why are we doing this can really help us know did that little burst of extra volume create a change? Did mile split times go down? Did a race time go down? Did strength go up maybe two pounds or five pounds or whatever? Can I do two muscle-ups now instead of one muscle-up? So on and so forth. Having those objective indicators lets us know, okay, we're making the progress we want to see, and as long as everything is feeling good, we're good to continue going to that next step on the staircase of increasing volume. And when we think about how we add in this training, most importantly, we have to ensure that this extra training does not impact the normal training, right? The worst thing you can do is have your extra volume, make it so that when you show up to your normal training, so in my example, I never wanted to get to a point where my running made it so that I could not come to CrossFit, right? That's a dangerous spiral to get into, where now my normal baseline strength and conditioning program can't be performed, and now I'm adding extra volume even though I can't handle the current level of volume I was already doing before I added in my extra training. So being sure that whatever we're training at baseline, CrossFit, weightlifting, running, whatever, that does not become impacted by whatever extra stuff we're doing. Now that being said, if we're feeling good, we feel like we're making progress, we are objectively making progress, and our normal training is not impacted Okay, continue to either maintain that extra thing, whatever you're doing, or maybe even progress it a little bit.

WHO IS APPROPRIATE FOR EXTRA VOLUME?
Now the final part of the equation is who should do this? I would argue the answer is very few people should do this. Who is the type of person that is appropriate for extra volume? that person should be incredibly consistent with whatever they're already doing, right? Which by default erases most of the people who want to do extra volume. A lot of people perceive a gap in fitness between maybe themselves and their friends in CrossFit class or themselves and their friends and their run club or whatever. They want to close that gap even though What they don't want to hear is that maybe the gap there is because they're already not consistent with what they're doing, right? They hit the snooze alarm a couple days a week on CrossFit class or going for their run, right? I want that individual who is already incredibly consistent with their normal training. They are training four to six days a week, every week. They understand the importance of active recovery and rest days. They are prioritizing their sleep and their nutrition. The volume means nothing if we can't match that volume with an appropriate dedication to recovery. Again, we're trying to create bouts of small windows of functional overreaching. We're trying not to throw somebody into a downward spiral, a death loop of overtraining where they're going to be at increased risk for injury, where their fatigue, their soreness, whatever is going to impact all of their training, not just the extra volume that they're now doing. Most people are not consistent enough with what they're already doing to consider taking on extra volume. And I think that's tough to hear, but it's the right decision. for you as the coach, the clinician, whatever your role is, to have in a conversation with that athlete. If you are only coming to CrossFit on Monday, Wednesday, Thursday, you sleep in on Tuesday because Monday wrecked you, you sleep in on Friday because you're sore, you don't come to the gym on the weekend, let's see what your fitness looks like when you're consistent with your current fitness routine, and then maybe later on we can revisit talking about extra volume. I have found in my coaching career that the folks who come up to me and tell me, hey coach, I'm ready for butterfly pull-ups, happen to also be, coincidentally, the people who maybe can't even do strict pull-ups, right? The folks who are able to tolerate extra volume, extra skill progression, are the folks who are already very consistent and it's very clear that they, because they are consistent with their normal level of training, recovery, attention to their sleep and diet, They are aware, and I am also aware, that they can probably handle extra stuff, and that the people who want it really, really, really, really bad are almost always likely the people that should probably not do it because they are so inconsistent already.

CASE EXAMPLE: RYAN
A really good example I have is our friend here at the gym. His name is Ryan Battishill. You may know him. He develops a lot of your websites. He's a website developer by trade. He's a member here at our gym. I love how calculated and intelligent he is with just a little bit of extra training every day after class. So I want to tell you a little bit about him and then tell you the volume that he's added in in the results. So Ryan's been doing CrossFit for five or six years now. He has a history of running as well. He has a good morning fault squat. So a very kind of hingy squat. It tells us there's maybe a deficit in the quads, wants to get better at gymnastics, and wants to train for a half marathon as well. So, a lot of different goals, but it's good. Again, why are you adding extra volume? Are you just doing it meaninglessly, or do you actually have a goal? Okay, we have a couple of goals here. We want to improve our foundational lifts, we want to improve our back squat, our deadlift, We want to improve running. We want to improve our gymnastics. Okay, good. We have concrete objective ways to know that volume is working. What does that extra volume look like? And I think you would be surprised to hear that his extra volume is about 10 to 15 minutes a day after class. It's nothing crazy. One day he does an EMOM, usually a 10 minute EMOM of strict pull-ups and push-ups to help his gymnastics foundations. One day he focuses on front rack barbell step ups to focus on quad strength. Another day he does hip thrusts to work on his posterior chain and low back strength. And a fourth day of the week he adds in a couple extra miles of running. Nothing he does conflicts with his ability to come to CrossFit five days a week. He's a Monday through Friday regular, very consistent with five days a week of CrossFit training, very consistent with his nutrition, very consistent with his recovery, right? Somebody that's getting on most nights, eight plus hours of sleep, getting plenty of fuel as well. What are the results? A lot of people might look at the work he does and say, there's no way that 10 to 15 minutes of extra work could translate into anything meaningful, right? A lot of us look at extra volume, we think, if I want to be better, I need to run five miles extra a day, I need to do an extra hour of CrossFit a day, right? I need to do more and more and more volume instead of really intelligently planned extra accessory work. Over the past year of adding in that extra volume, he has broken through plateaus on his back squat, his deadlift, and his bench press from all of the strict gymnastics, the front rack step ups, and the hip thrusts. He has improved his running, even though he's already a great runner, in accordance with his goals to be able to run and complete a half marathon. and his gymnastics are certainly becoming on another level. His kipping pull-ups, his toes-to-bar, his muscle-ups, his handstand push-ups are all also improving accordingly because of his focus on strict gymnastics work. So I hope from that you glean that when we're talking about adding extra volume, it doesn't need to be this grueling stuff. It doesn't need to be very high-intensity stuff. It just needs to be intelligently designed in a way that does not affect our current training, And that puts us in a short state of functional overreaching, but does not become this long-term overtraining issue. Understanding that as we increase that volume, our nutrition, our calorie intake should increase as well. And we definitely need to make sure that our recovery is on point because we're now taking on extra physical volume that our body will need to recover from.

SUMMARY
So extra volume, why should we do this? We should do this only to address a specific perceived deficit that we can objectively measure the impact of extra volume on. When should we do this? When we have perceived a plateau, right? If every time we're testing a lift or testing a mile pace or a 5k pace and we are still getting faster, getting stronger, whatever, we have not yet reached that plateau. And so I'd argue it's not yet a time to consider taking on extra volume. If we do decide extra volume, extra work, extra accessory work is appropriate, how should we do that? We should do that very carefully. We should do that as a stair-step approach. We should do that in a manner that we can reassess the impact of our extra training. Is it actually working? And we should do it in a way that our normal training is also not impacted. We should never be skipping our normal run because of our strength training or our speed work. We should never be skipping CrossFit class because of our extra running or our extra accessory work that we maybe do before or after class should not impact our normal training. And then who should do this? Again, I would argue a very small amount of people should actually do this. Folks who are already incredibly consistent with their normal training routine, who are training four to six days per week, understand and are consistent with recovery, right? The stuff that happens outside of training, diet, sleep, nutrition, recovery. and folks who are aware of the nutritional goals are meeting them and are also aware that adding extra volume is going to increase the demand on how much and the dedication we have to our recovery. And then finally understanding it doesn't have to be crazy high volume, crazy high intensity to have an impact. 10 to 15 to 20 to maybe 30 minutes of extra work just a couple of days a week can go a really long way if the extra volume is done in a meaningful manner to address those extra deficits. finishing a metcon and doing another metcon is usually just going to result in that metcon being of even lower intensity that you may have to scale the weights and the ranges of motion more rather than coming over and doing some front rack step-ups or doing some strict pull-ups or doing some sort of skill practice or really judicious strength piece or run piece, cardio piece, something like that, right? Extra metcons, a 60-minute AMRAP, at the end of a 40-minute AMRAP is really not going to push the needle. Again, we're looking for that functional overreach and making sure we don't push that into overtraining. So, extra training, who, when, why, and how, those are our thoughts. So, hope you have a wonderful weekend. If you're going to do 24.1, I hope you have fun. My advice, go fast at the start, go fast in the middle, go fast at the end. It's designed as that kind of workout. Low skill, high work. one of my specialties. So hope you have a great Friday. Have a fantastic weekend. If you're going to be on a live course this weekend, we hope you enjoy yourselves. Have a great Friday. Have a great weekend. Bye everybody.

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

Feb 29, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the mindset behind how we respond to news & change: do we respond positively or negatively? Jeff challenges listeners to consider the many positive benefits to responding to change with a growth mindset, looking for the benefits to change rather than catastrophizing the downsides.

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

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

EPISODE TRANSCRIPTION

JEFF MOORE
What's up, everybody? Welcome back to the PT on Ice Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursday, which is also a Gut Check Thursday. Remember, this is gonna be the last Gut Check Thursday that we have, because now the Open's gonna fire back up, so the workout for every week, of course, is going to be the Open. But if you wanna get in one more, it's relatively simple, starting from 500, 400 on the row, or it's just gonna be one time through for time. You're looking at 500-400 rower into 30 box jumps and 20 hang power cleans, 135-95. Then you're going to take down those reps across three rounds. So should be a relatively lighter load, pretty approachable. Good one to kind of keep moving as we get into some of the very challenging open workouts. I don't know about you all, I'm going to be doing mine today at 245, kind of right out of the gate. So mountain time, the announcement I think is noon. So I'm going to go right over to the gym at two o'clock. get warmed up and give it a go at 245. So I can't wait to see everybody's open adventures. Hopefully most of you got signed up and are going to see how you kind of stack up. Always important, right, to not run away when the measuring stick comes out. Get out there, do your best, see where you fall, and then look at over time if your consistency can't move you up in those rankings. So let us know, tag us, enjoy the journey. I will be starting mine here in a few short hours.

ALTER YOUR REACTION TO NEW
I have wanted to chat about this topic for months because of everything you can do in your growth and business interjectory. I think this one might be the most shockingly rapid as far as ensuring that your upward trajectory with whoever you're working for makes the steepest kind of hockey stick sort of climb. So let me explain. The episode is titled change this reflex and change your life. What it revolves around is altering your reaction to new. To new news specifically. altering the way that you compare to everybody else reacts to it. So I am in business, I am obsessed with asymmetry, okay? Where do you have it and where can you demonstrate it? The reason I'm obsessed with it is because it gets attention. And oftentimes, 90% of the battle is who can get somebody's attention. We are wired as creatures, we are wired to look for unexpected differences. That's what stops us in our tracks and makes us pay attention to something, right? I thought this was going to happen, but this happened. That generally speaking, is what gets a consumer's attention, it's what gets your boss's attention, it's what gets anybody's attention, because that's how human beings are wired. I thought this was going to happen, but this happened. Obviously, looking back evolutionarily, it's because that makes you safe, right? Things that aren't expected, things that are unusual, are usually worth paying attention to for survival. But for whatever, However, it came to be that can now be leveraged in the way that you move forward in both your career and your life What we're going to talk about specifically today is your response to change.

YOUR RESPONSE TO CHANGE: GROWTH VS. SCARCITY
So if you think about the importance of demonstrating asymmetry and you think about where you could demonstrate that that would matter, the number one spot that you could demonstrate asymmetry that would move the meter in the right direction would be your response to change. And the reason for that is because it's the one where it is so unusual to see a difference from a leadership perspective. Most people's response to change, and this is widely and universally known, right? Most, it's why they don't like it. Most people's response to change, the reflexive response is what am I losing? And that is deeply rooted in scarcity mindset, which most people have, which is why most people don't like change. It is relatively universally held that most people don't like change. And the reason for that is because their brains are rooted for scarcity. And so when something is changing, they always fear the worst. If you make an intentional habit to do the exact opposite, you will stand out in a way that I don't think that you could stand out more profoundly by making any other shift in your life or business. If you respond with what's the upside here. it will have massive downstream effects.

THREE BENEFITS TO RESPONDING TO CHANGE POSITIVELY
Let me just talk about the three biggest ones that will be immediate. If you can get your reflex response to change, to be positive, as opposed to, oh my gosh, what am I losing? Right off the bat, the first one is it will have a profound mental health uptick if you focus first on finding the positives, okay? Because, Wherever you start in anything, one of my favorite sayings in physical therapy is, wherever you start is where you wind up. Meaning, when you look at a lot of the big studies in PT, when people begin with a medical industrialized complex move, i.e. getting an MRI, getting higher level scans done, they tend to kind of stay stuck in the medical industrialized complex. But when they go to a provider that doesn't do those images, that doesn't offer those quote-unquote solutions, they tend to never go in that direction because they get moving and keep moving, things seem to resolve, and they stay in that lane. Because inertia drives so much about life. So wherever you start is where you tend to wind up. So why not start positive? Why not? I assure you, you'll figure out some of the downsides. Those won't escape anybody. We're wired to look for that. But why not start positive? Because now it's life's job to reveal enough to you to pull you away from that position. But it has work to do. So if every time a new thing or a change comes up, your reflex is, ooh, what's the upside here, right? What can I do with this? This could be really good. Now life needs to prove the opposite, to pull you away from that position, which is challenging because you've got momentum in that direction. Most people do the exact opposite, right? They start low, oh my gosh, oh no, what's gonna happen now? And now there has to be a lot of proof to pull them out of that negativity. If you start high, life has to prove to you that you should get pulled down, and oftentimes it can't. So right away, just by having a reflex where you're looking for the positive, the mental health trajectory is very real. Okay, number two, and probably now talking more about business, it will absolutely shock the person who's delivering the news in the best way. If your response, right, because leaders are always dreading sharing any news about change because most people being rooted in a scarcity mindset are going to begin peppering you about what they're losing or why things are going in the wrong before they've even thought it out. They're scared. They're nervous. Their reflex is negative. It's a lot of tough energy that comes at you when you're delivering change news to a group of people. If you're the person in that group that throws their hand up right away and says, Oh sweet. Does that mean that we can blank? If you don't think you've got the attention of that leader, you're crazy. First of all, you're the only person doing that. So already you are the asymmetry. And it's such a positive thing when the leader was expecting a negative response. And now you said, oh cool, does that open up this possibility? Or could we now do this? It will be as shocking as it is positive. So now you've got the attention of that leader and you've got them in an incredibly positive space. There is so much positive work that you can do from that position. And finally, third, and it usually builds off of number two, Looking for the positive reflexively and immediately places you in the best position to find it. With every single change comes new opportunity. Does not matter if it is at first perceived as a calamity, right? You think about big financial crashes. There are massive opportunities in every one of those calamities, right? But you have to be looking for it. If when things are moving and shaking and changing and the ground is shifting, if you're the person who's looking for in this new terrain, how can I now capitalize on variables that weren't present before? You have positioned yourself to find them first. Everyone's going to figure out the downside, but most people see the upside too late because they were consumed by the downside. So if you're the person who, when change is coming, you're looking for the upside, you're going to find it first. And now you've got the attention of leadership on you while you find the early opportunity and you are going to be on a trajectory that is so much quicker and faster than everybody else that when you telescope that out months or years, you obtain that position and thrive in it when other people are still figuring out why some of the change was good. Crew, things happen so fast in business and life. If you're the person who can gain positive attention from decision makers when change is happening, and you're the person that can see the opportunity that arises through change, and you put those two things together, you will move forward relative to your contemporaries at a staggering speed. Because the greatest asymmetry that you could ever demonstrate is being a person who has a reflexively positive response to change. When the entire world is rooted in scarcity mindset and thus has an immediately negative response to change. Enjoy better mental health and enjoy way more business success by making that one simple reflex change.

SUMMARY
PTOnIce.com, team. It's where all the courses live. Have an amazing Thursday. Enjoy the Open. I will certainly be reporting back on how it goes for me. It never goes overly well, but I will give it my absolute best. Enjoy, team. Have a great Thursday, great Friday, great weekend. 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.

 

Feb 28, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses how to introduce a fitness forward philosophy with your clinic/co-workers. Julie describes four main points to use when trying to change practice philosophy: put fitness forward on display, host in-services, let patients be your voice, and be a mentor to other clinicians.

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

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

EPISODE TRANSCRIPTION

JULIE BRAUER
All right, good morning crew. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Julie and I am a faculty member of the older adult division. This morning, I am going to be answering one of the most commonly asked questions that we get in our online courses and our live courses. That question is, how do I get others on board to a fitness forward philosophy? How do I create consistency when my coworkers don't understand this philosophy or potentially they don't care? The answer to that question is that we are going to pull and not push. We want to pull, not push to attract a fitness forward culture. So let's unpack it and I will give you guys a few actionables that you can start implementing right away.

PULLING VS. PUSHING TOWARDS BEHAVIOR CHANGE
So what do I mean by pull, don't push? You want to be attractive. You want to be magnetic. You want to pull people towards you and towards a fitness forward culture. You want people to be drawn to you versus pushing your agenda on others aggressively versus sending a message that could potentially be received as my way is better and I am better than you. All right. So I want to relate to so many of you in that I know so many of you are incredibly fired up and passionate about underdosing older adults. You get, I mean, your blood boils when you see that out in the clinic and I understand this. I've been there. And I know that it makes you want to call people out left and right. been there, done that, and I'm telling you that's not the way to get people to change the way that they do things. Now, I do think it's incredibly important to call our profession out as a whole. If you've been to any of our live courses or taken our online courses, you know that we call our profession out. and we ask our students to self-reflect on their clinical practice. However, I do think there's a way where you can be aggressive in that messaging and aggressive towards this mission of ending the professional pandemic of underdosage, but there's a way to do it and be kind about it.

APPROACH WITH GRACE
What I want to emphasize is that we have to approach this with grace. And believe me, I have made a ton of mistakes in my messaging and been way too aggressive. And that's not going to change culture. That's not the way to do it. But we need to realize that behind a lot of underdosed exercise that we see, there's still humans behind that underdosed exercise. Many of these humans are burnt out clinicians who are just trying to do their very best. And many times in a system that does not set them up for success. I know this to be true. I have hurt feelings of my own friends who are colleagues who are really good clinicians because of my aggressive messaging and because I wasn't realizing that people are out there and they have, they are in different seasons of life. They could be going through a lot of crap. And they're just treading water and they're doing the best that they can. It's not that always someone just doesn't care and wants to phone it in with older adults. We don't know what people are going through. So many people are in tough seasons of life that last a short amount of time or a long time. And we have to have some grace there. So instead, we want to invite people in towards this fitness forward culture. We want to be attractive. We want to be magnetic. So how do we do that? Here are a couple ways.

PUT FITNESS FORWARD ON DISPLAY
Number one, do your sessions out in the open. Put that fitness forward philosophy on display as much as you possibly can. Why? Because it's the most powerful way to share this message. And instead of, again, pushing a message or telling people what the right way is, you get to show them. So imagine this. You work in inpatient rehab. And instead of kind of flying under the radar, this is what I did a lot for a long time, and you bring your equipment in your own bag and you do that session in the room because you don't want people to ask questions and you just want to do your thing and move on. Instead, go do it out in the open gym. When you know all the people around you, you're going to look around and see we have yellow TheraBands, we're playing balloon toss over there, people are on the new step and chatting it up for 10 or 15 minutes, but you are in the middle of the room. You are loading your patient up with a kettlebell, they're doing a deadlift, you are blasting like really pump up music and drowning out the really like low slow music that doesn't make anyone want to work out so you're pumping the jams your patient is working really hard they're having fun you're having fun everyone around you gets to look over and see like damn i have that patient later in the afternoon and i saw them yesterday i had no idea they could do that Huh? They look like they're having a really good time. That is how you start to get people curious. Like, Whoa, how are they doing that with that patient? That's awesome. I want to learn more. You are pulling people in towards you without saying a word, without telling people, Hey, I want you to do things my way. So that's number one. Do your sessions out in the open as much as you possibly can. Put that fitness forward philosophy on display. Okay.

HOST IN-SERVICES
Number two, put on an in-service. Be a wave of influence here. This is one of the easiest ways to spread this message to as many people as possible. Okay. Now, a lot of you are like, I don't have time to put together a workshop or an in-service. I don't like to speak in front of a group. I totally get it. That is why the MMOA division has created workshops for you. They are done. They are skeleton slides. You can put your branding on them. You can add to them. You can do whatever you want with them. They're all done for you. They are on topics such as One rep max living, osteoporosis, arthritis, build better balance, learn how to fall. They're done for you. Even better, if you're thinking, okay, I love that the information is there for me, but I'm really nervous presenting in front of a group. We have a solution for you too. The workshops also come along with a recording. of one of our faculty members presenting this information to their communities and to other individuals. So all you have to do is watch the recording and you can say the phrases and do exactly what they do. So it completely mitigates this fear of public speaking because you have a perfect example of how to display this information. I will put the link to all of the workshops. They're on our website on mmoa.online under free resources. I will link it there for you. But that's one of the easiest ways to spread this message to a lot of different people. You get everybody in the same room, hopefully not only clinicians, so your peers, but managers and supervisors. If you were able to get some of the rehab doctors in on that workshop, that would also be amazing. So a wonderful opportunity there to spread this message wide, be a wave of influence.

GUIDE YOUR PATIENT'S VOICE
All right, number three, guide your patient's voice. Guide your patient's voice. If you want your colleagues to get on board with a fitness-forward culture, empower your patient to help you guys out. Think about what's going to be more effective here? You going to your colleague and saying, hey, I want you to do this with my patient or your patient when they are with one of your colleagues for their session that day or that week saying, hey, I did this thing called a deadlift with a kettlebell last week with Julie, and it was really awesome. I loved it because it really helped me realize how strong I can get so that I'm able to lift my granddaughter up from the ground. If a patient comes to you and says it like that, and they're so excited, you sure as hell bet that therapist is going to be like, okay, this is exactly what my patient wants to do. I'm going to figure out how to replicate what that other therapist did because clearly my patient is all about it. That is really powerful if your patient can also use their voice to help drive this change. So that could be a conversation you have with your patient. Hey, do you think what we're doing during this session has been really helpful? Your patient's going to say, yeah, I mean, it's hard and it's strenuous and I sweat, but I know this is going to help me. Then you guide them, all right, so next week, because I'm not gonna see you for another two weeks, let's figure out a way where you can advocate for yourself and so your next therapist continues to do this work so you continue to get better. So you and your patient come together and figure out what that conversation looks like and then your patient goes to your colleague and has that conversation. it's going to be a lot more powerful than you directly just saying to your colleague, do this, don't do this. Guide your patient's voice. All right.

BE A MENTOR
And then lastly, be a mentor, be a mentor. So we have a lot of people who at our courses will say, you know, let's say it's a, let's say it's a CODA. Okay. and who's at our course and they're like, well, what's going to happen? I mean, I will be doing this stuff, but my OT isn't going to be doing this stuff. Or it's a, it's a PTA saying like, I love this stuff, but my PT is definitely not going to do this stuff. What do I do? You want to be a mentor. Look at it Not like me versus you, right? Not what I'm doing is right, what you're doing is wrong. Look at it as this is a really great opportunity to teach my colleagues. how to do these things and and think about in a way not just because you know it's going to benefit your patient but because it's going to benefit your colleague. We all want each other to be elevated and we want each other to be inspired to do one percent better the next day with older adults. So why wouldn't we want to invite them in to share how to do this stuff? There could be a lot of reasons why your colleague isn't following your plan of care. They may not understand what an EMOM is or an AMRAP. They're like, what are those letters? I have no idea. Like we're spell check. I don't even understand this. They could never have seen a deadlift before in their life. And they're just very confused about what these movements are. Again, there could be a lot behind it. Don't assume someone is not reading your documentation or likes what you're doing. It could just be that they lack the confidence and they don't have the knowledge. So be a mentor. This is where you can go to your colleague and say, hey, Betty is loving what we've been working on. We're doing some really cool loaded carries and squats and deadlifts. I would love to show you what we're working on so that we can maintain consistency, because I know that Betty's going to get better faster if we do that. You can use your time. Donate your time as a mentor to pull them over, show them some of these movements, show them how you document them, and even better, If they have some time, be like, hey, I've got Betty at this time, right? Maybe you can have some overlap if you're in home health, or you can have some overlap if you're in acute rehab and be like, hey, could you come over and watch a little bit of my session with Betty so you can see what we're doing? and you really make it that individualized mentoring experience. And I guarantee you guys, if you approach this with kindness and try and pull people in and get them to be curious and present yourself as someone that an individual, your colleague can come to you and say, I'm a little nervous, I don't know how to do this. If you're able to do that over and over again, you're gonna start to have a lot of colleagues asking you questions and getting curious because they know that you're an approachable individual that they can seek mentorship from. And I promise that's going to make you feel really, really good about not only the work that you're doing with your patient, but being able to give back to your colleagues. All right. So those are the few ideas of how you can pull people in towards that fitness forward culture versus pushing that agenda on them.

SUMMARY
So to recap, number one, do those sessions out in the open. Put that fitness forward philosophy on display. Make it as visible as possible. Two, do an in-service. Be a wave of influence. I'm going to link that website for you guys in the comments of this post. Three, guide your patient's voice. Realize it's going to be so much more effective if your patient is advocating to do these fitness forward things versus you just telling your colleague to do them. And then lastly, be a mentor. Donate your time and energy to showing and educating your colleagues how to do this. realize that you're going to be helping them enjoy doing their jobs more, not just benefiting your patients. So it's a win-win. All right, guys. Lastly, I will let you know about what courses the older adult division has coming up. So in March, we're pretty darn busy. Well, first, well, yeah, March is this weekend. It's crazy. So we are in Maryland as well as Georgia this coming weekend. There are spots open for those two courses if you want to snag one. Then we will be in Madison, Wisconsin and Kansas the rest of the month, and we have our next L1 eight week online course starting March 13th. So March is super busy. Go ahead and jump into one of our courses. We would love to see you on the road. We would love to see you online. Have a wonderful rest of your Wednesday. Let me know if some of these techniques worked for you all the rest of this week.

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

Feb 27, 2024

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

In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses the safety, efficacy, and utilization of palpation when incorporating dry needling treatment into your practice.

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

If you're looking to learn more about our live dry needling courses, check out our dry needling certification which consists of Upper Body Dry Needling, Lower Body Dry Needling, and Advanced Dry Needling.

EPISODE TRANSCRIPTION

PAUL KILLOREN
Good morning, crew. We've got YouTube, we've got Instagram. My name is Paul. I'm representing the dry needling division for ICE. My name is Paul and I would like to talk about palpation this morning. Pretty dry topic you might think, but depending on if you're trained in dry needling and how you're trained in dry needling, palpation may have been one of the key aspects to your course, your training, and then fill in the blank from there. I mean, our accuracy, our safety, and even our effectiveness for dry needling relies at least somewhat, high percentage, low percentage, on palpation. So we're talking palpation this morning, not even actual needles in, but this is heavily a dry needling topic on our clinical Tuesday.

IS PALPATION-BASED DRY NEEDLING SAFE?
First of all, to get it out of the way, there is actually quite a bit of research saying, is palpation-based dry needling enough? Enough being, is it safe? Is it consistently effective? And the answer is yes, most of the time. Meaning there's solid data that says if we're palpating rotator cuff muscles, so a 2023 publication last year said, if we're palpating infraspinatus, even teres and supraspinatus, compared to ultrasound, we're reliable. Maybe that's because it's accessible, we have a big spine of the scapula to rely on, but unfortunately we have data, a publication from 2021 that says if we're palpating ribs, especially posterior ribs, so deep to rhomboid and trap and all of that, unfortunately we're not very reliable. So first of all, to say, um, not the topic exclusively for this morning is can we rely exclusively on palpation for dry needling safety? The answer is yes. Most of the time. Um, I mean, one stance we do with ice, even on our advanced courses that we do not do rib blocking techniques, uh, meaning we don't palpate and rely on the rib as a bony backdrop for for like thoracic extensors, rhomboid, all of those muscles. So we can rely on it most of the time. There are certain regions where it's less, research says it's less consistent, less safe. And that's pretty obvious stuff. Can we palpate everywhere else in the body? Spinous processes for the spine, trochanter sacrum for the glutes. Can we palpate muscles for quads and all that? The answer is yes.

HOW IMPORTANT IS PALPATION FOR DRY NEEDLING?
So really the topic of this morning is how important is palpation for dry needling? And I'm gonna break this, the rest of the discussion into two topics. The first one is how important is dry needling as a diagnostic criteria? And the second one is how important is palpation, we have to put it in the palpation bucket, but I'll say how important is tissue control when we're dry needling? So let's tackle topic number one. How important is palpation as a diagnostic criterion for dry needling? And this is where we'll start to see a separation based on when you were trained and how you were trained. Meaning, if you were trained more than five or 10 years ago, or if you took a fairly exclusively trigger point dry needling course, then palpation is key. as a diagnostic aspect, meaning hopefully you're doing other assessment, but when it comes down to firm pressure in tissue, identifying trigger points or top bands or even muscular tissue that reproduces a patient's symptoms or refers into different patterns, very, very high on that diagnostic algorithm, the palpation is. For ice, we are drifting in almost every respect away from the trigger point paradigm. I mean at the highest level we're drifting away from trigger points being necessarily the singular explanation for pain, the direct dry needling target, and even the twitch response as not necessarily being deactivation of shortened sarcomeres, trigger points, all of those things. So the question is immediately asked, so does that mean that we don't palpate? Are we just randomly, generically floating needles into a muscle? The answer is no. We don't palpate trigger points, we palpate motor banding. This follows other philosophies, but motor banding being a slightly larger, slightly more macroscopic tone, I mean it is palpable, but it's not on that microscopic sarcomere level. If you have been needling for any period at all, or if you do any type of any soft tissue work, you know that you can find motor banding in almost everybody's glute medius, vastus lateralis, medial gastroc, tricep, deltoid, infraspinatus. These aren't trigger points, these are motor bands. And there is value to palpating that, and there's value to treating that tautness, that motor banding for dry needling.

IS PALPATION DIAGNOSTIC?
So back to the question at hand is like, how important is palpation as far as a diagnostic criteria? For ice, for us, it's a little less important than perhaps a purely trigger point based therapist, but it's not completely unimportant. It's just a lower, it's lower importance on our assessment, meaning Hopefully we had a full patient interview, a subjective, a full assessment. There was something that led us to treat vastus medialis for Gladys' knee pain or infraspinatus for Gladys' shoulder pain. So we're already approaching the patient, essentially knowing that we're going to treat these muscles. Then, and the narrative that we use on our courses is that, that very last piece of the puzzle, like if there are any puzzlers out there in the group, you know, depending on how challenging your puzzle is. It just took you a few hours, a few days, a few months. You did the edge first, maybe that's your patient interview. Then you fill in different colors, different objects. Maybe that's the rest of our assessment. But then there's that last puzzle piece. Almost always it's lost under the couch or something, but it's that last piece. And you're like, sweet, found it. I'm gonna put this in. That is our palpation. meaning everything else in our assessment, in our treatment model, interviewing the patient, led us to treat this muscle. That last puzzle piece before we put in a needle, so we've decided we're gonna use dry needling, we've decided we're gonna treat infraspinatus, that last puzzle piece is spending five to 10 seconds finding that motor banding, finding tautness, finding any tenderness, finding anything that reproduces symptoms. But the shift that I'm acknowledging is that that final puzzle piece was not the full puzzle. Depending on how you're trained and when you were trained, palpation was what created the whole puzzle. Meaning if you are a little bit more trigger point centric, we really rely on palpating a trigger point or palpating that banding and having it reproduce the patient's symptoms or at the very least be a familiar sensation. Or to say an extreme opposite of, If you're relying exclusively on trigger point identification and you palpate, you dig your fingers into a muscle and don't find tautness, that almost starts to sound like, okay, we're not gonna treat this muscle. So again, the paradigm shift we're talking about is that palpation is always a part of the equation, even for diagnosis, I'll say, or even when deciding where to place our needle for dry needling. But depending on how you were trained, depending on how much emphasis you put on that pain generating reproduction of palpation based tone, it is like what decides if you're gonna needle at all, or it really just decides where you're gonna put the needle in. So that's number one. If we're just talking palpation this morning, the first topic I wanted to tackle was how important it was diagnostically. and the TLDR there was that we're going to treat that muscle anyways, but there is that final puzzle piece, that final five seconds or so where we look for motor banding. That is where we want to put our needle.

GREAT PALPATION IMPROVES PATIENT COMFORT
Topic number two, I guess we're still going to call it palpation, but now it is about the technical aspects of controlling tissue while our needle is in. No matter what technique, no matter how you were taught to tap the needle in, set up a bracket window with compressed tensioning of tissue, or squeezing, or setting up the OK sign. Now we're saying, how important are the more nuanced aspects of tissue control? So again, we're not talking diagnostic criterion anymore. Here is where this tissue control, this tissue feel, this firmness of palpation separates novice needlers and more experienced needlers. Here we are saying that this is one of the primary aspects for making dry needling comfortable. You could probably argue this is part of making dry needling safe, but here is where palpation, quote unquote, becomes hugely important. very specifically the technical aspects of needling. Myself, when I'm on courses, every once in a while I get on the table for our faculty or just to get some free needles or just to volunteer my body. And when I'm on the table, this probably applies to all of you out there who have been needling for a while or work with someone who's needled for a while, you can tell pretty quickly, meaning before a needle is even tapped in, you can tell pretty quickly how confident that clinician is, how experienced they are based on how they palpate. And that is key. This tissue control, how we identify those motor bands that we just discussed for diagnostic or deciding where to put our needle, but really making the insertion comfortable, getting through some dense fascial planes or deeper into tissue, or just quickly, confidently, consistently getting into a muscle. There's kind of a clinical proficiency here as well. That is an expert art. Masters who do dry needling do this very well. So again, we've split the road. We're no longer talking about that being important for diagnosis. Now we're saying this is what separates expert clinicians from newer needlers is the tissue control. If you've ever taken a course for me or a course for me recently, when we leave the weekend, the last few slides, I kind of give you a few things to remember. And one of those things I hope was, Dry needling is a skill that you have to use, use it or lose it, unfortunately. That's tough in some states where you just learned, you just took your weekend course, you just learned how to dry needle, and you can't immediately go back and start needling every single patient in the clinic. But what you can do is start palpating your colleagues, your partners, your patients. You can work on that firmness of tissue pressure, you can work on tissue control, and really I'll say that is a primary aspect for dry needling. Again, not diagnosis necessarily, but making dry needling more comfortable, more effective, and clinically more efficient.

SUMMARY
And that's where I'm gonna drop off today. I mean, the emphasis today, I'm Paul, I'm one of our leads for the dry needling division, so this is kind of a dry needling topic, but really, didn't talk much about needles today. The question I wanted to answer is how important is palpation? And if you're just jumping on, thanks for joining. See a bunch of folks joining on Instagram. First of all, can we be safe with palpation only, meaning compared to ultrasound guided dry needling? The answer is yes, most of the time in most places. If we're palpating ribs posteriorly, maybe not. Number two, How important is palpation for guiding our diagnostic, our diagnosis, as a diagnostic criteria and how important is palpation? And the answer there is a little less if we're not talking trigger points, but it is that final piece of the puzzle. There is that final three to five seconds before we put the needle in that says, aha, motor banding, just palpated it, that's where I'm going. The third aspect of palpation is how important is it for dry needling, comfort, efficiency, all of that. And that's where we say very high. That is really what separates experts from novice or that's what separates a more efficient, proficient, confident clinician when it comes to dry needling. So the challenge this morning is if you have not really been waiting palpation as important for that pre-insertion with your needle. The challenge this morning is to spend two to three extra seconds. Add five more pounds of pressure through your fingertips. See if you can be a little more precise with identifying your motor banding before you put a needle in. And from there, once you've tapped the needle in, maintain that tissue control or that palpation focus for the entire time the needle is in. So this morning we won't talk about are we gonna piston a bunch, are we gonna twist it, are we gonna just leave it, are we gonna do e-stim. For now I'll just say for the entire time you're inserting the needle, you're moving the needle, you're repositioning the needle, focus on the palpation, the tissue control, maybe more than you were before. That is what separates the experts. So with that, I'm going to drop off. I held it to 15 minutes, which is always a victory for me. I apologize for the darkness this morning. I have my ring light on, but otherwise, kiddo is sleeping right next door. So we are dark and quiet here in the Killoran household. It is very early on the Pacific coast. So if you're jumping on, catch the recording, catch the first 10 to 15 minutes. How important do you feel palpation is? Or even to ask it another way, how do you feel your palpation, your tissue control, your confidence in palpating stuff has matured and improved from when you started dry needling to today? I'd love to hear, I'd love to have a poll, maybe I'll throw it up on Instagram, but I'd love to hear some comments on has it gotten better, has it stayed the same, more important, less important, where do you place palpation on your paradigm of importance, your pyramid of significance when it comes to dry needling. 
Otherwise I'm dropping off, if you're trying to catch a dry needling course with us for ice, The next few months are key, meaning we've had a really busy February. We have a really busy March and April. Then things kind of slow down. May, we take Mother's Day off. We have Memorial Day off. We have a post-sampler rest. So things start to slow as we get into the summer. All of our faculty have kiddos and family, and we know you all do too. So the summer will be a little lighter for courses. So if you're trying to catch us before the summer, Check out March and April courses. Ellie will be in Bozeman, Montana this weekend. I'll be in Baton Rouge. And then we've got a handful of other ones coming up. Otherwise, we're setting up our fall calendar now. So keep your eye on the calendar if you're looking for something post-summer for dry needling. As always, at PTONICE.com or check us out Instagram at Ice Physio or DPT with Needles. Thanks for listening, folks. Catch you next time.

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

Feb 26, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the sport-specific nature of gymnastics to the fitness athlete, introduces the strict pull-ups, considerations for when to modify, including the rack pull-up and box-assisted pull-up.

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

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

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

EPISODE TRANSCRIPTION

JESSICA GINGERICH
Good morning! Hello, my name is Dr. Jessica Gingrich. I am on faculty with the ice pelvic division here at ice. And today we are going to jump in to treating the pregnant athlete during gymnastics. So gymnastics is a broad term and it encompasses a lot of different movements that are utilized in a lot of different sports. So sports like gymnastics, kind of what we typically think of like with the beams and the floor routines and the uneven bars. That's what we typically think about. We also have cheerleading and we have yoga and trampoline, um, um, stuff, um, and CrossFit. So CrossFit is what we are going to focus on today. There are many movements in CrossFit that are under the term gymnastics. So we have pull-ups, we have handstands, we have toes-to-bar, we have muscle-ups, rope climbs, and even things like pistol squats are considered gymnastics. And of course these movements can be done either strict or kipping. The term gymnastics is defined as physical exercise used to develop and display strength, balance, and agility, especially those performed on or with an apparatus. You will see a lot of things on social media around the dangers of kipping movements within the sports of or in the movements of gymnastics. You may even think that yourself. And so what I want to do, I want to challenge you to reframe how you view kipping. So we're not going to talk about this today, the kipping, uh, any kipping movements. I'm going to talk about that next time I'm on the podcast, but I want you to start thinking about this because this is sports specific, right? So let that sit for a second.

GYMNASTICS IS SPORTS-SPECIFIC FOR SOME PATIENTS
We talk about sports specific as physical therapists all the time. So if you are talking to an athlete and you're talking about how dangerous and how funky it looks or whatever, it is part of their sport. And you see it in CrossFit and you also see it in gymnastics. We don't tell the baseball player or the baseball pitcher specifically to stop pitching, even though his arm goes through a really gnarly range of motion and kind of looks funky in those pictures once they're slowing down. What we do as physical therapists is we prepare them. We prepare them from a mobility perspective, a strength perspective. We talk about things like programming, sleep, nutrition, stress management, and we try to maximize their recovery so they can maximize their performance. So I wanted to mention this before we dive in to what we're going to talk about today, because I'm going to talk about it later. And then also during pregnancy, we also get that same language, right? We get the language around something being unsafe or dangerous, and it's simply just untrue. It's more about preparedness. So pregnancy does not mean that you have less of an athlete in front of you. So what does it mean for our pregnant athletes that want to come in and they want to continue doing gymnastics movements?

THE STRICT PULL-UP
So today we're gonna talk about specifically the pull-up, and even more specific, the strict pull-up. So first and foremost, we want to talk about points of performance. Whether your client listens to you or not with the points of performance, because you will run into that, that is something we should be teaching in our space. So the points of performance for a pull-up are your hands are just outside your shoulders, You have a full grip on the bar, so your thumb is wrapped, it's not here. And you start in a full hanging, full elbow extension position. And the movement is complete once you pull and your chin is over the bar. So, is pull-ups during pregnancy dangerous? No. Short answer and long answer, no. When coaching or modifying the pull-up, we want to consider those points of performance that I just talked about. We even want to consider having that athlete get into a hollow position, maintaining a hollow hang throughout the range of a pull-up. If your athlete just simply cannot do it, we modify. But if they can do it, and they are doing a strict pull-up, but they break the points of performance, then we also modify. Now, I know that a lot of you are thinking, what about coning? What about doming? What do we do when we see that? If your athlete is maintaining points of performance at any point or any modification, if you will, in a pull-up, so that is a strict pull-up, that's a band-assisted, that's a box-assisted, we're gonna talk about a couple of modifications. If they're breaking that point of performance in whatever modification they're using, then we further modify.

CONSIDERING CONTINUING
If they're maintaining their points of performance, but they're still coning, you may consider letting them continue. Now, all of you may be like, oh boy, that's not what we see. Right. However, that's where also when we program, when we talk about sleep and nutrition, all of this stuff comes together. So if you have someone who is, who is maintaining points of performance, but they're also coning, you're not going to necessarily say, Hey, go do a hundred pull-ups. That's where our skills and programming can also benefit these athletes. Remember that some of your athletes may have been able to do, these pregnant athletes may have been able to do a strict pull-up even one week ago during their pregnancy. So that can be incredibly frustrating when they come in and they're like, gosh, I could do this a week ago, what happened? Even five pounds of weight gain, if you've ever done a weighted pull-up, it's significantly harder. Now that weight gain is normal, but it's sometimes really difficult from a mental, physical, emotional perspective. But we want to still be able to give them the appropriate challenge. So their grip strength, their core strength is continued to, is able to continue to grow. So when we modify, we are encouraging movement. We are encouraging strength. we are encouraging that mental load, something where they can go to the gym and just like let the day go and not be even more frustrated by something they can't do. So now, before we go into the modifications, I will say I have had athletes that have maintained points of performance in strict pulling even well into their third trimester. So they keep going. We just let them go. We talk about symptoms to modify for, so if they're doing a pull-up and they're peeing in their pants on that pull, we wanna modify. If they're losing those points of performance, we wanna modify. Those who can't, when we modify, we really just wanna encourage the pull strength. When we talk about the strength, talk about grip and I've talked about core, I am lumping lats into core because I know some of you guys are thinking that.

MODIFYING THE PULL-UP: THE RACK PULL-UP & BOX-ASSISTED PULL-UP
So, two of my favorite pull modifications are the rack chin pull up in the box assisted pull up. So, where you're uh you got your feet assisted on the box. So, the rack chin pull up is going to be on a low bar or the child's pull-up bar. And so the athlete will stand and you want the bar just under their chin. Then they're going to hang from the bar and they're going to pull from that low bar, both feet on the ground. The box assisted pull-up is going to be the same setup, just with a box. Maybe they have to put a plate on top of the box and they'll stand up and their bar or their chin should be over the bar that they're doing their pull-up on. So the reason we love these is if you have a foot-assisted pull-up, you can use as much or as little assistance as you need in that moment. And if you haven't tried these, I'm gonna encourage you in your clinic or at the gym, try them. I've done these modifications for some shoulder stuff before, and they are hard. I am very sore after using these as a modification. And so this can be awesome. A really awesome, awesome modification. They're on the rig, they're feeling really good. With that box assisted, you can also use one foot instead of two. You can work on negative, so time under tension. They're really, really awesome. This will allow your athlete to continue pulling vertically instead of horizontally with a ring row at really any point in their pregnancy. They can use these as modifications in their workout. They can also use it as accessory work. They can do EMOMs, you can do anything with it. And so, as you go out this week, you've got your pregnant athlete, maybe you even have a postpartum athlete and they're wondering about pull-ups, try these modifications. They're hard, they're challenging. Do it with them so you can see what it feels like. Maintain those points of performance. Get that hollow position. and see how you do.

SUMMARY
So before I hop off, I'm gonna talk quickly about some of our upcoming courses. So our next online course is already sold out. So if you are wanting to hop on that course, head over to ptonice.com to sign up for our next one. It's gonna be April 29th is that start date. We are on the road this month. We'll be in Newark, California on March 2nd, and then Bismarck, North Dakota on March 9th. So we hope to see you out on the road. And like I said earlier, stay tuned for when I am on the podcast. Next, I'm going to talk about kidney and pull-ups during pregnancy. Have a great week.

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

Feb 22, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Older Adult Division faculty member Ellen Csepe demonstrates an example of using motivational interviewing techniques when discussing weight loss with a patient.

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

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

EPISODE TRANSCRIPTION

ELLEN CSEPE
Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a physical therapist. I'm bringing to you live the Technique Thursday and we're going to talk about motivational interviewing today. I'm joined by my co-worker Rachel Jordan. She and I are both physical therapists in Littleton, Colorado. And today what you can expect out of our episode is we're going to talk about what motivational interviewing is, what to look for in our kind of, um, reenacted interview between a patient and a provider and then we're going to kind of sum it up and bring it back home talking about how this case went at the end of the day. So we had an awesome discussion about weight management with one of our patients in the clinic within the last few weeks and I really wanted to share that with you guys. We used motivational interviewing strategies to talk about weight management and truly it was a slam dunk. So today we'll kind of start talking about what motivational interviewing is. So motivational interviewing is basically a counseling technique where we talk about where we invoke out of a patient their own wisdom and their own ideas on how to solve their problems rather than barking at them and telling them what to do. Motivational interviewing is a really powerful technique for providers to really treat patients first like people, then like patients, all while showing them that you genuinely care. This is an excellent strategy to talk about weight, which can be a hugely uncomfortable topic for some providers and patients. So this discussion that we had went super well. Rachel's going to be the patient. I'll be the provider. And what I'd like you to look for in our discussion are four key topics that kind of illustrate the spirit of motivational interviewing. And so those four key topics that really kind of reflect the spirit of motivational interviewing are partnership, acceptance, compassion, and empowerment. So think of it this way, partnership. I want Rachel to leave our session knowing that she has somebody who really, really cares in her corner. Partnership. Acceptance. I'm not gonna look down the end of my nose at Rachel while she's struggling. I'm in her corner and I'm cheering for her. Acceptance. Compassion. I recognize that weight management is really, really hard. From a biomechanical level, from a neuroendocrine level, Weight management is super difficult. So compassion. I see her struggle and I care. And then empowerment. I want Rachel leaving our session like she just won a game of elementary school dodgeball. I want her leaving this session feeling like she has got it made. I want her to leave here feeling like she has a plan, like she's on top. So again, partnership, acceptance, compassion, and empowerment. So we'll go ahead and get into character. So Rachel, I understand that your doctor sent you over to us to kind of check out your ankle. It looks like you had an ankle surgery, but it looks like it's going pretty well. Tell me a little bit more.

RACHEL
Yeah, I had the ankle surgery not too long ago. I repaired my deltoid ligament. Overall, the ankle's doing pretty well, but ever since, I've had a lot of falls and I'm having a lot of pain and weakness because I keep falling. And, you know, I really think it's a lot to do with my weight, that's why I keep falling.

ELLEN
It sounds like you're thinking that your weight has been an issue for you in the past. Is this the first time that you've kind of talked about this with a health care provider?

RACHEL
I've talked a little bit about it with my primary care doctor, but she doesn't really seem to take interest in having a conversation about it. I've asked her about the GLP medications that just came out, because they also have diabetes. She doesn't really seem interested in prescribing them and I just don't feel like I'm really feeling hurt when I go into the doctor.

ELLEN
That is really frustrating and it sounds to me like you're ready to make some changes. Like you're really eager to change your weight because you know that that's going to be a real stepping stone for you to be healthier in the future. Well, we can definitely talk more about that. So tell me a little bit more about what your history of managing your weight has looked like in the past. How can I help you?

RACHEL
Yeah, about 17 years ago I had gastric bypass surgery. But ever since, I've pretty much gained all the weight back. And so I'm just really frustrated because nothing has really worked. I've tried all the diets and that's been pretty unsuccessful in losing weight. I'm just feeling really hopeless about how to even go about that or what to do.

ELLEN
I am so sorry, and I just want you to know you're not the only person. Weight is really hard to manage long-term, and obesity is a chronic disease. Did you know that everything in your biology, after you lose weight, fights to get it back? Your body doesn't know the difference between intentional weight loss and starvation. So I hope you know that you're not the only one. And it can be really hard, but those new medications could be really helpful. It sounds like that's a goal for you, and that's something you've been interested in trying.

RACHEL
Yeah, I'm definitely interested. I just feel at this point I just need to do something because I'm unable to play with my grandchildren right now because I'm scared of falling and I can't get off the floor because I feel like I'm just really heavy and things. So I'm kind of feeling down about that.

ELLEN
So it sounds like you're feeling down about that and you're feeling kind of hopeless. Tell me a little bit more about what steps you're taking to manage your mobility. It sounds like It's the weight, but it's also your ability to balance, your strength. All of those things have kind of been keeping you back for the past few years. Tell me more. Are you doing any exercise participation right now?

RACHEL
No, I don't really like to exercise. I've tried some stuff in the past, but I just don't enjoy it and I feel kind of uncomfortable because I don't know what to do. And I think I just might hurt myself if I try to go.

ELLEN
That is totally understandable. And I'm sure every exercise attempt that you've had in the past has been to lose weight. Am I right about that? Yeah. And I mean, if you've been unsuccessful in losing weight, I bet exercise could be, feel really like a wasted cause and a lost cause. Yeah. So let's, um, I'd love to challenge how you see exercise because really exercise shouldn't be about punishing your body for what it isn't. It should be helping empower you to do what you want to do. For example, I know that you love playing with your grandkids. Lunges are a really great way to get up and down from the ground. So if you think about it that way, I'm not exercising just arbitrarily to lose weight, but I'm training for grandma duty.

RACHEL
That's what I really want to look for.

ELLEN
That's a really great point. It sounds to me like you're ready to make some changes. I have a few ideas that I can offer to you and I want you to tell me what you think. I have a few primary care doctors that I know are really on board with prescribing GLP-1 medications when it's appropriate. If you'd like, I'm happy to send you their names and you can check them out and tell me what you think. Yeah, I think that'd be great. It sounds like your foot is doing great. That's kind of on the back burner of what's important to us. Why don't you and I look at kind of creating an exercise program. to see if we can match what you care about to functional things that you can do in the gym. And if you don't like going to the gym, I can give you a lot of other options, too, to do these exercises at home and still feel like you're really getting a great workout. OK.

RACHEL
Yeah, I don't say I don't really like going to the gym, but I used to do a swim class, like swim aerobics, and I loved that. That's great. I felt comfortable and, you know, I didn't feel the weight on me.

ELLEN
Yeah, feeling weightless in the pool, there's nothing like it. And I know, I saw in your intake that you're a scuba diver. I am, I love to scuba dive. That is so cool. I definitely want to get you back into the open water. I bet you love scuba diving for that same reason, just feeling weightless and like you're floating. We've got to get you back into the water. And I know if you felt better about your balance and your mobility, those things would be way more confident. You'd be way more confident in those things. Am I right about that?

RACHEL
Yeah. Last time I tried to go scuba diving, I actually took a fall before and wasn't able to go because I hit my head. Oh man. And I just ever since haven't really tried again because I've just been a little discouraged about it.

ELLEN
Oh, I totally get that. That would discourage me too. And it sounds like if you and I have a plan to not just go to the gym mindlessly, but to really say, I'm working for a pragmatic goal to be able to get up and down from the ground, to be able to lift all my equipment, to be able to play with my grandkids. That's far more meaningful than going to the gym to bust out cardio.

RACHEL
i really feel good about this. I agree. I've never really thought of exercise that way.

ELLEN
Oh, well I'm so glad that we can kind of reframe how you see exercise because truly exercise isn't punishing you, it's enabling your body to do all the wonderful things that it can do.

RACHEL
This is awesome. I'm really excited about this. I feel like I have a little bit of hope now that I might be able to play with my grandchildren.

ELLEN
Well, I hope you know I'm on your team and weight loss and weight management are really tough. And I hope you know that I'm in your corner and I'm here to help you figure this out.

RACHEL
I really appreciate that. I feel like I finally felt heard today.

ELLEN
Oh good. So that was almost exactly the conversation that we had in the clinic within the past week. It was a slam dunk. And if I can kind of illustrate how this went further, She came in for an ankle surgery, a deltoid ligament repair, but by the end of the session she left here feeling super positive about the strategies that we discussed. to help manage her weight. And kind of the happy ending to this story is that the patient did get on those medications with her doctor after switching doctors. Her doctor was super old school. She started working with a new doctor and it went super well. It was the perfect medication for her to use. She started exercising regularly at home and she was able to get up and down off of the ground with some skilled training. from our team within a few weeks of this surgery. So I kind of just want to illustrate that this motivational interviewing can be hugely impactful for your patients and in your practice to talk about uncomfortable subjects like weight. The things that we really wanted to look for in our discussion were partnership. Rachel knew that after our session, she and I were on the same team. I was here to help her. Acceptance. I didn't look down the end of my nose and say, well, eat too much and that's why you have obesity or you don't exercise and that's why you're struggling with your weight. She knew that I accepted her for who she is and I saw her journey. So compassion. She knew that I had compassion for this struggle. She knew that I wasn't judging her. I genuinely cared because I genuinely do. empowerment. She left our session having a plan, having a goal, knowing exactly what she was going to do to manage her weight in the future. So thank you guys for joining us on today's Technique Thursday. I'm so glad that you could be here with us and I hope that these motivational interviewing strategies were helpful for you in the clinic. Have a great morning.

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

 

Feb 21, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones Dives into why working on kneeling is not a matter of IF we should do it but WHEN. Dustin covers a sequence of kneeling progressions, designed to gradually expose patents to kneeling in a manner where they have control over how much they flex their knee & how much pressure they allow onto the knee cap.

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

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

EPISODE TRANSCRIPTION

DUSTIN JONES
What's up crew, good morning and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division and today we are going to be talking about kneeling after a total knee replacement. kneeling after a total knee replacement. We're gonna dive into this somewhat hot topic if you will or debatable issue that we come across so often with our folks but more importantly give you progressions so you can actually get people's knees to touch the ground again. Alright this is a big issue that in my clinical experience I would often see the detriment of people not working on kneeling you know years decades after they had said surgery and it was really eye-opening for me and I'm sure many of you all as well to see what that does to people when they go for so long thinking that they are not allowed to kneel to let their knee apply pressure to the ground or that they're they're just afraid to right just think of all the functional implications that that has when you are scared to death to let that knee kiss the ground to be able to pick something up off the ground to be able to play with your grandkids to be able to kneel and garden right this is a This has huge implications for our patient's quality of lives and what's unfortunate is that it's often neglected, right? You think about your standard post-op protocol, what are you working on, right? You're trying to get full range of motion, trying to get that full extension, then really working on getting that flexion to be symmetrical with the other side. We're working on our strength deficits, we're working on our balance. and working on getting back to their independence in terms of gait as quickly as possible. But how many of y'all are getting applying pressure to the knee and progressing it to the manner where they're doing half kneeling, full kneeling, floor transfers, burpees, for example. How often is that getting neglected in the rehab setting? And it is far too common, far too common.

NO EVIDENCE THAT KNEELING IS HARMFUL AFTER JOINT REPLACEMENT
Now the unfortunate reality is we do not have any evidence to state that kneeling is actually harmful for individuals after they've had a knee replacement. There's even a really good article in the Journal of Knee Surgery, all right, so this is an orthopedic surgeon journal, in 2020, that basically said, I'm gonna read this verbatim, which I love this, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. I'm gonna repeat that again for the folks in the back, there is no biomechanical or clinical evidence contraindicating kneeling after a total knee replacement. The folks that wrote this article and this quote are orthopedic surgeons from Johns Hopkins University that work in the orthopedic surgery department. These folks are doing lots and lots of total knee replacements, doing lots of follow-up visits. And they're saying there's no reason why we should not be kneeling with these folks. So I think for us as rehab providers and some fitness professionals as well that watch this or listen to this, it's not a question of if we're going to kneel, it's more a question of when. When are we going to kneel in that rehabilitation process? And how do we progress people to the point where they can bear full weight on those knees and trust that they're going to be just fine, right?

KNEELING PROGRESSION
So let's kind of go through some of these progressions. I'm going to do a reel later on, probably the next couple of days, giving you some tangible video examples. but I'm going to talk through this, especially for the folks that are listening, we'll make sure that you're able to understand kind of this progression that we're talking about here. Alright, so kneeling progressions, this could be in the span of, you know, a few visits for some of your patients, it could be the span of weeks, but there's some important things that we want to have when we're talking about kneeling progressions. is an Airex pad or some type of pillow, right? The home healthers, you got a pillow, probably have an Airex pad as well, right? But you want a soft surface that is mobile, that you can apply to different surfaces, like when you go to the ground, when you go to a box, for example, or some type of elevated surface. You want something that you can take in terms of a soft surface. That's going to be very, very helpful for that individual. And then you want to have good elevated surface options. In the home, it is the couch, right? It is maybe a step. It is a kitchen chair. It's a recliner. It's a bed. In the clinic, it's a therapy table. It may be a plyometric box that you can apply the Airex pad on to give some padding. It may be a lobby chair, for example. Or a bench is another one. You want to have lots of options for these elevated surfaces. So typically when we're thinking about kneeling, where we want to start is with just manual overpressure into extension, maybe their legs just propped up, that person is applying pressure themselves. They are in control, and that first entry into kneeling, we want to do it in a manner where they feel like they're in control. You're probably already doing some manual overpressure, working on getting that full extension back, so we're already covering that, but that is going to translate well when we're applying pressure to kneeling, all right? So doing all that work that you're already doing to get range of motion, that's a good place to start when we're thinking about getting to the point full kneeling. The big thing is that they are applying that pressure. We want them to be in control. because that is going to give them the ability to probably progress a little bit quicker. Alright, so manual overpressure, we're already doing that stuff. Now we're talking about actually getting maybe in a standing position or we're talking about maybe getting to a kneeling position. You want to think about what available flexion do they have, right? And what is the status of the incision? Is the incision healed? Is the scar tissue solid? Are we not worried about any splitting, any tearing, any bleeding, so on and so forth. So if we're kind of well past that healing phase, then all right, we're somewhere, we're in a good spot, but we also wanna be considerate of how much flexion that they have. So if they are really struggling with their flexion, let's say they don't have 90 degrees, or 90 degrees is really tough, we can still apply kneeling in a 45, 60 degree angle, but in a standing position where they're going to apply pressure into a horizontal, or sorry, a vertical surface, all right? So let's say you're standing, your knee is bent to 45, 60 degrees, can have some type of vertical surface. In the home health setting where I would do this, it would be a kitchen cabinet, typically, and I would have some type of padded surface. I would get them to bend as much as they're able to bend, and I would have them shift their weight and basically think about putting their knee into that cabinet or that vertical surface, applying pressure in that manner. They're still in control. They are grading how much pressure they're applying, but they're getting used to applying force through that knee. Alright, now when we get more or closer to full range of motion, 90 degrees is real easy for them to do, then we can think about tall kneeling. When we go tall kneeling, what can be helpful is to have one leg on the ground and one leg on an elevated surface, right, like a bed is a great example, but what's really important here is to have upper extremity support. In the home setting, what I typically do is at a kitchen counter, so I have the hand on the counter and And then I would have a chair on the same side as the surgical side. I would have a cushioned mat, like an Eric's pad, for example. They would put that knee on that chair, and then with their hands, they would shift their weight, shift their weight. They would be grading that pressure, and over time, they would get more and more comfortable, all right? The upper extremity support is really important. Some type of cabinet. If you're in a clinic with parallel bars, that's really great as well. That's going to be very helpful for these individuals. All right, that checks out. Awesome. Let's go on to quadruped. Bed therapy table can be very, very helpful where we're able to really grade that pressure and they're able to rock and shift back and forth. applying more and more pressure to that surgical side. Once they're in quadruped, you are 75% home, right? If they're able to get in that quad position, you're in a really good spot. This is where we're going to start working our way to the ground. Now, when we go to the ground, you want to think about the softness of that surface, right? That's going to be way more tolerable for many of these individuals in a really hard, cold surface. So, if you have maybe a gymnastics pad, if you can maneuver that Arix pad that you've been carrying around under their knee when they're going to the ground, that can be really helpful. You may have a set of knee sleeves. which can be very, very helpful for these individuals. Or you may say, hey, let's get on, you know, two pairs of sweatpants, for example. So just think of some cushion and some padding. When you go down to the ground, that's going to make it a little bit easier for folks. Then we can go all the way to the ground, get in quad, work on getting in prone, working on coming up. In this phase, you do want to have some upper extremity support around. We cover this extensively in our MOA live course where you troubleshoot floor transfers, but there are certain positions where you want a box or a chair at certain phases of a floor transfer that's going to make it conducive for them to be able to use their upper extremities. But have a chair around that you can move around so you can place it appropriately. they can put their upper extremities on it and help grade some of that pressure that they're experiencing through the knee. And as we're working on floor transfers, and they're getting pretty comfortable going to the ground and up from the ground, that's where we may just speed it up, where we may go on to a full-blown burpee, right? So this progression from kind of that manual overpressure early on, still kind of worried about the incision side, we don't have full range of motion, to where they've got partial range we can start to do some standing, not necessarily kneeling, but driving that knee into a vertical surface if they can't get that full 90 degrees and then we're progressing it down to where they're in that quad position doing floor transfers and progressing to a burpee. This is a kneeling progression that almost all of us can do with our folks in some way, shape, or form, right? And I challenge you clinicians watching right now that are listening right now. Zach Kaufman, what's up? I challenge you all to not think of if you want to consider kneeling in your post-op protocol or plan. It's more a matter of when. You need to do it. I've seen the implications of what that means for folks 10, 20 years down the road when they have had the fear of God instilled in them to get down on their knees. dramatically lowers their quality of life and what they are able to do and what they choose to do. It is absolutely sad to watch and you can prevent that by incorporating kneeling and kneeling progression into your plan of care that you're gonna give this person so much freedom to experience so many good things in life when they have the ability to let their knee hit the ground. All right, appreciate y'all. Let me know your take on kneeling after total knee replacement. We could say total hip as well. It's just as applicable for hip replacements too, but let me know your thoughts in the comments of this YouTube video or hit us up on YouTube podcast listeners. We'd love to have you jump on social media. I think this is a really important discussion, something that we often neglect, and I think we need to really change that narrative. All right, appreciate y'all watching. Have a good one.

SUMMARY
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.

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

Feb 20, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division faculty member Jordan Berry discusses how slowing down in the clinic both with evaluation & treatment can give clinicians a clearer picture of patient symptoms. Going slower early in the plane of care allows clinicians to better understand if treatment is creating meaningful change or not, thus allowing treatment to accelerate over time. The alternative of attempting to perform multiple treatments to multiple regions each visit can actually complicate clinician understanding of a patient's progress, slowing rehab down significantly.

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

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

EPISODE TRANSCRIPTION

JORDAN BERRY
All right, good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management. It is Tuesday, so that means it's Clinical Tuesday. Today we are talking about why in the clinic you have to slow down to speed up. Because if I was reflecting on what is the feedback that I give to most clinicians, either myself that I'm watching clinicians treat, or I'm doing case reviews, working through challenging cases with clinicians, or if we're at our cervical or lumbar live course, we're chatting through some of the more challenging present presentations and patterns. Probably the most common feedback that I found myself giving is telling that person to slow down, right? And you have to slow down in order to speed up the rest of the plan of care. So I want to unpack why if you slow down during the initial eval and during the first few subsequent follow-up sessions, you are going to be able to in turn speed up the rest of the plan of care and maximize your outcomes in the clinic. I think the quote, slow down to speed up, could be somewhat interchangeable with do less, better, right? Which we always talk about in the clinic, doing less, taking your time, but doing a better job. But I want to talk about why specifically slowing down is going to allow you to speed up over the long haul throughout the plan of care. And putting this together and this idea, I have to give a shout out to the book Unreasonable Hospitality by Wilgie Dara. I love that book. If you have chatted with me at all over the last year, year and a half, you know that I love that book so much. I've read it multiple times. And it's something that they talk about in that book as well. The idea of slowing down to speed up. They're talking about it more. So if you're not familiar with that book, you've got to read it. It's about it's about a restaurant and how they grew that restaurant to be the best restaurant in the world So they got ranked number one a few years back and one of the concepts they talk about is slowing down taking your time and making sure that you have everything correct up front as you're servicing that table or waiting on that table to make sure that the rest of the meal goes smoothly. And I love that idea. I think it was because prior to PT school, I was in restaurants. I worked in the restaurant industry pretty much my entire life prior to that. But the idea of slowing down in order to maximize your outcomes applies to the clinic too. And so I want to talk about two case examples. and how we would apply that in the clinic.

CASE EXAMPLES: WHEN GOING FAST GOES WRONG
Okay. So first case example, we're going to call her Kathy. So Kathy rolls in and she's got a bunch of symptoms. She's got neck pain. She's got shoulder pain, some referral up into the head, maybe some paresthesia down into the forearm and hand. The whole works, right? We know that patient. And during your initial evaluation, day one, right? You're definitely trying to figure out where the symptoms are coming from. In addition to all the other things that we would be trying to do during the initial evaluation. But one of the primary things is you're figuring out what is the primary symptom generator, right? What area am I going to intervene on day one? And let's say that you go through the objective exam and a bunch of things show up. So you're going through cervical active range of motion, you're going through the cervical segmental exam when you're testing the joints and both of those things provocate symptoms. But then also, let's say you're testing the shoulder and in range flexion brings on symptoms and you challenge external rotation manual muscle test, right? And that brings on symptoms. You palpate the posterior rotator cuff and that lights it up. So we've got a bunch of things on board day one. Here's the fork in the road that separates novice from expert on deciding where you're going to go with that initial treatment. What does a novice do with that presentation day one? They try to attack all of it. So in that, let's say eight to 12 minutes of that initial trial treatment, they try to shove all of the cool stuff as many things as they can into that initial treatment. So maybe they do, let's say cervical retraction, let's say some distraction, they're cracking the upper thoracic spine, they're cracking the neck, they sneak in some soft tissue work to the shoulder, they're loading external rotators, the whole thing. And let's hope, number one, that they've done some sort of reassessment throughout. Likely, if they do a reassessment at all, it's at the very end, after they've done all of these interventions, And let's say the patient, Kathy, let's say during the retest, she says, okay, that does feel a bit better, right? I don't have as much pain. Here's the problem. Here's the trap. Regardless of whether or not the patient is feeling better, right? And whether or not they improve over the next session, you have just set yourself up for disaster. because you have no idea what treatments actually helped the patient and they have no idea what treatments actually helped. So over the next few days between this session, the next session, they have absolutely no idea what they should focus on, what area they should be focusing on, what they should be paying attention to. And more importantly, during the next session where they come back, you have no idea of how to press. Because you threw everything at it, well, really your only choice next session is to continue to throw everything at it. So next session, you've got to crack the neck, you've got to crack the upper back, you're doing the soft tissue work, the retraction, you're loading the shoulder, maybe some dry needling now, some soft tissue work, right? You're doing all the things because you did that initially and now we've just got to continue with that. In other words, because you were trying to go fast, You've number one, likely failed to dose anything with enough intensity to actually make a meaningful change. And number two, if you plateau, let's say on visit four, visit five, you literally have no idea what to shift to or where to go because you threw the kitchen sink at it. So you tried to go fast early on and you wound up slowing yourself down over the longterm. Now on the other hand, right, the expert, that initial evaluation after you do the objective exam and all the things show up, what if you stepped back and said, you know, Kathy, we're seeing some different things here. We have some things that showed up in the neck, some things in the shoulder that both brought on your symptoms. However, for today, I'm only going to treat the neck. We will treat the shoulder over the next few sessions, but today I'm only going to treat the neck so that we know over the next week or so what things are actually related to the neck and changing. Now I want to say here, I don't think it matters if you treated the neck or the shoulder day one. I think what matters is that you actually just chose one area and you stuck to that one area. Because let's say she comes back, let's say Kathy comes back next session and she's feeling a bit better. Well, because you only treated the neck, you now know exactly how to progress things. You can say, okay, Kathy, that's great. I'm glad actually everything's actually a bit better than what I was expecting. So now we know the symptoms are primarily coming from the neck, not the shoulder. Now we can focus here. or if Kathy comes back and maybe she's not doing so hot, right? You're not seeing the symptom change that you would expect, right? It's not ideal, but you can still spin it now in a positive way. You can say, okay, Kathy, that's great information. That's not the changes that we were expecting, but what that does is confirm that maybe it is the shoulder that's driving more of the symptoms. So today, if you don't mind, I'd love to change gears and focus now on the shoulder, and we will be able to track this forward and see what kind of symptom change we get from that. But either way, you can now dial in the rest of the plan of care, right? You started out slower. You took your time during those first few sessions to understand the presentation. And now you're going to speed up the progress over the next few visits. And you're going to end up making more change over the longterm than that novice clinician that wanted to throw everything at it from the start. Most complex clinical presentations are just simple presentations, simple patterns stacked on top of each other. I repeat, most complex clinical presentations are just a few simple presentations stacked on top of each other. So all you have to do is take your time and tease them out one by one to figure out what is causing what and what is affecting what. And that will guide how you move forward. Okay, example number two. So it's a little bit shorter, a little bit more simple, right? So let's say Kathy rolls in more simple presentation. She's got some unilateral low back pain referring down into the glute. You go through your objective exam, lumbar active range of motion, pretty limited in all planes and recreate some symptoms. So it's pretty stiff and a bit painful, specifically flexion, super limited. She bends forward, no reversal of the lumbar spine, segmental exam, super stiff, hip totally clear. And you decide, um, for your initial trial treatment that you want to do, you want to mobilize the lumbar spine, right? You want to see if we can improve some of that motion. And let's say you choose that sideline lateral glide, non thrust mobilization. Side note, if you don't know that, that, that lateral glide mobilization, you've got to learn that. We teach that in the live lumbar management course for sure. That is by far my most used non thrust mobilization to the lumbar spine. Anyway, let's say that you choose that and you dose that for two to three minutes. Kathy gets up and let's say you reassess flexion and she's got a nice five degree change in range of motion. So she improves by about five degrees and a little bit less pain. Now, nothing miraculous, but you see a small positive change. Okay, here's that same fork in the road of novice versus expert. So if you were to ask that clinician, the novice clinician, what are you going to do next? Almost always they are going to say, well, I'm now going to do blank, which is some other cool intervention, right? Well, I'm going to do some dry needling. I'm going to do some decompression with cups. I'm going to crack their back. I'm going to do this exercise. It's something different. On the other hand, what does that answer look like from the expert? When you see that small positive change, what are you going to do next? More. You're going to do more of it. So you say, Kathy, get back down there, right? You mobilize your back for another four or five minutes. She gets up. You see another small positive change. What do you do next? You get back down there. You keep working the thing that is working. The expert sees the change and doubles down and does more of it. Maybe you change your angle a bit on the mobilization, maybe you do both sides, maybe you work up and down the lumbar spine again, but you are not leaving that intervention while it's still giving you additional benefit. You ride that horse until it bucks you. If it works, great. Do more of it. Instead of trying to cram everything that you possibly could during that session, right into that one session, focus on the thing that is working and just increase the intensity. And now the patient has one thing to focus on. They know exactly what is actually changing their symptoms and you can sell the next session. Just say, Kathy, when you roll in here next time, we're gonna add a little bit of A, B, and C on top of the thing that we already know is working. And now you can take your time, right, and you can stack interventions on top of each other. So many times in the clinic, when I'm reviewing the quote-unquote challenging cases with clinicians, when they're telling me what they've done, right, throughout those first few sessions, They typically have done at least one intervention that has given some change, some positive change, some improvement. And I always ask, well, why didn't you do more of that? Why did you actually go to this instead of just doing more? And it's crickets. We're so obsessed with doing things, with trying to give the person more interventions, more of our skillset. instead of just doubling down on the thing that's working. So I will take something in the clinic, an intervention is working. Let's take that lumbar spine mobilization. I will just hammer it until it doesn't work anymore. Right? So if you're retesting four times during a session and every time it gets better, just continue to use that same intervention until on your test retest, it fails to give additional benefit. it will simplify your clinical reasoning, slowing down with your intervention, again, allows you to speed up over the long haul. So think about those two examples this week in the clinic, slowing down to speed up. So early on in the plan of care, focus on tackling one area, commit to it, and watch your decision making throughout the rest of the plan of care become so much more clear. And once you do have that treatment that's working, commit to it and ride that horse until it bucks you. Until when you retest, it gives you no additional benefit. But if it does, you stick with it. Those two things together are going to allow you to maximize your outcomes in the clinic. All right, would love to hear thoughts on this.

SUMMARY
If you want to learn more about this or that technique that we mentioned or any of the clinical reasoning around it, we've got a few live courses coming up. Let's see, for cervical management, we've got one in February in Simi Valley, California. We've got two in March in Kuna, Idaho and Longmont, Colorado. And then for lumbar management, we've got one in March in Cincinnati that is actually sold out already. And then we've got Milwaukee, Wisconsin at the end of March as well. So that is it, team. Have an awesome Tuesday in the clinic. If you're coming to a cervical or a lumbar live course, we will see you soon. Thank you.

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.

Feb 19, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares some insights and a “big win” from a coffee marketing meetup with a physician. She cites 5 clinical pearls for how to approach challenging the status quo of practice patterns with the providers in your community.

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

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Good morning, everyone. This is Dr. April Dominick. I am on faculty with the Ice Pelvic Division. And today I wanted to discuss a recent marketing win that I had with a physician and some insights regarding how to challenge the status quo of practice patterns within providers in your community. One concern that we often get with our ICE courses and especially in the pelvic division is someone will say, hey, I love all of this incredible research that you all are sharing that is completely different from the way that I practice and I'm so stoked and I'm so behind it. But how do I recommend or how do you recommend that I bring this back to a community of providers who are pretty steadfast in their practice patterns? So today I'll share that recent interaction. And again, it was a marketing meetup with a physician and I want to share how it went from an invite for a latte to an invite for a lecture that I could give And all of that happened in just under 35 minutes. So I met with an OB who I have a pretty solid referral relationship with. She refers folks to me, I refer folks to her, and we were just catching up over some mutual patients that we had. And the conversation ended up turning towards how she counsels patients in the pregnant and postpartum space in regards to exercise. And she absolutely encourages people to continue moving, keep exercising, working out. But she says, you know, I caution them against doing planks and I don't really support twisting and turning because I don't want to make that diastasis recti worsen or that thinning of the linea alba. And she also says that she cautions individuals with any sort of impact because she doesn't want to further any sort of urinary incontinence. In my head, I was like, ooh, gosh, there's so much research that has come out, especially in the past six to 10 years, that doesn't support that line of thinking. But how do I share that with her without, you know, stepping on her toes and interrupting this beautiful relationship that I've developed with her? So I asked, I said, would you mind if I shared some updated evidence that we have regarding all of those topics? And she was totally game. She was like, fire away. Yes. So I shared the benefits and the protective mechanisms that we know about as far as core strengthening during pregnancy and early postpartum. I relayed to her the reality of the situation regarding diastasis recti is we don't even really have a consensus in the literature for defining it. And I also quoted some studies that we also talk about in our live courses and our online courses about when it comes to someone who is one year postpartum, they are likely still, some of them still have a diastasis recti and that those with a persistent diastasis recti tend to have a weaker rectus and oblique strength score compared to those without a DRA about a year postpartum. I also anecdotally, I mean, I had to squeeze this in somehow, but I anecdotally shared that since I started loading the core more during pregnancy and early postpartum, that some of our mutual clients, I did some name drops, have actually had relatively quicker recoveries on the back end, on the PT side. And they've returned to their functional activities seemingly with more ease. And that was, of course, all things considered and just an anecdote, but it's something that a trend that I've noticed. And that's all for folks who have prioritize course strength training as opposed to those who have not or those who continued some sort of resistance training of some sort. We also talked about other topics and I threw in that we have a lot of evidence regarding the benefits of resistance training and lifting heavy during pregnancy and some preliminary evidence that says hey, exercise and heavy strength training may support the role of lowering some pregnancy complications, including gestational diabetes, gestational hypertension, and even some perinatal mood disorders. And then of course, I let her know, you know what, I am there to help support someone in their endurance training, their impact training, Um, and I help address that pelvic floor dysfunction. So I actually will come alongside someone, um, with those goals. And if there is any sort of pelvic floor dysfunction or urinary leakage, um, I got them. And, and that's not something that I discourage. Her mind was blown. Like she was glued to me as I was just rattling off all of this new information to her that differed from her current practice patterns and likely what she had been trained under when she went to school or in the last continuing education class that she went to. Or maybe she just hasn't really been to any of this because that's not necessarily her expertise. So she was just mind blown and she was so excited to learn this new information. And I said, you know what, this line of practice that I just shared with you, all of these recent updates and literature, this is more of a recent shift even for me. When I first started practicing in pelvic health, up until three to four years ago, I had many of the same practice patterns that you just shared with me. And in fact, many PTs, many other pelvic PTs are still currently practicing with those similar philosophies because that's how we were trained. And not everyone is caught up in respect to the latest evidence. So we talked about different concerns also that we hear in our clinic rooms. And that was fascinating, a whole nother podcast episode, but it was just really fascinating to hear that some of the concerns that her clients have, that our clients have, what they tell her in the clinic room is very different from what the conversations I have. And of course I shared with her, you know, a lot of the folks who are pregnant and postpartum, They have so much fear on board regarding getting a diastasis recti during pregnancy. By the way, it's 100% normal. And how they often pay for generic programs to get flat abs from Instagram influencers and they don't work and then they're frustrated. Or they share with me how they're just terrified about getting a perineal tear during delivery. or they're just determined not to have their organs fall on the ground after pregnancy. And it was so interesting because she, she was like, April, that is, those are not the main concerns in my sessions. And she was like, this is so informative to hear what's happening over there. She also doesn't have Instagram. So I feel like that may influence what it is that she sees and hears. But again, we were talking about in our clinic spaces. So I also got curious because I had some questions that were more on topics about her expertise, like perimenopause, menopause, and hormone replacement therapy, which all of those topics are being discussed way more in the pelvic PT space now. So at the end of the conversation, she thanked me so much for sharing the recent literature. She said, I am so much more confident now promoting whole body strength, including the core, like I feel comfortable because of what you shared with me, promoting people doing planks and promoting impact exercise throughout pregnancy and postpartum. She wanted those articles emailed to her immediately. And the most surprising and probably the best part of this entire meetup was that she asked if I would like to give a presentation at Grand Rounds of the do's and don'ts of exercise during pregnancy and postpartum. She was like, my colleagues would 100% benefit from hearing what you have to say. It'll be a tough crowd because she said many of her fellow nurses and physicians assistants and doctors practice from what they learned, uh, 20 to 30 years ago and are even way further behind than how she practices. She's like, some of them are still promoting bed rest. Um, even when the client doesn't meet that criteria. And she said that she often will come behind providers as she's rounding up the hospital and say to the clients, no, I want you to get up and move. Moving is good, exercise is good. Because I guess some of her other colleagues have said, no, no, no, just stay in the bed, stay in the bed, that's gonna be better for recovery. So I was of course ecstatic when she asked me to do a Grand Rounds lecture. I told her, you know what, it would even be very helpful from my perspective if clients heard about the benefits of continuing resistance training and core work and impact exercise from the medical community because Clients have so much respect for the medical community. So if they are hearing about it first from them and then they get to see me later, if that's the order that happens, even better that we are reinforcing that strength is queen and that can help knock down a lot of those fear-based messaging that our clients get. So, In a matter of 30 minutes, I went from coffee grounds to grand rounds. I want to identify just five things or themes that I came up with from that interaction that may help you cultivate a relationship with a provider, whether it's an OB, an orthopedic surgeon, or a chiropractor, massage therapist, whatever. Use these when you are going to market.

LEVERAGE THE LITERATURE
Number one, leverage the literature. and thoughtfully ask if it's okay for you to share that recent literature has overturned some of those old tiny beliefs. So reference some of the amazing evidence-based pearls that you've gotten from your ICE courses or from some of our posts. It's all about being respectful for that delivery in the question. So I'd recommend that you just be honest and say, would it be okay if I shared some of the recent literature with you that I have found incredibly helpful for my practice in bettering client outcomes?

VALIDATE THE OTHER PERSON
Number two, validate them. Share that it wasn't long ago that you were practicing in a different way that maybe didn't align with some of the recent clinical practice guidelines. Sometimes the oldest techniques don't necessarily stand the test of time and they may not be the most effective.

SHARE CLINICAL OUTCOMES
Number three, share some stellar clinical outcomes. Use wins from mutual patients if that's an already established referral source.

ASK FOR ADVICE
Number four, ask them for advice. When it comes to a topic that is in their expertise that you may be curious about, or maybe you have an uptick in this particular diagnosis on your caseload. There is nothing that people love more than talking about themselves. Exhibit A, just kidding. Um, but they love talking about how they treat their philosophy. And when you ask someone for insight that shows, you know what, that shows that you're curious and you're wanting to learn from them. So it becomes more of a two way street.

LEAN INTO YOUR PERSONALITY & PASSION
And then finally, number five, lean into your unique personality and passion. When people get a sense of how incredibly passionate you are about changing lives and how you practice being about it day in and day out, they listen. Think about the first time you tuned into a PTA on Ice podcast episode with Jeff Moore or Christina Prevett blasting their truths from behind the mic. how you can feel their excitement through your speaker as they rap about getting that PT version 2.0 going, about how we need to remove barriers to exercise in the older adult, the pregnant and postpartum space. So lean into your personality, whether it's loud and proud or quiet confidence, and let that drive your passion behind changing the status quo in your community. I hope you found this marketing one of mine and those insights helpful for your next marketing meeting. Remember, leverage recent literature, validate the provider and how you may have just recently shifted to using these more evidence-based interventions and strategies, share recent client wins and trends, get curious about their expertise, and then lean into your personality and let that elevate your passion for providing Fitness Forward, evidence-informed care in the PT space.

SUMMARY
If you're feeling like you need to brush up on some of the latest research and treatment strategies in regards to fitness, guidelines, and any sort of pelvic health issue, join us in our Ice Pelvic Courses. We have some live courses coming to you. Alexis and Rachel will be in Newark, California. the first weekend of March, and then Alexis and I will be in Bismarck, North Dakota the second weekend of March. There's still time to sign up for those. And then from an online perspective, our next level one cohort starts March 5th, and we only have a few seats away from being sold out for that cohort. So hop on in. Thank you so much for joining and remember to bring that Be About It attitude not just to your workouts but to your marketing meetings and coffee meetups as well. 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.

Feb 16, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses current recommendations on protein intake, new possible recommendations, and barriers to showing efficacy with different amounts of protein consumption.

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

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
All right. Good morning. PT on Ice Daily Show. Happy Friday morning. Hope your morning is off to a great start. My name is Alan. Happy to be here today. Currently have the pleasure of serving as the Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Friday. It is Fitness Athlete Friday. We talk all things related to CrossFit, Olympic weightlifting, powerlifting, endurance athletes, If you are working with a patient or client who is recreationally active, out on the road, on the bike, in the gym, Fitness Athlete Friday is for you. Just a quick announcement before we get into today's topic. If you're going to be at CSM or you're already at CSM, join us tomorrow morning, 5am, CrossFit Southie. We have a free workout going on, led by me. I'm getting on a plane later tonight to fly out there and run the workout tomorrow morning. So whether you have many years of CrossFit experience, whether you have zero minutes of CrossFit experience, we're going to have a fun workout tomorrow morning at five. Please go on our Instagram, go into the pin post and sign up for the sign up form. The link is in that pin post. So today, Fitness Athlete Friday, what are we talking about? We're talking about a paper that just came out at the end of 2023 and was published a few weeks ago, looking specifically at protein digestion. Hang on, buddy. Come here. Sorry about that. We're going to talk about protein digestion and the upper limits of what we think can happen with protein digestion. So we're going to talk about current protein recommendations based on the current body of research. We're going to talk about what this paper found and the conclusions it drew that may change those protein recommendations. And then we're going to talk about barriers to this research.

CURRENT PROTEIN CONSUMPTION RECOMMENDATIONS
So the paper we're referencing today, the title is the anabolic response to protein ingestion during recovery from exercise has no upper limit in magnitude and duration in humans. was a paper published in December 2023 by Tromelin and colleagues, pardon my sick son coughing, and the journal title is Cell Reports in Medicine. So that's the paper we're referencing. Current protein recommendations quite old and they typically recommend and advocate that humans can't digest or otherwise synthesize protein in amounts above about 20 to 25 grams of protein per hour and If you're like me, you were sitting in a lecture in undergrad maybe 20 years ago and you heard that based on literature from the 90s and the early 2000s and you thought, hmm, that seems really specific and also really impractical given how much protein we're recommending that people eat. How can somebody possibly only synthesize and utilize 20 to 25 grams per hour. That would mean an individual, especially a larger, more muscular individual, would basically need to be always eating protein, right? A lot of these studies look specifically at whey protein, a faster digesting version of protein. Whey protein is essentially the watery portion of milk with all the fat strained out. But even at moderate protein consumptions, think about an individual who's maybe 6'6", 300 pounds. No, no. No, no, okay, we're gonna hold you all the time. Somebody who's 6'6", 300 pounds, that person would need to eat 20 to 25 grams of protein for 12 to 14 hours in a row to get all of their daily protein in, maybe just at a maintenance protein level. That is really impractical and yet, up until this paper was published in 2023, we don't really have any other recommendations that we could give. So cue this paper being published at the end of the year. You see yourself, hi.

NEW PROTEIN CONSUMPTION RECOMMENDATIONS
This paper, fantastic methodology, amazing study, really good incorporation of inclusion and exclusion criteria of the subjects used, but also did a really good job of being very thorough in measuring and tracking the protein synthesis in the subjects in the study. So let's talk about that study. This study looked at 36 healthy males between 18 and 40. Inclusion criteria, they had to have a BMI between 18 and 30. They had to have already been exercising one to three days per week, so they needed to basically be familiar with exercise, particularly resistance training. And exclusion criteria included anybody who smoked, anybody who was lactose intolerant, and anybody who was taking any sort of prescription medication. So basically we looked at rather young, rather healthy men. What did we do? We had them all perform the same type of resistance exercise. We had them perform the same resistance exercise protocol. They went into the gym, they performed one set of 10 reps at 65% of their max on lat pulldown, leg press, leg extension, and also chest press, so bench press machine. They then did four sets to failure at 80% of their max. So they did all the same resistance training protocol. And then what changed, what varied in this study was how much protein they consumed after the resistance training protocol. So some subjects were given no protein, that was the control group. Some subjects were given 25 grams of protein. And then another group was given 100 grams of protein. So four times current best recommendations. And the hypothesis was, how much protein synthesis might we see compared to the 25 gram group in the 100 gram group. We looked at immediately post-exercise, we looked up to 12 hours post-exercise and we found some really interesting results that essentially the higher protein group saw continually increased levels of protein synthesis out to the end of the study, the end of the 12-hour period. So the 25-gram group had increased protein synthesis obviously compared to the zero-gram group, but the 100-gram group had 20% increased levels of protein synthesis in the zero to four-hour measurement window and 40% higher in the four to 12-hour post-exercise window. So this paper is great because it really opens up the notion that we can front load our protein and that we can potentially catch up on a protein deficit later in the day. For a lot of our folks, especially our active folks who are also maybe working, wrangling kids during the workday, trying to get enough protein in and trying to get it in those 25 gram feedings is probably just not feasible when we're looking at individuals eating 200, 250, maybe even 300 grams of protein a day. Simply not possible to get that. So a lot of those folks have issues with timing of protein intake. and also the belief that any consumption beyond 25 grams might be wasted. This article is really a landmark paper because it shows that that might not be the case, that we can front load large doses of protein or catch up with big doses of protein later in the day and see really long windows of protein synthesis after resistance training. Again, 40% higher at the 12-hour mark compared to 20% higher at the 4-hour mark tells us protein synthesis actually increased the further away we got from both the exercise and the actual consumption of that protein.

RESEARCH BARRIERS
Now there are some barriers with this research, we need to be mindful of what this paper does not say. This paper did not look at objective measurements of things like strength or hypertrophy, so it would not be fair, hi buddy, you're gonna knock my tripod over, It would not be fair to use this study to say that eating 100 grams of protein at a time makes you stronger, makes your muscles bigger because the study did not look at this and therefore we cannot conclude that 100 gram doses are better. What we can conclude is that this may be an alternative way to consume our protein that results in equal or even higher amounts protein than the traditional recommendations of 25 grams per hour. What we also need to be mindful of is that all of the research on 25 grams per hour looks specifically at subjects fasted eating whey protein. This study literally did the opposite. It looked at individuals who were fed, who had just performed resistance training, and who were essentially eating casein protein, the fatty portion of milk protein. So eating basically the opposite aspect of the protein and doing it under a different mechanism, doing it after exercise as compared to doing it fasted. So it is a little bit of comparing apples to oranges. Nonetheless, what we can take away from this paper is an alternative feeding strategy, especially for those individuals who we see in the clinic, who we see in the gym, who may tell us that they simply don't have time in their day, time in their schedule to eat protein in 25 gram feedings. If those patients, if those athletes, if those clients are already saying, hey, I know I'm not getting enough protein because I don't have time to eat 25 grams every hour for 14 hours, and I'm just simply not eating protein, then this is a very viable alternative solution of, hey, let's try front-loading your protein before you leave the house for the day. Let's try eating, you know, 50, 75, 100 grams of protein, maybe half, maybe 75% of our protein intake for the day before we leave the house. Now again, what we can't promise those people is that they will have equal or better levels of muscular strength or hypertrophy gains, but nonetheless we know how important protein is at least for recovery. so we can make that alternative recommendation to those patients and clients.

SUMMARY
So, protein, is 25 grams an hour the maximum? It doesn't appear so. It appears that the more we eat, the higher levels of synthesis that we have, at least in the scope of this paper, up to 12 hours after we've consumed that protein. Is it better? We don't know yet. We need more research. We need to now look at a study of folks eating 25 grams versus 100 grams and now measuring them more longitudinally and seeing what does muscular hypertrophy look like, what does muscular strength look like, even what does functional outcomes look like, different functional tests. but that being said this is still a very landmark foundational paper that should change our mind about how we think about eating protein that we can think about front loading if we need to we can think about catching up at the end of the day eating a big dose of protein maybe with dinner. I know Mitch Babcock who teaches here in the fitness athlete division a big fan of a big bowl of cereal with protein powder on it on the end of the day just to get a big lump of protein in before the day's end and that might be a viable successful alternative for a lot of our patients and athletes. So protein get it in get it in where it fits in even if it's a bigger dose than previously you may have been led to believe would be effective. Courses coming your way really quick. If you want to come learn more about protein, recovery, nutrition from the Fitness Athlete Division, our Level 1 online course starts again April 29th. Our Level 2 online course starts September 2nd. And we have a number of live courses coming your way throughout the year. A couple coming your way the next couple months. We have Zach Long down in Charlotte, North Carolina. That'll be February 24th and 25th. Zach will again be out on the road, this time in Boise, Idaho, March 23rd and 24th. And then we have a doubleheader the weekend of April 13th and 14th. Joe Hineska will be out in Renton, Washington, near Seattle. And Mitch Babcock will be down in Oklahoma City, Oklahoma. So I hope you have a wonderful Friday. Please join us at CSM if you're going to be there. 5 a.m. tomorrow morning, CrossFit Southie. Other than that, we hope you have a great Friday. Have a great weekend. Bye, everybody.

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

Feb 15, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses the differences in how regret can present from overworking an unrewarding job, but also from underworking in a career with a lot of potential for both personal & professional impact.

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

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

EPISODE TRANSCRIPTION

JEFF MOORE
Alright team, what's up? Welcome back to the PT on Ice Daily Show. Thrilled to be here on Leadership Thursday. I am Dr. Jeff Moore, currently serving as the CEO of ICE and always pumped to be here on Leadership Thursday, which always pairs as a Gut Check Thursday. Let's get right into it and talk about the workout. So what we've got is the CSM workout. Both Alan Fredendahl and Paul Kalorin of Ice and iDryNeedle, the combo, are going to be there to lead you all through a workout Saturday morning. Anybody at CSM who wants to get some movement in, please join us. 5 a.m. CrossFit Southie. You've got to sign up on the form. So go to the Ice Students page. The form is on there. It's here on Instagram. It's on the pinned post for the CSM WOD. I think we have like 20 signups and I want to say they're taking in 30 or 40 so as we get very near to Saturday morning make sure you jump on there if you indeed want to work out. It's going to look like this should you choose to attend. It is going to be an AMRAP 25 minutes. Now mind you, anybody not at CSM should still do this. Teams of 2. We've got a 100 calorie row. We've got 80 alternating hang dumbbell snatches at the usual 50-35. You've got 60 box jump overs at 24-20. You've got 40 toes to bar, and then finishing off with 20 burpees over a dumbbell, and then going back up to the top, should you have more time in your 25 minutes. Should be a really nice chipper running through that. Gonna get kind of a one-to-one work-rest ratio. Should be able to keep moving. Should be an awesome workout. If you go to the CSM workout, please make sure to tag us. I won't be there, so I'd love to see photos and videos of all of you getting after it. Let's jump into Leadership Thursday.

DEATHBED REGRETS
The topic is deathbed regret. Will you have them? I think perhaps not. Let me explain. So the usual story goes something like this, and I think we've got to respectfully counter it. The usual story goes something like this. Your grandfather or your grandparents in their twilight years are regretting spending too much time at the office. right, saying, you know, oh, I wish I would have pursued more of my hobbies, done more things that I really cared about, et cetera, et cetera, et cetera. And the cautionary tale here that we're supposed to pull away from this constantly heard story is that you shouldn't overwork, okay? This is the concern, this is the moral of the story, if you will.

REGRET FROM OVERWORKING
Okay, I don't know about you all, but my grandfather worked in paint factories in downtown Detroit, Michigan. Tough gig, tough city, right? But he did what he had to do. I have no doubt, given the option, he would look back and say, I never asked him, but I'm sure he would have looked back and said, I wish I could have done a bit more of that. Or I wish I would have chose to, if there were sufficient resources, do a little bit less of that and spend less time there. I have no doubt about that. That's fair. If your job feels like that, like it's tough, it's grindy, it's not necessarily one that you're super passionate about it. You're kind of doing it because you have to, but you can't change that because you're doing what you have to do. That's the job that's available to you and you're getting it done because that's your responsibility. Not only is that noble, but it's totally understandable to do what you need to do, but I would agree, maybe don't do a ton extra. And I can totally appreciate how regret at end of life could come should you choose to do a ton extra of something you don't necessarily love. I will cough that up. I will agree with that. I can appreciate why that's been the narrative for a lot of years. That being said, It is much more likely that you are doing something that you chose and that you are passionate about and that you love. Particularly if you're sitting here on Thursday morning, taking in leadership Thursday, the odds are really good that you chose your career amongst a variety of options and you chose one that you believe in, right? You probably didn't choose the paint factory in downtown Detroit. It's a tough gig, right? That probably isn't one you were drawn to. And again, if you're in this ethos, where you're taking in this kind of content, you're probably in a position where you chose something you loved. Now, if you started a company, or you joined a company that you really believe in, regret is unlikely going to be the byproduct of your hard work in that space. So what I'm saying is that we need to advocate, or I wanna advocate, for a shift from people on their deathbed say to or towards people on their deathbed used to say. Because I don't foresee myself or any of you saying in your twilight years, I really wish I wouldn't have fought so hard for something I believed so much in. I just don't see that coming. I totally see it from the paint factory, right? I don't see it when you chose your passion that you feel most aligned with, where you want to be of some use. I don't see that statement on the horizon. For me, the thing that I believe I'm fighting for is freedom for everybody from dependence on the medical industrialized complex. From the pharmacy, from the surgery, right? Instead, a belief in a utilization of one's own physical resilience, right? The belief that changing the narrative and educating the public that if they train and fuel well, and they don't have a bad accident, that you can maximize and enjoy an incredible health span. And unfortunately, the narrative in this country is solely the opposite. The amount of people who are unbelievably dependent on a ridiculous amount of prescriptions, that are so quick to surgery, that leave anything healthy once they're injured, that we have so much to fight against. But I believe in this fight. And I don't believe that when I'm 80, I'm gonna say I wish I would have fought it less. I don't believe that. The principle runs too deep.

REGRET CAN ALSO COME FROM UNDERWORKING
Instead, and to close off the episode, a bit of real talk perhaps, I think that our regret risk in this generation, now that that shift where choice is kind of the driver of career has been made, the risk more lies in the following items. I feel like I never made a difference. I feel like I didn't fulfill my potential. I didn't go hard enough. I never found my limits. I don't know what I was capable of doing in the good fight. I never generated sufficient resources to be able to support myself and others. I think this is probably the list of regrets that is more common and they come from underworking, not overworking when you've chosen something that you believe in. And many of us get to make that choice. So my message to you on this Leadership Thursday is first of all, make sure you're doing that if you're able to. I do not mean to put anybody in a bad mental spot if they're like, dude, I'd love to, but my cards don't allow it. My situation, maybe right now and future, totally respect that. Do what you have to do. There's so much honor in that. If you get to choose, if those are your cards, choose something that you believe in and go all in. If you are a part of a team that achieves something that you believe to be deeply meaningful, you are not going to look back and wish you spent more time on yourself on vacation. That isn't how it's gonna shake out. You're gonna look back and say, I'm so glad that I was of some use. I'm so glad that I figured out the maximum that I was able to contribute in an area that I believe needed my efforts. That isn't something you regret. That is something you celebrate. It's time to push back against the narrative. Things have changed. Let's acknowledge it and let's stop scaring people into not working enough to find their potential because of things being different 30, 40, 50, 60 years ago. Give it some thought. Thanks for being here on leadership Thursday. We've got a million courses coming up. It's our busiest time of year. I think this weekend alone, we have 12 to 15 live courses. Make sure you jump on ptonice.com and check out that schedule. Get those skills, get out there and help some people y'all. 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.

 

Feb 14, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones as he discusses what it looks like to discharge as a fitness-forward clinician. In this episode, we’ll cover the do’s & don’ts to discharging and even challenge the whole notion of discharge itself.

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

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

EPISODE TRANSCRIPTION

DUSTIN JONES
Welcome y'all to the PT on Ice daily show. My name is Dustin Jones, one of the lead faculty within the older adult division. And today we are gonna be talking about the fitness forward discharge, the fitness forward discharge, how we can set our patients up for that fitness forward lifestyle once they leave our doors, all right? So before we dive into this conversation, I wanna start by really saying that the whole concept or notion of the discharge as we know it, traditionally, really needs to be challenged, right? The whole concept of, I'm gonna see this person for six to eight weeks, and then I'm gonna have no contact with that person whatsoever, and then cross my fingers and hope that that person will hopefully come back if they do have issues down the road, right? Hopefully, we see some of the issues with that. Hopefully, we can see the problem with bragging about how few visits it takes for you to get particular results, right? It's like we've created this badge of honor for how little that we're seeing people. And if you spend any time around the Institute of Clinical Excellence at any of our courses, you start to see what you have to offer people. Why in the world would someone like you, a fitness-forward trained clinician, want to be around someone less. You have so many valuable skills. You have such an amazing influence. Your be a valid approach, this fitness for lifestyle that you lead and can ultimately give to your patients. Why would you not want to rub shoulders with these folks that you can absolutely change their lives, right? So the whole notion of discharge, I really want to challenge. I think the Onward Physical Therapy crew is doing such a good job with this with their Restore and Perform program where they will have patients and they will transition to more of a maintenance type situation. I know many of you all watching have similar services where they may come off of quote-unquote physical therapy but you're still getting those touch points to change their lives. That is really, really good. What I want to speak to today in terms of the Fitness Forward Challenge is for many folks that are working with individuals and patients that do not partake in fitness, that these folks are not a part of a fitness community and you're going to work with this person and we need to set them up for success after your course of care. How do we handle those situations? I know for The vast majority of you all watching and listening, that is the case. I can say that for myself, definitely in the context of home health where I've spent most of my time. clinically, but now I'm on the other end of the equation where I am mainly in the fitness space at Stronger Life Fitness in Lexington, Kentucky. So I've really enjoyed experiencing what it's like to get people into our fitness community from different clinicians and what clinicians have done really well to set them up for success, but also what they've done really poorly that's made our job really difficult. And I think about all the folks that even come into our doors because of something that happened in that course of care. All right, so the fitness forward discharge for you clinicians that are working with folks that do not partake in fitness right now. We're gonna dive into some practical things. I want you to think of this in three steps.
All right, number one is that we start with the end in mind. Number two is we prepare for what's ahead. And number three, we test the plan. All right, I'm gonna dive into some specifics. within those three chunks.

START WITH THE END IN MIND
So number one, starting with the end in mind. Many of us will hear this saying all the time, especially when you are in a more acute setting like acute care clinicians, right? As soon as they do their eval, they're planning their discharge, right? That is For many of them, the goal is that, all right, what's the discharge disposition so we can get this person to a place where they can receive care? And I think that's a good mindset for us to have across the continuum of healthcare. Discharge planning starts day one. Where is this person headed? where are we taking this individual? Now, for you all, the fitness forward clinician, the question that we often ask ourselves, but ultimately ask the patient or the client, is how fit will you let me get you, right? Betty comes to you for her back, her back pain, and we're gonna take care of that back pain for sure, but ultimately we don't wanna stop there, right? We change lives, not just pain. We're gonna see how fit we can get Betty ultimately in her one rep max living and help her live the fullest life that she can imagine right that goes beyond pain reduction techniques right so how fit will you let me get you now what is really important when we start thinking about the next step after our course of care when we're discharge planning and starting on day one we need to consider what this person is going to be willing to start and but then also sustain in terms of a fitness routine. What they're willing to start and then sustain. And I would say the latter is more important. It's easy to start something, it's tough to sustain it for months, years on end. So this is where we really need to spend a lot of time understanding this person's goals, their desires, their deep desires of what they want to be able to do. What keeps them up the night? What would they want to be doing if they had no pain whatsoever? And then match the fitness regimen that could ultimately make that happen, right? And with that, we have to consider so many factors, like personal preferences. past experiences, their perceptions of certain communities or fitness modalities. What's their financial situation? What do they have available to them to help offset some of the financial barriers? If someone is on Medicare or have a Medicare Advantage plan, there's lots of things available to help reduce the cost of fitness services. Where are they located, right? Location is such a huge variable in the adherence and consistency of an exercise program when someone is leaving their home to partake in fitness. It's a lot easier for someone to go around the corner as opposed to driving across town, right? And what social support, what resources does this person have? We need to take all of these into consideration and that is going to form our recommendation of where we are headed and we can set that out very early on in the process. So for the outpatient clinician, many of you all watching, many of you all are probably a part of some type of CrossFit community or CrossFit box, right? And you may be treating some patients in the outpatient setting where that transition may make a lot of sense. They may be familiar with it. They may not have a lot of baggage associated with that brand or that gym, that CrossFit box. And that transition can be relatively easy for you. And that's a no-brainer for many of you all. But for a lot of folks watching and listening, they have patients that are likely never going to step foot in a CrossFit gym. And I would go as far to say that CrossFit gym is not the best place to serve some folks, right? I know that's blasphemous on this podcast, but the local CrossFit box may not be suitable for every single person that you're working with as a physical therapist. So we need to understand, are there communities out there that can meet this person where they're at and help them make this a sustainable long-term fitness routine? and for the home health clinicians watching. Is there something that could be done for someone that is currently a homebound status? Is there some type of online community? Is there some type of online service or some type of YouTube channel, for example, that someone could partake in and consume that's going to be suitable for their situation? You cannot make these recommendations without truly understanding the person sitting in front of you. So we have to dig in. What are they willing to start and then what are they willing to sustain? Now, this is going to require some work, right? You need to know the communities out in your area, of the differences of them, of how some may be more suitable or welcoming to other groups of people. there's gonna be big differences there. You need to understand what services are available online to folks that may not be able to get out, what services are available that are willing to accept some of these Medicare Advantage plans or Silver Sneakers or Renew Active if they're on United Advantage, for example. So we need to do some work so you can make some of those recommendations. If you're like, what in the hell is he talking about? Hit me up or join the MMoA community where we have a lot of these discussions and we have a really helpful resource of where clinicians threw in some of their favorite YouTube channels, for example, and different resources that they help encourage that fitness-forward lifestyle beyond discharge. But there's options out there. We can do the hard work for you. Hit me up, DM me, and I'd love to share some of those resources. So that's the first one. Start with the end in mind.

PREPARE FOR WHAT'S AHEAD
Two, we prepare for what's ahead. So we start with the end in mind and then we prepare for what's ahead. When we start with the end in mind, we get a good idea of maybe what type of fitness regimen, what type of fitness community is gonna be good for this person so they can sustain and continue their health journey, right? If we understand what that community and that regimen is about, we can prepare that person for said regimen in our course of care. And I view this kind of like graded exposure. or gradual exposure, where we're gradually exposing people to elements of that fitness community or fitness regimen. Let's take CrossFit, for example. Let's say you have a patient that has never done CrossFit and they have agreed, yeah, I'm going to join that community down the street once we're done. That's really interesting to me. You can do that person a solid by exposing them to some of the CrossFit movements, of some of the movements that you're commonly going to see in the programming. getting a barbell in their hand, teaching them some of the basics of a squat, a deadlift, a press, and then maybe even getting to Olympic lifting. Expose them to those movements to reduce that new member suck, right? We've all experienced it. There are some benefits to the suckiness of being new and not knowing a lot about what's going on in the community. I do want to acknowledge that, but man, it's really nice if you come into a community having a little bit of familiarity with some of these movements and jargon and so on and so forth. So we want to gradually expose them to the movements that are going to be coming down the pike. We also want to expose them to the intensity that they're going to see. This can also be new for a lot of individuals, particularly going into something like a CrossFit gym or some high intensity interval training bootcamps type fitness community, that if these folks have not experienced true intensity, we can do that in the course of our care and expose them to that so they're not blindsided when they join this fitness community. We would also argue within the MOA division that you want to do that regardless to get better outcomes, keep in mind. But when we also think about that fitness forward discharge, this is really, really helpful to do. So gradual exposure to that intensity that they're likely going to experience and then gradual exposure to the movements that they're likely going to see. The beautiful thing about this is it reduces that new member suck when you're partaking of something for the first time. But for a lot of our folks, it often gives them trust in their bodies, that they can trust their body again. Think of what so many of these folks have been through, especially the older adult population that I particularly work with. We're talking decades of different healthcare interactions, maybe a dozen courses of care in the context of physical therapy, who knows how many surgeries, who knows how many diagnoses that were given without context, who knows how many damaging words have been said to this person where they believe that they are weak, fragile, slow, that they are broken pieces. We have the opportunity to show them that is not the case. That is not the case whatsoever. You can trust your body again and you can push your body again and your body can improve and get better and you can do things that you thought were absolutely impossible. You can show people that through this gradual exposure. So that's how we wanna prepare, that gradual exposure to intensity and movements. Number two, we also want to give people a plan to troubleshoot the difficult scenarios that are going to come up, right? Jeff Moore always says this, and I love this, where he will talk about the path to fitness is always gonna run through some musculoskeletal issues, right? And this is where we are such a huge service for individuals, that we, throughout our course of care, can give people a plan to be able to troubleshoot what is ahead, what is common, the question of hurt versus harm. When am I doing damage versus when a little bit of discomfort is okay? Maybe giving them something like the traffic light analogy where, you know, that zero to three out of 10 is kind of that green light. Still send it, you're good. But if that lingers on to, you know, that four, five, six range, that's kind of in the yellow. We need to start thinking about modifying. We're still moving, right? And then, you know, that seven, eight, nine, 10, where we're in kind of that red light, where we're thinking, still need to keep moving but I may need to go come back and see you physical therapist or PTA or whoever you are so that strategy of if this than that so they understand the difference between hurt versus harm and when they need to come back to see you can be very very helpful another one particularly in a population that's not used to exercising is DOMPS. For many of you all you don't even remember what it was like the first time you felt delayed onset muscle soreness if you've been exercising regularly but for someone new it's a very frightening thing when they do something that they perceive is going to be beneficial and helpful for them and then they try to get out of bed the next day or the day after and they're absolutely miserable. a lot of things can go in your head of what may not be helpful or beneficial about what you did that caused so much discomfort and so you can give them context. I've made this mistake way too often where I did not give context to delayed onset muscle soreness and it really comes back to bite you. You can lose that that clip that trust of the patient but ultimately we want to give them the ability to handle kind of the ups and the downs to understand hurt versus harm, to understand DOMS and what to actually do about it, and ultimately, when they really need to come back to you versus continuing on in their fitness regimen or community. Alright? So, number one, start with the end in mind. Number two, prepare for what's ahead.

TEST THE PLAN
And then last but not least, and where most people really drop the ball, is we test the plan. we test the plan during our course of care. So as the course of care is winding down, we may be kind of reducing some of the focus on pain reduction and thinking more about building physical capacity. We're starting to stress test this person, of how they're handling what we know they're gonna experience down the road, right? This is where Alex Germano, she's watching here, but she has said before that we need to make PT sweaty again. And I absolutely love that phrase, and I feel like that is very, very pertinent throughout the whole course of GARE, but particularly for this phase. That last few weeks where we're stress testing our plan of care, where we're getting people sweaty in PT, seeing how they respond. These folks, we also, during that transition, want some overlap where they're actually partaking in that fitness regimen or a part of that fitness community. When we still have those regular touch points and we're able to handle some of the ups and the downs and what may come and answer some questions and just make sure this person is well prepared while they're under our care, that makes it very, very easy for them to continue and make this a sustainable effort. So we want to test the plan. stress test them in your session. Make PT sweaty again. And there's usually kind of a turning point that you'll see, particularly in Jerry PT, Jerry OT. And sometimes it happens sooner, right? If you really push intensity and your sessions are very challenging and it kind of catches them by surprise. But at the latest, this should happen. during this test the plan phase and what typically happens you got bob that's been coming in bob good old boy wearing his wranglers tucked in button up got a big old leather belt probably has some 30 year old fry cowboy boots rolling in here He's getting after it, just sweating his rear end off during your sessions. Then the next session comes around. What's Bob wearing? Bob's probably still wearing his boots, his fry boots. He's probably still wearing his button up, but he swapped out the Wranglers for some Fruit of the Loom sweatpants. still tucking the shirt in, the hem's probably right around his belly button, you know, that waistline area for them. He has seen, oh my gosh, this is not, quote unquote, physical therapy or occupational therapy. I'm going here to work out. We're getting sweaty, right? We're stress testing Bob, and he changed his outfit as a result. I cannot tell you how many times this has happened in the context of even home health, but then outpatient, and we definitely see this in the context of fitness. as well, but we want to try and see that. We want to stress test for if something bad happens, if they have some type of flare-up, for example, if they have some type of questions, we can handle it within our course of care. And ultimately, you're allowing a little bit of overlap where you're still seeing this person, but they're transitioning to that fitness community. That is what a fitness forward discharge looks like. We start with the end in mind. We're thinking about where this person is going. How fit are you going to let me get you and where are you going to end up? Whether it's a fitness community, whether they're doing something at home, whatever fits their particular needs, we start there. Number two, we prepare them for what is ahead. We make them familiar with the intensity, the movements that they're going to experience and we help them troubleshoot the challenging scenarios that are going to happen. DOMS, hurt versus harm. When should I seek care? when is it okay, when do I need to modify what I'm doing, right? Then number three, we test the plan. We stress test them while we have them in our course of care, while we're regularly seeing them. They may even already be starting that fitness program or fitness regimen. We're able to handle the bumps that come with that and really set them up for success as they continue forward. The fitness forward discharge. I appreciate y'all listening.

SUMMARY
Before you go, I want to mention MMOA courses. We've got a bunch of stuff lined up for 2024. If you want to see us on the road, I want to highlight a few weekends that are coming up. February 17th, 18th, this upcoming weekend we're in Oklahoma City, so catch that if you're in that area. March 2nd and 3rd, we've got Tripleheader. We're going to be in Rome, Georgia, Halifax, Canada, Glencoe, Maryland. We also have our Level 1 and Level 2 online courses. Our Level 1 course is going to be starting March 13th. We'd love to see you on that. Appreciate y'all. Have a lovely rest of your Wednesday. Go Crutchets!

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

Feb 13, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity lead faculty Cody Gingerich discusses the importance of thorough palpation to rule in or out differential diagnosis during an objective exam.

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

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

EPISODE TRANSCRIPTION

CODY GINGERICH
All right, good morning everybody and welcome to the PT on Ice daily show. My name is Cody Gingrich. I'm one of the lead faculty in the extremity division coming to you on a clinical Tuesday. So getting into it, what I want to talk about today is talking about palpation and using a good palpation exam in your objective exam for doing some differential diagnosis. We're going to talk about the upper extremity and the lower extremity and why doing a really solid palpation job in those areas, specifically when you're dealing with extremity management. is going to be super, super important when you're trying to differentiate, is this something that might be more of an extremity issue or is this potentially something that's coming more from the spine, okay? We're going to talk about different things that you might see from a subjective standpoint that might lead you to figuring out, not having a super clear picture on which of those two things it might be.

UPPER EXTREMITY PALPATION
So we're going to start in the upper extremity, okay? So things that you might see or hear, I guess, from your patient when you're doing your subjective exam. right? Numbness and tingling that comes down the arm that comes down lower than the, um, than the clavicle elbow, potentially even all the way into the hand. Okay. Anything noticing tingling. A lot of times when we hear numbness, tingling, we're immediately clued into, Oh, that might be a nervous system problem. That can be a cervical radiculopathy, all of those types of things. but then some of their other aggravating factors are going to be, right? Potentially sitting at a desk, if it's a more of a fitness athlete, pressing overhead, all of those type of things might bring out their symptoms. So if they're sitting, if they're driving, where they could be stressing the actual cervical spine, but they could also be very much stressing that posterior shoulder, okay? Another thing that I see all the time is anterior shoulder pain. Okay, anterior shoulder pain with a lot of pressing type of movements and a lot of times if you know someone's sleeping on that shoulder or whatever else, we need to figure out is that coming from that anterior shoulder, but also we get a lot of referral from the posterior shoulder that pings right to that anterior shoulder. Okay, so I want to talk about how then your palpation job is going to be most efficient in bringing out some of those symptoms. The number one thing is you have to have a system. You have to have a system to know when you're going, where you're going to be and how you get back to that spot every time and how you touch each and every muscle area on what you're trying to palpate. In the extremities, specifically posterior shoulder and posterior hip when we get to it, posterior lateral hip, you can actually hit all of those structures and feel good about where you are palpating is touching what you want to touch. In the spine and areas like that, there are so many layers of tissue, you can't really always say, like, I know what I'm on, but specifically in the back of the shoulder, you can say, I'm on infraspinatus, I'm on supraspinatus, I'm touching teres. All of those things can be very confident that you're hitting that. So where do you want to start? Inferior angle of the scapula. Then you work laterally. You know then when you work laterally and you come back to that inferior angle, you go thumb, thumb, and then you start here and then you work away again. Come back, thumb, thumb, thumb. Now you're three thumb widths up. Each time you're touching your thumb, like working and doing your palpation every time. Now the key with this is if you find a spot and your patient says, Ooh yeah, that's tender. You can't just say, oh great, and move on. You need to spend some time in that area and hold and sustain that pressure. If in this objective they said, well it takes sometimes half of the day in order to bring out my symptoms where I start to get that tingling, then four seconds of you palpating that area on the back of their shoulder is not going to be enough to bring out those symptoms. Maybe 30 seconds, maybe 40 seconds of you really sustaining pressure there is going to be necessary before maybe they start saying, Oh, you know what? It's not just tender there anymore. It's actually starting to creep a little bit here. That's when you can say, Oh, well, maybe that extremity management or that extremities focus is going to be where we need to be. And it's not as much in the cervical spine, right? So that's where you want to really pay attention to what you're doing. You don't always have to get symptoms all the way down the arm, because that may take a very long time for them to get those symptoms all the way down. But if it starts to creep, down the arm like this, you can be pretty confident. There's definitely something coming from that shoulder, that posterior shoulder, where it is relevant as opposed to the cervical spine. Same exact conversation. We're talking about anterior shoulder pain. We are really thinking a lot of times when someone says, Hey, yeah, it hurts right here. First clue might be like, Oh, that might be some biceps, uh, tendonitis, tendinopathy, something like that. But If you, and most people are going to be tender when you palpate right on that anterior shoulder. Note that, but also make sure you do that really solid palpation job on the backside of the shoulder and sustain some pressure. If they find some, if you find something that's tender, sustain that pressure very often. They're going to say, Oh, you know what? I actually do feel that in the front of the shoulder. Okay. Now we need to be hitting the back of the shoulder to treat the front of the shoulder. Okay. And that's where our differential diagnosis, that hypothesis list that we generate from the subjective exam pressing, right? You're like, Oh, okay. That's an anterior shoulder. Definitely a lot of heavy work for the anterior shoulder. But if we're pressing, if we're really working our elbows into that front rack or something like that, that post to your shoulder and that rotator cuff in the back is also getting a lot of work to get that hand on top of your elbow. Okay, so both things are relevant there. Those are going to be the two main things in the upper extremity that you're wanting to change that hypothesis list. Cervical spine, we're getting a lot of just numbness, tingling symptoms down the arm. Okay. If the cervical spine is not blipping a bunch of that stuff, check posterior cuff. Same thing with anterior shoulder. If they're saying anterior shoulder, I get that when I'm benching, when I'm pressing, when I'm whatever, palpate the back of the shoulder, make sure you're doing a good job sustaining pressure. This position right here is occluding blood flow to the back of the shoulder where we sit almost all day, just like this. We are now no longer giving the back of our shoulder a really good environment to allow blood flow and healing. Okay? And so if they're just tugging on those structures all day long, now all of a sudden sitting at a desk can bring out some of those symptoms.

LOWER EXTREMITY PALPATION
Shifting gears to the posterior lateral hip, very similar conversation. In extremity management, palpation can matter. You can be confident in what you are palpating to know that you're on the structures that you are trying to hit. Again, you want to have a system. There are two ways that you can really create your system. If you want to start at the greater trochanter and work your way superiorly, you can do that. And then each time, you know, I went immediately superior from this greater trochanter, we're hitting glute med, and then we are working and fanning away from the iliac crest. and we can work away that way to the posterior hip. So that way we can know we've hit glute med, we've hit glute min, we've hit glute max. You can also start from the PSIS and work your way more anteriorly and then down to the greater trochanter. Very similar in that you will probably need to sustain pressure. There are people that are going to be mostly tender there. If you find tender spots, sustain some pressure. if you have not sustained pressure for upwards of 30 to 45 seconds to at least see if symptoms have changed at all. And the question is, are you still feeling that right under my thumbs or has that started to creep anywhere? you'll get symptoms all the way down the leg. If we're trying to differentiate between lumbar radiculopathy, symptoms down the leg, into the calf, all the way into the foot, can be symptom generators coming from glute med, glute med. They can also be symptom generators of the spine. Okay, you have to get on those structures and see, is there anything creeping? Do you feel changes in your foot in your calf when I'm sustaining pressure on the muscle tissue? If you are on the muscle tissue, you can be pretty confident that that is not a back thing anymore, at least not fully. And you need to then have a good understanding of where am I? Can I then treat that out? We need to pump some blood to it. If we need to do dry needling, if we need to do some soft tissue and then work some strength, some blood perfusion type of exercises there. Okay. Also, hamstring type of things where people are not sure did I tweak a do I have like a high hamstring injury? Do I have more of a low back injury? That's another differential. When you're here and subjectively right sitting prolonged sitting is going to bring on these symptoms. Well, prolonged SIM sitting is stressing the lumbar spine, you are sitting in some lumbar flexion when you're sitting. The other thing that you're doing is you are occluding blood flow to that posterolateral hip at the same time. Okay, so both things can happen and then that can create irritation to the tissue. Very similar to this posture, any prolonged sitting can bring on that posterolateral occluding blood to that aorta and bring on tissue dysfunction. And that can create symptoms down the leg, again, hamstring, calf, foot, ankle, anything like that.

COMBINING SUBJECTIVE & OBJECTIVE EXAMS
Okay. So the big takeaways here are subjectively, these things are going to feel, you're going to have your hypothesis list, but you may not be like, they might be pretty equal when we're talking about the hypothesis list before you touch the objective exam. Then, same thing, when you're going through your objective exam, if you just do range of motion, if you do lumbar flexion range of motion, and that comes out, potentially you have stress lumbar flexion, yes, you are also tugging on your posterior lateral hip when you bend forward into flexion. Okay, so don't forget to make sure that you are ruling out that palpation and that lat posterior lateral hip in the hip, or that posterior shoulder when you're in the upper extremity, because those things might still be relevant. And you need to do a good job in palpating to make sure that you are clearing those areas and creating a really solid differential. because subjectively your hypothesis list is going to be very equal going into objective exam and not always with functional movements or range of motion. Are you going to really be able to bump one of those things up or down? But if you get into that palpation and say, you know, I've hit these areas and it wasn't maybe it was tender, but I sustained that pressure and I made sure I hit every single section because I was efficient and I was clean with where I was going each time and nothing really came out. then you can be pretty confident. Maybe it's not those tissues in the posterior shoulder or the posterolateral hip. Maybe we are looking more at the spine, okay? So that's really what I wanted to come on here and talk about today. In the extremity management division, we touch on that briefly when we're going through our objective exam, but I wanted to give a little bit more clarity today on what exactly you're looking for subjectively, and then how can you make a really clean objective palpation exam when you're trying to differentially diagnose. So that's what I wanted to come on here and touch on today. If you want to catch Extremity Management on the road here in the next couple weeks, we've got Lindsey on the road out in Carson City this weekend, so if you want to catch Mark or myself, both of us are on the road March 16th and 17th. I will be in Aiken, South Carolina. Mark will be in Spring, Texas. So we pretty much have West Coast to East Coast covered here over the next month or so. So jump into one of those courses. We'd love to see you out. And hopefully we will catch you all tomorrow on the iShow.

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.

Feb 12, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the ins and outs of bracing and how to engage in conversations with fitness professionals to make sure we are all speaking the same language.

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

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today’s episode, I want to talk to you about VersaLifts. Today’s episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today’s show notes to get your VersaLifts today.

RACHEL MOORE
Good morning, PT on ICE Daily Show. What is up? It is Monday morning. My name is Dr. Rachel Moore. I am here representing our pelvic division, hanging out today to chat with you guys about bracing. So really breaking down the brace, understanding this concept a little bit more, understanding maybe where some pitfalls are in our communication with our fitness professionals that we are working with. So diving into that, let's just get started.

IS ALL BRACING INSTRUCTION THE SAME?
The brace as a term is kind of like poorly defined. There's really an understanding maybe in the PT world of what the brace is and then maybe in the strength world of what the brace is. And oftentimes what we're seeing or what we're getting feedback from is maybe there's a disconnect between what we're teaching as PTs or being taught as PTs and what the fitness professionals in our communities are being taught. And we wanted to kind of break down where this comes from. So for one, a lot of times fitness professionals aren't necessarily ever truly like taught how to do a brace. The most common cue we hear in like the fitness professional space is brace like somebody is going to punch you in the belly or like somebody is going to hit you in the stomach. And a lot of times that kind of brings about, or people think that this means this push out and this push out. on the PT side of things is actually what we're trying to avoid. And so we get some feedback from students in our courses and that's actually kind of what inspired the topic today is we got an email from one of the students who had taken our courses who said that she was kind of hearing from fitness professionals in her community that the way she was teaching the brace wasn't correct. So what do we do with that conversation? How do we navigate that conversation with those fitness professionals? And how do we kind of get across that we're probably saying the same thing, but it's not coming across the same way.

WHAT DOES IT MEAN TO BRACE?
So first thing I want to do is really define what the brace is. And in order to define what the brace is, we have to define the component pieces of the core canister, which is what's involved in the brace. So when we're talking about our core canister, we're talking about a 360 degree canister that has a top and a bottom. The top of that is going to be our diaphragm. The bottom of that is going to be our pelvic floor. The front insides are our anterior abdominal wall. A lot of times people just say, oh, that's the transverse abdominal muscles. But in reality, we have to understand that that is more than just the transverse abs. That's actually all of the layers of the abdominal wall. and then the back is the spine and the muscles of the spine. When we talk about this brace, we want the canister to have equal pressure distributed around it and dissipate forces in an equalized manner, rather than maybe one side of the canister getting too much force, which then causes a leakage of pressure into a different direction. So when we're explaining the brace, or we're teaching the brace, We oftentimes teach it as tense your abs, or think about pulling your pelvic bones together. A cue that we use a ton over in the pelvic division with our pregnant athletes is if you have a baby, hug your baby, or if you can remember what it felt like to recently be pregnant, hug baby, that pull together of the abs. We are never queuing a push out because if we think about this canister, a push outwards is going to cause a mismatch of pressure within the inside of that canister. That's then going to come downwards through the pelvic floor. And oftentimes in the pelvic space can elicit pelvic floor symptoms like leakage, heaviness, or farting in the bottom of a squat or when we're lifting. so we expect that the pelvic floor is going to match the degree of abdominal brace we don't necessarily cue an intentional pelvic floor contraction when we're saying brace we might in our populations that are having issues with symptoms cue almost like an over correction because especially if there's somebody that's actually bearing down or pushing when they're bracing and not understanding that they're lengthening their pelvic floor rather than either staying at the same level or allowing their pelvic floor to match the demand of everything that's on top of it. So when we're cuing our brace, it is tense your abs, pelvic floor either stays the same or we slightly lift pelvic floor to match that pressure. That's how we teach that brace.

THE CONFUSING NATURE OF THE WEIGHTLIFTING BELT
The confusion I think comes in especially when we start talking about layering in a belt. So oftentimes in the strength training world, we see athletes busting out a belt and maybe they're using it all the time for every However, whatever the weight is on the bar, it's not necessarily just that they're heavier lifts or maybe they're reserving it for their heavier lifts. The key thing with the belt is that when we layer in the belt, the brace doesn't change. And that's something that I think we need to make sure our athletes and our coaches are understanding is that the belt is there to give us this extra support and really proprioceptive input to allow that increase in spinal stiffness to happen, but it is not a mechanism to push into. and I have my husband's belt. I left mine at the gym, so this isn't gonna fit me exactly right, but I wanna walk through the fit of the belt and where I think this confusion maybe comes from when we start talking about fitness professionals queuing a push-out. So with the belt, when we're talking about using a weightlifting belt, we want to think about, if you have YouTube or Instagram live up, I've got the belt here, and I'm just gonna kinda walk through the fit of the belt and what we're looking for. So when we are putting a weightlifting belt on, we're looking to fill that space in between our pelvis and our ribcage. If there's a little bit of overlap, that's totally fine, but we're kind of going like the top of the pelvis and that's my marker for where this belt is going to go. When I put my belt on, I'm going to put my belt on and as I tighten it, I want to fully exhale. I'm not like sucking in and shrinking and shriveling up as tiny as I can. I'm just doing a comfortable exhale. And then from there, I'm tightening. And in this tightening, I can breathe. I can talk. I can put a finger in between me and my belt, and I'm not uncomfortable. It's not squeezing me. If we have the fit of the belt correct, then that approximation that comes from inhaling i think is maybe what the confusion is coming from so if i have my belt on right i tightened it on my exhale as i do an inhale and i think about inhaling into my belly and into my spine that good solid 360 breath i feel my tissues push into that belt that is different than me intentionally pushing into the belt, that push your belly out sensation. If you're watching this live or listening to this later, put your hands on your belly and feel what happens when you push your stomach out. What do you feel at your pelvic floor? More than likely, it's a dropdown. If we think about tensing our core, Usually we don't feel much there. Maybe we feel a slight lift. And if we do feel a drop down, then we over correct and think about going up towards the basement to mitigate that. But the key here is the fit of the belt and understanding how to do that brace. So where does the confusion come in? When we're talking about our fitness professionals or maybe people who have never been trained in how to use a belt, the thought is to push out into the belt to create that contact with the belt. But if we have the belt fitting correctly, we don't need to do that push up. That's the biggest thing that I want you guys to understand and take away is it all comes back to the fit and making sure that we're using that belt correctly. Even without the belt, our brace stays the same, right? We're thinking inhale into belly, tense abs. It's never push out as if we're pushing our abdominal wall away.

WORKING ALONGSIDE FITNESS PROFESSIONALS
So when we're having these conversations with Fitness professionals or other coaches in our community who are maybe pushing back and saying like that's not how we teach our brace Really breaking this down and explaining to them where we're coming from and why. I think a lot of the time like we assume that everybody is just saying the opposite just for the sake of saying the opposite or maybe like they're just digging their heels in and there's no sense in educating them. But in reality like we have a lot of opportunity here to create bridges with these fitness professionals and create positive relationships. And we're not gonna do that by saying, well, you're wrong, or telling the athletes, well, your coach is wrong, just do it how I teach you. So using this as an opportunity to get in front of those coaches and those fitness professionals, and as a way to kind of bridge this relationship of, hey, you guys are coaching, I'm teaching your athletes, I would love to get on the same page, this is how I teach a brace, this is why. The goal here is to create equalized pressure across this core canister, If we push out in one direction or another, we put ourselves at risk of potentially having pressure leakage, quote unquote, out through that wall. It's also just not as strong. And at the end of the day, all of us are here to help people get stronger and move better. So if we think about this and conceptualize all of these walls of this castle being strong rather than one being broken or pushed out, then we can kind of understand that that applies into better, more efficient bracing mechanic, which then leads into better lifting and higher strength with our sets that we're working on, increasing our strength and capacity there. If this is confusing to you, I've got another podcast episode, episode 1577 of PT on Ice Daily Show that's all about the Valsalva, kind of breaks down a little bit more of the specifics of the Valsalva, which is that breath hold with the brace. The Valsalva can also have the belt, so we can have this spectrum of breathing.

SUMMARY
We really break down the spectrum of breathing in our live courses. Our live course is coming up in March. There are so many opportunities to catch the live course out on the road in March, y'all. March 2nd and 3rd in California, 9th and 10th in North Dakota, 23rd and 24th in South Carolina. So holy cow, so many opportunities to come hang out with us. Be on the lookout. Christina Prevett and I also did a clinical commentary that will be coming out in the spring 2024 edition. of the Journal of Pelvic Obstetric and Gynecologic Physiotherapy, so that should be coming out here pretty soon. We'll be blasting that all over the place when it does come out, but be on the lookout. Sign up for our pelvic newsletter, because that's gonna be one of the first places that drops, as well as on our hump day hustling. Thanks for joining me this morning, guys. I hope that cleared up some confusion. If you have any questions about bracing, or you're not sure how to explain it, or anything along those lines, please reach out, shoot me a message. I'm happy to chat with you more.

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.

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