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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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Now displaying: December, 2023
Dec 29, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses assessing & treating for issues related to shoulder internal rotation & extension limitation with overhead movement in the fitness athlete.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

ALAN FREDENDALL
All right. Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning's off to a great start. We're here at Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things fitness athlete, CrossFit, Olympic weightlifting, powerlifting, endurance athletes, and any recreationally active person. we talk about how to address those concerns. I have Dr. Haley with me here today. She's going to be my demo for some hands-on stuff. If you are listening to the podcast right now, I don't know why I pointed to my ear. If you're listening, you can't see me anyway. If you're listening, please switch over to our YouTube channel and watch the video because about halfway through, I'm going to show a lot of hands-on assessments and techniques, and you're not going to be able to see that if you are just listening on the podcast.

SHOULDER INTERNAL ROTATION & EXTENSION: ANATOMY
Today, what are we talking about? We're talking about the combined motions of shoulder internal rotation and extension in the shoulder, especially its relevance to the fitness athlete. So when we talk about these motions, we're primarily talking about the subscapularis muscle of the rotator cuff and the shoulder blade. So this muscle gets neglected a lot, mainly because most human beings no longer exercise, which means they are no longer vertically pulling and pushing above their head. So they're often not needing to use a lot of internal rotation and extension of the shoulder because they live their life with their arms relatively neutral. But if we look at the actual anatomy specifically of the subscap muscle, we know it is actually the largest and strongest rotator cuff muscle. It takes up the whole anterior portion of the shoulder blade on the anterior side of the scapula and is primarily responsible, yes, for internal rotation, but when the arm is elevated or out in front of the body, It also performs some combined motions of adduction and extension. It functions very similar to our lat muscle. So we have our subscapularis and our lat muscle counteracting all the other muscles of the shoulder and the rotator cuff that elevate our arm above and overhead. Most importantly, from the anatomy is knowing the attachment points. It attaches right on the anterior capsule of the shoulder. And when we see referral pattern, we can see anterior shoulder pain, folks point directly to a spot right on their anterior shoulder. But it also has referral into the posterior rotator cuff and into the medial scapular border. So a lot of times we can chase treating the posterior rotator cuff, especially in the fitness athlete when we actually need to be treating subscapularis.

SHOULDER INTERNAL ROTATION & EXTENSION: ASSESSMENT
Now how do we know this is a target for treatment? Well that's going to be revealed in our subjective and objective exam. So when someone comes in and I'm gauging their symptom behavior and I'm getting a list of their eggs and eases, especially with a fitness athlete, I'm looking to hear things like pain with dips, pain with bench, especially in the bottom position of a bench press, things like pain in the turnover, or what we call the catch of a bar or a ring muscle up, handstand push ups, again, especially the lowering the eccentric phase, where we're now going from an overhead, flexion, abduction, external rotation. And now we're lowering eccentrically into extension and internal rotation, very similar to the bottom position of a bench press. And then in that pull, that high pull motion that we have in our cleans and snatches with Olympic weightlifting. So when I hear aggs like that, my hypothesis list subscapularis jumps up. I'm looking to assess internal rotation and extension in that athlete, much more so than that sedentary person who comes in and complains of shoulder pain. I'm really not thinking this person is probably having a lot of issues with loaded internal rotation extension in the gym. because they don't go to the gym, right? That is a person where I'm probably going to look to the posterior rotator cuff and maybe the lats for strengthening and the delts for strengthening and just basically get that person's shoulders stronger versus specifically addressing a specific muscle like the subscapularis, which I would with a fitness athlete. So let's talk about how to actually assess the shoulder. So I have Haley here. We're going to demonstrate on her shoulder. You're all probably very familiar with this seated screen. It's something you learned in school. We're going to go through it really quickly. So having Haley lift her arm up and overhead and sitting to look at flexion, coming out to 90 degrees to look at abduction. We can meet in the middle and look at scaption at that 45 degree angle like that. We can put our arm at our side and now we can look at extension. And then we can hold our arm at a side and we can go across the stomach, internal rotation, and then out away to look at external rotation. Now what do we like about that screen? It's a screen, that's it. I hate almost all of that for the fitness athlete. Why? It's really not challenging a lot of true end range positions, especially of extension and internal rotation. The main thing to remember about internal rotation is if Haley's arm is at her side and she's internally rotating, she can palpate on herself. When the arm is at the side, the pec is the main mover there. It's not actually subscap or the deltoid at all. So when the arm is at the side, we're not even challenging actual internal rotation. We're using nothing about the subscap at all. Likewise, if we're seated and we're going through extension, I need to know how can I challenge sheer force to the shoulder like it might encounter in a bench press, a muscle up, a handstand pushup. I can't do that in sitting.

SHOULDER INTERNAL ROTATION & EXTENSION: DITCH THE SEATED EXAM
So for fitness athletes, we need to ditch the sitting exam and we need to go prone for the shoulder. So I'm gonna have Haley lay on her stomach here. We're gonna look at her left shoulder. We're going to look at internal rotation first. So I want her arm out at 90 degrees, about parallel with her shoulder, and I'm going to instruct her to bring her palm up towards the ceiling. And I want to look at that internal rotation. So we're cheating a little bit here, a little bit of abduction, but we have a really good assessment of internal rotation here. I can overpressure this as well. Haley, don't let me put your hand down. And I can look to see if that's symptom-provoking. So that is how I will assess internal rotation. Is the motion full? Is it provocative with an overpressure test? We can also look at extensions. I'm going to have her scooch a little bit to her right. She's going to bring her arm up at the table next to her side, and then she's going to lift her arm up in the air. And I'm looking to see, again, does she actually have full straight plane extension, or does she drift out into a lot of abduction? Good motion here. Same thing. I'm going to overpressure this. Don't let me push you down. And I'm going to see, is that symptom-provoking? So I'm going to challenge extension in a manner where gravity is providing sheer force through the labrum for me to see if that's provocative. And then I'm also going to overpressure the arm to see if I can overpressure and get any symptom provocation out of the shoulder. The last test that I will do is I'll have Haley stand up and then she's going to turn her back to the camera. We call this the liftoff test. It's also called Gerber's test. Very old test, almost 30 years old now. Tons of great research on it. So I'm going to ask her to pick a hand and I'm going to have her put it in the small of her back. And really I'm going to see how far up her back she can go with that hand. So can she go any higher? Good. Some of you might measure range of motion this way. That's great. I usually see what level of the spine can the thumb get to. Very functional for women, right? Somebody that can't even put their hand in the small of their back is probably going to have a lot of trouble with something like taking a bra on and off. But we get a good measure of range of motion. We know that if she can reach the small of her back, we're primarily now looking at subscap. A really good study by Greece and colleagues way back in 1996 found that if someone can get their hand in the small of their back versus down at their glutes, that just by getting it higher to the low back, we can get 33% more subscap activation. So I know if a person can achieve this position, they have really good range of motion out of that subscap muscle and that we're primarily now looking at subscap in isolation. What do we do now? We do the actual lift off. So I'm going to have Haley lift her hand away. She can lift her hand away and keep it approximately in the small of her back. And then if that's not pain provoking, at this point I am confident in ruling out subscap. Why? This test has 99% sensitivity. If that is negative, I can cross subscap off my hypothesis list and now I can look a little bit deeper into the shoulder. All of that has only taken us eight and a half minutes with a lot of talking. This is something you could probably do in a minute or less in the clinic and immediately rule out the subscap and be really confident that it's not the subscap. So, Haley, go ahead and have a seat.

SHOULDER INTERNAL ROTATION & EXTENSION: TREATMENT
So, what if it is a subscap, right? What if somebody like me walks in, my left shoulder looks okay, my right does not, Immediately I'm thinking I know which side I'm going to treat. I know which muscle I'm going to treat. We're going to talk about treatment next week. Zach Long is going to get on here. But the main thing is we need to restore that internal rotation range of motion, especially under load. Why? These folks are using this range of motion in the gym or they're trying to use it, which is maybe why they're bumping into symptoms with things like handstand pushups and Olympic lifting and muscle ups and that sort of thing. So we need to restore that full internal rotation range of motion. we need to increase its load tolerance, and we need to, in general, get the shoulders stronger, both delts and lats. But specifically, working on the subscap is going to give a lot of benefit to that athlete. So someone like me, I would needle my own right subscap, try to improve some of that range of motion, and then try to load that internal rotation. We'll talk more about treatment next week with Zach. He's gonna do a follow-up episode specifically on how to treat the subscap for the fitness athlete. So make sure you tune in next Friday. That's all we have for you today. I hope you have a fantastic weekend. Courses coming your way. Head on over to ptinex.com. Remember, all of our courses priced at $6.50 will become $6.95 on Monday. So if you have a course on your list, make sure you buy it over the next couple days and avoid that price increase. All of our courses from the fitness athlete division are on PTONICE.com. Hope you have a fantastic weekend. Have a wonderful new year. See you next week. Bye everybody.

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

Dec 28, 2023

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses balancing consumption with creation, the illusion of consumption as productivity, and the need to be authentic to stand out.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

JEFF MOORE
Okay, team, what is up? Welcome back to the PT on ICE Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of ICE, and always thrilled to be here on Leadership Thursday, especially as we go into a new year, and always happy to be here on Gut Check Thursday. And this one's gonna be a little bit different. I present to you our Gut Check Thursday for this week is a 36-hour water fast. So maybe it's a little bit of a pushback against some of the excess of the holidays, kind of pulling that back in, especially around New Year's Eve time. We are going to run our official Ice Physio Water Fast from Friday at 5pm until Sunday at 5am. So it's going to be 36 hours. We're going to break that Sunday morning. Um, for those of you that don't know, um, over at ice physio, we have a relatively large group of us that does a 36 hour water fast every month. And then a prolonged three day fast every six months, which we're actually moving to a four day fast. Um, in the middle of next year. Um, again, that'll be our first four day water fast. Um, that'll be done annually, but, um, lots of thoughts behind this. Um, a lot of things about, kind of the qualities of restraint and enjoying maybe the exact opposite of excessive consumption that we're oftentimes so drawn into, which is the topic of today's episode, but a really good time of year to maybe pull in those reins. So over the next week. See if you can find a 36 hour period where you can just consume water. And feel free to consume it liberally, but I think you'll find it, if you have not engaged in this, to be both a unique experience and a very, very productive one. Not to mention maybe some benefits in longevity and you think about apoptosis and the ability of your body to clear some of that stuff out. Join us. It's both a mental and a physical feat that we think has some great rewards. So that is the Gut Check Thursday. It is not adding on to high-intensity stimulus. Over the busy week, it is in fact going the other direction and see if we can't exercise our restraint for a 36 hour period. So if you have any questions, hit me up, let me know. It's something we do every month and we love it. We'd love to have you join us. We will be going in Friday, 5 p.m.

AUTHENTICITY
Sequels suck. I think we can all agree with that. So let's dive in and talk about why. And I want to give you an action item as we are about to turn the calendar page to 2024. I want to leave you with a thought to maybe move in the opposite direction of what is too commonly done, not unlike the gut check Thursday this week. So we all agree that sequels suck. The question is why do sequels consistently suck? And of course, there's some exceptions and we don't need to play that game. Generally speaking, they leave a bit to be desired. Why? The answer is that it's impossible to be authentic when you're copying from a template and people connect with authenticity. One of my deepest beliefs is that real makes you feel. If you're wondering why in a certain relationship or when you were listening to a certain speech, you felt particularly captivated, it's because the person was being real. Whether you're delivering or receiving, real makes you feel. is a tried and true reality. There is something unique that each of you bring to any situation to bear that nobody else possibly could because it is uniquely you. When you present or deliver or connect from that space, it is absolutely captivating. Sequels, by design, make that impossible, right? It can't be truly unique because you are intentionally building off a template. And so there is already the impossibility of that uniqueness to fully manifest in that piece of work, which is why we tend to really struggle to connect with sequels. Now, many people have become sequels. This is why a lot of times content is boring. Sometimes I hate to say this, but it's why sometimes relationships or engaging or people themselves seem to lack a bit of sparkle because so many people have become sequels and they're not trying to do this, right? There is just too much information coming at us. If we don't want to become sequels, if we don't want to constantly be consuming all this information and then essentially just building off it in the same way a sequel would, you have to schedule breaks from it.

REBALANCE CONSUMPTION AND CREATION
What I'm saying is you need to rebalance intentionally consumption and creation. The problem is consumption feels like you're moving forward. This is where most people run into trouble, right? There's so many good things, so many great books, so many amazing podcasts. There's so much out there that you want to consume. And while you're constantly consuming it, you feel like you're moving forward. But there is undeniably a ceiling or an upper limit on where that is no longer a reality. The best analogy I have for you is it's like taking notes on your notes, right? That always used to bewilder me. I would watch people take notes in class or whatever. Then they would go to the library and take notes on their notes. And it's this never ending, right, reading and reading and reading and feeling like you're learning, but you're not. If you really wanna learn, stop. Stop and think about your notes. Stop and actually listen to that person talking and think, man, what do I and don't I believe? What naturally jives with me and where do I feel some dissonance? Now, where that dissonance is, why do I feel that? Get in to the thought and the why and the wonder. Because that's when things really start becoming a part of you. That's when things truly assimilate and become usable. It's not just constantly reading and copying and reading and copying. It's when you stop and say, what do I think about that? How does that jive with what I've known up until now? It's when you pause that the actual learning happens. Even though the constant consumption feels like learning, it's when you pause that you allow the knowledge to change you. And so when you're constantly consuming, that second part never happens.

STOP READING & START LEADING
Which is why my action item for everybody in 2024 is to stop reading and start leading. Stop reading and start leading. Create between every knowledge acquisition. This is my challenge. And I don't mean stop reading entirely. I mean begin to develop a more balanced schedule between creation and consumption by committing to creating in between every knowledge acquisition. As opposed to finishing the end credits on one Audible book and starting the next one immediately. Give yourself a break. to create, to think about how that, what you just engaged in, altered you, changed you, challenged you, and do something with it. Now I wanna give you an actionable how, because I think sometimes we get into this philosophical space and don't deliver that. My how for you in 2024, if you're trying to rebalance consumption and creation, is to have a forced content schedule. Meaning something that you commit to putting out for somebody Okay, this could be for your business your community your family your gym your church, right? Whatever you're involved in commit to a content schedule being forced to create At a regular rhythm is the greatest way that I know to successively approximate your true self, meaning your unique self, meaning the thing that people are drawn to and captivated by because nobody else could be that thing. Being forced to create at a regular rhythm is the greatest way that I personally know to successfully or to successively approximate your true self. Commit to a schedule. As I kind of look at my world, there's nothing I'm more thankful for than this podcast is a great example, which every week we're having to think about how do we think about things and how could we share that with our community. And I think about things that we do at ICE like hump day hustling or even gut check Thursday, like coming up with that fast this morning, but we are committed to you all. that we're going to put things out for you. And that forces us, if we don't just want to be replicas, to be original and think about what we want to share, what means something to us. And that allows us then to come to these platforms and try to successively approximate our true selves. And that process is really in many ways, in my opinion, anyhow, what life is all about. And certainly one of the things we enjoy most about sharing and receiving is when we do successfully approximate our true selves. So commit to a rhythm. In new years, in this new year coming up in 2024, don't create an endless consumption list. Instead, share your unique creations on a committed schedule. It will force your hand. It will make you say, well, I can't go consume nugget number 7,206 this week. I need to pause because I said I was going to put something out. I need to stop taking notes on my notes and start doing some real thinking because I need to bring something to bear. Commit to creating regular organic content to somebody, to your family, gym, church, business, community, whatever, and decide that in 2024, you're never going to miss one of those marks. You are going to find by the end of the year, that you have learned so much about the way that you think about the constant stream of information coming at you. And it will be that that will carry more value than I promise you any single part of that endless, incessant communication or information stream, because it is your uniqueness you're trying to find and share with the world. And it is that which they will receive most voraciously, I promise you. In 2024, let's rebalance consumption and creation. Team, big alert on the courses. The prices go up Monday. So if you want to grab an ice physio course, all the 650 courses go to 695 on Monday overnight. So you need to grab those courses by Sunday. If you want to save whatever it is, 45, 50 bucks a course, it's not a huge amount of money, but if you're going to grab a couple of courses in 2024, grab those ASAP so you're not paying extra. over at PTOnIce.com is where everything lives. Team, have a wonderful new year. Enjoy the weekend. For those of you joining us on the Water Fast, Friday at 5 p.m., we'll cut off the nutrients, all water, till Sunday morning at 5 a.m. I promise, it's a unique stimulus that is highly productive. Cheers, team. Have a wonderful weekend. Happy New Year.

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.

 

Dec 27, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses research supporting the effects of high-velocity resistance training on older adults, including benefits for bone mineral density, the effects of detraining, and different ways to implement power training with patients. 

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

JEFF MUSGRAVE
Welcome crew to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here with you. Hopefully you have been enjoying the holidays however you enjoy to celebrate over the last few days. Super excited to bring to you really interesting systematic review looking at high velocity resistance training for adults 50 plus. So what we're going to be covering today is you know what are the primary results, what can we learn about dosage when implementing this intervention for adults 50 plus and then we're gonna spend actually quite a bit of time talking about clinical considerations for this type of information and talking a little bit about just the body of research that already exists. So let's get into it team. This systematic review included 25 randomized controlled trials. We had 12 original studies. We had 13 follow-up studies. What they did is they were applying high-velocity resistance training to older adults. People 55 plus and they define this as having a slow eccentric phase with a explosive concentric phase. So in general, we would just reference this as power training, right? Kind of like a broad jump where you're going to slowly load the movement and then you're going to explode. then the other piece of this is having additional resistance with this. So traditionally this is basically just power training. Power training could include jump training, it could be Olympic style lifts like snatches or cleans with dumbbells, barbells, whatever implement you want, kettlebells, any of those type of implements.

EFFECTS OF HIGH-VELOCITY RESISTANCE TRAINING ON BONE MINERAL DENSITY
So What they did is after they included their studies that met their criteria, they dug in and they had to have pre and post DEXA scans to figure out what their bone mineral density was at the beginning and then also at the end. They also had to have a six-month follow-up One of the studies actually had a 16-year follow-up, which is pretty wild. Being able to get a randomized control trial with a year follow-up is pretty great, but 16 years was pretty wild. So they looked at bone mineral density at the femur, the femoral neck, the lumbar spine, and also the distal radius. Only two of the studies looked at the distal radius to see if there were any changes in bone mineral density. The rest of the studies did not look at that area. Unfortunately, those two studies showed no change. So we'd need to dig into those studies more specifically to look at the loading strategies for those to really try to figure out what happened there because we know Basically, in general, our body's gonna respond to all the load. So if we get proper loading, due to Wolf's Law, we know those osteocytes are gonna start producing osteoblasts, and then we're gonna lay down fresh bone if we get proper loading. So no changes in the distal radius with using high-velocity resistance training. They did, however, find statistically significant results looking at the total femur on the DEXA scan, the femoral neck, as well as the lumbar spine. So there were statistically significant findings there using high velocity resistance training, AKA power training. So that was pretty cool. So we know that that is a modality that would be beneficial. The dosage, if we're moving on from what were the results, so it was beneficial, then the results were the results in the dosage were that twice a week is kind of the minimal dosage to see change in the skeletal system. So at least twice a week is what we should be looking for for dosage. Unfortunately there was so much heterogeneity in our different interventions that they weren't able to conclude a specific loading percentage. We do know just in general when it comes to power training that our percentages are going to be lower than resistance training because we're adding the component of speed. So if we're going to slowly get into that eccentric position to then explode into concentric, it can't be at the same percentages that we use at resistance training. So we know as a blanket statement that it's lower load than resistance training traditionally is. But what that is, there was not any formal consensus found from the systematic review. But they did find that two times a week is the optimal frequency that we're looking for if we're trying to change the skeletal system. they did find because their minimal follow-up was at six months, that if there was no training across that six-month period, that the gains that were created were also lost.

THE EFFECTS OF DETRAINING
So we want to keep that in mind that detraining, just like for the musculoskeletal system, the skeletal system as well, if you don't maintain those results, you're not going to be able to keep them. A really easy way to think about this is fitness is forever. It's just like brushing our teeth. We don't go to the dentist and say, well, you know, you've done a good job the last 50 years, so you know what, let's just take off the last 40 years. You don't really need to brush your teeth anymore. No, the results are not gonna be sustained and the same thing goes for our skeletal system. So once we get those results, we wanna make sure that we're getting people to be loading their bones at least twice a week. And this to be a thing that it's like, it's gotta be scalable across a continuum, across a lifespan for people, or it's not gonna necessarily be beneficial. We can give them a little bump, but that just makes it so much more important. that we're selling fitness from day one. What are you gonna do once care ends? If you wanna maintain these results, we know we can give you results. We know we can get you there, but you're gonna need to continue this training, kind of indefinitely. So finding fun forms of exercise that's gonna include high-velocity resistance training to help maintain bone density is helpful. Now, where we're gonna spend the bulk of our time is on clinical considerations. So I talked about there being high heterogeneity in our interventions. So the interventions included dumbbells, they included machines, resistance training. I found this very interesting. There was actually a masters football team that was included in this study, which I think is super cool. There were also some Olympic lifts that were being completed. in this study as well. Now, probably the most disappointing part of this study for me was this quote, which I'm gonna read to you. It may be unlikely that older adults are willing to engage in Olympic style lifting or soccer and that performing explosive concentric with slower eccentric movements using machines or free weight style equipment may be more feasible, safe and result in better adherence for the population. Now that was researcher opinion. And I can understand if you've got someone that is super sick, super frail, super deconditioned, it may not be feasible to get them out playing football or playing soccer. But when we're thinking about our active 50, 60, 70, 80 year olds, I mean, we've got people pole vaulting in their 80s. These things are not out of reach for older adults. For them to be doing Olympic style lifting, explosive type movements, Just anecdotally at Stronger Life, we do tons of agility, power, jump training with people all the way up into their 80s with no injuries. So a little disappointed in that statement. I can understand clinical practice, maybe we're talking, you were in the ICU, you're in acute care, you're like, okay, yeah, we're not probably gonna be playing soccer in my sessions.

"THE NEEDS OF AN OLYMPIC ATHLETE AND OUR GRANDPARENTS DIFFER BY DEGREE, NOT KIND"
But when we're thinking about long-term, we're thinking about strategies for for people that are over 50 like these are not out of reach we can absolutely be doing olympic style lifts and it reminds me of the quote from coach greg glassman who created crossfitted the needs of the of athletes and our grandparents are the same. They differ by degree, not kind. We need these types of interventions for our older adults to help with their bone density. And I would argue that power training, Olympic-style lifting, some of these more explosive-style activities are actually way more fun. I mean, let's think about pickleball, for example. Pickleball has tons of power training incorporated in it. And I would say, although it is becoming more popular in younger populations, I would say 50 plus probably has a market cornered on those style of movements. So the big takeaway there is don't count out power training for our older adults, Olympic style lifting. where they're moving quickly. Now another interesting discussion in there while we're talking about power training is that there were specific adaptations that were special to some of these cutting and power agility type movements that they described as odd stressors. So when we're thinking about the bone, if the load is only in one direction, we're only going to get adaptations, by and large, in that direction. When we start thinking about loading the bone from different angles with different cutting and different movements, then we can get adaptations in different directions, which, by and large, is going to help make our bones more resilient, less likely to fracture if they've encountered load in multiple directions and odd type stressors.

POWER TRAINING VS. RESISTANCE TRAINING
Now the study was, this systematic review was not strong enough to say high resistance interval training, or sorry, high intensity, high velocity resistance training is superior to high load resistance training. So we can't say power training's better than resistance training. We can't say that those odd type stressors with agility type movements are superior either. So basically this is all modality we should have. It was strong enough results that if you're not doing power based movements, agility, jump style training, Olympic style lifting, you should get that included into your clinical practice for older adults that are trying to improve their bone density. It is clear that it should be part of the approach. Now I will say if you're looking at the overall results, the two different, levels of quality here. We've got a systematic review, which way trumps the randomized control trials I'm about to reference. But if you look at this multi-modal approach, because the systematic review really did not have just high-velocity resistance training, there was strength training, there was balance, there was functional training. There were all these different modalities. It wasn't just high velocity resistance training included in the study. So it was really a mixed modal approach, but a common thread was that high-velocity resistance training was included. Now, some former studies of a lower level of evidence, if we're looking at the Lift-More or the Lift-More-M trials, those are both free access to the public, you can Google those very easily, use this mixed modal approach, but it had a much more specific dialed-in approach to loading. So there was high resistance training, 80% plus of a one rep max included and power training included. That mixed modal approach with a higher percentage of resistance seemed to be very beneficial when we're looking at the Lift-More and Lift-More-M trials. I would say that's one thing that's different from the systematic review is the criteria did not include a minimum threshold of resistance. Now those are my caveats from reading this and kind of thinking about the body of research.

SUMMARY
So if we're gonna boil this down, we're gonna ask, does high velocity resistance training help build better bones? We would simply say yes. Dosage that we need, two times a week. We know that there's a detraining effect if people stop this training for more than six months. So fitness is forever. We need those training methods, those modalities to continue. Considerations for clinical practice. Can we hang our hat on just high velocity resistance training? No. This was not strong enough to rule out just heavy resistance training. The body of research is larger there for making changes in bone mineral density just in general. It should probably include some power training like Olympic style lifting or agility training as well. That's also going to be beneficial. No clear winner on the type of modality, whether we're going to use dumbbells, kettlebells, barbells, resistance bands. All of those things are on the table, which is actually great because we don't always have those same exercise modalities. So it seems to be more important to hit those thresholds for power training, to hit those thresholds for resistance training, but maybe it's not so important that we just have X equipment in our clinic or at our disposal, which is actually great news. Team, I hope you enjoyed this review. I will have the the DOI listed if you want to look at this article more in depth on your own as well as the ones for the Lift More and Lift More M trials. If you found this interesting and you're interested in coming to see us on the road, I tell you what, live is a great place if you are new to loading bones or maybe you want some new Method styles to load your bones for your older adults. We have a whole impact training lab Lots of resistance training labs where we can help you dial in the dosage for the person in front of you From the ICU all the way up to fitness and masters Athletes, which is wonderful in our older adult live course. The next ones are going to be in Santa Rosa, California That'll be January as well as you can catch us in Marysville, Ohio on the 13th and 14th of January, then we're going to have Clearwater, Florida just a week or so after. If you're looking to continue your journey towards getting your MMOA cert, if you want to catch us in the L1, Previously Essential Foundations, that will kick off on January 10th. In the L2 course, which prior was called Advanced Concepts, is gonna be kicking off on January 11th. I hope you have or are still enjoying your holidays. Love to get your thoughts, comments on this super interesting systematic review. And that is it for now, team. Catch you later.

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.

Dec 26, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey discusses the need to assess beyond the physical properties of a scar. Scars can have deep meaning to our patients, and learning the human story behind the scar can help with better understanding a patient. Whether the scar was planned or not, the story behind the scar has value.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, 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 h 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.

LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How's it going? My name is Dr. Lindsey Hughey. I am extremity faculty, and I'm delighted to be with you here the day after Christmas. For those that are on YouTube Live, unfortunately, that is not working. So I'm just gonna have to send it via Instagram. Today, I'm gonna chat with you all about how scars, and I promised a month ago that I'd be chatting about actual scar management.

THE HUMAN SIDE OF SCAR MANAGEMENT
But what I didn't tell you last time was that we're gonna focus on the more human side of scar management for our post-op folks. So after surgery, no matter what extremity is involved, whether it's shoulder, maybe it's elbow, maybe it's hip, knee, ankle, maybe it's even back surgery, right, there is a scar that comes along with it. And as physical therapists, we tend to focus on the more physical part of managing that scar. And so what I mean by that is we focus mechanically, right? How's it moving? What's its pliability like? What's the elasticity surrounding that tissue, right? Is it moving well with the fascia? Are there any adhesions? Our scar tissue buildup. We are looking at the pain response of the patient, right? To show if there are any signs of infection. Think red, hot, tenderness, or spreading redness, right? We're looking for the management and guiding education accordingly. In addition, we're looking for any excessive swelling, right? Is the scar raised? Is it flat? And then we're really focusing our efforts on educating, mediating, against infection and then how to keep that scar moving. We aren't often focused on what that scar might represent from the patient. And what I mean by that is some intangible and unquantifiable measures like their emotional and their mental and their social response to having that scar. I wanna share two personal anecdotal experiences with scars that I've had myself to try to illuminate that part that's more unquantifiable, right? That emotional, social, mental piece in our scar management. So I have three kiddos, 13, 12, and seven. Some of you that know me already know this. And they were all born via C-section. C-section was not what I wanted. I had this whole natural birth plan written out, and it didn't really go according to plan. For that first one, it was emergent, and the second one was planned, and then third one was also planned, but there were some complications with actually having Luke, where he needed to be rushed off to the NICU, actually, because of some breathing issues. And I'll tell you, in general, the scar, I focus a lot on its appearance, right? That it's ugly. For those C-section mamas you know, there's like often this like shelf or invagination where that scar is and so tissue hangs over it. And besides it not being kind of the birth plan that I wanted, that appearance part of the scar really bothered me. So it represented kind of two things. Something that I didn't really want to have or how I wanted my birth experience to go and then also just the appearance like that there's this lingering scar that has now like affected my body makeup and how I'm presented to the world and The reason I share that is I don't think we think about that with our patients, right the connotation with the scar. We're again always thinking about physicality. How's it moving and is there any signs of infection and giving them tools to manage that.

THE STORY OF THE SCAR IS IMPORTANT
Well, when I realized the story is important, I want to share one particular moment that I had with my scar and the management of it. And it actually happened with my third c-section. So About a year after having Luke, I started having like spasms in my rectus when I would laugh and or when I was doing gymnastics work. So not only was the appearance kind of bothering me, it was starting to become painful because I would get these spasms that would double me over into trunk flexion. And so it made me talk with a colleague at the time I was working at Baylor and Dr. Jen Stone actually is a pelvic floor therapist and she offered to take a look at it and literally we're like in between teaching classes um on a break and she's like yeah lay down and i'll assess it and she starts assessing um the scar mobility and i was not a good pt patient and i hadn't done much scar work and so she starts you know telling me it's hypertonic and not moving well and more on that left side and she's just palpating and then she just offhandedly says what was your birth um experience like and I'm starting to tell her the story and I just start weeping. And it was so unexpected because I started telling her, basically, I'm on this OR table, in this Vitruvian man position, you can't get up. And I look over and Luke, you can see his red flashing lights. and his pulse ox was low. And the nurses were kind of telling me like, Oh, he's fine. And kind of pretending like he's fine, but really he couldn't breathe. He was having transient tachypnea, which is come to find out normal after C-section in many babies, because they don't get that birth canal squeeze. So fluid sits around their lungs, but I had never experienced that with the other two C-sections. And so like emergently he's wheeled away from me and I'm still like open on the OR table and so I start telling her this and like I'm crying as I'm telling her this and I get to kind of the end of the story how I never got to hold him like you know that first hour of nurturing time I didn't get and I didn't actually hold him for like 12 hours and we're like when I'm waiting post-operatively to see what's going on they don't really they didn't tell us much so I'm like in limbo thinking like is he gonna die but again Turns out to just be the transient tachypnea, not a really big deal. And I'm recounting this whole story to her how it was like tough. I didn't get to hold him. I didn't get the skin to skin time. And, you know, we're literally were afraid he was going to die. You know, he only needed two to three days in the NICU, it turned out, and he was all good. But in that moment, I realized like Jen gave me permission to tell my story and really unpack it because I'm kind of like a power through type of human, got through that last C-section and went back to CrossFit and thought I was fine and dandy. And it was in that moment where she just, you know, was palpating the scar and took the time to like understand the story behind it. And so it makes me pause and Consider maybe all of the folks that I kind of bypassed thinking like total knee replacement, total hip replacement, and what those scars might have meant. Or someone after trauma think ACL or getting that triad where they have this surgery where it takes them out of their season, right? It's out of their control. Those are two different kind of scenarios, right? I didn't want the C-section, right, in any of the cases. but the C-section kind of chose me. In that case of like a total knee replacement or a total hip replacement, something where we get gradual worsening pain and function and we have to elect to have the surgery.

SCARS TELL A STORY OF RELINQUISHING CONTROL
I have another personal story to share where even when you elect, so like those three sections not really in my control, There are surgeries we have to choose sometimes because of pain worsening function and or failure of our tissues. And so the second scenario, I want us to appreciate too, because both involve a little bit of relinquishing control, which is tough for our patients. So my second scenario is also another personal story. Having had the three C-sections, right? And we fast forward seven years to the present, I, in this last year, started experiencing a supra-intra-abdominal hernia. So I noticed this mass above my belly button to the left. So because it's asymmetrical, it wasn't like the Linnea Alba issues. It literally, or Diastasis Recti, it literally is a hernia because of that asymmetry. throughout the year kind of started getting bigger. And I consulted with some pelvic floor PTs, and they're like, that's not necessarily pelvic floor, right? Start working on your intra-abdominal pressure to help. But you should get that checked out, because the mass on your stomach is kind of concerning. And come to find out, I put it off for quite some time, at least six months, and I go to this intra-abdominal specialist, and he does, in fact, confirm that it is a supra-abdominal hernia, and that there's subcutaneous fat, and that, right, if you ignore it long enough, this can turn into an issue where there's strangulation, which then can become like an emergent issue if you become sepsis, if it were to triangulate and cut off blood flow or like your intestines, right? The reason I share this story with you is the second part is this was a surgery that I had to opt for, kind of like when someone has to choose that total knee replacement or total hip replacement. I was starting to have some pain associated with eating big meals, and then some exercise-induced nausea with high intensity. It was only intermittent, right? Sometimes, so for at least a year-ish, I had been putting it off. I've since had the surgery, right? December 13th, I had it. And now I'm in this new zone. You can't actually even see the scar, right? Because it's under steri-strips. But what I want you to think about and what has me pausing and thinking from my own personal experiences, this scar, although a little bit out of my control, right? It's abdominal wall failure due to intra-abdominal pressure issues, due to that history of C-sections. It's not really something I wanted to do. I don't want the downtime of not lifting heavy things with my friends. I don't wanna build my gymnastics from the beginning. I don't want this break of time where I'm not lifting heavy and I'm not working intensely, right? It's this forced slowdown. But in a lot of ways, like I chose this, right? I chose to schedule this surgery due to some failure in the tissue and some worsening pain and weakness. The scar, once it heals, it'll represent a pause in my story. But it also represents an opportunity, if I'll reframe it that way, right? An opportunity to work on my intra-abdominal pressure from the start, now that I don't have a 1.5 by one centimeter hole in my fascia, right? And now there's no longer subcutaneous perineal tissue sticking out.

SCARS REPRESENT A SLOW DOWN
Our patients, no matter their surgery, whether they had you know, a history of various surgeries like I had and have had to have subsequent surgeries like I just needed to have because of those, they are coming to you and they are in a time where there is some uncertainty on board, where they have to slow down in their story, right? Which affects them mentally, socially, emotionally and spiritually, like when they're not involved in the activities that like bring them joy in their life. And They have to give up some things for a time and that can be really hard. And so scars, let's approach them. Let's take the opportunity to not only obviously address that physicality piece, right? and safety about infection, and make sure the scar is moving well, but take the opportunity to understand the story behind maybe why they chose that surgery, or were advised to have that surgery, or maybe why it was emergently, right? If there's some trauma associated around having to have the surgery, that can be tough, and they've maybe never been asked to share that story, and maybe they'll have that kind of emotional release unexpectedly when you ask them that question. What I want you to reflect on is, have you even thought of the human in front of you and the story behind the incision and what that might mean to the patient? Can you take the time to give them permission to tell that story? And it may unlock some sadness and fear and angst. But if you don't invite that opportunity, then you miss the opportunity to help them reframe that experience for the better. you miss the opportunity to deliver control to their story right where they're the heroine of that story. So two real action items today is learn the story behind their scar and their incision from the beginning and then of course create a complimentary rehab program that makes their extremities, their spine, robust and that makes that scar just be in a badge of honor, right? And just a reminder of a moment to get after resilience in their story. A lot of times in our extremity management course, we can't dive into postoperative care. We speak a ton about upper quarter and lower quarter extremity resilience and how you can get after that with your patients. We have so many offerings to dive into that in January. And so if you'd love to learn more about extremity care and resilience, we would love to have you at one of our upcoming courses. We are literally stacked in January, January 13th, 14th. We are not only in Richmond, Virginia, but we are also in Greta, Louisiana, and we are also in Fayetteville, North Carolina. So all of our extremity faculty will be out on the road teaching that weekend. be there at one of those locations. In addition, January 27th, excuse me, I already said that, January 13th and 14th, we also have opportunity. I kind of flipped that actually. Check us out on btoknights.com. The 13th, 14th is when we're in Virginia and Louisiana, and then the 27th is when we have three opportunities. Forgive me for that. Fayetteville, North Carolina, Athens, Georgia, and then Burlington, New Jersey. And then literally most months of 2024, we are somewhere in a city near you. I thank you for taking the time to listen to my story today. And I hope again, that you will consider the patient's story behind their scar. Have a great day, everyone.

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.

Dec 25, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick unpacks the one emotion you are underutilizing during client sessions: “Awe”. In this episode, she defines awe, discusses benefits of experiencing awe both as a provider and client and gives examples of how to spark awe during PT sessions.

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.

APRIL DOMINICK
What is up everyone? Happy holidays and welcome to the PT on an ice daily show. My name is Dr. April Dominic. I am with the pelvic faculty today. I'm hopping on to talk about the craft of sparking awe via PT. So what is awe? We'll talk about what it is. We'll talk about the benefits, and then I'll give you some examples of how to spark awe during your physical therapy sessions.

DEFINING AWE
First off, let's define it. Researchers define awe as the feeling that occurs when you encounter something unexpected, something vast, something extraordinary. And this emotion awe can come across the gamut of types of emotions. It can be positive in the sense of inducing pleasure. It can be neutral in the sense of inducing connection. and it can be negative in the sense of having some sort of uncertainty about it. With awe, what it tends to do is it diminishes the focus on the self and instead reflects it to the collective. So folks tend to be a little more concerned about others, about the grand scheme, about the collective versus themselves. And often people think of awe as if it's this vast, physical, massive thing that has to happen, like seeing the view of earth from space. It can actually be that, but also be something a little smaller or a little more emotionally dense. Some examples of awe, there are so many, we'll go through a few. Awe can be the emotion that's emitted when an orchestra finally reaches that crescendo during a long drawn-out musical phrase. It can also be something very impactful from a social perspective, such as, do y'all remember when we used to clap for the healthcare workers during quarantine around 8 p.m. That was something that was happening across the world that was just very unison in nature. And it can be the sting of a slam dunk of the opposing team with two seconds to go, resulting in a loss during a basketball game. I have a few instances of awe that I'm reflecting on from my personal life, Uh, and one is a couple of years ago, I had the opportunity to say goodbye to my friend from physical therapy school just three hours before she died. And that was a very powerful, impactful way of feeling off for myself in contrast with a very natural, big phenomenon that I got to experience this past year. I was in Iceland chasing the Northern lights. And I just wasn't successful with that. I finally came home and, uh, draw drew the curtains on my Airbnb just one more time at 2 a.m. And lo and behold, above me was this incredible, incredible feat of nature of dancing Northern lights, just neon greens and soft pinks. So vibrant right over my Airbnb. And it was, it was just so incredible. And then it can be something smaller. Like yesterday I was taking a walk in the Texas Hill Country neighborhood and I looked up and across from me just yards away were two brown and white stags just majestic and staring at one another. So those are some examples of awe. They can be big, they can be small.

THE PURPOSE OF AWE
And what is the purpose of awe? The purpose is to pause. It's to allows time to slow down and to allow us to reflect on understanding an event that just happened to us. So how do we express awe? I want you to know how we express awe so that you can identify it during your physical therapy sessions. We do so via language. Wow. Ooh. Or some might say, oh, that was awesome. or I'm awestruck. We do so with verbalization of wonder. We may, after witnessing an incredible event or listening to a heartwarming story of one of our clients saying, I was finally able to lift my grandkid after having shoulder surgery and I did it with no pain. We may express awe via emotions. It can be tons of tears or, um, laughter or goosebumps even. And we also do so via facial expressions. So it might be a jaw drop or eyes widening. Eyebrows lifting, these are all things you may encounter, see folks do in your physical therapy sessions. And that is something that you can do as well with your own expressions and reactions to them. According to the research team Cohen et al, awe is a universal expression that is distinct from 50 other emotions. And it is also present across 144 different cultures. They, in one study, they looked at 2 million videos of people watching fireworks and individuals seem to express awe in similar forms.

THE BENEFITS OF AWE
So why is awe beneficial? There are so many benefits to the emotion awe. Mentally, it induces a sense of calm. It reduces anxiety and depression. And per researcher, Dr. Keltner, he has suggested that awe also has a role in the grieving process. This can be grieving of a human, of a pet, or even of a body part, if someone's had an injury or a surgery, or maybe even time, thinking of the postpartum individual who may be grieving her pre-partum self. Physically, awe can show up and it's beneficial from a physical sense in terms of it dials down the fight or flight response. It can increase cardiovascular health and longevity. And then on a transcendental level, the emotion awe helps us feel part of something larger than ourselves. We think of this from our clients perspective in the sense of some of our clients come in and they let their diagnosis just identify them, right? They come in and they're like, well, my fibromyalgia, yada, yada, yada. Right. And they are just blaming everything and, and saying that their existence is due to fibromyalgia. and that is going to get them to perseverate on their injury or their condition. Awe or practicing awe would be an awesome thing for them to do just so that they can kind of step out, zoom out and look at the collective and take the instance of focusing on their own injury or condition away. We can also think about it from what we do on a day to day. We are sitting there listening and working with all different kinds of individuals right then and there. We as clinicians are practicing awe as well as we're focusing on others, not ourselves. And I think that this can maybe even help us with our burnout in our profession. Just remembering and reflecting on those instances of awe.

HOW TO SPARK AWE
So let's discuss how we can spark awe in our PT sessions through our environment and through our interactions. From the environment standpoint, awe can be induced by just even the music that you're playing. Music has an incredible power in the sense that sound waves activate the vagus nerve. It activates our dopamine a regulation or reward system. It lowers cortisol. So just by turning on music that brings you or inspires all in you or asking the client, Hey, what kind of tunes can I put on for you? And then decorating your clinic with maybe pictures or, um, pieces that represent bring us like, uh, photos of scenes from your travels or photos of your pets, your family, your dogs, all of that can induce awe and help in the client environment overall. And then finally, interactions that we have in our PT sessions via assessments and treatments. I've got a few here. So the first, we can inspire awe by our reactions during session, whether that's a concerned jaw drop or those widened eyes or even dropping a verbal phrase for the client. Since they've said, oh my gosh, I've just started exercising so much now, my frequency has increased. I went and bought that 50 pound kettlebell that you suggested and we can give them praise. and inspire awe in that way. Also, we can use our senses as a gateway to experiencing or expressing awe. With the exception of taste, we tend to utilize all of our senses in our PT sessions. Hearing, we actively are listening to our clients as they share their stories. sight, we're watching them and helping and suggesting different movement patterns for them. We are touching them via palpation, via assessment, via our manual therapy skills. And smell, that may be just for our wound care colleagues. And then in terms of treatments for patients, you can suggest all practices, We can play games during our sessions or encourage them to play games. This is going to ignite that childhood sense of wonder. Every time I think of sense of wonder, I'm thinking of Leanne Ryan's, I Hope You Dance or Leanne Womack. It might be Leanne Womack. She says at the very beginning of her song, I hope you never lose your sense of wonder. And then another lyric is, I hope you still feel small when you stand beside the ocean. All of that reminds me of awe and wonder. So we can tap into our childhood feelings of discovery with our clients and encourage them to do so as well. And then we can suggest all walks. This is something where, you know, maybe we're doing fitness outside of the clinic or we're asking them to do their rehab emoms outside because maybe they'll hear the birds chirping, cute birds chirping, or maybe they'll see a new bloom in their garden from a flower. just different ways to bring out awe. And then we can also use awe as a meditation or mindfulness supplement. In case you want any other resources or you want to dive deeper into the research on awe, check out Dr. Keltner's book on awe, the new science of everyday wonder and how it can transform your life. So to sum up today, we can't all fly to space and take a bird's eye view of earth to experience awe, but there is everyday awe around us, even in the clinic. Awe is an emotion that's extraordinary. It removes focus from the self. and transfers it towards the collective from an emotional bit standpoint, like supporting a client's aha moment when they're saying, Oh my gosh, I think my pelvic pain and my urinary urgency are related to that episode of abuse that I had. Or when a, when we as a PT break down a client's thought virus that they think lifting heavy will result in injury. And then in that very same session, both the client and ourselves experience awe when that client cranks out 12 deadlifts at 80% one rep max, feeling no pain. And they thought they'd never be able to do this because of their bum knee. Awe is perceptible in each of your PT sessions, whether it's with a new client or with someone you've seen for years. Remember, how do we increase awe? We can do so through increasing our own awareness of all happening throughout our sessions. We can do so through facial expressions, watching someone's body language, through the words we say. And remember to use your senses. And we also can encourage folks to utilize awe and seek and appreciate awe inside and outside the clinic. This is all going to help with increasing their mental and physical well-being. So I'm faculty with the Pelvic Division here at ICE, and we have so many offerings that we'd love to see you get some awestruck education with. We've got our weekend live courses starting January 13th and 14th in Raleigh, North Carolina, and January 27th and 28th in Hendersonville, Tennessee. We'd love to see you live or at any of our online offerings, head to beauty on ice.com to check those out. I hope y'all have a wonderful holiday and experience large doses of awe this week. And as you ring in the new year with those fireworks display, know that folks all over the world are expressing similar instances of awe, just like you take care 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.

Dec 23, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses why & how interval-based training causes positive adaptations, how to assess & program intervals for patients and athletes, and how to help them approach interval-based training.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

ALAN FREDENDALL
Good morning, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. My name is Alan. I'm happy to be your host today here on Fitness Athlete Friday. Currently I have the pleasure of serving as Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. Fitness Athlete Friday, if you're working with that person that is recreationally active, the CrossFitter, Olympic Weightlifter, Powerlifter, the Endurance Athlete, whatever, Fitness Athlete Friday is for you. Today we're going to talk about intervals. I think this is a great topic because what we're going to talk about today can really apply to all of these athletes. Runners, cyclists, swimmers can obviously benefit from interval work, but so can crossfitters and powerlifters and Olympic weightlifters. And we're going to talk about types of intervals, why do intervals work, how do we program these intervals more specifically. to the weaknesses that these athletes need to work on. And then we're going to talk about how to actually approach these intervals as if we were in the driver's seat. Being that athlete, how should we approach interval based training? I'm going to reference a paper today that is just basically a review of a whole bunch of different research articles on interval based training. It's by Oticon and colleagues from 2021. It's the International Journal of Environmental Research and Public Health. and the title is Evidence-Based Effects of High-Intensity Interval Training on Exercise Capacity and Health, a Review. And this is just a paper that consolidates a lot of different research on what is actually happening to the body physiologically when we do intervals, what is the benefit of interval-based training, and then a little bit about adherence and enjoyment as well as we talk about compliance with interval-based training versus other types of training.

WHY DO INTERVALS WORK?
So let's discuss the first part that a lot of us maybe have questions on, especially if we're explaining to patients or athletes why we might be doing interval-based work, even in the course of their rehab. If they're doing remoms, if they're doing AMRAPs or something with rest, when you have folks doing interval-based exercise in the clinic or in the gym, why do intervals work? The first thing I want to speak to is the concept of excess post-exercise oxygen consumption, often abbreviated as EPOC. For a long time, this was thought to be the main benefit to higher intensity interval training, that somehow, because we were working so close to our max threshold, that as we did interval-based training, our body could somehow not supply enough oxygen to itself during the training, had to pull oxygen from other sources, and otherwise created a large deficit that throughout the day would need to pay down that deficit, would lead to a huge consumption and calorie burn, would lead to otherwise a lot of increased metabolic effects throughout the day after interval training had completed. We know now that has been thoroughly trounced in the literature, The most effective thing you can do for EPOC is actually resistance training, right? To accrue more muscular mass that is more metabolically active, that's going to result in an increased metabolism throughout the day, and actually every day, the more and more mass you accumulate, right? Very large muscular people have very large base metabolisms, and that's related to resistance training, not related to high intensity interval balance, of aerobic exercise. So know that EPOC is really not what we're after. What we're actually after, depending on the type of interval and training we do, is looking at central versus peripheral cardiovascular adaptations. So with central cardiovascular adaptations, we are mainly targeting the heart. We have improvements in ventricular hypertrophy, we have improvements in maximal stroke volume, the amount of blood that gets sent out every beat of our heart, and an overall increase in red blood cell volume. Now, when we do moderate intensity steady state exercises or longer, slower intervals, we primarily get peripheral cardiovascular adaptations. We get increased mitochondria, we get increased capillary density, we see improvements in lactate buffering and transport, converting pyruvate that's broken down during exercise back into lactate to be reused for energy. And the key there is that when you do really long, slow aerobic training, or you do very, very long intervals, you are only really becoming better at doing long, slow aerobic training or really long, low intensity intervals. That really long aerobic training or long aerobic intervals only make you better at long aerobic training as a whole. So when we discuss intervals, especially when we're talking about how to program intervals for maybe crossfitters, powerlifters, or Olympic weightlifters, we need to understand that the kind of craze right now in training for them of 40 minute EMOMs and 60 to 90 minute zone two training sessions has really a minimal benefit for those folks. Those folks need to be doing shorter, higher intensity intervals to get those central adaptations. Literally increasing the size of their heart, their stroke volume, their red blood cell volume, giving them more power and energy for those shorter bouts of exercise that they're conducting, Olympic weightlifter or powerlifter, you know, maybe one heavy lift, maybe a double or triple crossfitters, maybe exercising in the 8 to 12 minute time domain. Those folks are really not going to benefit from those peripheral adaptations from really long aerobic training. So we really don't want to see those people doing a lot of long aerobic training, especially if it's competing with their weightlifting or natural crossfit training. And then translating out of the gym, most human functional tasks and sports exist in a relatively short time domain that's also going to benefit from those central adaptation improvements. So we need to understand that if I do 90 minutes of zone two a day, that's probably not going to help me in a sport like football, in a sport like basketball, which is much quicker, much shorter, short bouts, When you look at a game of like basketball or football, it almost looks like interval training, right? Play for 30 seconds or a minute and then there's rest, right? There's timeouts, that sort of thing. Very different than going for a five mile run or a 10 mile run or a marathon. So if you're not doing long aerobic events, you should steer away from long aerobic training or long aerobic intervals. And then the final benefit of why do intervals seem to work? They seem to work because people really seem to enjoy them. When we look at research around high intensity interval training, we see that exercise adherence and enjoyment is very, very high. And I think we've talked about this before. It's often overlooked, right? Of what do you like to do? We should probably program that stuff because it's going to be stuff that you're going to do more often. And if your adherence, your compliance, your enjoyment is high, you're much more likely to come to the gym or go to the track or whatever and do it. and that consistency is what is going to increase your health and fitness over time. So that's why intervals work. They may benefit central versus peripheral adaptations, and that's going to depend on the athlete in front of you of what adaptations they may be seeking.

HOW TO PROGRAM INTERVALS
Now, when we're programming intervals, whether it's a patient in the clinic, whether Darlene's in the clinic, or we have Frank the CrossFitter, whatever, how do we program these? Remember, with intervals, intensity is the goal. We're looking for most interval sessions, especially if we really want to produce a lot of those adaptations, to be around 90% of our VO2 max. If you've never done a max effort Bruce treadmill test, looking to find your true 100% VO2 max, it's quite the experience, right? You're running on a treadmill, you have the metabolic heart, you have the oxygen mask on, you're running on an ever-increasing speed and grade until failure. With a true VO2 max test, Failure is when you pass out, right? There are people behind the treadmill to catch you as you pass out. You reach the point at which you can no longer pump enough blood to all of your body and you pass out. That is the true test. So we're not going for that with our intervals, we're not going for 100% blackout, but we are looking for 90% or maybe 80%. So we're looking for very, very, very hard efforts. The type and amount of those intervals is going to be key to facilitate that intensity. That's going to be a combination of work and rest, hopefully working on things that that athlete or patient needs to improve related to time domain and functional tasks. So if intensity is the goal, how do we notify that intensity? If we're not having folks do a treadmill test to failure, well, we do need to do some testing. We do need to have some sort of baseline measures in place to know what sort of paces are we looking for. We can get a metabolic heart in the clinic. We can measure heart rate. But the easiest, most practical thing for a lot of us is just going to be to have somebody do something like a 500 meter row one day and then a couple days later do a 2000 meter row or a run or a bike or whatever. Get some sort of short time domain effort and some sort of longer aerobic time domain effort. And the key there is we're looking to establish fatigue fall off factor. So we know does this individual need to work on speed or do they need to work on endurance? Now, with some of our patients, especially more of our deconditioned patients, we don't need to do a lot of testing to know what they need to work on, right? That patient that barely makes it into the clinic from the parking lot, the 20 second walk from their car to the chair in the lobby was max effort for them. You know where you need to start with that person, right? That person needs to work on shorter intervals. They have no aerobic capacity. Certainly, they're not gonna do well on something like a six minute walk test. Shorter intervals for that person, build them up. But with somebody who's already active, how do we know their weaknesses? We need to calculate that fatigue fall-off factor. How do we do that? I've got it written out on the whiteboard here. I hope you all can see it. I hope it's not backwards, but I'll read it out loud nonetheless. So, I happened to just do a 500 meter row yesterday and find a new PR. It was 133. That's 93 seconds. I already know my 2,000 meter row time. 2,000 meter row is gonna feel a lot like a mile run. it's 648, which is 408 seconds. So what is the time difference? If I think about, if I could hold that 500 meter row four times, I could theoretically get that 2000 meter row done in 372 seconds. However, that's not realistic. Why? Fatigue falloff factor. As exercise bouts get longer, There's some natural fatigue accrual that's going to slow me down more than just thinking I could rock my PR 500 four times in a row. If that PR short distance effort is truly max effort, there is no way you could sustain that for four times as long, right? And that time difference is called fatigue falloff factor. So 372 seconds over 408 seconds is about a 91% Integer there, that means I have about a 9% fatigue fall-off factor. Now, how does this let me program? If folks have less than a 10% fatigue fall-off factor, they need to be working on power and speed. Folks that have more than a 10% fatigue fallout factor, they need to work on endurance. So that kind of tells you right away, does this person need to be working on shorter intervals, more power and speed? Or does this person need to be working on longer aerobic intervals to build up their endurance? And then again, the final key there is, what is this person actually doing in the gym? Because at the end of the day, if they're not doing long aerobic work for training, even though it may seem like they need to train endurance, again, does not make sense for them to train a lot of endurance and vice versa. So make sure we're training the right energy system. I love testing this stuff with patients. I've watched a lot of people row a very slow 2K row just to get that data. Data might not change behavior, but it certainly does inform our decisions when we're gonna start creating some exercise programming. Now, establishing that baseline, knowing intensity is the goal. How do we implement this in the gym and the clinic? For a lot of folks, that's going to look like running or using a machine. Why? Because our bodies are very, very efficient at using cardio machines or running, we get to use our full body, which means we get to get a lot of blood pumping, which means we get to buffer a lot of things like lactate, much more so than if we decided to do intervals of something like strict pull-ups, right? Where muscular fatigue, the lack of muscular endurance or indoor strength is going to affect our ability to do work. Not many people have gone to the point of failure on a bicycle and collapse on their bicycle due to a lack of leg strength pedaling that bike, right? It's always usually at the end of the day an endurance thing. So when we're having folks do intervals, yes, in CrossFit, we can do intervals, but we often do intervals, we mix things up, right? We have biking, pull-ups, and kettlebell swings or something, right? We have enough work where just as we get tired, we move to the next thing, and then we get some rest. We don't just do big rounds of one movement unless we happen to be on cardio machines or running. So make sure in the clinic or the gym, you have a rower, you have a bike, you have a ski machine, whatever, or you have a treadmill or otherwise ability for the athlete to run. So that's how we program intervals.

EXAMPLE INTERVAL PROGRAM
I want to show you an example now of how I would program for myself based on the data I just shared. So same whiteboard, right? We know that we want to be ideally 90% intensity of whatever we just did. I know my max effort 500 is 133. So that means that if I'm going to be doing rowing, again, my fatigue fall off factor was 9%. I need to be working on power and speed. I'm going to program myself 500 meter row repeats with some rest. Why? Because I need to work on that power and speed. How do I know my pace? Well, I know my PR and I know my intensity thresholds. So I know if I want to be doing these 500 meter rows at 90% I need to be rowing at at least a 143 per 500 pace. If I wanted to work at 80%, I could be rowing at a 151 per 500 pace. And now I can give myself a range. Hey, I'm going to do five sets of a 500 meter row. My range is a 143 on the fast end and a 151 on the slow end per 500 meter row pace. And I'm going to rest three minutes after every round. Why? Because I want to be resting at least as long as I'm working. Now, how do we approach this? How do we help patients? and athletes approach this interval work. Now that we know why we're doing it, now that we know how we program it, first things first, what is the goal? For a lot of our patients in the clinic, statistically 90% of them are completely sedentary, so anything goes, right? They can benefit from both short time domain and longer time domain intervals. They can benefit from doing it on any of the machines. They have room to grow on running, biking, and rowing. With those folks who maybe, again, They clearly do not appear to have any long aerobic system left. You're probably going to be stuck with short intervals in the short term until they start to build that aerobic base up. If we want to improve power or speed with these folks, we want to keep the time domain two minutes or less, right? We want to keep it in that anaerobic time domain window. So if we're thinking rowing, if we're thinking running somewhere between 100 and 400 meters and we want to have relatively short bounce, with longer rest at least one to one rest to really facilitate our ability to repeat those efforts to hit those paces with power and speed. Now on the opposite end, what if we want to improve longer endurance? Well, we're probably looking at running 800 meters or longer, we're probably looking at rowing 1000 meter repeats or longer. We're otherwise looking at exercising longer than the two minute time domain. Here, the bouts are going to be longer, the rest is going to be a little bit shorter, because again, longer effort, lower intensity, we don't need as much rest, so here you could get away with maybe one to two rest. If it took you four minutes to run an 800, you could rest two minutes and then run that 800 again, hopefully in another four minutes or whatever your pace may be. I cannot stress enough that you should match the modality of what the patient wants or needs to get better at, right? If you want to get better at running, you should probably do most or all of your interval-based training running. I hope I don't have to explain why being specific there is really important. But most of your intervals should be on the modality that you want to get better at, especially if we're talking about doing this for performance. Yes, there will be some carryover from the rower or the bike to running and in between. But if you want to become a better biker, you should do a lot of biking. If you want to become a better runner, you should do a lot of running.

APPROACHING INTERVAL TRAINING
And then the final thing I'll say is make sure that you're actually getting the stimulus. Remember, these efforts should ideally be around 90%. They are higher intensity because they are intervals, because you are eventually going to get some rest. You should not be shooting to get a PR during your training, right? If it's a test day, it's a test day. If it's not, we should not be shooting for 100%. We see this a lot in the CrossFit gym. We will have 400 meter repeats. or 500 meter repeats. And our guidance is these should be at 80 to 90% of your max PR of whatever, whatever distance we're going. And what do we see a lot, we see a lot of people swing for the fences on the first round, and PR their runner row, maybe they puke in the bushes, and then some of them are not able to complete the rest of the training, right? So some folks may even fall short of a PR, they try to get it, they miss it, and then they're not able to complete the rest of the training. Completing the volume of the training at the intended intensity is getting the stimulus and making sure that we're actually trying to get max effort, but we're not going for 100% every time it's time to run a row. On the other side, we make sure we don't under dose ourselves, right? If we're aiming for 80 to 90% of our max, we should not see a slow warm up in those intervals where maybe only the last couple rounds are actually at 80 to 90% of our max capacity. Again, intensity is the key here. All of those benefits central or peripheral come from getting close to those intensities. If we miss those, I don't want to say you're wasting your time, but you're not getting the same benefit you could as if you were really pushing yourself. Interval based training should be very, very, very uncomfortable. You should feel like you need that rest break. You should feel like, geez, I wish I had more of that rest break. If that's the subjective feeling you have with interval training, you are doing it correctly. So interval training, why does it work? Central versus peripheral adaptations, different needs for different patients and athletes. How do we program it? We program it by making sure we establish some baseline testing, find out what our person needs to look at. How do we approach it? We understand if that person needs power or speed, they should be doing shorter time domain, longer rest. If they need endurance, they should be doing longer time domain, shorter rest. And whenever possible, we should be matching the modality. If you wanna get better at running, you should do your intervals as running. Make sure we're getting the stimulus, hitting that 90% mark, and actually getting good effect from our training in the clinic or in the gym. So that's interval based training. Very quickly, some courses coming your way. Your next chance to join the fitness athlete division online will be our level one course that starts January 29th. And then our level two course starts February 4th. Live courses coming your way in January, Portland, Oregon with Zach Long, January 27th and 28th, February 10th and 11th of 2024. Mitch will be in Richmond, Virginia. and then February 24th and 25th, Zach Long will be at home base in Charlotte, North Carolina. So check us out, ptownice.com, click on our courses, see where we're coming your way. I hope this was helpful, hope you have a fantastic Friday, have a wonderful weekend, have a great Christmas, we'll see you next week, bye everybody.

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

Dec 21, 2023

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

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty member Ellison Melrose discusses how to dry needle the occiput to address headache complaints. Elli orients listeners to the anatomy of the occiput as well as muscles to target when needling. She also discusses what stim parameters to use when treating headaches.

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

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 h 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.

ELLISON MELROSE

All right, good morning, Instagram and YouTube. Welcome to the PT on ICE Daily Show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division. We're gonna dive right into things today. I am here to bring you dry needling for the suboccipital headache. And why I say that in quotations is because oftentimes when people are complaining of headaches at the base of the occiput, If we actually take time to palpate those tissues, it's not the true suboccipitals, okay? So we are thinking about the occipital insertion of things like upper trap and semispinalis. Those are our two main culprits when we have patients that complain of the headaches that start at the base of their occiput. So before we dive in, first of all, I have already cleaned the tissue of my patient here. but let's orient ourself to the anatomy of this occipital area.

OCCIPITAL ANATOMY
So in order to do so, we are gonna start by palpating for the external occipital protuberance, which is the protuberance, which is the nice bump on the back of our head here. So that's going to give us that orientation of where that superior nuchal line is, okay? Superior nuchal line is going to be the superior border of those occipital insertion of upper trap and semispinalis. We can follow that superior nuchal line down towards the mastoid process here. That's going to give us our, again, superior border of where those needles live. If we follow the mastoid process medially, it dives deep, but the inferior nuchal line is going to be the inferior most border of where we're needling today. What I want to do is I wanna take some time to find where the true suboccipitals live as to avoid needling in this area. So in order for us to do that, we're going to, there's a couple ways to find this region. First, we can palpate that EOP, external occipital protuberance, and drop down. The first spinous process we come in contact with is going to actually be spinous process of C2, as C1 does not have a spinous process. So that is going to be the inferior aspect of where the true suboccipitals live. Let's come back towards the mastoid process. From there, if we drop just distal, feeling the lateral like pillars of the neck, that is going to be the transverse, the first thing we palpate there is a transverse process of C1. So the true suboccipitals live between the spinous process of C2, transverse process of C1 and that inferior nuchal line. So we do not want to be needling in that area today, as it's a little bit more of an advanced technique. And I think when we're talking about the headaches that present at the base of the occiput, it's actually not the true suboccipitals. So for orienting ourself to where the muscles are, we have two main muscles, but we have bilateral tissue. So we're going to be treating bilaterally for this headache presentation. We are going to find that external occipital protuberance. If we step just about a finger breadth lateral to that, we can palpate a tootsie roll shaped tissue, and that is going to be your upper trap insertion on the occiput. When we're needling this area, we want to be mindful of some sensitive structures around this tissue. For example, what kind of is around the upper trap insertion is going to be greater occipital nerve. Essential anatomy is going to make it really seem very easy to find and it's not necessarily easy to find. One way that we can avoid too much interacting with this nervous tissue is going to be limiting our pistoning in this area.

NEEDLE INSERTION ONTO THE OCCIPUT
So for treating these occipital insertion musculature, we want to be using our E-STIM with pain modulating parameters. Okay, so EOP, first step lateral, is going to be that tootsie roll of upper trap. From there, we can take another finger breath lateral to that and we can find semi spinalis muscle belly as well as it inserts on the occiput. So let me do that on the other side. EOP, upper trap, we got a good old tootsie roll here. And then just stepping just lateral to that, we have semi spinalis. There is an area we want to avoid in this area, region as well. And it's going to be, if we find the mastoid process, about one finger breadth medial to that, there's a little sulcus. That sulcus is where the occipital artery lives. And if we go too deep there, we can interact with things like the vertebral artery and such. So we don't wanna be interacting with that tissue there. So we are gonna be keeping, it's pretty small territory here, but keeping our needles about, you know, two finger breaths away from that EOP is where those needles are going to be living. Let's talk about needle application. So in this area, the occiput is kind of diving anteriorly, right? So we want to have a bony backdrop for these muscles, and that's going to be on that occiput. We want to be using a firm palpation to mitigate the sensation of the needle inserting into the tissue. There's a lot of tendinous tissue here, so sometimes it can be a little bit more sensitive of an area to needle. So we can mitigate that sensation with increasing our palpation and our compression there. Our needle angle, let me just grab a guide tube out and we can kind of go over that. Our needle angle is going to be almost perpendicular to that occiput. So if we're thinking about the needle angle is like so. So for upper trap, we're thinking about angling that needle almost towards the eyeball or on that ipsilateral side of that muscle. For the semispinellas, it's a little bit more lateral. The occiput is diving, again, anterior. So there's some 3D anatomy here. We wanna be inserting, again, perpendicular to that occiput. So our needle angle, may look a little bit more flared towards midline, or that needle angle is going towards the contralateral eyeball, okay? So, again, let's orient ourself, and we'll then start placing some needles, because that's why we're here, right? So, palpating external occipital protuberance, stepping just distal to that and lateral, so we're underneath that superior nuchal line. If we are at the level of the EOP, we're going to be in more tendons. We wanna be a little bit more distal between superior and inferior nuchal line. Finding that tootsie roll, that's going to be upper trap. We are using a firm two finger digital compression to rock climber grip that upper trap against the occiput. We're using some short needles here. So I have 30 millimeter needles, and that should be sufficient enough to access this tissue. My needle angle for upper trap is going to be, compress, create a small treatment window between my fingertips, and I'm letting that needle settle. My needle angle is directly towards the eyeball on the ipsilateral side. Firm tap, and then we're going to advance our needle towards a bony backdrop on that occiput. So there we have upper trap on the patient's right side, And then our semi-spinalis is going to look very similar to that. We're just thinking just lateral to that insertion of upper trap, okay? So this is a petite anatomy here, so we don't have a ton of space between that kind of mastoid process and the upper trap needle that we just placed, right? So what we're going to be doing is the same sort of thing, hook, rock climber grip, Now my needle angle's a little bit more flared towards the midline, towards the opposite eyeball. Firm tap needle towards occiput. So now we have placed both upper trap and semi spinalis needle on the patient's right side. For treatment purposes, I would be doing bilaterally. And we can walk through that if, let's do it. Why not? Let's do it again. So, again, we're gonna find EOP, drop just distal to that, just distal to that superior nuchal line, stepping one finger breadth laterally, that's gonna be our upper trap insertion. Needle direction is towards the eyeball, perpendicular with the occiput here. Two finger digital compression, firm compression, creating a small window between our two fingers, firm tap, advancing the needle to a bony backdrop on the occiput. Again, we're limiting the pistoning in this area because we have some sensitive structures like that greater occipital nerve, really close to the upper trap insertion there. We are then going to step just lateral to that to interact with the semispinalis insertion at the occiput. So again, one finger breath lateral to that, avoiding that sulcus between the mastoid process and this muscle tissue, compressing tissue. Now my needle angle is a little bit more towards the contralateral eyeball. And we're again, looking for a bony backdrop here, maintaining that depth as we let that tissue recoil. So again, optimal treatment for these muscles is going to be setting up a circuit for pain modulation, and treating that tissue there. We want to limit pistoning in order to mitigate interaction with some more sensitive structures, including the greater occipital nerve. Again, for these suboccipital headaches, we are not treating the true suboccipitals. We are a little bit more proximal to that. We are thinking we are at the occipital insertion of upper trap and semispinellis. We want to orient ourself to this anatomy by finding the EOP mastoid process, and the region of the true suboccipitals as to avoid that area. We're using a firm compression to mitigate the sensation of the needle insertion. Upper trap is going to be perpendicular to the occiput. Needle direction is towards the eyeball, ipsilateral eyeball. Semispinalis is just about a finger breadth lateral to that, and we are angling the needle towards the contralateral eyeball. So there we have the needling technique for treating the suboccipital headaches. Um, there's actually the occipital insertion of upper trap and semi spinatus So that's all I have for you guys today. If you guys can catch us out on the road next spring We have some upcoming live courses in january. We're kicking off the the new year strong I will be teaching in rochester, minnesota the second weekend of january. I believe that's the 12 through the 14th, and Paul will be up in Bellingham, Washington for our first advanced course that same weekend. Then you can find me teaching the upper quarter in Longmont, Colorado two weeks later, so the last weekend in January. And Paul will be continuing some courses out in Seattle. So feel free to hop onto PTOnIce.com to check out where we are on the road. Again, this is We're starting the new year off really strong with some upcoming courses and our first advanced concepts course that Paul will be leading in Washington. So hope you guys have a great rest of your Thursday and I am signing off. See ya.

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

Dec 20, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Julie Brauer discusses the importance of fracture risk screening & osteoporosis management, including utilizing the FRAX tool & DEXA scans to better help assess & manage fall risk with patients.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

JULIE BRAUER
Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I'm a member of the Older Adult Division. Excited to be talking to you all this morning all about the big critical piece that is missing from our fall prevention and management frameworks. The big critical piece that is missing from our fall prevention and management framework. So before we get into the goods, I want to let you all know about our courses that are coming up in January because we are hitting the new year just right out the gate. We are absolutely slammed. So our L1 and L2 online courses kick off January 11th and January 12th. And then we will be on the road all throughout the month. So we will be in Columbus, Ohio, We will be in Santa Rosa, California, Clearwater, Florida, and Kearney, Missouri. So we would love to see you in our online courses or out on the road starting the year off strong with us.

FRAMEWORKS FOR ASSESSING FALL RISK
Okay, let's dive in. I want you all to think of your typical frameworks for your fall risk assessment and your management plan. I want you to think about it. So I want you to think that 70 year old Betty is coming into your clinic or you're going to see her at her home or in her hospital room. She's been referred for strength and balance deficits. She's had a fall in the past. I want you to think about kind of that long list of assessment pieces that come into your head. You know, what you're probably going to evaluate or be thinking about. So when I think about that long list, here are some of the things that come to my mind that are probably coming to your mind. You may do some evaluations and assessments like the short physical performance battery. You may run a tug. You may look at strength. You're probably going to do a gait speed. Maybe you want to do a mini best and check Betty's vision, check her cognition, talk to her about her environment. Maybe you do a medication review or you check her shoe wear. Maybe you're going to check her vitals, right? This list could go on and on. It's definitely not all inclusive, but I would bet that a large percentage of you that for a large percentage of you, the piece that didn't make that list was fracture risk screening and osteoporosis management.

FRACTURE RISK SCREENING & OSTEOPOROSIS MANAGEMENT
This is our critical missing piece, fracture risk screening and osteoporosis management. So we are going to start by setting the foundation and talk about why that piece is commonly missed. We are going to talk about why as fitness forward rehab professionals, fracture risk screening and osteoporosis management has to be on our radar, especially given the fact that we have the goal, especially in this crew, we have the goal of identifying, seeking out, and absolutely destroying one ret max living in order to make our older adults as robust as possible. And in this specific case, helping to make their bones as robust as possible. And then I will give you guys a few clear, easy to implement actionables that you can start getting after this week that are going to be able to give you a very comprehensive clinical picture of your patient's skeletal health. Okay. So first and foremost, we need to think about why is this not on our radar? You know, why for many of us was fracture risk screening and osteoporosis management not something that came to our minds. And if you're like me, I didn't really learn about that in school. It wasn't emphasized. I definitely didn't learn it out on clinical. And I really didn't address it in my clinical practice. If someone, one of my patients had osteoporosis, I kind of just assumed that it was going to be managed by their PCP or the medical team. And I didn't really have a big role to play, right? And we also have to realize that we understand that falls and fractures are important, right? Like falls and fractures, especially in working with older adults, this is on our mind a lot. And we know that as our older adults age, falls and fractures are going to increase. And we know that This results in years and years and years of disability that our older adults have to live with. So we know that it's important. So we have to start thinking like, why isn't this on our radar? So I want you all to start getting really curious about your patient's skeletal health. And when we look to the literature, we further see that this is an undertreated and an underdiagnosed condition. In the literature, it'll be deemed as the silent disease. And there are so many retrospective cohort studies that show that individuals who sustain a fracture after a fall, a very alarming high percentage of them were never scanned. They never had a DEXA scan. They were not on osteoporosis medication. And a very high percentage of them will go on to have another fracture in a few years. So this is a massive, massive problem that we are seeing and we have to realize that we have a role here and we can be the individuals to help screen and identify this as a problem and interrupt that cycle. So when we start to get curious about our patient's skeletal health, I want you all to think about Betty, right? About 75-year-old Betty who's coming in to see you. And we're really good at looking at Betty and assessing Betty and thinking, like, Betty's got a lot of muscular weakness on board. So if we know that Betty is weak muscularly, we have to remember that it's called the musculoskeletal system, and that those bones also may be very weak as well. So as soon as you identify muscular weakness in Betty, I want you all to be thinking, okay, I need to start thinking, hmm, are those bones weak as well? The other side of this, though, is that Betty may blow that, you know, 30 seconds to stand out of the water. Her gait speed may be great. Like she's really kind of crushing it on her on these outcome measures that we're running. And we may think like, oh, she's thriving. However, we can't automatically assume that those bones are thriving as well because there are so many factors that go into bone health that are not visible to the eye. So don't make the assumption that her skeletal system is absolutely crushing it. You want to continue to be curious and you have to start thinking there's so much more that goes into this. I need to do some assessments and do some screening to really get a clinical picture of what Betty's skeletal health is actually like, right? And we need to start thinking about this in terms of urgency. In the older adult division, the urgent situation is identifying someone who is at one rep max living, and then triaging our fitness forward approach, because that individual needs our fitness forward approach the most. So if you think about it, and Betty is coming in, and you're running assessments on her, and she's at risk for falls, and you haven't even looked at her skeletal health yet, Well, you're going to say, whew, Betty's at risk for falls. I definitely need to really triage a fitness board approach for her. But then if you also assess her skeletal health and you realize that she has weak bones and she's at risk for falls, my God, that is an incredibly, incredibly urgent situation. That individual needs our fitness forward approach the most, but we're not going to be able to know how to intervene, how to appropriately intervene if we don't even know the problem exists. So we have to be able to identify that this is a problem. We are the providers that can make this silent, invisible disease very visible. So how do we do that? Let's talk about some actionables here that you guys can start doing immediately that are going to be able to give you really critical data in order to gain a comprehensive picture of her skeletal health. Number one, it is the lowest hanging fruit. It's the easiest place to start.

SCREENING FOR FRACTURE RISK: THE FRAX TOOL
You can screen for fracture risk and you can do that by using the FRAX tool. The FRAX tool is so easy, so quick to implement. I will link it here for you. It takes two minutes, but the algorithm gives the 10-year probability of a fracture. So it's gonna give the 10-year probability of a hip fracture and the 10-year probability of a major osteoporotic fracture, so of the spine, forearm, hip, or shoulder. In the questionnaire for the FRAX, ask some questions that start giving you an idea of things that affect bone health. So really easy, they're going to be asking just age and height and weight, right? These things you can get from EMRs or your patient. really quickly and then they're going to be asking some questions like have they had a previous fracture? Did one of their parents fracture a hip? Are they smoking? Are they on medications like glucocorticoids? Do they have an inflammatory disease like rheumatoid arthritis? Do they drink excessive alcohol? All of these factors that can really affect our bone health negatively. It will also ask for their bone mineral density. And you do not have to have Betty's bone mineral density in order to fill this out and for it to be to give you a validated probability. The frax has been validated without a bone mineral density value. However, Betty may have her bone mineral density. She may have a DEXA scan, and you can use that value, but only for the femoral neck. It is only validated for the bone mineral density of the femoral neck. So that's the caveat there, right? So really quick and dirty, you can do the FRAX tool. It's going to shoot out a probability. What happens next? This is going to start to give you an idea, like, whew, there's a lot going on here that I didn't realize with Betty. Her skeletal health isn't really thriving. And let's assume that Betty has not had a bone mineral density scan. And you're really thinking, well, I mean, gosh, she smokes, she's been on glucocorticoids, she drinks alcohol, she has had a previous fracture, like, she should probably get a DEXA scan. and you're thinking like, but you know, what are some, like, should I suggest that? The great news is that there are guidelines that tell us if we should suggest that Betty get a bone marrow density scan. I will link the clinician's guide to prevention and treatment of osteoporosis as well for you all to look at, but it just gives some general guidelines. A lot of the things that you have just heard about from the FRAX tool. So, it will tell us that we should consider BMD testing if with individuals based on age, based on the clinical risk factors such as taking glucocorticoids or having an inflammatory disease, individuals who have had a fracture. So we have guidelines to tell us this.

TESTING FOR OSTEOPOROSIS
So You've run the FRAX tool, you've looked at the guidelines, you are sure, you're like, Betty needs to go get a DEXA scan. So you're gonna communicate this to Betty. But what you're gonna do next is not, hey Betty, I really want you to go get those bones looked at. So schedule that with your doctor. I'll see you next week. That's not what we're gonna do. you're gonna help Betty set that appointment up or call a doctor, right? You are going to help her advocate for herself. You're not just gonna give that piece of education and then peace out, Betty. So what can you do? You can get the doctor on speakerphone during your session with Betty. and you can guide the conversation while she asks to set up an appointment to get a DEXA scan done. You can make sure Betty knows how to get into her MyChart so she can send a message to her doctor and you can help guide her on how she should formulate that message so she's communicating effectively. Make sure that you are a guide during that process and that you're not just throwing an educational piece at her and expecting her to take care of it. Help her through the process. Okay, so let's say we got a DEXA scan scheduled for Betty and she goes and has her appointment. She gets her DEXA scan. She has her results. This is where you can have a major role, not only in helping to deal hope to Betty once we are looking at those results, but it's also gonna be your guide when you start to implement your interventions. And it gives you very critical information, okay? So if you all have not seen a DEXA scan in the wild and what that looks like, I'm gonna tell ya, it's not patient friendly. I have seen one after my mom had to get one before she had a lumbar fusion surgery. It is chock full of scary words like osteopenia, fracture, osteoporosis. There's a lot of negative values, right? Like her T-scores all over the place and there's these negative numbers. It'll say increased risk for fracture. It is not easy to comprehend. and it deals a lot of fear. So this is an opportunity to help Betty interpret what this means. And you can really offer a lot of hope here. So with the DEXA scan, right, and with this data, you can be looking at it, and it's gonna give you that T-score, right? Betty may be looking at this and be like, oh my gosh, this number is so low, this is awful, right? I'm so scared. you can deal hope because you know, based on the law of initial values, those lower T-scores are going to respond to bone loading the best. They're gonna have the best result from starting to load those bones up. That's an amazing thing. You can share that news. So even if that T-score is really low, you can say, Betty, that's all right. That low score, those bones, you're gonna respond the best. And together, we're gonna help get those bones stronger. So right away, you can start dealing some hope. It's also going to tell you where those low T-scores are. The location of where the osteopenia or osteoporosis is is incredibly critical. How many of you have had patients come into your clinic and say, I can't lift that because I have weak bones? And you know, Betty, if it was Betty, she may assume that her weak bones are all over the place. However, that DEXA scan could tell you that the only place where she has weak bones is in her radius. Okay, well, all those squats and the jumping and things that Betty's like, absolutely not, I can't do, they're kind of irrelevant because it's in her radius and not in the legs, right? So to help Betty alleviate some of that fear, you could reassure her where those weak bones are. And that could really work in your favor when you're trying to get her to buy in to do exercise. However, you are also thinking, I need to know where and where is important because you know that bones are going to adapt specifically to where load is put on them. So let's say the low T score is in Betty's hip. You know that you have to load that hip up in order for that bone mineral density to increase. However, you also are taking this information and being cautious to say where it is so that Betty knows, yes, it's weak here. She may be a little apprehensive to load that area. So you know that you can give her the hope of, hey, it's weak here, but your bones are strong in these other places. So we can start loading where those strong bones are. So you can gradually expose her and mitigate some of the fear she may have. The other piece of information that is really important from the DEXA scan that you get as a provider is that it just gives you the severity, right? How low is low in that T-score? Because that is going to determine your rate of loading progression. So you have to know, hey, maybe this is someone where we are not going to start with impact exercises, we're going to start with just resistance exercises. And maybe I'm going to modify where I place that weight based on where that low T-score is. And maybe if we do start impact, or when we start impact, it's going to be upper extremity assisted versus just having Betty do jumping right away. So it's incredibly important so you know where the entry point is of appropriate and safe loading. So the bone mineral density scan, helping Betty interpret that information and you using it as a guide, sets you up to be able to appropriately intervene and start loading those bones up. All right. That is it, that is what I got for you all. I want you to start getting really curious about your patient's skeletal health, and then get after these two easy actionables. Run the FRAX tool, advocate for a bone mineral density test. Once you get the DEXA scan and you get that information, interpret that with Betty, use that as your guide, use it to deliver hope to Betty. After that, it is off to the races with your loading interventions. this framework of how to manage osteoporosis. This is one small piece. We expand on this so much greater in our L2 course. We talk about medical management. We talk about further into guidelines and how to load and what's appropriate to load. And we dig into the research. We would love to see you in that L2 course so that you all can really get a comprehensive really get comprehensive knowledge of how to manage this condition. In our live course, we have an entire lab focused on impact training, so it gives you all the ideas, all the ideas. You get to try them out of how to initiate bone loading for your athletes who are seated and they are non-ambulatory, they're in wheelchairs, all the way up to a very high, highly active older adult. That's what I got for you guys. I would love to hear if you all run the Fractual this week or interpret your patient's DEXA scan with them. I would love to hear how that goes. Have a wonderful rest of your Wednesday.

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

Dec 19, 2023

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

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses using the "Five A's" model in the clinic with patients to begin to address obesity management as part of a plan of care.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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 h 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.

ELLEN CSEPE
Hey, good morning, everybody. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'll be your host today. My name is Dr. Ellen Csepe. I'm with the MMOA Older Adult Division, whose life's mission is to give grandma gains this Christmas to fight off frailty and level up what it means to be a geriatric clinician. So before we get started today, let's talk about our upcoming courses. We have two courses online that are eight week long cohorts where we talk about discharging the ankle pump and dialing in our skills for dosing in the level one course, which starts on January 10th. January 11th, our L2, level two course, we take it to the next level to really dial in our skills for older adults with specific conditions like osteoporosis, osteoarthritis, and even we have a new segment recently added on cognitive changes in dementia. So we're really glad that you're here today. Our topic for today is gonna be on obesity in the five A's framework. So your job, as a clinician and managing obesity in the Five A's framework. So I don't need to tell you guys, obesity is a growing health concern. Obesity and pre-obesity affect nearly 70% of the American population. This is obviously a big concern for us as a community, as a country, and as clinicians. And believe it or not, most patients believe that this is our job to manage, Managing obesity is something that is within our scope, and talking about the health considerations and health behaviors that contribute to obesity are within our scope as providers. But we have to take on this responsibility with excellence. We do everything here with excellence. And it's unfair to give this patient population anything less than that. And I've been saying this for a while, friends, but Our profession is uniquely positioned not to just add our opinion on how we should manage obesity, but in my opinion, we should be the leaders in health care. for how to manage obesity. We squander so many different resources that puts our profession above others. Things like time. We have more time with patients than any other provider and we often waste that resource because we're not confident in managing this problem well. We spend so much time with our patients and we have the strongest therapeutic alliances with them. We know our patients and spend hours with them as they recover from injury where they're kind of uniquely positioned at a position for behavior change. They're really primed to make the most with their health because they're afraid, unfortunately, because of their injury, because of what happened to them. prime time for us to change behaviors and we really waste that opportunity for lots of different reasons. And friends, we can no longer pass the buck off to other health care providers and say that this is their job. You know what I'm talking about. We ask our patients, does your doctor ever talk to you about exercise? Does your PCP ever talk to you about nutrition? They're like, no, they've got five minutes with me and they didn't do that. And we raise our hands and say, this is the problem with our healthcare today. No, we have a job to play in managing obesity. We have a role in this and we have to do it well because Friends, if you wish to treat obesity, you're responsible for not just identifying it as a problem in your patient population, but knowing what's going to work. For example, if I have a car and my battery is dead and I know my battery is dead and I take it to a mechanic and that mechanic says, yeah, your battery's dead. Good luck. That didn't help me at all. I need a mechanic that can identify the problem and then take the next steps to helping me fix it. We can no longer merely identify that obesity is a disease that causes significant harm to our patients. We cannot just merely identify it, cross our arms, look down the end of our nose and blame our patients. We can't do that anymore. We cannot just watch our patients suffer with a chronic illness and do nothing pragmatically to help support them. With that in mind, that same analogy of a car battery, if you had a car that needed a new battery and you came to me and I was your mechanic, I have no idea how to change a car battery. No clue. But if you came to me and I said, oh yeah, I've got this handled. I can help you out. That's an even bigger problem. We cannot address this concern with merely confidence. We have to have the skills to help our patients manage obesity. We can't just have confidence that we're providers of choice and that we're excellent. We need to have real skill in treating this concern. And friends, patients know that their weight is contributing to their problem. That's not that telling them is not the skill. That's not the skill. We need to be able to create an environment that's free of stigma. free of bias and filled with empathy for our patients that are struggling. Because patients know their weight is contributing to their issue, but in this void, in this vacuum of clinically meaningful discussion around weight and around behavior change, things like fad diets, diet pills, failed attempts at managing weight, ignorance to what might actually work, poor access to health care, and really at the bottom line, addressing their health alone. That's what happens if we don't bring skill to this discussion. If we can't bring skill to this issue, to this massive health crisis, what happens is the flip side. Patients having to figure it out on their own. So what I mean to say is there's a big difference in shooting from the hip and saying, yeah, you know, you'd probably have less pain if you weren't overweight or obese. There's a difference in that versus, can you tell me more about your exercise habits? Can you tell me, have other health care workers talked about how your weight might be changing or your weight might be impacting your condition? There's a huge difference and what that skill, if I could really articulate what that skill is, this skill is the hardest job that we have. The skill that you need is really the soft skills of being a good clinician. That's the hardest job we have. It's way easier to needle somebody's trap than it is to develop therapeutic alliance with them and make sure that they know that you're on their team and that you're an empathetic listener. That is way more abstract of a skill than just being able to do one small part of our job tactically. And I would argue that it might be the most important skill that we have. Patients need empathy if they're facing a health concern. Patients need us to see them as a person and not just as a patient. We need to address our own biases to really be impactful for this patient population. We need to acknowledge that if it were easy to lose weight, everybody would do it, but it's hard. Obesity is a relapsing chronic health condition that's multifactorial and it has a lot of psychological impact or impact bi-directionally that we don't even really fully grasp yet. Obesity is not easy to change and we need to address that first. So the next part of our discussion today, we're going to be talking about the five A's in obesity management. Now, when we talk about workouts, we're often given ideas and options to scale a workout. And so friends, if treating your patients with empathy and understanding and listening and patient-centered language is too big of an ask, I'm going to give you an option to scale this discussion with them. If the 5 A's and treating your patients with dignity and empathy and listening and respect sounds too hard, here's your scaled option for this discussion. You can say, it sounds like you're concerned that your weight is a contributor to this issue. I can refer you to a colleague of mine that has more empathy than I do and can have this discussion with you better. Bottom line, if you don't have empathy for your patients, if you haven't done the work to check your bias and how you might look down the end of your nose towards people struggling with your weight, looking for your help, then please step to the side and let a clinician come in to intervene that can have empathy and listening. Because unfortunately, you're likely doing more harm than good. Patients know that you're biased against them. They don't need you to tell them. Your face says it. And unfortunately, negative interactions with health care providers with weight bias often leads to further binge eating episodes for patients with a binge eating disorder. So no, you're not just telling them what they need to hear. You're actually being supremely unhelpful and likely making their problem worse. So if you can't have empathy, please scale this discussion and relay them to a provider that can actually be helpful.

THE FIVE A'S MODEL
So what are the five A's? The five A's model originates from the U.S. Department of Health and Human Services where it was developed as a framework for encouraging smoking cessation because, believe it or not, sticking your nose up in the air and saying, you know, those things are going to kill you actually doesn't help anybody quit smoking, shockingly. The same is true for older or for people struggling with obesity. So this framework was really developed to help put the patient who needs to make decision making changes in the driver's seat for their behavior change. So the five A's.

ASK
The first A is ask. Ask, is it okay to discuss lifestyle factors today during our session? Is it okay to talk about how weight might be contributing to your condition? Is it okay for us to talk about contributing factors like sleep and stress and nutrition? Have other health care workers discussed your weight in a way that was helpful or meaningful? So the five A's first, we want to ask for permission and some patients might tell you, no, that's okay. If somebody says, no, you know what? This really stresses me out. I'm not interested in talking about this with you. I just met you. That is understandable. We don't need to have a wrestling match with our patients. And if you have these soft skills, it should not feel like a wrestling match. It should feel like a natural discussion because again, patients already likely assume that their weight is contributing to their problem. You can ask which factor of their health they want to address today. So whether we know that sleep, stress, weight, exercise, diet, all interweave in regards to behavior change. We know that those things are interwoven and impact each other.

ASSESS
So our next A is assess. Assess, so you can ask a patient, hey, what do you want to talk about today? There are a few different things about your lifestyle factors that might be contributing to your condition. Yeah, your weight might be part of it. Also, sleep has a bidirectional relationship with weight. Exercise habits, dietary habits, stress, which do you kind of want to dive into today? And then let that drive the next tool of assessment. So if your patient says, you know, I actually don't know how much I weigh, do you have a scale here? Of course, that's within our scope to weigh our patients, to calculate BMI, to look at waist circumference. An important note should be that we do that in a private area because discretion with privacy is super important with this patient population. So we can't make good decisions with bad data. That's from our CEO, Jeff Moore. We can't, give patients and shoot from the hip that they need to lose weight when we don't know anything about their body composition. So weighing patients, providing that information about their waist circumference or their BMI is our next A for assessment.

ADVISE
The next advise, so the third A is advise. advising patients that sleep, exercise, appropriate nutrition management can be helpful in reducing pain. Most patients come to see physical therapists because they're in pain and so understanding that those factors deeply influence our success with rehab, and those are things that we can modify, that is hugely important for our patients to know. Also, not setting the goal too high. We might say, here's what your BMI window would be if it were normal, but who cares? Our goal initially should be to manage weight for five to 10% because even small percentages of weight change can be hugely impactful on lifespan. There's a lot of discussion about whether or not weight cycling and trying to lose weight only to gain it can be bad for our metabolic health, and meta-analyses recently would show that, hey, even if you lose weight and regain it, that can be beneficial for your overall health long-term, and you can still have a decreased risk of experiencing diseases. Noting that, you know, advising the patients that, hey, if you've tried losing weight in the past and it was a real stressor for you, we can talk about just increasing your activity level. It doesn't have to be a goal to lose weight. That does not have to be our goal. We can advise patients to just increase their activity level or decrease their added sugar, irrespective of weight changes, and that alone can be helpful in managing pain and managing injury. Third A is advise.

AGREE
The fourth is agree. So this is super important for our patients. We have to agree. We have to come to an agreement as to what we're going to do next. This is a pro tip. Let your patient set the goal. set what they want to do. Being told, okay, we are going to agree for you to stop smoking. We are going to agree for you to cut back to two cigarettes a day. Nobody likes to be told what to do. So asking your patient, what would you like the goal to be for the next week before we see each other again? Let's agree to talk about this again in the future, but I want you to set the goal for what sounds realistic for your life. I'm not going to tell you what that is.

ARRANGING
And then the fifth A, likely the most important, is arranging. So arranging for services for our patients. This is probably where we like to, you know, shoot from the hip and say, have you tried cold plunges? Have you checked out this latest app? Have you seen this new meal subscription plan? So arranging for our patients to access services is a huge, role to play in a patient's weight management, I would advocate for you guys. Really challenge your biases here. If you had a patient that had a resting blood pressure of 200 over 130, you'd be like, shoot, man, you are in danger. You are not okay. We need to send you to your PCP to talk about blood pressure medicine. That's what it's there for, right? Friends, if we can say that about blood pressure medicine, Why can't we say the same thing about medicine that would help manage obesity? We know obesity is a chronic, relapsing, difficult to treat condition. We know that it's a disease that requires medical management in some cases, and that people with just diet and exercise alone still struggle with success with managing their weight. If we're going to say that our goal is to manage weight for people that struggle with obesity, why are we so against referring them to get medicines. Why are we so averse to referring out to clinicians that would do this better than we would? It's no shame to say that you might need medicine to help manage a chronic health condition. So referring patients back to their primary care doctor to determine if it's appropriate for them to be a candidate for bariatric surgery, or talk with a nutritionist, or talk with a dietician, or be on medications. That is within our scope as well. And you really, friends, have to check your bias. If that puts a knot, a ball of wax in your throat, that you're like, oh, I really don't wanna do that, that's cheating, cheating. It's cheating for a patient to use medication to lose weight. They should do it the hard way. Like, we're not gonna be effective to patients coming at a chronic health condition with that bias. Can people be successful with managing their weight without medicines? Absolutely, but those medicines are underutilized for the people that truly need them and overutilized by Instagram models. So I think that we can do our patients a favor and check our bias when we're talking about medications and other procedures related to weight loss.

SUMMARY
First, ask. Then, assess. Third, advise. Fourth, agree. Fifth, arrange. So those are the five A's for obesity management and the conversation that we had around them. Friends, I am so honored that you would spend your time with me to talk about how to serve this patient population better. This patient population deserves our best stuff. They deserve excellence. They deserve people who are truly compassionate. And friends, we have a strong role to play in this huge problem in society. You know, it's really easy to acknowledge that chronic pain, um, chronic pain and over-utilization of obese or of opioids is a huge problem in our world. We know that overdosing from opioids is a huge problem that physical therapists can be super impactful in treating. I would argue that we have a much bigger role to play in managing obesity and supporting our patients than we assume. We really don't do enough for our patients because we're often limited by fear. We're often limited by a lack of skill and a lack of knowledge into what we should do. And I am so honored that you would spend your morning with me sharpening those skills. Our patients suffer in the void of these meaningful discussions. Our patients suffer by themselves, not knowing if there's a clinician who has empathy and support for them. I'm so thankful that you listened to this podcast today to really better serve those patients who are vulnerable in our healthcare world. Thank you so much for joining me. Have a great rest of your day.

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

Dec 18, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of estrogen in the body, the important role estrogen (or lack thereof) may play in rehab outcomes, assessing menopause in the clinic, and hormone replacement therapy.

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

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

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

EPISODE TRANSCRIPTION

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.

CHRISTINA PREVETT
Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty within our pelvic division. And y'all, the pelvic division has been just really busy over the last couple of weeks, couple of months, heck, the entire year. But if you did not see, we actually just sold out our first online cohort for 2024. And so that is sold out. So our next cohort for our online level one is March 5th. Our brand new inaugural cohort for level two, if you've taken level one, is April 30th. And in 2024, I am going to be in Raleigh, North Carolina with Rachel Moore, January 13th, 14th. And Alexis is going to be teaching in Hendersonville, 27th, 28th of January. And then we're heading over to Bellingham, Washington, February 3rd and 4th. Those are the first three courses of 2024 if you guys are interested in coming to our live course and doing some of our skills check for cert.

ESTROGEN & REHAB
Okay, so I kind of want to talk about estrogen and specifically estrogen in later life and lack of estrogen and how it influences rehab. So this has been something that I've been really kind of geeking out about over the last little while around, you know, not just as pelvic therapists, but as anybody working with a person going through menopause, if you are working with anybody over the age of 50, a female over the age of 50, you are interacting with a person who is going through estrogen depletion in their body. And As I've learned more about the influence of estrogen on our bodies, the more I am recognizing even outside or maybe even especially outside of the context of pelvic health when I'm seeing people who are postmenopausal, but in my orthopedic rehab, how much it is influencing our outcomes. and just a person, a person who is a female in an aging body, what the lack of estrogen may do for the way that we experience aging. And then I kind of want to cap this podcast off talking a bit about some of the myths and misconceptions around estrogen replacement therapy. or menopause replacement therapy. And we'll talk a little bit about the change in the labeling of these types of treatments and where some of the thoughts around risk for things like sex-related cancers has come up. So to start this off, I want to start with a story. So I was working with a woman who was coming in. She was in her early 60s and dealing with shoulder pain. She had a history about 10 years ago of frozen shoulder. So when it comes to adhesive capsulitis, we know that being a female and being kind of in middle age is a risk factor. And I never really thought about that risk factor being linked to estrogen status or like the beginning of perimenopause. Still wasn't really thinking about it. But she said, you know, that was a really long journey when her shoulder froze. And but it got better, got better over time. She realized that she was going through hormone replacement therapy or she was going through menopause. She got put on hormone replacement therapy. She was on it for 10 years. And then her doctor on a follow up where she was trying to get a renewal said, actually, you've been on it for too long. I'm going to take you off of it, which that That's a whole other ethical scenario, especially because we should be weaning off estrogen replacement therapies, not just going cold turkey. But however, took her off and within a couple of months of that weaning process, her other shoulder started to freeze. I've obviously been in the weeds of this research right now around the influence of estrogen on our body, but I was thinking about and reflecting on how many women I have worked with over my career.

THE INFLUENCE OF ESTROGEN ON OUTCOMES
I've been a PT for 10 years, so very still early on in my career, but how many have I not recognized the influence of a person's estrogen status on our outcomes? And so when we think about estrogen, we think about fertility, rightfully so. We think about pelvic floor physical therapists kind of specializing in the fertility space, granted, but estrogen, when we have a depletion in estrogen as women go through menopause, it affects every part of our body where there is an estrogen receptor. And I don't think that many orthopedic therapists or people who kind of aren't niching into this space, myself included until I got into this arena, recognize just how widespread that is. And in pelvic health, we've done an incredible job of advocating for individuals in the perinatal space. We still have, of course, ways to go. However, you know, there's this rise of individuals going through menopause who are starting to advocate that we need that same type of education. And too frequently now that I've been asking are my patients saying to me, oh, well, my doctor said it was just part of aging and I shouldn't be on hormone replacement for this long or like have just been dismissed about their symptoms and have not linked some of these other body systems and the experiences that they're having in these other body systems with their estrogen depletion. I have a client seeing me for ankle pain and she's kind of in that postmenopausal window and she said, I am trying to learn a new body that I do not understand. And I think that was such a profound statement because so many individuals are feeling this way and we have a huge role to play in rehab. And I'm not talking pelvic, I'm talking generally.

THE ROLE OF ESTROGEN IN THE BODY
And so when we think about estrogen, estrogen has receptors in our brain. It has receptors in our joints and muscles. It has receptors in our heart, and it influences our bone, right? Bone is probably the easiest one. We know that individuals who are postmenopausal are at increased risk for osteoporosis osteopenia, that there is an accelerated rate of decline in bone mineral density loss with estrogen as rates of, estrogen helps rates of bone build up. And with estrogen depletion, we see a switch in the slope of the line where bone breakdown exceeds rate of bone growth. And so rates of osteoporosis go up postmenopausally. We also see that individuals who are in an estrogen depleted state have higher rates of joint pain. So kind of an umbrella term of joint arthralgia. and we see links to risk factors around things like adhesive capsulitis in individuals going through perimenopause, but very little research has actually looked at individuals' experiences of musculoskeletal pain in the postmenopausal window. So we could have individuals who are not responding as quickly to rehab, even though we're throwing everything at them that is evidence-based and evidence-informed, because they are going through menopause and it's the influence of their hormones is changing the way that their body is responding to some of our rehab interventions and we don't know about it. Our body also has estrogen receptors in the heart. And so we see that men tend to have a higher rate of cardiovascular disease and heart disease than women, but that change in rate between men and women starts to change in that postmenopausal window. So rates of heart disease start to go up postmenopausally because of the protective effect of estrogen on the heart. What we also see from a metabolism perspective is that there is a change to the way that fat is laid down when individuals are postmenopausal. So where we have the protective subcutaneous fat that tends to be something that is kind of a net, potentially neutral way of laying down fat, the more dangerous fat is visceral fat lay down, and that tends to accelerate in a postmenopausal female because of estrogen deficiency. which then increases risk for a whole bunch of different metabolic diseases, including, you know, heart disease, stroke, Alzheimer's disease, like all these diabetes, all of these things that we know are linked to pro-inflammatory cascades. It accelerates for individuals as they go through menopause. And then finally, from a cognition perspective, we have systematic review evidence that Individuals who go through premature ovarian insufficiency. So individuals who go into menopause before the age of 40 are at an increased risk for cognitive decline. So rates of Alzheimer's are higher in individuals who go through early menopause. And we see that there may be a protective effect, preventative effect of the development of cognitive decline for these individuals who are going through menopause early if they are on hormonal contraception. Which gives a very strong argument for the link between estrogen status and cognition. And when we think about symptoms of menopause, we kind of put them into different buckets. We talk about, you know, vasomotor symptoms, which are night sweats, issues with sleep, sleep disturbances are very high around the postmenopausal or menopausal transition, and hot flashes. Right? And there's kind of like this immediate withdrawal effect of estrogen. Like you could almost think about it as like a drug withdrawal. Like when we get withdrawn from estrogen, those vasomotor symptoms kick up. And then eventually our body gets used to being in that state of estrogen deficiency and those withdrawal symptoms kind of go away. But genitourinary syndrome of menopause is really focused on the aging of the pelvis and its influences. And so when we're in pelvic health and we're talking about estrogen deficiency, we see, you know, adhesions in the labia minora to the labia majora. We see an increase in friability of tissues. We see an increase or a changes to the pH of the vaginal microbiome. And so these all have influences, but the genital urinary syndrome very much focuses on the pelvis.

ASKING ABOUT MENOPAUSE
And so if you are not in pelvic health, you may not be really considering it a reason to be asking about symptoms of menopause and when you went in through menopause. But if you are an individual who is working with anybody who is a female over the age of 50, you should be asking, are you in menopause? Have you gone through menopause? When did you go through menopause? And menopause is diagnosed as the 12 month mark of not having a period. So when you have not had a period for 12 months consecutively, that is considering being in menopause. Average age is 50 to 51 in the United States. asking around changes in symptoms around the menopausal transition. Did you notice a change to your mood? Did you see a change to your sleep? Did you see a change to your cognition? Did you see a change to all these other things? Because we know that if you're depressed and not sleeping and your joint pain is up, we're probably gonna have a lot of conversations that we need to have around recovery. It's gonna influence the way that our treatment is going to go. And then we can be an advocate for ways to manage. Too often, and there is nothing that makes me more mad. Like when I see individuals who have gone to their doctor and they say, I am suffering with vasomotor symptoms. I am suffering with all of these things. And they say, I have no libido. And they say, well, you are going through menopause. And that's kind of the way it is. Men will get Cialis or other types of hormone replacement for their sexual dysfunctions very readily. And it is met with hesitation when we are talking about female reproductive aging. And I was just at a course where it has some individuals who are part of the military and the military nurse practitioners were there, which is really cool. But they said, you know, we are so willing to prescribe Cialis but we are very hesitant as a division to give hormone replacement therapy.

HORMONE REPLACEMENT THERAPY
And so the next part of this conversation, one, estrogen affects everything. It's absolutely gonna influence our pelvic floor. It's absolutely gonna influence our pelvic health. But then the next thing that people are asking is around estrogen replacement therapy, sex hormone replacement therapy, and its safety and efficacy. So I wanna do a little bit of a history lesson here around where this risk is coming from. So there is a large longitudinal study called the Women's Health Initiative that has been collecting data on women for a very, very long time. And early, early on in about 2001, a study was released from the Women's Health Initiative that said that there was a 25% increased risk of sex-related cancers for individuals who are on hormone therapy than individuals who are not. This was, potent, like kind of true, but it missed the forest for the trees. And so when we kind of zoom out and we look at relative risk of sex-related cancers, that, well, that translated into, instead of it being three in 1,000, and these are not perfect numbers, I don't remember off the top of my head, it changed to a four in 1,000 rate or incidence of sex-related cancers. When if you think about it like that, that is not the biggest difference. However, that one study came out and it changed everything. It was largely disseminated, many media outlets put it up, and it made everybody very, very fearful of prescribing hormones. So there's a couple things nuanced to this. When we are taking any type of medication and our sex hormones are not anything different, there is always going to be potential risks. Those have to be balanced by the benefits. We see, for example, that individuals who are on replacement therapy have a lower risk of Alzheimer's, dementia, especially if individuals are going through a menopause early. We see sexual health, sexual, satisfaction increases on hormone replacement therapy. We see an increase or rather a decrease in rates of urinary tract infections. And if you are working in the geriatric space, move this into Wednesday. It makes a huge difference. A urinary tract infection can change a person's life. A person can die of a UTI because it can end up, they get in hospital, UTI becomes sepsis, sepsis becomes a full blown, you know, it's now a full blown infection and individuals don't get out of hospital or they see a consistent change in function. All of these benefits for many are going to outweigh that slight increase in risk. Now, we have evidence since then that that risk percentage may have actually been when we replicate a study, which is super important before we're making very broad sweeping statements. There is a range of that relative risk and it actually might be lower. And because of that, we now have good evidence for individuals who are going through chemo to be able to have, because it can irradiate and bring you into a low estrogen state, where they may use topical estrogens. We have more evidence for individuals who are on estrogen receptor blockers, like tamoxifen, to, again, have topical estrogens. Because, obviously, we're not gonna wanna ingest estrogen when we're trying to block it so that cancer doesn't regrow, but to put it on the external genitalia, that would allow us to remove some of those pelvic-related symptoms for individuals being in low estrogen as a consequence of cancer treatment. And this evidence is continuing to grow.

NO EVIDENCE FOR AN OPTIMAL HORMONE REPLACEMENT WINDOW
The other question, when I go back to my patient that I talked about, is that he said, well, you've been on it for enough, this physician, and I'm gonna take you off. We actually, again, don't really have any evidence around where that window is. Like how long you can be on it before the risks start to outweigh the benefits. And because we don't know, individuals are just creating a risk tolerance zone for themselves and then unilaterally kind of applying it in their practice. And so we still have so much work to do in this space. We are starting to see a change in our language around hormone replacement therapy, and it's being changed to MHT, menopausal hormone therapy. And it is actually encompassing a variety of different treatments. It is not just a systemic pill that you can take that is a natural replacement, there is those. There are progesterone replacements. There are estrogen and progesterone combos. There is evidence for testosterone replacement and testosterone replacement helping individuals with hyposexual disorders. And then there are topical estrogen therapies where individuals who are experiencing recurrent UTI, individuals with issues with labial adhesions, individuals with clitoral adhesions, all these different things can see a huge benefit to this type of hormone replacement. And so, The role that we have to play here, if you were a pelvic clinician listening to this, we have a ton of advocacy to work on. Staying up to date with the evidence, referring back for potential counseling on hormone replacement, and continuing to have those conversations with our physicians is gonna be super important. If you are a person who's an orthopedic specialist, you need to be asking about estrogen status. Have you lost your menstrual cycle? That puts you in low estrogen. Have you recently had a baby? If you're a postpartum and you're dealing with a wrist injury, that low estrogen is gonna impact your ligaments. It's going to make it so that you may be more likely to have things like mom wrist decorvains tendosynovitis. And then if you're working with individuals who are older, then again, we're gonna be asking about when you went through that menopausal transition and how you're feeling. A lot of people feel like, oh, well, I'm going okay through my menopause right now. I don't really need it. The thing is estrogen deficiency is accumulative. So it is also a discussion around the preventative aspect of continuing to have individuals on hormone replacement. I don't know the answer to this, but it is a continual conversation. It is one that is happening in lots of spheres and one where there is a role for rehab. And this has been such an important part of the development of our research base in pelvic and a huge portion of the proportion of individuals that we are seeing in our practice that we have put it into our level one. So we have an entire week on the influence of menopause on the female body and an entire module on the way that we would work towards treating individuals and advocating for individuals who are going through menopause, who are subsequently feeling issues with pelvic health. So if you are interested, get into our March cohort. I could rant about this all day. I'm already 20 minutes in. I'm gonna get off here, but it's important. And it is not just important to our pelvic health clinicians. It is important for everybody who is working with a female body over the age of 50. And we're not even going to go into the perimenopause part because perimenopause could be 10 years before. So if you're working with anyone over the age of 40, this is relevant and it influences our rehab outcomes. All right. I hope you all have a wonderful week. Merry Christmas. If you are off, happy holidays. Whatever denomination you are, please hopefully have some time to spend with loved ones. And I hope that you get some of the rest and relaxation that is just something that you are looking for. I have two little ones, four and two, and the magic of Christmas and the holiday season is so alive and well in our house, and it is such a beautiful thing. So I hope you all get that. You are so welcome for me talking about this. I promise you, I will be diving more into this onto my personal Instagram, and it's definitely gonna come onto ICE because I think it's really important, and I think it's a huge miss that we have. So thank you for listening, and I am so excited to continue these conversations. Merry Christmas, happy holidays, and hopefully you get all of that rest and relaxation for the end of 2023.

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.

Dec 15, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses how to adapt the @concept2inc rower for patients & athletes who cannot use both legs, both arms, or seated athletes.

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

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

EPISODE TRANSCRIPTION

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 h 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.


ALAN FREDENDALL
Alright, good morning everybody. Welcome to the PT on ICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan. I'm happy to be your host today. Currently I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness Athlete Division. It is Fitness Athlete Friday. We talk all things CrossFit, Powerlifting, Olympic Weightlifting, Endurance Sports, Triathlons, Marathon Runners, Cyclists, figure skating, all that wonderful stuff. If you are working with a person who is recreationally active in the gym, on the road, whatever, Fitness Athlete Friday is for you. Today, we're going to build upon an episode from three weeks ago, introducing you all to the Concept2 Rowing Machine. We're going to build and show you how to adapt this machine for a lot of different folks who might show up in the gym or in the clinic, post-op, adaptive athletes, all that sort of thing. Before we get started, just a heads up about courses coming your way from the fitness athlete division. Your next chance to catch us online for our level one course, online course, eight weeks, entry level course previously called Essential Foundations will be January 29th. So our Clinical Management Fitness Athlete Certification, Level 1 online, prerequisite for Level 2 online, that class begins February 5th. And then our live seminar is its own standalone event. Those are all over the country this coming year, so check out PTENICE.com and look for Fitness Athlete Live for courses coming near you. And then check out our two online courses beginning in January and February. Just a reminder, all of our courses currently priced at $6.50 will jump to $6.95 on January 1st. And really, we don't want to pressure you, but most of our quarter one courses, live and online, are selling out. Our pelvic level one online course just sold out yesterday, about a month in advance. So we're seeing about a three to six month sell out window currently. So if you had an eye on a course, we'd recommend grabbing it sooner rather than later, especially if you can take advantage of saving some money on that price increase. So that's courses coming your way from the fitness athlete division.

ROWING 102
So before we get started, I'm going to show a lot of stuff today. So if you are listening on the podcast, and you are a visual person, or you're not very familiar with the rower, I would recommend you stop the podcast, you jump over to our YouTube channel, and continue watching this episode here on YouTube so you can actually see what I am doing. So I'm going to reference two previous episodes as we talk about today's topic. So we're going to get into some advanced mechanics of the rower, how to adapt the rower with different equipment. Go back three weeks, episode 1606, where we talked about the very basics of the Concept 2 rower, how rowing works mechanically, how to put yourself in the best mechanics to row, how the rower itself too works as far as what are the different pieces of equipment, how to clean them to make this machine last you, 10, 15, 20 years, and then also how to use very basic things on the rower like drag factor to understand where you should place your damper on the flywheel, again, to optimize the very basics of rowing. I want you to go back two weeks to Guillermo's episode, episode 1611, to learn a little bit about how intervals, he specifically talked about research on assault bikes, but how intervals on earth machines in a very small time window, two to three times a week, for eight to 20 minutes of work can have a significant increase on VO2max. So never forget, when we're working with patients, working with athletes, especially those folks already active, at the very least, we can help them maintain their current level of fitness, being intelligent with how we use machines, how we adapt the machines, and that's the point of today's episode, of how to adapt these machines. So folks coming in, they can only use one arm, they can only use one leg, they're pregnant, they're postpartum, whatever, how can they get on this machine and at least maintain their fitness as we work through their rehab.

1-LEGGED ROWING
So I want to talk about how to set up the rower to row with just one leg. I want to set up the rower and show you how to row with just one arm. And then I want to show you what many people don't know is that the rower actually breaks down in half. Yes, to make it easy to store, but also to get rid of the rail so that seated athletes in a wheelchair can roll up to the rower and row on a Concept2 rower. So the first thing I want to show is very simple, one-legged rowing. So what you're going to want is one of these little things. If you've ever changed your own oil on your car, you know what these are. These are little caddies that roll underneath your car. So they have wheels, six axis, they move in any direction, and they're mainly designed to hold tools and stuff if you're working underneath in your car. So you can get these at an auto parts store for 10 or 20 bucks. You just need one of them and they'll last forever. Alternatively, you can also use a skateboard or something like that. But what we want is we want something that we can place someone's foot inside of that moves, ideally moves what we call six axis, right? Forward, backwards, side to side, and then each diagonal, right? It can potentially move 360 degrees so that as a person rows, their foot can move alongside the rower. So let's set that up. So for example, let's say I can't use my left leg, maybe my left leg is locked in a knee brace, I'm locked in full extension, maybe after ACL reconstruction or something, I can still get on the rower and row with one leg. So I'm going to get on my rower, I'm going to strap in, grab the handle, Until my wife was on the rower last, she cinched the straps all the way down. And now, instead of putting two feet in, because I can't bend this knee, right, it's locked in extension, I'm going to kick it out to the side of the rower, and I'm just going to let it rest in this whale caddy. Now, I can still more or less perform all of my normal rowing mechanics. I can still drive with my right leg, I can still lean back, and I can still pull with my upper body. So this is fantastic, folks maybe working with an amputation, folks locked in a brace, maybe folks that just can't tolerate that loaded knee bend, knee extension with that leg for whatever reason, we can have them still row using something like an oil caddy or a skateboard. So that's one leg rowing.

1-ARM ROWING
Now, one arm rowing is totally possible. You're going to want a device like this. This essentially just looks like a hook. You can get this from Adaptive Training Academy. So if you don't know Adaptive Training Academy, we highly recommend them. They have a wonderful course on basically adapting all things fitness for adaptive athletes. So it's a course that has its origins with CrossFit, but now has expanded into the rehab community as well. How rehab providers and fitness professionals can work with adaptive athletes to get them moving, keep them moving. They have a wonderful store full of all sorts of really, really, really cool things to help you work with adaptive athletes. And this is one of the tools they sell. So these hooks are going to latch on to the handle of the rower, and they're going to allow me to row with one hand. If you'll notice on the rower handle, in the middle, it has places technically to row with one hand, but they're not very comfortable. you need to essentially weave your fingers through and then you have the metal chain kind of bashing against your knuckles the whole time you're rowing with one arm. It's also very wide, so you'll sometimes see people row with a neutral grip and that's just not very mechanically advantageous. This is designed to improve that. To bring the handle in so that I can grab it with one hand, I can technically even hook grip this to really get the most out of my grip on my right arm or left arm and row to my chest and maintain my normal rowing mechanics. This is also fantastic for pregnant women who maybe don't tolerate the flexion on the rower anymore because of their stomach or the extension because of the stress it places when they lean back. What's great about these is you can build them on each other and you can essentially reduce the range of motion needed to reach towards that handle. So this can even be great for kids to get them on a rower at a younger age or maybe they literally don't have arms long enough to reach the handle, we can bring the handle to them. So I'll show you what that looks like with one arm rowing. So sitting in the rower, taking the hooks, latching it onto the handle, and now it's reduced the range of motion by about six inches towards me. And now with one arm or the other, I can pull and I can maintain all of the same mechanics of rowing. with one arm. I'm still able to drive with my legs, lean back, and pull the handle to my chest. Again, if needed, I can put another one of these on here and continuously bring that handle closer to me. So this hook is available again from the Adaptive Training Academy store if you want to pick that up for your rowing.

DISASSEMBLING THE ROWER FOR SEATED ATHLETES/PATIENTS
The final piece is breaking the rower in half. Again, a lot of folks don't know that the rower actually disassembles into two pieces. That's to make it easy to store. It's totally possible to break this rower in half, and if you have a larger car, an SUV, certainly a truck, you could take the rower with you, maybe if you're a home health clinician, and bring it into people's living rooms. it is made to break in half and all things considered once it's broken into half it's not very cumbersome and it's not very heavy. So let's talk about how to do that and then adapt that for the seated athlete. So right here at the base of the foot plates you're going to see a black piece and you're going to see a little handle to lift up. If I lift this handle up you'll see that the rail of the rower is just sitting on metal rod that's connected to the flywheel and the computer portion of the rower. So if I lift this up, I can now disassemble the rower into two pieces. So now the rails here, this weighs almost nothing. This weighs a couple of pounds. Again, this would be very easy to throw in the back of an SUV or a truck. The heavier part, of course, is going to have the damper and the flywheel, and all of the computer parts, but now I have the front part of the rower. Now I can have somebody in a wheelchair roll up to this. We can play with different variables. In the gym, we like to lift it up a little bit, and we like to put sandbags or plates to anchor it down, and we like to sit it on some sandbags or plates. So depending on the type of wheelchair that your patient or athlete has, you may need to bring the rower up a little bit so they can roll up, get into a good position and row. And then definitely, because it's no longer as heavy as it once was, you're going to want to make sure you weigh it down so that as they begin to pull the handle, this thing doesn't move around. But with a little bit of ingenuity, this is something you could even bring into someone's home, maybe wheelchair bound, where they're able to row, maybe do some intervals on the rower. So make sure you understand that the rower breaks down. This also makes it really easy to store rogue fitness. So you can see one over here in the corner, my bench is hanging on it. They make hangers that can be mounted to a wall that can hang either benches or it's designed to hang the front part of your rower off of. If you're thinking you're in the clinic and you don't have room on the ground for a rower, that's okay, you don't need it. You can break the rower in half at the end of the day and you can hang it on the wall. So make sure you understand that the rower breaks in half. That's made for storage, for travel, but also really important to make sure that we can get seated athletes using a rowing machine. So rowing, this is a very versatile piece of equipment. Make sure you understand how to use it. Make sure you understand that you know how to adapt it for different patients and athletes that present to you in the clinic in the gym and get more people rowing, get more people working on or maintaining their current level of fitness as you help them through the rehab process. I hope this was helpful. I hope you have a fantastic weekend. Our very last live course of the year is this weekend. It's happening right now in Salt Lake City. It's a dry needling course with Ellis and Melrose. So if you're there, I hope you have a fantastic time. Other than that, I hope you all have a wonderful Christmas, a very happy new year. 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.

Dec 14, 2023

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Office Jeff Moore discusses how the pursuit & achievement of clinical excellence solves many problems. Individuals who produce high-level outcomes in the clinic tend to be the ones who get paid more, work less, dictate their schedule, and overall feel a significant return on the time investment they spend in the clinic. 

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

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

EPISODE TRANSCRIPTION

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 h 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.

JEFF MOORE
All right, team, what's up? Welcome back to the PT on ICE Daily Show. It is Thursday. I am Dr. Jeff Moore, currently serving as the CEO of Ice, and always thrilled to be here on Leadership Thursdays, which are always Gut Check Thursdays. Let's get it out of the way. Let's talk about the workout, and it's a banger. We've got three sets of the following rep schemes and movements. We've got 21 burpees to target, followed by 15 devil's press, Okay, it's gonna be with 35s or 20s. Okay, so going into that deficit push-up, pop into a squat, weights above the head, and then back down. 15 of those, nine burpee into a chest-to-bar pull-up. Then, however long that took you, you're gonna rest one-to-one. So if that took… Let's see, maybe three-ish minutes, right? You're now going to rest for that same amount of time, and then you're gonna fire back up set number two. The workout is three sets with that one-to-one work-rest ratio for time. That, I'm looking at that, I'm gonna need to settle into about 20 minutes or somewhere on that workout. That is going to be rough. Okay, as far as upcoming courses, one thing I wanna mention is that Pelvic Live, I'm sorry, Pelvic L1 Online only has four seats left. I also wanna say a lot of the courses in January are looking that way. Remember, our prices go up January 1st. It's only 45 bucks. It's from, all the 650 courses go to 695, but if you're gonna grab a Q1 course, they're already all on the schedule. Make sure to jump in and grab that course before January 1st, because right now you can buy them all for the $650 price. So if you have any courses you're looking at in 2024, you know you're going to take anyways, just jump on there and grab them before that price jumps up to $695. on January 1st. So you've got a couple weeks, that being said, a lot of them are selling out. So try and scoop up those tickets over at PTOnIce.com as early as you can to save yourself a few bucks going into the new year. So that is my course announcement.

EXCELLENCE SOLVES EVERYTHING
Let's talk about excellence. So the topic of today is excellence solves everything. And what I mean by that is, There is a threshold of excellence at which no barrier survives to your success. This is where the idea of becoming undeniable feeds in really well. Now, we're going to chat PT, but you can think about this anywhere. Think about that musician who doesn't have a major record label. Think about that busy restaurant in a horrible building or a terrible part of town or bad location, what have you. Think about the individual player with a mediocre teammate who still wins the championship. There is a level of excellence at which once achieved, nothing else matters. That being said, that's very, very high level from a success perspective. Now I want to drill down and talk about a specific thing that possessing that excellence gives you or benefits you or arms you with because it is so relevant to today's practicing professionals.

EXCELLENCE DRIVES AUTONOMY
Possessing excellence, certainly at a level like we discussed before, allows you to always be deciding. And as I look at why that's so important, it's because autonomy is, from my vantage point, the most modifiable and important burnout variable or job satisfaction variable. Autonomy is the most modifiable. Burnout or job satisfaction variable. I was talking with Adam Fritsch down at South College I work with Adam over at South and that he and his colleagues over at Bellin published a paper I think it was in March of this year titled feeling exhausted how outpatient physical therapists perceive and manage job stressors and in that paper All the things you would expect kind of fell out of solution, right? Like if the workload was unmanageable or perceived to be unmanageable, that was stressful. If cultural differences were present, that's stressful. But what pops out at me in that paper, because it's so directly modifiable, is the lack of control or this idea of not having autonomy. Namely that if people did not perceive themselves to have control, they felt more burned out. Everybody I talk to making their way up the professional ranks, that constantly jumps out at me. Now, let me talk about why excellence takes care of that problem. That is because it allows you to always be deciding and that's what autonomy is. When you achieve a certain level of excellence, You get to always be deciding. You get to always have control. And I think the data shakes out to say that will prevent burnout and maximize job satisfaction. Let me give you some really specific examples of where you get to always be deciding that other folks might not that are going to lead to you perceiving that feeling of control that avoids burnout increases satisfaction. Number one, which insurance is to take? When you hit a certain level of excellence, you're deciding that. You can say to the insurances, look, your customer's gonna come to me either way. They're just gonna be furious that you're not covering it. But they're not gonna make a decision to not come. They're gonna come and then be mad at you. At a certain level of quality of service delivery, you will hit that reality. Right alongside that, how much to charge. You're the one deciding. The solution to burnout is appropriate return on your time investment, another huge variable. You can't balance an equation with the wrong numbers. You need to be able to drive what you receive for your time delivering services. at a certain level of excellence, you get to decide that. You're not thinking about what might this market handle or what's the, you're thinking, this is what I'm gonna charge because this makes sense for my model. Now, you're gonna combine a few things when you do that. Number one is make sure the equation works, but number two is putting that price point in a spot where you actually get to serve all the folks that you want to serve, that you feel called to serve. So, it's multivariate that coming to that number. but you get to come to that number, right? That's the beautiful thing about it. Number three, when to work. There are few things that decrease stress like having complete control of your schedule. This is the one that hits me the most personal. I have no issue giving you massive volume of work days. I have no issue being up at four, 4.30, getting after it, putting out a lot of production. I have no issue with that as long as Right now I'm holding 4.30 to 5.30 because my kids might text this morning they wanna hit CrossFit. As long as I have the autonomy to hold these parts of my schedule that are non-negotiable, I have no issue with the work output on the other part of the day. It's being able to control when you work that I think is probably a bigger variable or a bigger factor than the amount of work and people just haven't put that together yet. But again, at a certain level of excellence, you control that. Because when you say to that patient, I can only see you at seven a.m., if you're good enough, if they perceive you as valuable enough, they're gonna say, well darn it, that isn't a perfect time for me, but there's no way I'm not taking the appointment. They're only saying that if you've achieved a certain threshold of excellence. So now you're deciding when to work. You're deciding how or even if you want to market. You may choose to not spend any time in that space. I wouldn't advocate that from kind of a business consulting perspective, right? All the best companies market when they're busy. That being said, you could decide that. at a certain level of word of mouth demand, right? But certainly when you do market, it doesn't have to be salesy. At a certain level of excellence, you're simply reminding people that they want to come see you. They've already heard from nine other people they should. They've already been thinking about coming in for a long time. Now your marketing simply becomes creative reminders, which is a much nicer way to go about engaging with your audience than always trying to sell them something. So you get to decide at that certain threshold of excellence how or even if you market. You decide whether you stay at your job. You no longer need to stay at your job because you have to. You stay at your job because you love it. Because the people that have created the environment have done a great job. And you can't get enough of the culture. And you're learning a ton. And you're serving people you care about. You're staying for all the right reasons, but none of the wrong reasons. Because you can walk any day. You think to yourself every morning, need this. The people want to come see me no matter what. I'm choosing to stay here because I love it. That's a lot different professional world. You don't feel stuck. You're driven by choice because you've achieved that level of excellence. Excellence is so unique. because it solves all of those problems. Those are all problems that every business guru is trying to sell you an individual solution for, right? How to navigate the insurance market, how to come up with your pricing, right? How to get more control of your schedule. You could find individual products that would try to solve only one of these, all of them.

EXCELLENCE: THE CLEAN SWEEP
Excellence is a clean sweep. Once you get good enough, every single one of those problems gets erased at the same time with one thing. But there's one other thing before I sign off that I want you to think about that is so unique about possessing excellence. And that is that it travels with you. I don't think enough people think about this. Excellence travels with you. Relationships, local marketing, et cetera, all of those things, if you change where you're working, if you move or relocate, all of the other business hacks, if you will, that you leverage have to be started back up. But your excellence travels with you. It's gonna meet you there, right? Right from patient one, they're going to perceive the asymmetry and the quality of what you deliver, and all of those problems are gonna vanish without you having to restart any of the other machines. Excellence travels with you wherever you go it meets you there. This is why it is hands down because it solves all the problems at once and wherever you go it meets you there, it travels with you. This is why it is the greatest and most urgent investment. I'm not telling you not to leverage all the business tools. I would totally encourage you to leverage a wide variety of business tools and strategies. I'm just saying for the greatest ROI, Get good first. Get good, then busy. Because excellence is the greatest decider to your overall success and certainly the greatest driver of your individual autonomy. And that's what I think results in incredible levels of job satisfaction and very, very low levels of burnout. Get good. You'll get busy, but you'll also solve every other problem in the process. Team, PTOnIce.com is where everything lives. Thank you all for being here this morning. Have a wonderful Thursday. We'll see you next week.

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

 

Dec 13, 2023

Dr. Alex Germano // #GeriOnICE // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how relationship, communication, motor learning and environment can impact your outcomes and plan of care delivery while working with people with dementia. 

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

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

EPISODE TRANSCRIPTION

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 h 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.

ALEX GERMANO
Hello everyone and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today's segment of Geri on Ice. My name is Alex Germano. I'm a member of the older adult division and we just finished up our last cohort of our level 2 course. this past a week or so ago and we just debuted our new week all about cognitive impairment and I found one of the articles to be very impactful and I wanted to review that here with you all today. It is called a framework for rehabilitation for older adults living with dementia by Julie Reese from Marymount University in Arlington, Virginia. We'll dive into these four best practice domains that you can incorporate when working with this population and then how that'll really change kind of your outlook and how you see exercising and rehabilitation in this population. So before we dive in, I just wanted to orient you to some of the new courses or the courses that we have upcoming in the new year. First, we have MMOA Level 1 and Level 2. Those are our online courses. Those begin in early January. So we would love to see you hop into those cohorts. They typically sell out or get really close to it. So we'd recommend you jump in early. We also have upcoming live courses. I'll name some of the spots through February here. So we've got Santa Rosa, California, Greenville, South Carolina, Kearney, Missouri, as well as Oklahoma City, and Gales Ferry, Connecticut. So we hope to see you on the road in 2024.

BARRIERS IN DEMENTIA CARE
Now, let's dive in. So first, many rehab providers recognize that people with dementia would benefit from rehab services, but we run into many barriers and biases when working with a population that impact the delivery of our services. We have problems like, well, they're non-compliant. They don't cooperate. They won't get better, so they don't need our services. Or they don't have caregivers, so our services aren't trainable, and therefore, it's not gonna be necessary. Or if you're like me, you run into a lot of personal frustration. And I will speak to myself, or for myself only here, but it seems to, I've had some recognition from other providers that they also feel this way. I struggle bringing my fitness forward approach to this population, right? I'm, if you know me, I'm very like exercise heavy, like doing very traditional strength and conditioning movements. And sometimes those types of sessions don't work well for subsets of patients with mild cognitive impairment or really dementia. I struggle when I have goals in mind for the session, And then we get none of them done because most of the time I'm managing behavioral outbursts or orientation problems. And when I only get three out of the 10 exercises I wanted to do get done, when I got those done, I feel like a failure, right? Three out of 10, that's not great for me. And I feel like my immediate reaction is sometimes, oh, therapy, I'm not going to work for this person. But really it's the type of exercise I'm providing, how I'm delivering it, that isn't working. Okay, so it's not them, it's me. And my thought is that many of us are out here fighting to push our agenda on patients with dementia, when in reality, maybe our role as providers in this space is to be someone who's providing an opportunity for movement and letting go for the concern of what type of exercise and how much exercise that we need to get done in the session.

REFRAMING SUCCESS IN PATIENTS WITH DEMENTIA
I've started to reframe my vision of success during a session with somebody with dementia who may not follow those typical exercise instructions. I have started to realize that by me just being there, if we moved at all, that's 100% more movement than they were going to do if I didn't show up. or they didn't have me that day. And no movement is, there's no movements out there that are bad movements. And there's no exercise that is bad exercise, especially in this population. So any movement or exercise should really be success for us, right? If we got them moving at all, that should be successful. And so if we change our expectation, I think the number one way, that's the number one way we can really fight some of the burnout that we're experiencing when working with this population. Now, how to structure these sessions. Let's jump into this paper because I really found this super interesting. This paper explains a model with four domains that we should focus on or emphasize when working with patients with dementia. We have relationship, communication, motor learning, and environment.

RELATIONSHIPS OVER EVERYTHING
First, let's talk relationship because this is where we're going to spend a lot of the time. A lot of the time. Nothing is going, we prioritize relationships over everything. That's your new mindset. Relationship over everything. Nothing will get done if we don't have a personal connection with the patient and understand with great curiosity what they enjoy in life, who they find important, and what makes them tick. So in our evaluations with patients, we're not only trying to solve their movement problems or screen those, we need to find out about this person. Give me some details. Give me a list of names that's important to them. Who are your loved ones? Also, what were your past hobbies? Even when we don't have access to a ton of personal information, our approach in prioritizing a relationship will matter. We need to be consistent. We need to be empathetic. We need to always enter these interactions with the expectation of success. Our patients can feel that energy coming off of us and it's important that we bring that to the table.

MANAGING SYMPTOMS OF DEMENTIA
Now, a giant barrier to exercise is managing behavioral or psychological problems and symptoms of dementia. This can get in the way big time of that fitness forward approach or bringing exercise to the patient. Now, first, these symptoms, and it's important to recognize that these symptoms are often a manifestation of something else going on. It could be an acute medical problem, could be a UTI, could be an infection. It could be unmet needs. They're hungry. They're tired. They need to use the bathroom. They feel unclean. It could be from a lack of a meaningful activity. It could be from stress from a caregiver or a loved one, they can feel that stress, it could be an uncomfortable environment. So before we write people off, we have to go, hey, maybe we need to problem solve some of these things and really clear and make sure none of these things are going on before we say that they're non-compliant with therapy. And we need to lean into that problem solving during the sessions. That's why we're there is to solve this problem of why won't this person move much, right? So we're going to spend time solving the problem. Now, I'm not saying that we can spend 10 sessions with a person doing absolutely no physical interventions. I don't think that's terribly appropriate. And I think Medicare at some point would be wondering how they could reimburse us for all that time. But I am saying that we are going to spend time during sessions working on the behavioral problems, working through it to get to some type of skilled, meaningful movement. All of that time, all that problem solving, that behavioral management, that's skilled time. That's skilled and that's billable. We just need to do a good job in our documentation of explaining what we did, how we did it, and what the result was. And then we use that information next session to kind of guide us and get the patient hopefully moving faster and getting them up and going quicker.

POPULATION SUBSETS: IS THIS PATIENT APPROPRIATE FOR THERAPY?
Now I'll show you an example though, because I understand there are going to be subsets of this population we meet that wouldn't be appropriate for therapy after a certain amount of time. So I'll share this example of how behavioral management led to a discharge for me. I had a gentleman in the very end stages of dementia. I think I saw him during the last year of his life. He was very agitated and very aggressive. He wasn't very fit. He wasn't doing well physically, so he could not hit me, but he sure did try. And he became very agitated and very upset in my presence more often than not because he started to associate me with movement and he could not get his body to move how he wanted right he knew he there was some perception he knew what i was asking him to do was very difficult and very hard um and he associated me with that and that frustration and Stayed on for I think like 10 plus sessions like quite a bit of time Trying many different techniques trying many different behavioral management strategies giving them different equipment to use Showing really the caregiver and the wife how to do exercise with him in a meaningful way There was a lot of cursing me out. There was a lot of near hits to the face, but I Well, we started to realize that I was his trigger and that he was much happier exercising with the caregiver or the wife. So I gave them as many skills as I could. And then I bowed out. I got out, right? I was his trigger. So we parted ways, but I was able to provide some meaning and some context and at least explain how to exercise with him to his caregivers and loved ones with whom he'd exercise much better with. So I'm not saying every patient we need to fight through these issues, but we need to do a good job problem solving and giving as much meaning and value as we can. All right. Relationship number one.

COMMUNICATING WITH PATIENTS WITH DEMENTIA
Next up is communication. Highly important. We should be using communication with short, simple phrasing, yes, no options. We should consider eliminating distractions using repetition in our language, using body language, visual cues, and being comfortable with silence. So having a lot of patience. What's more important though than slow speech, because it could be that we see people and we're like, they have a cognitive impairment. So we're just going to go really, really slowly. That's not what we should do. Instead, we should speak at a normal pace, but allow more time for processing. So we're going to consider the pacing at which we're giving information. Now we should not see this diagnosis with dementia and automatically go to the most basic communication level. That can be, that can absolutely be wrong. People with mild to moderate, even dementia can actually understand, have meaningful conversations and execute multi-step commands. So don't just see the diagnosis and go straight to the bottom levels of communication. Always consider eye level positioning, getting down onto their level. It kind of reduces this hierarchy effect that we can have if we're talking above them. We're going to use lots of positive body language and gestures. You've been seeing me gesture at you for the last 10 minutes. We're going to use lots of gestures. Remember that our patients do communicate through unwanted behaviors. So if they're getting tired, if they're getting more confused, and that may cause disengagement and looks like they don't want to do therapy, We need to recognize that and work to find the problem before we start saying people are uncooperative, before we start giving these super unhelpful labels. Also consider your cueing strategies in this population. I think these cueing strategies are for everyone, but especially in the context of dementia, it can be easy to jump right to physical cueing. We want to start first with a verbal prompt. move towards a visual cue or model the behavior. We then may use a tactile cue or some physical guidance. And then lastly, physical assist. So we're like waiting to do physical assist to the very end.

REMEMBER MOTOR LEARNING
All right, the next category is motor learning. We want to encourage implicit procedural type movements and training with folks. Learn by doing is our mantra. We need to prioritize both salient and functional tasks for the patient. It's gotta mean something to them. That's why digging into their hobbies and their life is really important. So if we wanted to do squats with somebody, potentially doing sit-to-stands from their favorite chair may actually improve participation. When we design sessions for older adults with dementia, we want to consider using a lot of repetition, the same exercises very consistently. We want to do a lot of blocked practice. So instead of maybe programming two very unique sessions each week, we would prefer keeping the same exercises in both sessions instead of using random practice like our AMRAPs, EMOMs, supersets. We may have to focus on one exercise at a time or maybe just two. Okay, so keeping it a bit more simple. In patients with Alzheimer's disease as well, we see that we need to set them up for a lot of success and do more exercises that encourage errorless learning as errorless learning is more superior to errorful learning or really effortful learning. So we want to get our patient to move without a lot of mistakes. Obviously, we'll have a range of mistakes that we deem allowable, but we want to really try to cue right before an error is made and not let them error through a movement. That struggle is not as beneficial to this population.

MAINTAINING INTENSITY
Lastly, we want to ensure we have sufficient intensity and challenge. The article writes, I love this portion, this article writes that we can confidently and competently oversee intensive interventions and encourage patients to work hard. We find that by people feeling challenged by exercises and activities, this is a positive and rewarding experience associated with increased confidence and self-esteem in individuals with dementia. So it seems like more intense exercises actually may be better perceived by this population, right? No infantilizing exercises here. So we need to monitor for intensity. We need to look for any observable physical signs of intensity, but also, behavioral signs, cognitive signs. One of my favorite things the article goes on to talk about was excess disability. That a lot of people with Alzheimer's disease have this excessive disability, which they're more functionally disabled than they should be given their impairments. And this is often a result of diminished opportunity for task performance, driven by well-intentioned or time-sensitive caregiver assistance. Loss of opportunity leads to loss of skill. Loss of opportunity leads to a loss of skill. So we need to encourage our caregivers to find small pockets of opportunity for the patient during the day to help maintain their activity levels. So the caregiver relationship is a whole different podcast, but really talking with that caregiver about, hey, when you're structuring your day, what can the patient get involved in doing? Where can we get them a little bit more activity during the day? Loss of opportunity leads to loss of skill. So that's something I talk often about with caregivers because unfortunately they make a lot of decisions to kind of cut out the patient in the process for very good reasons. I have an 18 month old at home. I understand why people do this, but it's having a lot of grace and trying to see where are some opportunities that we can get this person to practice more.

THERAPEUTIC ATMOSPHERE
Now the last environment was domain. Super simple here and probably pretty intuitive. We need to be mindful of our therapeutic atmosphere to encourage success. We need to prioritize patient safety. We need to keep them comfortable. Us documenting on a computer in a really busy environment may not be it for this person. We need to keep things routine and consistent. Don't send in Different person for therapy every time this person's probably gonna need a very familiar face. So you're gonna want to keep the same provider at the same time at the same place Consistency is everything we want to minimize distractions and create an atmosphere of joy. I know that sounds really simple. I But these changes in particular can make a big impact. Honestly, changing my attitude was one of the ways that's really helped me when working with this population. I have become super joyful when I walk into the room, no matter what I am met with. I am very curious about what the patient has to offer that day, what excites them, what makes them tick. And it's made one of the biggest impacts on my ability to care for this population. and give them meaningful sessions. So changing expectations is what we, you know, about what we should achieve. Letting our patients guide more of the session. That's really reduced a lot of my own personal burnout and stress surrounding these interactions and sessions. I have just come to recognize and document all of these strategies that I use and what impact that they had on my ability to deliver care and to deliver movement for this population, right? I've recognized that these skills and these decisions that we're making are skilled behaviors. And I value my own time and bill all of this while I'm with the person. Remember, you're providing an opportunity for movement in this population, an opportunity for movement. I hope this article gives you just that sense and boost of motivation that you were needing to feel successful in treating these folks. You guys are out there doing an absolutely amazing job. I hope this just makes your job a bit easier. All right, y'all have a good rest of your Wednesday and we'll 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 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.

Dec 12, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses isometric exercise, in particular, that isometrics are beneficial for more than pain reduction. Mark cites research from the tendinopathy space about the importance of not using isometrics as a quick fix for pain, but as the starting point to gradually reintroduce functional, full range of motion exercise including concentric, eccentric, and power movements in order to fully rehabiliate a tendinopathy.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

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 h 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.

MARK GALLANT
What is up PT on ICE crew? Sorry for being a minute or two late here having some technical difficulties over on the YouTube side. So it looks like that is trying to get going as we speak. We will see if that that comes online here as we're talking. What I'm what I'm currently seeing for you YouTube folks is just a spinning wheel of death saying going live, going live, going live for the last three minutes. So hopefully that'll that'll pop up here over the next second or two for you all. So I'm Dr. Mark Gallant, lead faculty for the ice extremity management division coming at you here, clinical Tuesday. We are done with live courses for the year. I believe there's one more live course, dry needling course this weekend. And other than that, we've got a few weeks off. So we'll be sharpening the iron over the next few weeks, gearing up for for the next year of the ice season. And we can't wait to see you all out on the road. So all of our courses, all of our online courses will be kicking off in January. And all of our live courses will be kicking off the first and second week of January. So if you all haven't been on here the past couple weeks, checking in, there will be a price increase for all ice courses starting January 1. If you've been eyeing those courses and you know a course you want to take over the next few months, we would highly recommend popping in, purchasing that now, save yourself $50.

ISOMETRICS: CLINICAL VALIDITY & CLINICAL APPLICATION
So what I'd like to talk about today is isometrics and their clinical validity, what they're good for in clinic. And isometrics have come up a lot recently. If you've been a daily listener to the podcast, what you'll have seen is Jordan Berry came on here two weeks ago and he talked about using isometrics for specifically for low back pain and then Alan Fredendahl came on last week and he did a podcast talking about how using the rack pull can be a nice way to add isometrics into a more functional movement, getting your folks back towards the gym. So clearly as a company, we really enjoy using isometrics and we believe that isometrics are a key part of clinical practice. However, isometrics have been under fire recently on social media, in the research, because they got touted as being a silver bullet for pain relief a couple years ago. So where this all came from, Ebony Rio published an article in 2015 looking at six male volleyball players who had patellar tendinopathy. And what she found with these six male volleyball players, if they held an isometric contraction at 70% of their max volititional contraction, for five sets, 45 seconds, that we would see a dramatic decrease in pain. And that's what she found. So for these young, healthy male volleyball players who had about five to seven out of 10 anterior knee pain, their knee pain was fully resolved after doing those isometrics and 45 minutes later. And so, of course, as a profession, we got extremely excited, like, oh man, these isometrics are the key to relieving pain. for our tendinopathy patients. We've gotta use these for everyone, so we extrapolated that to not only patellar tendinopathy, but to rotator cuff tendinopathy, Achilles tendinopathy, lateral elbow tendinopathy. We really just ran the gamut as far as tendinopathy goes, looking at this research. Again, it was one study, six healthy males, With that extrapolation, what of course followed was a lot of repeat studies. So this has been looked at about 10 times over the last eight years. So we've had people look at it in the rotator cuff, in the Achilles tendon, in the lateral elbow. We've had a couple editorials written. We've had one systematic review. And what's shaken out is it's been very inconsistent over the last eight years. There were a couple studies that showed very similar to what Ebony Rio showed, that there was a dramatic pain reduction using isometric contractions. And other studies did not get the same magic bullet results when it comes to isometrics.


PAIN RELIEF OVERSHADOWS TENDON HEALTH
And we really believe that this study has overshadowed the bigger picture with isometrics. and why we really love isometrics. So of course we live in a society that wants that instant pain relief. That instant pain relief is such a central nervous system component and it is unlikely to actually benefit the person who's got a true mechanical musculoskeletal problem long-term because what we see is if you get that dramatic quick pain reduction, although it's great, everyone wants to be out of pain, Oftentimes, that leads to the person not continuing out with rehab over the long term. And we know from a lot of research that most quick changes within the first six weeks are mostly central nervous system changes when it comes to how tissues respond, certainly to pain. And then at that six-week mark, we start to see a lot of muscular changes. And then for tendons, it can really take six months and up to two years to get a dramatic change. And so if we get that instant pain relief, we may actually be doing a disservice to the long-term health of that overall tissue and rebuilding that capacity. I don't like reading directly off of things, especially while we're here on the podcast, and I don't think that I need to defend Ebony Rio. She's one of the premier researchers in the world. listening to a lot of lectures that Ebony Rio has done, listening to her on multiple podcasts, reading basically every article that she's ever published. I believe that her intent was not for these isometrics to, for this small, small case study article to create such a huge wave and ripples across the rehab professions that anytime you listen to her speak, what she really dives into over and over and over again, is that isometrics are a nice starting spot and that we really need to rehab these people fully out with isometrics, heavy concentrics, eccentrics, dynamic speed and power training over a long period of time. So I want to read a quote from Ebony Rio that came out two years after the article with the Patella tendinopathy that sent ripples through the profession. And what the quote says, simply taking away someone's pain with a medical intervention may not result in a positive medium to long-term outcome, it is possible that simply removing pain does not equate to a positive tissue adaptation. So there's Ebony Rio directly saying that that quick removal of pain is not directly correlated to positive tissue changes. If we look at Karin Silbernagel, who's another premier tendinopathy researcher, and her response to the fad of isometrics being a huge pain reducing intervention. She states, a change in focus from improving resilience to a focus on acute pain relief may likely misguide patients and clinicians into thinking there is a quick fix. So what both of these women are saying, who are premier researchers in the tendinopathy spaces, there is no quick fix, that we need that long-term loading regardless of whether we get quick pain relief or not.

THE LONG-TERM FIX: TIME UNDER TENSION, INTENSITY, SYMPTOM MANAGEMENT
So why, despite all that, are we at ICE still advocating for and sticking with isometric interventions, both with our tendinopathy patients, our low back patients, literally for every region of the body, isometrics can be a nice tool to get your patients moving along the way. So let's break down why we believe that. So when we're looking at tissue care, there are a few things that we know have to be true to move and adapt those tissues in the long term. Number one is time under tension. There has to be enough time under tension for the nervous system in that tissue to respond to adapt. If it's just one quick motion that never gets repeated and has no time under tension, the nervous system doesn't have, isn't easily as easy to adapt to that stimulus. So time under tension is number one. Number two is intensity. There has to be enough of a stimulus to that tissue to create mechanotransduction to have that tissue adapt. And then number three is that we have to manage our patient's symptoms while trying to maximize the other two. So that's what makes us unique as physical therapists is we're creating time under tension. We're creating intensity while we have those symptoms on board to manage. It's really like this seesaw that we're managing. So we have symptoms on this side, we have time under tension and intensity on this side. It may start out that we've got more symptoms at first and we're trying to balance that scale and eventually have less symptoms, more time under tension, more intensity to our interventions. What isometrics, what we've gotten into over the last eight years is Even if you have 7 out of 10 pain while you're doing this, go ahead and do it because it's going to eventually reduce your pain overall. And we just need to get that time and attention. Well, what that creates with someone who's got fear of exercise and apprehension is a lot of yellow flags. So that's when you get people saying things like, I hate going to physical therapy. Oh, it's so uncomfortable. I really don't want to do this. And they start avoiding their intervention. The first thing we want to make sure is whatever that stimulus we're giving to the person, that they feel psychologically ready to tolerate that. Are you cool with exercising into three out of ten pain? Oh, you're not? One out of ten pain would be more tolerable to you? Okay, let's find an intervention that we can do there. So those are the three big components. Getting their symptoms, getting a stimulus that puts them in a symptom range that they can tolerate, creating a lot of time under tension, and creating enough intensity.

ISOMETRIC EXERCISE: CONTROLLING MULTIPLE VARIABLES
The reason we love isometric so much early on is because it's a much easier intervention to control all the variables that will allow you to balance those scales. So we go back to a podcast I did a few months ago talking about the guitar amp and things that stress tissues out. What we really are looking at is our knobs that we want to play with is the overall work volume, how much work has been going into that tissue over the course of a few days or a week. How much load has been going into that tissue? What is the actual weight on the bar, the body weight, the resistance of the band that you're looking at? What is the compression and strain on the tissue? So is that tissue all the way compressed in like that or is it strained all the way stretched out? That's gonna be one another way that the tissue can be stressed out and then the speed of the the speed of the intervention so if i do a heel raise versus sprint that's going to put a definite a very different type of force through that achilles tendon so again we've got overall work volume we've got the actual load on the bar we've got compression or stretch or strain and then we've got speed as all ways that that are going to manipulate and change the stress of the tissue. The beautiful thing about isometrics early on and why we're recommending them is you can control all of those variables much easier. So the overall work volume, you're going to be able to very cleanly set that with your patients. I want you to do five sets of 45 seconds or five sets of 30 seconds. whatever the agreed-upon work volume can be, and then it's clear with that isometric. It's very well set. As far as the load, that's not going to change with the isometric. You're going to determine with your client or patient, okay, I want 5 pounds on the bar, I want 10 pounds on the bar, I want 15 pounds on the bar, and then that becomes static. For compression and strain, you're going to find the range of motion they can tolerate. Okay, it's in a mid-range, that angle does not change. So we are no longer getting a change in compression or strain or say we bend it to 90. Now that's the new angle. There is no change during the actual intervention in compression or strain. So we have now controlled that variable. And then for speed, the speed is literally zero. Once you get that weight and that load into the position you want it, it's not moving for the remainder of that intervention. you can really control all the variables quite easily with the isometrics so that you know when something gets challenged or something gets flared up, well, ooh, it's really only these one or two variables that we're manipulating, and so you can much easier control the progression of treatment. So if we're looking back at Alan's example from last week, it's like, okay, Julie, we're gonna hold five sets for 30 to 45 seconds of this rack pull. We know very clearly that you can tolerate 135 pounds of weight. We know the angle of the hinge that you do well with is at about your knees pulling up there. And then once you start pulling, you're immediately going to get the block of that rack. So those angles are not going to change. You're not going to get any change in compression, stress, or speed from that movement. And then as you move that person on, okay, we can progress. Let's change the angle a little bit. or maybe we're going to change the load a little bit, and you can very isolated change these variables until that person's symptoms reduce enough, where then you get into your concentrics, your eccentrics, then you can progress them to your dynamics. So we are not looking at isometrics as this silver bullet of dramatic pain relief early on in tendinopathy. We're looking at it as a nice entry point into giving enough time of retention, enough intensity to a tissue while managing symptoms, because we can control more of the variables. And once those symptoms come down and we don't need to control those variables as much, then we can get more into our concentric eccentrics, more into our dynamic exercise where our buoys are a little bit wider. So Hope this helps. Hope this explains why we've been so excited about isometrics over the past couple days. For those of you on YouTube, sorry about that. I'm still getting the spinning wheel of death, but wanted to make sure that I got on here. Again, to repeat, isometrics, if they work for your patient as a dramatic pain reduction, that's wonderful. That's a home run. Make sure they understand that they've got to continue loading over the next six months to a couple years to get all of those positive tissue adept patients. If you do not get a dramatic reduction, it's six out of 10 pain down to zero, not to fret. As long as you can control their symptoms with the isometrics by controlling all the other variables, it is a wonderful entry point into moving those patients forward. Hope you all have a wonderful rest of the year. Have a happy holidays. Can't wait to see you on the road. Make sure you get those tickets to courses before the prices increase in three weeks. Have a great new year.

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.

Dec 11, 2023

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses how to better educate patients on prolapse, including a three-step framework focusing on education, risk factors, healing timelines, and empowerment.

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

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

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

EPISODE TRANSCRIPTION

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. My name is Dr. Rachel Moore. It is Monday morning, which means it is pelvic day on our podcast here. So, we are going to dive in today. Our topic is using words that heal to talk to our patients about prolapse. So we want to make sure that when we are talking about our patients that have prolapse or maybe have been given this diagnosis of prolapse, that we’re using words that are going to empower them. So we’re going to dive into that today. Before we do that, a couple of housekeeping things, just letting you guys know the courses that we have coming up within our pelvic division. So we are done for December, nothing left in 2023, but we are kicking off 2024 strong. We’ve got two courses on our live docket in January. So we’ve got one January 13th and 14th in North Carolina. We’ve got one January 27th and 28th in Hendersonville, Tennessee. And then February 3rd in Bellingham, Washington. So we’ve got three chances within the first like month-ish of 2024 to catch us on the road. um on the those live courses that’s where you’ll be taking your certification test if you’re interested in having that pelvic certification which includes taking all three we now have three of our pelvic courses our next online level one cohort starts january 9th and the sign up for our level two is now officially open so if you want to hop into that cohort it starts april 30th and that will be the first cohort of our level two so Really excited to kick that off and just kind of get that rolling.

TALKING PROLAPSE
So without further ado, let’s dive into our topic of the day. We talk a lot about ICE or talk a lot at ICE about using words that heal, not harm. We preach it a lot and sometimes it can be really tough to figure out how to explain like difficult diagnoses. Especially things that are maybe controversial when it comes to the postpartum space and we’re gonna see that with things like diastasis or prolapse and a lot of times our patients are coming in and maybe they’ve been given this diagnosis by another provider and it’s not really explained very well and so they go down this scary Google rabbit hole and they come in and with all of these preconceived notions um oftentimes mostly negative preconceived notions from all of this research that they’ve done and they feel like they’re empowering themselves with knowledge but in reality there’s a ton of negativity and fear-based messaging about these topics so today we’re going to talk about prolapse later on in a future episode we’re going to talk about diastasis and i really just wanted to talk about some actual quotes that i use with my patients or kind of an outline or a framework of how we can break these scary diagnoses down, especially if you’re newer to the pelvic population, you haven’t had a lot of reps practicing talking about this, so that we can make sure that all of our patients are leaving their sessions feeling very empowered and excited to be working with you.

EDUCATE
So the first step of our three-step framework is going to be educate. I can’t tell you how many times I have people come into the office and they’re sitting there and they’re squeezing their legs together because they are so terrified that if they aren’t constantly contracting their pelvic floor and squeezing their legs together that their bladder is going to fall out of their vagina because they’ve been told that they have a bladder prolapse. with no other explanation this happens so often people will go to a provider the provider maybe will be doing a well women’s exam or a check for whatever reason postpartum follow-up whatever and they tell them you have a bladder prolapse or you have a rectal prolapse and then that’s it and they don’t really tell them anything else and maybe they don’t even really prescribe them physical therapy and they just wander into your clinic um on their own but there’s not a lot of follow-up in most cases. So the very first thing that I’m doing when I’m sitting down with patients is breaking down. Okay, you were told you have a prolapse. Did anybody explain to you what that is? And usually that’s followed with no, I went on Google and I saw a bunch of scary things. I’m like, okay, great. Like we’re going to undo all of that. And even sometimes if they were explained, it maybe was using a very medicalized definition that can be, again, terrifying if you don’t really know what’s going on. So I’ll bust out a whiteboard and I will draw out the pelvic organ. So if you’re watching on Instagram or YouTube, you can kind of see with my hands, but if you’re not listening, just visualize. I’ll draw out, like, here’s our bladder, here’s our uterus, here’s our vaginal canal, and here’s our rectum. All of these organs sit within our pelvic bowl. When we have pelvic organ prolapse, essentially what that means is there is a descent of one of these organs or a drop down that pushes onto the walls of the vagina. at this point usually i’ll take a minute to explain to people that the vagina is not a hollow tube it does not look like this it actually looks more like sides of soft tissue coming together most people don’t realize that because every picture we’ve ever seen of a vagina in a textbook in anatomy books anything Looks like a hollow rigid tube. So a lot of times even letting them know like hey your vagina is not like this It’s like this you’ll see a light bulb moment where they’re like, oh Okay, so maybe that’s not a prolapse that I’m seeing maybe that’s actually just my vagina. So that alone can be really helpful We’ll talk about the fact that the vagina is not a hollow tube and that it is soft tissue and with that it is influenced by other things around it and so then we’ll kind of break down here’s your bladder maybe you have a descent of your pelvic organs and we see this kind of drop down if vaginal canal is here and our bladder is dropping down slightly and pushing onto that vaginal wall what we may see is a slight drop down of that vaginal wall oftentimes we’re doing this test on our backs Oftentimes gravity is pulling everything down a little bit more and so when we take this person who’s upright like this and put her on her back, our bladder drops down and we can kind of see and maybe feel that drop down sensation. When we layer in gravity with standing, we’re upright, we drop down, we can sometimes feel that heaviness sensation from the vaginal wall not necessarily supporting that drop down quite as well. It is really important to highlight and differentiate an organ falling physically out of the vagina which can happen if we have a uterine prolapse where the uterus is dropping down into the vaginal canal versus an anterior wall or a bladder or a posterior wall or rectal prolapse where it is not the physical organ dropping down, it is just the wall of the vaginal canal dropping inwards. That education is huge. You will see people have this like weight lifted off of their shoulders knowing that their organs are not actually falling out of their bodies. Education is important.

DISCUSSING RISK FACTORS
Talking about risk factors is also incredibly important. Letting them know what the top risk factors are. Genetics and connective tissue immobility, BMI, chronic constipation, which comes along with that straining, that consistent straining mechanism where we’re bearing down repeatedly over time, pregnancy or parity, and vaginal delivery. A lot of those aren’t things we can necessarily control for, but what’s important to let them know is that exercise is not one of those factors. We want to make sure that our patients know that they didn’t cause their prolapse by doing too much too early, especially if they’re in the postpartum space or if they have this like shame associated with, I have a prolapse and I did it to myself. That’s not the case. More often than not, if a prolapse or a pelvic organ position change is going to happen, it’s going to happen in a vaginal delivery after a pregnancy. And it’s not necessarily something that they’re causing by doing activities later on. Letting them know that they didn’t cause this thing to happen, again, can be huge for somebody’s mental state. If they’re feeling like, oh, I did too much and I caused this, that can kind of cause this negative spiral of fear for movement in the future.

DISCUSSING TIMELINES
Finally, we want to talk about, on the education standpoint, timelines. It doesn’t make sense to have somebody at six weeks postpartum come in and say, yep, you got a grade three prolapse. Your bladder is dropped down and your anterior wall is coming out of your vagina. We expect there to be changes. we expect that after a vaginal delivery, those tissues aren’t just going to pop back and get to their original position or even a new baseline for a longer timeline. So talking about the fact that early postpartum is not the time to be diagnosed, quote unquote, with a prolapse or to even really be concerned about where things are. Instead, we want to talk about ways to talk to them about um body mechanics and um their strategies for bracing we want to talk about bowel health and making sure that they’re not continuously straining and bearing down and let them know that when we layer these two things in And then we allow time as a factor. Where they’re at at six weeks postpartum is going to look different than where they’re at at six months postpartum, even if that was the only things that they did. So education is huge. Educate them about what prolapse even is, educate them about what the risk factors are, and more importantly, are not, and talk to them about the timelines for healing. The next step in our little three-piece framework is going to be normalize. there is so much conversation happening in the pelvic floor PT world that a prolapse or a like a grade one prolapse which is just a slight descent of pelvic organs might be normal in the postpartum population. Just like we don’t expect our breast tissue to look exactly the same after breastfeeding, we can’t expect our pelvic organs to be in the exact same position after they’ve undergone nine to 10 months of low load, long duration stretch that creep has set into those tissues. And then we also potentially layer in a vaginal delivery. A grade one might not be a big deal at all. That might just be a typical postpartum change. On top of that a grade two might even be somewhat of a normal finding I have not yet seen a grade zero quote-unquote after a vaginal delivery I think it’s a unicorn that actually doesn’t really exist and we’ve had a lot of conversation about this within our pelvic crew of has anybody ever seen that The consensus so far is no. And so if you guys have, drop it in the comments. I’m curious. But we want to talk about normalizing this change. We expect physical changes in our body after pregnancy. We expect physical changes in our body after vaginal delivery. It’s OK to look like you’ve had a baby. It’s OK for your body to show those signs. this can be a big thing for people to wrap their heads around because there’s a lot of talk within our culture about bouncing back to what your body was before and Switching up that conversation to we’re not worried about what it was before We’re getting to a new baseline and that might show changes that have happened and that’s okay Normalizing the fact that our bodies are going to change during pregnancy after a delivery is important The other part that we want to normalize is that in the early postpartum timeline, those muscles are recovering, especially following a vaginal delivery where they’ve had a stretch injury, they’ve been stretched out, elongated, they’re returning back to their resting state. We expect those muscles to have a lower threshold for activity than they did before. as pts this makes sense as patients it not it doesn’t necessarily um come to the forefront of the mind so reminding them these are muscles think about any other muscle in your body maybe you’ve pulled a hamstring maybe you’ve pulled your quad maybe you’ve overstretched your shoulder those few days maybe weeks afterwards it took less activity for you to feel something in that area in this case specifically what I’m really kind of preaching to people is that if you get up and you’re feeling good one day and you go for a walk with your kiddo around the block and that’s the farthest you’ve walked and then later in the day you start feeling some heaviness you didn’t cause a prolapse likely those muscles are just tired. They worked harder than they have all this timeline leading up to this. And so they’re fatigued. And just like every other muscle that fatigues when it fatigues, it doesn’t work quite as well. And so we feel that heaviness sensation. normalizing that heaviness sensation. I love to do this when people are pregnant, set that expectation. Hey, look, as you start moving more, you might notice that you feel a little bit of heaviness. It’s not a big deal. That’s kind of our buoy lets us know where we’re at. You’re not causing any damage. It’s going to be okay. That heaviness will resolve and over time you’re going to build up your capacity where that heaviness sensation comes on later and later and later normalizing what a prolapse is, normalizing what the grades are, normalizing the changes of our body that happened during pregnancy and postpartum and normalizing recovery of those muscles and potentially having an onset of symptoms.

FINISH WITH EMPOWERMENT
Finally, we want to empower our patients. This is where our bread and butter lies. This is what we are here for. We are all about empowering women in this pelvic space. we have evidence that we can reverse a prolapse up to one grade. So that means if somebody comes into the grade two, then potentially we can get them to a grade one. Realistically though, at the end of the day, I don’t even really care about that. What I’m really harping on more, really focusing on more with my patients is that We know that the degree of prolapse or the descent of those pelvic organs and how much they are descended has no correlation with your symptoms. You can have a grade three and be highly sensitized and feel everything. You can have a grade three and have no idea that you even have a change on the flip side. You can have a grade one and feel like things are falling out. so talking about the ways that we can directly impact that by calming down the system giving them tools like laying on their back with their feet elevated adding in some bridges to get some muscle activation kind of taking the pressure off of the pelvic floor so that they can decrease that symptom of heaviness discussing things like bowel health, like we chatted about earlier, avoiding straining, using a squatty potty, making sure that they’re drinking enough so that they’re not falling into this chronic constipation camp, and then talking about body mechanics. That’s one of the biggest things that we really want to focus on. We have to know what they’re doing when they brace. We have to know what they’re doing when they bear down. We have to know what they’re doing when they do a pelvic floor contraction. we need to collect that data. We need to calibrate to make sure that they’re not dropping down with their pelvic floor and increasing that heaviness sensation with their daily tasks. That is a huge piece of the puzzle. So our three-step framework, when we’re talking about somebody coming into the clinic day one terrified that they have a prolapse. The first thing we’re going to do is educate them. We’re going to talk to them about what a prolapse is. We’re going to talk to them about the risk factors and what potentially caused it and what definitely did not cause it. And we’re going to talk to them about timelines. We’re going to normalize. We want to make sure that they leave feeling like their body, their vagina, their pelvic floor are normal. And even if you have somebody come in with a grade four, We’re still normalizing. We’re still talking about all of the ways that we can help. We can work on prehab. We can take those same tools and improve things so that going into a potential surgery, they have better outcomes. And anything less than a grade four, you better believe I’m normalizing. You might have a change in your pelvic organ position, but you know what? That’s totally normal after having had a baby and a vaginal delivery. The third step is we’re going to empower. We’re going to make sure that our patients feel confident in movement, feel confident in that bracing strategy, feel confident in what they’re doing in their daily lives so that we can build a stronger and more resilient human being who can tolerate more things before symptoms come on. I hope you guys enjoyed this. I hope it helped clear some things up, especially if you’re newer in the pelvic space and you really understand what prolapse is, but you’re just not quite sure how to talk to patients about it. It can be intimidating, but I trust that you guys have got this. If you’re not confident in treating heaviness and pelvic organ descent, um, and that sensation of heaviness hop into our live course, we spend a ton of time going over bracing. We talk a lot about what prolapse is, We have a whole matrix and kind of framework about treatment approaches for each of these little camps, whether they have symptoms objectively or subjectively and what the combinations are. I hope you guys have a great Monday. Get out there and crush it. 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 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.

Dec 8, 2023

Dr. Zach Long // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Zach Long discusses Testosterone Replacement Therapy, including research supporting its use, side effects, understanding dosing, and common clinical presentations related to TRT use.

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

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

EPISODE TRANSCRIPTION

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 h 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.

ZACH LONG
Good morning, everybody. Welcome to the PT on Ice Daily Show. It is Fitness Athlete Friday, the best day of the week here on the podcast. I'm excited to be with you as your host, Dr. Zach Long. And today we're going to talk about a topic that's a little out there, like it's not something we talk about a whole lot in the profession, and that is testosterone replacement therapy. And we're going to discuss four or five things that I really believe that those of us in outpatient orthopedics need to understand about testosterone replacement therapy because you are for sure seeing these patients in your clinic with certain conditions and being aware of a few things will help you out clinically. Before we jump into that topic, upcoming courses that we have inside the fitness athlete division. Our live course is, we have one more for the end of the year. That's Colorado Springs, Colorado this weekend. Mitch will be teaching that. If you can't make it to that in quarter one, we will be in Portland, Oregon, Richmond, Virginia, Charlotte, North Carolina, and Boise, Idaho. So check out those courses, pglnice.com. We also have our advanced concepts course. We'll be going live at the beginning of the year. That course always sells out. If you've already taken level one, you can jump into the online level two, but that sells out. So you want to look at jumping in and booking your spot as quickly as possible.

TESTOSTERONE REPLACEMENT THERAPY
Let's jump into testosterone replacement therapy and what physical therapists need to know about that. Testosterone replacement therapy is injecting testosterone into your body, which is the male sex hormone, prescribed by doctors at times to treat hypogonadism. We've seen a giant increase in the number of people and the acceptance of people being on TRT in the past few years and I think that's why it's so important for us to understand that because so many individuals are now when they you know get into that 35 40 50 year old age range where their libido goes down a little bit. They stop improving quite as much in the gym as they used to. They start to have a little bit more general fatigue, anxiety, et cetera. We're seeing more and more men jump on TRT. I found a research study from 2017 looking at the rates in the US population of people being on TRT. And in 2017, they estimated that between 1% to 3% of men were on testosterone replacement therapy. which that number was a threefold increase in the number of prescriptions of TRT from 2007 to 2017. So threefold increase in those 10 years. And I would even say since then, in my opinion, it has become more popular or at the very least more accepted. Back in 2017, you wouldn't hear a whole lot of people talk about being on TRT. And now I feel like I see it all the time. I see big time influencers talking about being on TRT. all the time on social media, when I'm talking to people at the gym, they're regularly talking about their doctor just put them on TRT, whatever. So there's a lot less stigma around it and there's a lot more people getting on it. And I think that's really important for us to understand because there are gonna be a few things that we see in the clinic in people that are on TRT. And so asking this question more frequently to your male patients, especially that are between the ages of say 30 and 50 years old, is going to change a few things that you might be thinking of clinically. So three-fold increase in those 10 years and probably a little bit more than that. Another really interesting study that I found with testosterone replacement therapy was this study called Testosterone Dose Response Relationships in Healthy Young Men. So this was a really cool study where they took individuals that had previous resistance training experience and they told them that they weren't allowed to exercise during this six-month study. So If they've done previous resistance training, we kind of know that they're going to be through their beginner gains, their newbie gains in the gym where they would have really easily put on several pounds of muscle. So these aren't people that you're going to expect to see drastic increases in muscle mass in a short period of time. especially when they're not working out. But what they did in this study was for six months, they put these men on testosterone replacement therapy at different dosages. So the dosages were 25, 50, 125, 300, and 600 milligrams of testosterone for 20 weeks. So a wide range of doses from 25 milligrams a week to 600 milligrams a week. And they looked at a number of different things, such as their fat-free mass and their leg press strength, and then a number of other different physiological factors. But I'm gonna focus on those two, mostly muscle mass here. So again, we wouldn't expect these individuals when they're not resistance training, but having had previous resistance training experience to gain a lot of muscle mass in this time period. But what they found was that the group on 125 milligrams a week during those six months gained six pounds of muscle on average. The group at 300 a week gained 12 pounds of muscle mass on average and the group at 600 milligrams a week gained on average 19.5 pounds. So a lot of increase in muscle mass during that time period, especially when people aren't doing any resistance training.

UNDERSTANDING TRT DOSAGE
And so I bring those dosages up because I think that's one really important thing when you have a patient on testosterone replacement therapy, I want to know what that dosage is. So when you're treating hypogonadism, less of this like people getting on TRT to try to improve their sports performance, their aesthetics, their strength, et cetera. What you tend to see is much lower doses in terms of testosterone replacement therapy. Like getting on those low doses under typically 200 milligrams a week is what you'll see a lot of doctors prescribe here. And that's going to do a lot to help improve libido and anxiety and other symptoms like that of hypogonadism. But when you get to that 125 milligrams a week, that's when we start to see a large increase in muscle mass. And what you'll often hear referenced by doctors prescribing TRT is sports TRT dosages versus hypogonadism dosages. And the cutoff there that you'll hear most people discuss will be 200 milligrams a week. So when you're taking 200 milligrams or more, that's when you're getting into a bit more of the sports performance arena than just purely addressing hypogonadism. And I think that's important because of the next studies that we'll talk about in a second here. But 200 milligrams a week, when people are on that, I'm thinking, all right, we're on a pretty good dosage. And if we go back to that study where the milligrams per week range from 25 to 600. It's important to note that testosterone is obviously a performance-enhancing drug. It can be used for medical reasons. It can be used for recreational and sports performance reasons. And when people typically do like a steroid cycle, not TRT, like trying to put on as much strength, muscle mass, sports performance as possible, the dosages that people will typically be at will be at 300 or more. Typical dosage that you'll hear a lot of people talk about doing a starter steroid cycle is like 500 milligrams a week So this study was really aggressive in the dosages that they did there like especially the group that was doing 600 milligrams a week for six months like they were doing a full-blown steroid cycle, but remember 200 milligrams a week is kind of your cutoff there in terms of sports TRT versus just standard TRT.

THE RELATIONSHIP BETWEEN TRT DOSAGE AND TENDINOPATHY
Why that's important and why I want to know the dosage that my patients are on if they're on TRT is because One thing that I clinically see quite a bit is that those individuals on TRT, I'm frequently finding them showing up to the clinic with tendinopathies more than any other injury out there. In fact, when I see a male between the ages of 30 and 50 years old that's coming to me with a tendinopathy and I know that they're exercising and they look relatively fit, this is a question that I will just straight up ask them. because I think it's valuable information to know. And the reason why it's valuable is that there are actually two research studies out there that have found, one of them found an increased risk of rotator cuff tears in men on testosterone replacement therapy, and another one found an increased risk of distal bicep tendon tears and increased risk of needing surgical intervention to repair that distal bicep tendon tear. And so if we know from these two research studies that these men on TRT are at increased risk of a tendon tear, that would suggest that there's likely some degeneration already happening to some tendons in men that are on TRT. Now, why that is? Can't for sure say though. One theory could be here when we go back to that dose-response relationship study where men taking 125 milligrams or more per week are putting on significant amounts of muscle mass in a six-month period. It could be. those muscles are responding really fast, and those tendons are responding a little bit lower. It could be that maybe these men had low energy, anxiety, depression, they get on TRT, now they're feeling better, and they go from a low amount of activity to getting more aggressive in the gym, so they see training load spikes that challenges those tendons more than they're able to recover from. Whatever reason that is, it happens. We're probably seeing degenerative changes in tendons of men on TRT.

TENDON HEALTH ON TRT
And we need to be aware of that because that might lead us to want to have more discussions with individuals. on taking care of their tendons if they're on TRT. Like maybe they need to spend a period of time every few months doing heavy, slow tempo work on their spots. Like if you're in CrossFit, maybe not always bouncing out of the bottom of the hole as aggressively as possible. Maybe they have to spend a period of one month every six months where that tempo's going really slow. Maybe we need to be prescribing some extra rotator cuff loading, tendon work, or maybe even different supplements that might have a positive effect on their tendons, such as taking Collagen and vitamin C. There's some research by Keith Barr on that potentially having some positive effects on our tendon health. But that's definitely something worth discussing and having in the back of your mind when you see men taking testosterone replacement therapy is what can you do to help improve their tendon health?

INJECTION SITE MATTERS WITH TRT
And then the final thing that I think is important for us to understand with TRT, I would have never thought of this unless Jordan Berry, my business partner at Onward Charlotte, also a faculty member for ice in our spine division, hadn't treated somebody that was on TRT and came into the clinic with incredibly debilitating neural tension. So this guy had previously been a bodybuilder that had abused performance enhancing drugs and now was on TRT, but the guy could barely walk, couldn't pick anything up off the ground, had a 10 degree straight leg raise. As Jordan evaluated the guy's lumbar spine, the lumbar spine was completely clear. And Jordan kind of recognizing in this guy's body type that he looked like somebody that may have previously or currently was on performance-enhancing drugs, Jordan went ahead and kind of broke out that with the individual, started talking to him about his previous performance-enhancing drug history. It turns out the guy was still injecting testosterone regularly. He was on TRT after years of being on more performance-enhancing drug dosages of that. And Jordan asked him where he was injecting. And the guy was injecting his TRT dead center in the middle of his… to inject TRT or the place that's safest to inject it is actually going to be glute med. So if I'm looking at your butt from behind, if I drew a line straight down the middle of your glute, both horizontally and vertically, we want to be in that upper outer quadrant or in the vastus lateralis. Those tend to be the safest areas to needle. When he was going dead center in the glute, he was constantly hitting his sciatic with his injections. And so hitting his sciatic nerve as he was giving himself TRT injections resulted in some scarring on that nerve. And that was what was leading to his intense sciatic and neural tension. So I hope that gives you some ideas and things to think of clinically when you see guys on TRT, or at least makes you more aware of the prevalence of this, and that when you see people with it, you might want to be thinking of some different strategies and different questions if they're coming in with things like tendinopathy or weird neural tension. Hope that helps. Hope we see you on the road at a future Fitness Athlete Live course. Have a great day, 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.

Dec 7, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO & Fitness Athlete Division Leader Alan Fredendall discusses utilizing the rack pull as a way to begin to load the spine isometrically. Alan demonstrates the rack pull, how to set it up, how to modify & scale it, and how to prescribe & dose loading of the rack pull.

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

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

EPISODE TRANSCRIPTION

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 h 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.

ALAN FREDENDALL
PT on ICE Daily Show, happy Thursday morning, hope your day is off to a great start. My name's Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer and a faculty member in our Fitness Active Division. We're here on Technique Thursday, that means it's also Gut Check Thursday. This week's workout, we have a 15 minute AMRAP, so a little bit more chill than previous weeks. We have an ascending rep scheme of American or overhead kettlebell swings, 5, 10, 15, 20, so on and so forth. Recommended weight, 53 pounds for guys, 35 for ladies. And then you're going to pair that every round with 10 back squats. We're going to do that at 135, 95, and then 30 double unders after every round. So a good goal there is to get maybe four or five rounds deep into that AMRAP. accumulate a good volume of everything. You're going to end up at about 50 to 75 reps of the kettlebell swings, of the back squats, and of the double unders. So that's Gut Check Thursday. Courses coming your way. We are basically done with live courses for the year. We have live courses this weekend, but they're all sold out. And then our very last live course of the year is next weekend in Salt Lake City with Paul for dry needling. So if you're trying to make a course before the end of the year, that's the last one you can sign up for. All of our other courses starting up in 2024 are on our website, ptenice.com. Remember, price change going into effect January 1st. Our rates are going to go from $6.50 per course to $6.95. So if you already have an eye on a course, make sure you sign up before January 1st and save yourself 50 bucks.

MASTER THE RACK PULL
Today, Technique Thursday, what are we talking about? We're talking about the rack pull. So I want you to go back to last Tuesday's episode with Jordan Berry, episode 1608, Spine Isometrics, to talk about all the research and the clinical reasoning supporting something like a rack pull. I want to take a deep dive into this, because on the topic of spine isometrics, I think this is a very effective exercise to use in the clinic with patients with low back pain, folks who are having trouble deadlifting, to really build a strong, robust low back, so that bending over and picking up stuff from the floor is no longer bothersome. Today I want to talk about why we're doing this, I want to talk about keys to success, and most importantly I want to talk about how to load and dose this and prescribe this to patients.

WHY THE ISOMETRIC RACK PULL?
So, why do we do this? First of all, it's simple and effective. It's essentially a very small partial range of motion deadlift. It is very scalable based on your patient's presentation. Somebody who's very irritable has very severe low back pain, we can move the safeties and the J-hooks to maybe above the knee, maybe right below level of hip, so we have a very small range of motion that we're contracting through. And we can scale that back down though as somebody starts to feel better. We can take that all the way down to a rack pull from mid-shin as if somebody was lifting from the floor. We can meet our patients where they're at with the scalability of that. The nice thing, like Jordan said last week as well, the key to a lot of isometrics is that most people can do these at home. A lot of folks have a squat rack. or a barbell in plates in their garage or the gym. So they can set something up close to this at home and be able to do that for home exercise. Those individuals already active in the gym already have access to this equipment at the gym they go to, so they can also do this as part of their home exercise program at the gym. Now that's why we do it.

KEYS TO SUCCESS
What are some keys to success? The keys are The setup here is everything. So you'll see I have a pair of safety bars here and a pair of J-hooks. My preferred way to do this whenever possible is to set it up like this. Whether I have two pairs of J-hooks or cups in the rig, I have a pair of safety bars and a pair of J-hooks. I have basically two start and stop points that's gonna let me control that range of motion. So setting it up is really, really, really important. So set up your environment correctly. The J hooks should be upside down. So what we'd like to see is that they're actually upside down so we have more surface area to lift the barbell against. So I'm going to show you a rack pull right now. and show you what it should look like. So, in this example, I'm starting right at the top of the knee. The goal with the rack pull is not to finish the deadlift. If I'm standing at the top of my deadlift, there is no tension here, there is no work needed out of the low back. I need to somehow stop myself short of full range of motion, so my back has to work to keep myself in the position. So, from mid-shin, a nice hinged position, and now I'm gonna lift and pull up against the J hooks and now I can't reach full extension and here my low back is just working to keep this barbell in place and then when I'm done I don't have much room to go to set it back down. So again the issue with the J-hooks put into the rig like normal is that that barbell can actually roll off in a way and lifting a bunch of weight off like that, surprisingly, can upset some people's low back. So if you're going to use just J-hooks, again, take them, turn them, and then flip them upside down. Now we have more surface area. We also have kind of a framing here of the J-hook so that the barbell can no longer slip down, out, and around the J hook. So that's setting up the rack pull. Again, meet your patient where they're at. Adjust the range of motion as needed. If you don't have two pairs of J hooks, by a second pair or what you can use in place of two sets of J-hooks, you can place the barbell on some plates as the lower edge of your range of motion and use the J-hooks to stop the top motion. Again, the key here is that this is an isometric exercise, so we wanna be pulling up against something for 45 seconds. All the benefits that Jordan talked about last week, the stress relaxation response, strengthening, blood flow, pain relief, and then being able to reproduce this in the gym or at home. Now finally, why do we do this? How do we set it up?

DOSING THE RACK PULL
How do we actually dose this? Again, that's gonna depend, what is it gonna depend on? Your patient's current level of irritability. Somebody that is very flared up, maybe you're thinking about starting with something like a reverse Tabata, so you're gonna do eight rounds, 10 seconds on, 20 seconds off. progress them maybe to a full Tabata, where they're now doing eight rounds, 20 seconds of work, 10 seconds of rest. And then for me, my ultimate goal, following some of the tendinopathy literature, is to get to that 220 seconds time under tension. I like to see patients be able to progress to five sets of 45 seconds of work, and then really however much rest they need. 15 seconds is probably too short, so an EMOM timer is probably not appropriate. I like five seconds of 45 on, 45 off. 5 sets maybe of 45 on, a minute, a minute 15 off, so maybe you can set every 2 minutes for 5 sets on your timer. Something like that though, building to that 220 seconds time under tension, ideally showing the capacity to be able to hold that rack pull for at least 45 seconds. So meet your patient where they're at, progress them, progress them, progress them, time under tension. Now what about loading? This is a partial range of motion that you don't need to lift from the floor. What does that mean? That means this should be quite heavy. This should be near, at, or maybe even above that patient's deadlift max, if we know it. Again, we don't have to lift it from the floor. The hardest part of the deadlift is done for us. It's already sitting above our knee. All we need to do is just a little lift and then hold. So, that means that this should be quite heavy. How heavy? whatever weight they can feasibly hold for maybe that reverse Tabata, and then that full Tabata, and then that full 45 seconds on with the rest coming. The key human beings who come into your clinic are not gonna be challenged by an empty barbell rack pull, even if their low back pain is really irritable, so keep that in mind.

SUMMARY
So the rack pull, why? We like that it's scalable. We like that it is easy to set up. It basically requires no thought or mechanical skill to be able to get into that position, We'd like that we can transfer this to home. A lot of folks have access to a barbell and the setup needed to do this rack pull. We'd like that we are really easily able to make people successful with this by just modifying the environment, setting up with plates as blocks and J-hooks as the top limit, two pairs of J-hooks, squat safety bars or J-hooks, whatever. This is very easy to set up and be successful with it. And then we like that it is easy to dose. We can see patients make progress from maybe 10 seconds on, 10 seconds off for a couple sets, to a full reverse Tabata, through a Tabata, and then maybe into somebody who is probably now ready to start deadlifting from at least the knee through a partial range of motion, if not from the floor, is somebody that can come up here, lift and hold for sets of 45 seconds. Five sets of 45 seconds really seems to be the sweet spot for the back to start feeling good, for the back to start feeling strong, and to now reintroduce full range of motion deadlifting, things like kettlebell swings, back into a person's exercise routine if they're already doing, or now, maybe for the first time, instruct that patient in the deadlift. So, the rack pull, easy to set up, easy to mess up too if you don't have a lot of attention to detail, but relatively easy to set up, load, dose, and prescribe as homework for our patients. So try that out. Thanks everybody, have a great Thursday.

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.

Dec 6, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Dustin Jones discusses the scary stats of sarcopenia: increased risk of falls, fractures, loss of independence and the list goes on and on. Dustin emphasizes that rehab providers have HUGE opportunity in this department but often leave so much on the table.

Listen in as Dustin shares some new research about Sarcopenia and it’s implications for our work.

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

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

EPISODE TRANSCRIPTION

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 h 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.

DUSTIN JONES
Alright Instagram, good morning, good morning YouTube. This is 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 leaving nothing on the table when it comes to sarcopenia. Leaving nothing on the table when it comes to sarcopenia. We're going to be covering some new literature that looked at the variations of intensity of different exercises with and its impact on sarcopenia and what that means for us as clinicians or fitness providers. Before we get into the goods, I do want to mention CERT-MMOA is rocking. CERT-MMOA is for those that complete our three MMOA courses, our online level one and level two. then our live courses. We have shut things down for the rest of this year but I want to let you know as soon as 2024 kicks off in January we are hitting the road hard. Both of our online courses are gonna be starting that second week of January and then we've got a few courses I want to mention that are gonna be absolutely awesome in that month of January. We got Santa Rosa, California January 13th, 14th. On the 20th, 21st we're gonna be in Greenville, South Carolina the 27th and the 28th we are going to be in Missouri. So we'd love to see y'all on the road.

SARCOPENIA
So let's talk about this, sarcopenia. So sarcopenia, for those that are not familiar, is age-related loss of muscle mass and strength. Sometimes now you are going to see the word function or physical function be thrown into that definition, but by and large, most of the time when you see this, it is age-related loss of muscle mass and strength. This is very important for every single person listening to this podcast because the vast majority of y'all are treating older adults in some way shape or form. But what we're seeing is that the term sarcopenia is starting to apply to individuals that may not have that older adult tag on them. Maybe those folks that are south of 65, maybe those folks that are in their 50s, sometimes even their 40s that are gonna qualify based on the criteria of sarcopenia. So this is a big issue and it impacts a large, broad audience. Just some stats, just so you are aware of how this could impact the folks that you're serving. 10 to 40% that's a wide range, but estimates are saying that 10 to 40% of community dwelling older adults have sarcopenia. All right. So 10 to 40% of folks, independent older adults that are walking amongst this, out in the community walking into your outpatient clinic would be categorized as having sarcopenia. And we would argue that that number is largely artificially low, that there may be even more. If you are a clinician that is working in a more acute setting out of the community, right, like acute care, home health, skilled nursing facility, this number goes up exponentially. So for you all, the vast majority of individuals, particularly older adults, would fall into that category of having sarcopenia based on the diagnostic criteria. So all to say, a lot of folks across the whole healthcare spectrum would fall under this category.

SARCOPENIA: WHAT'S THE BIG DEAL?
Now why is this a big deal? This is a big deal because if you have that label sarcopenia, you are at 60% increased risk of falling, If you fall, you're at an 84% increased risk of having an injurious fall or with a fracture. Those are big statistics, and we know the negative implications of those health outcomes. It is a big deal. It is an absolutely big deal, and it's important for us to understand how big of a deal this is, but then also to know what to do with it, all right? And this is where this new research, this new literature that was just published comes into play. There's a recent systematic review and a network meta-analysis that was published in the European Review of Aging and Physical Activity that looked at randomized controlled trials that use exercise in different intensities of exercise and how that impacted different outcome measures with folks that have sarcopenia. So they found that there were about 50 randomized controlled trials that totaled of about 4,000 participants. And all of these studies looked at the following outcomes. They looked at muscle mass, which we're usually measuring with something like a DEXA scan, right? Muscle strength tested by hand grip strength, chest press, and then a leg press on a machine. And then physical function, functional outcome measures, five times sit to stand, 30 seconds sit to stand, timed up and go, short physical performance battery, which is, you'll commonly hear us refer to it as the SPPB, the six minute walk test, and gait speed. All right, so these studies were measuring a lot of things that have huge implications for a lot of physical therapy and even fitness outcomes. All right, so all these studies were looking at those things. and they performed exercise at different intensities. So they performed exercise potentially at light intensity. This is categorized as at zero to four out of 10 on that modified Borg score where we're looking at relative intensity or RPE, rating of perceived exertion. that could also equate to under 49% of someone's one rep max. So typically what you saw in this meta-analysis is that the randomized control trials that were using that light intensity, they were often using aerobic-based training. So we're going to throw that in, kind of that light intensity category. Then we had moderate intensity. So this was that five to six out of 10 on that RPE. kind of 50 to 69% of a one rep max was considered to be moderate, and then vigorous, six to eight out of 10, and kind of that 60 to 80% of that one rep max. All right, keep in mind the updated ACSM recommended guidelines are calling, particularly for sarcopenia, are calling for 60 to 80% of someone's 1RM. They're calling for vigorous exercise, in particular resistance training for these individuals, all right? So they had those different intensities and they saw, all right, what's going to happen here with these folks that have sarcopenia? And the interesting thing to think about this is there's a lot of individuals, particularly when someone has sarcopenia on board, that the main focus is that, hey, this person may be relatively sedentary. They have low physical activity levels. Let's just get this person moving, right? Let's get them started in some type of physical activity. Let's bump up their overall physical activity. That's going to be a huge win. I would agree with that. Anytime that we move someone from being relatively sedentary or low physical activity levels and we can bump that up, we are going to see some positive benefits. We cannot deny that there's good in getting people to move more.

STOP STOPPING AT LIGHT INTENSITY
But what we need to acknowledge, especially after these results, is we cannot stop there. That is the first part of the journey to pushing people to more activity, but more intense activity. So what they found with this meta-analysis is the individuals that only received that light intensity, the only improvements that they saw across all those different outcome measures that I mentioned before was they did see some improvements in their hand grip strength. Awesome, that's great. That's a great correlation to lots of health outcomes, right? It's not a bad thing to have an improvement in hand grip strength. Great, that's awesome. There's a point for light intensity exercise. Now, moderate intensity exercise saw improvements in hand grip strength and important outcome measures like a 30 second sit to stand, a timed up and go, and leg press. Awesome. That's a few points for moderate intensity. We should probably be giving more preference to that than light intensity. And then the vigorous intensity crew saw improvements in all of those things previously mentioned that the light and moderate intensity experience, but they also saw improvement in muscle mass. They saw improvement in gait speed along with 30 seconds at the stand, five times at the stand, timed up and go, hand grip strength, leg press, chest press as well. They saw significant improvements across that broad spectrum of outcome measures that I talked about before. They get 10 points for those types of benefits, right? So if we're to rank them, the vigorous benefited tremendously much more than the moderate and the moderate benefited more than the light. So what this is basically telling us is that these folks that had that sarcopenia tag, which is based on, you know, a DEXA scan, but then also, you know, SPPB under 8 out of 12 or hand grip strength under 26 kilograms for males and under 16 for females. That's what we would typically look at, right?

SARCOPENIA NEEDS VIGOROUS INTENSITY
Folks that have that diagnosis that we need to be giving them vigorous intensity activities, particularly resistance training. If we do not give them vigorous exercise, we are leaving a lot on the table. Yeah, they're going to get better. They're going to improve on some of these outcome measures, but we leave so much potential benefit on the table that we're ultimately doing a person a disservice. So based on this research, I wanna focus on three main takeaways that we should walk away with after coming across some literature like this, all right? The first one, particularly for the ICE crew, you have such a unique opportunity that you spend so much time with these individuals, comparatively more time than any other healthcare provider, that you need to be well-equipped to screen and identify when sarcopenia is on board. We cover this extensively in MMOA level one and in our MMOA live course, but you need to be able to run an SPPB. You need to be able to run a hand grip strength. You need to be able to interpret those results and let that influence your course of care, particularly for the outpatient clinicians, because why do people come to you, right? What is a primary driver for your services? People are typically coming to you for pain, which you need to focus on, but that may not be the biggest issue. All right. So one we're screening, we're identifying number two, we are leveraging intentional under dosage. You've heard us talk about this podcast before. We've done whole episodes on this. So I'd encourage you to search that if you had, if this is a new term for you, but we need to leverage intentional under dosage because that is typically we're lowering the barrier of entry for individuals. So they're going to partake in particularly a new activity, right? For so many of these folks, they have not exercised before, they've not performed any intensity of resistance training. This is completely new territory for these individuals that we need to make it approachable. And so we may typically underdose initially.

SHORTEN YOUR UNDERDOSAGE
But in light of this evidence, that intentional underdosage period needs to be as short as possible. We don't have a lot of time here with these individuals and we need to make the most of our time. The quicker we can get to that vigorous intensity level so we get all those benefits that this meta-analysis discusses, the better, right? So that intentional under-dosage period needs to be as short as possible. That's a very vague thing, right? For some individuals, you may have their first visit where it may be intentionally under-dosed for their capacity. and then the next visit based on their response, their trust in you, their willingness to perform maybe a more challenging activity, that intentional under dosage period may be the span of one visit, right? But I know for me, particularly in home health, I've had intentional under dosage periods that have been well into the months. based on the person that I'm working with. Whatever it is, make it as short as possible. So we screen and identify, we leverage that intention on your dosage. And then number three, and I think this is something that we really need to grasp, is the clinical urgency in this situation. that if you continue with your light, with your moderate intensity exercise with these individuals, you're leaving a lot on the table. And ultimately, you are harming that person. You are robbing them from the potential benefits that we've seen in this meta-analysis, that they see the big improvements in the functional outcome measures, in their strength, in their muscle mass. These people have the capability to get those kinds of results. And if we waste our time and spend too much time in that intentional underdosage period where we're doing that sedentary, doing light to even moderate intensity activities, you are doing that person a disservice. You are doing that person a disservice. It is a dangerous situation that you're playing with. We need to have a sense of urgency when we're talking about sarcopenia. All right. I'm going to drop the link to this meta-analysis at Open Access. Really good read. It gives you a good idea of kind of the big body of literature around sarcopenia, but what they found in terms of these outcome measures. I'll drop that in the comments. If you have a tough time getting that link, just shoot me, DustinJones.dpt or the ICE account a direct message and we'll get that over to you. But this is a big conversation for many of you. You all are seeing tons of folks that would have that sarcopenia label put on them if they were properly screened and identified and you have a huge opportunity to give them that vigorous intensity, that amazing dose that is going to give them huge benefits across such a broad spectrum of outcome measures that have a huge implication for their quality of life. Alright, y'all have a lovely rest of your Wednesday. Go crush it. I'll talk to y'all soon.

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

Dec 5, 2023

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

In today's episode of the PT on ICE Daily Show, Spine Division leader Zac Morgan discusses recent research supporting the effectiveness of conservative care compared to invasive care, but in particular, the efficacy of chiropractic care compared to physical therapy care. Zac postulates that being hung up on the concept of spinal manipulation is often to blame for reduced PT outcomes when it comes to spine pain. He challenges listeners that the majority of patients are going to seek out & receive spinal manipulation for their pain, so the best course of action is to learn spinal manipulation, practice daily, and understand how to explain treatment to patients in a manner that does not facilitate dependence.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, 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 h 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.

ZAC MORGAN
All right, good morning PT on Ice Daily Show. I'm Zach Morgan. I'm lead faculty here with the cervical and lumbar spine management courses and lead that spine division as well. Wanted to bring forward some content this morning. So the title of this episode is the deck chair on the Titanic or deck chairs on the Titanic. But before we jump into the actual content and kind of unpack what we're, what I'm talking about with that metaphor, I wanted to start out by kind of pointing you all in the direction of the next courses that you can jump into from the spine management side. So we're wrapped up for the year, but if you're looking for next year, two options in the middle of the country for cervical spine on the weekend of February 3rd and 4th, we've got Wichita, Kansas, as well as Hazlet, Texas. So if you're in the middle of the country looking for cervical spine, those will be good options. At the end of that month, we'll be in Simi Valley, California on February 24th and 25th. If Lumbar is the one that you're looking for, there's one in January. So Rome, Georgia, 27th and 28th of January. And then March 9th and 10th, Cincinnati, Ohio. And then March 23rd and 24th over in Brookfield, Wisconsin or right outside of Milwaukee. So several offerings there to start the new year for cervical and lumbar. If you haven't looked into the ice ortho cert, do so. So we've, we've revamped our website and you can go on there and kind of look at what all is included. Um, but that cert is kicking off. We're testing people out on the weekends already and it's been a really good kind of, uh, initial rollout here. So if you're looking for an orthopedic cert, um, check out the new ice cert and let us know if you have any questions.

FIRST PROVIDER SEEN FOR ACUTE LOW BACK PAIN
I just wanted to kick off today by actually unpacking an article. This article was published in the PT Journal back in September. It came out of the University of Pittsburgh, so that's probably the crew that does the most looking into back pain, at least in our profession. University of Pittsburgh is pretty famous for a lot of their back pain research. Essentially, this article was titled, First Provider Seen for an Episode of Acute Low Back Pain Influences Subsequent Healthcare Utilization. So definitely a bit of a wordy title, but essentially looking at who do people present to first and how does that influence downstream medical costs. And this was from Christopher Baez and his colleagues over there. Anthony Delito was on this paper as well. So if you're familiar with Anthony Delito, he's definitely done a ton in the low back space as well. So really good university, really well done study here, published in our journal here just very recently. So very recent data that we're looking at here. And let me just kind of talk briefly through what they did with this article with the method standpoint, and then we'll talk about the outcomes. And then we'll unpack the metaphor and end with some action items this morning. So really what was done for this article was a retrospective analysis. So they looked back at cases of acute low back pain, meaning that the person had not been to any sort of a medical provider within the last three months for back pain. So they looked at acute cases of low back pain and they looked at where they presented and then those downstream medical costs and how those things were affected based off of where they presented first. So they were looking at chiropractic care, physical therapy, primary care physician, emergency department, and so on, and basically comparing the outcomes downstream depending on where the person went from one of those professions. As far as outcomes, what were they looking into? They were looking into things like episode length, future CT MRI use, how often did those patients wind up getting that advanced medical imaging, how often did they opt for things like injections or opioid prescriptions, specialist referral downstream, getting to a spine surgeon, those types of referrals. Actual surgery was one of the outcomes they looked at, and then just unplanned care. So they looked at all these variables, retrospectively after these people had presented to the health care system one way or the other to see if there was any difference in the variables over the following year after they had that first episode of acute low back pain. And two things really jumped out to me as I was reading this article. So there's two very obvious things to me.

CONSERVATIVE CARE OUTPERFORMS INVASIVE CARE
First, conservative care definitely outperforms more invasive care when it comes to the reduction of those expenditures. So physical therapy and chiropractic would be the ones we would lump into conservative and physical therapy and chiropractic significantly outperformed basically the emergency department primary care physician any of the other places that patients would have presented, which makes a lot of sense to us as the conservative care crowd. We know that a lot of times getting that patho-anatomic diagnosis is not helpful at all and often drives a lot more care. So if a person ends up getting that type of a diagnosis early on, often they're going to end up in the health care system for longer. as physical therapists and then even often as chiropractic work, we're more targeting symptom behavior versus anatomical diagnosis, so it makes a bit of sense that conservative care outperformed non-conservative care.

CHIROPRACTIC CARE OUTPERFORMS PHYSICAL THERAPY CARE
But the second thing that jumped out to me as I was reading through this paper is that chiropractic care significantly outperformed physical therapy. Basically, at pretty much everything other than use of radiographs, which is not overly surprising. Chiropractors have the ability to prescribe radiographs. But if you look at things like episode length, they got us by a couple days. If you look at CT, MRI use, injections, opioids, surgical referrals, actual surgery and unplanned care, The chiropractic profession outperformed the physical therapy profession within that conservative care chump pretty significantly. I'm not really trying to pin our professions against one another. What I'm more trying to point out is they pulled their weight. Whenever we look at this data set and we see essentially how this course of care went through for the patients, it's clear the chiropractors pulled their weight. Yes, we helped from the physical therapy side as well, especially compared to non-conservative care, but within conservative care, I would say we left them stranded a bit and didn't do as good of a job as they did. And so I couldn't help but start to think about why wow, we've really got to step it up as our profession. Like if we want to be in this conservative care battle, it's not enough for us to not contribute to that side of the fight. We have to step it up. We have to pull our weight in this fight. So let's talk a little bit about maybe some of the ideas as to why PT didn't do quite as well as chiropractic care in this study. Because they didn't postulate too much on that in the actual article, but I have some thoughts surrounding it. And so I just want to talk through those things a little bit.

WHY ARE WE SO AGAINST SPINAL MANIPULATION?
Let me just start by saying, team, every year since I've been a PT, even from school till now, things like spinal manipulation have always been super challenged within our profession. So it's very clear when you look at medical practice guidelines, when you look at our clinical practice guidelines, when you look at most of the clinical practice guidelines, especially for the management of acute low back pain, they have suggestions for spinal manipulation. But within our profession, what I've always witnessed is anytime we, as I put out posts about spinal manipulation, we get a decent amount of kickback from our own profession. we get all sorts of commentary on those posts suggesting potentially that it's not as safe as it should be or maybe it's going to create dependence or things of this nature and I think in our profession we argue about that a lot and it winds up plaguing us when it comes to the execution of those techniques or even feeling okay about using those techniques on patients and team This is something we have to get rid of if we're going to contribute our share to the fight with conservative care for the management of acute low back pain.

ARGUING AGAINST MANIPULATION IS LIKE ARGUING OVER DECK CHAIRS ON THE TITANIC
I don't remember when I first heard the metaphor about arguing over the deck chairs on the Titanic, but it really fits in my mind to this current conversation. It doesn't make any sense to argue over the deck chairs on the Titanic, right? But imagine that. Imagine the ship is sinking, it's dropping underwater, it's hit the iceberg, And you're up at the nose of that ship that's going to sink last, arguing about where the deck chairs go, which table they go out, how you want to orient those. That makes no sense, right? The ship is sinking. So I think in our profession, we tend to do this. We tend to argue over the deck chairs on the Titanic. Let me unpack that a little bit. What's the Titanic in this metaphor? The Titanic is that people are going to have their spines manipulated when they have acute pain. You can like that or not like that, but the fact is true that patients or just our communities seek that intervention out in relatively high volume when they have acute pain. That's happening. What are the deck chairs that we're arguing about as a profession? That's where these things like Will it create dependence? Does it work? Is it safe? These types of questions are arguing over the deck chairs. We know it's safe, right? Like that has become very clear. If you look through the literature, when spinal manipulation is done well, it's a very safe and effective technique, especially relative to other techniques that people might would choose or even other medications that people might would choose for the management of their acute pain. So we know it's safe. We know it works well for acute pain. We've got enough data to show that it works well. Also, I mean, I would say even empirically, just looking at how many people are driven towards that intervention, I think empirically we know it works. And then, does it create dependence? I think that comes a lot more from the narrative for how it is presented to the patient than it does from the actual technique. So I don't think it has to create dependence. And we sit here and argue over these types of variables. Meanwhile, people are going to have their back manipulated regardless of whether we come to some sort of a conclusion or not. And that conclusion doesn't really influence the end result of those people seeking out that intervention because they think it'll be helpful to absolve some of their pain scenario. So it's very clear to me that we need to start pulling our weight here. We're too busy arguing over meaningless variables.

START LENDING A HAND
What we actually need to do is lend a hand in this fight to our chiropractic colleagues who are doing a very good job managing things conservatively. It's time that we take some action here. So team, I wanted to end this podcast by talking about what that action might would look like as a profession and hope that over the coming years we can start to shift to the profession in this direction. I do feel the wave of that currently and it's really exciting to see that more and more therapists are starting to utilize interventions that their patients want to meet that patient expectation and help create a narrative surrounding it. But I wanted to leave you with just a few action points. So first things first, I think you have to learn how to thrust manipulate. I understand there's a lot of argument in this space, but if you aren't able to do the intervention, the patients will never hear these arguments. So if we leave them stranded, or even leave them to just seek out all sorts of other health care, when what they want is spinal manipulation and if you could provide that to them, you could then help them understand the mechanisms, those underlying mechanisms that might make them feel more robust about their body versus feeling weaker or feeling fragile. We want to learn to do it so that that way when patients need it, we can provide it and we can also provide a supportive narrative that creates independence, not dependence. And this is possible. And so I think we have to learn to manipulate, otherwise we have no fight. Nobody's going to listen to the data. They're going to need to see it empirically. And so I think for us, we've got to get them in and actually do these interventions with them. To get good at that, I think you have to practice daily. So first, learn to manipulate, then practice daily. So whether that's on your spouse, on a family friend, or practicing on patients that are in front of you with no contraindications and perhaps even some indications for doing those techniques, I think we should practice these techniques daily so that you can get good at the psychomotor skills. Once you've mastered them, of course, focus on other things. But if it's still a skill set that you're refining, I would do those speed drills that you pick up in classes. I would practice on your colleagues and friends and patients. And then lastly, I think we have to, while doing these techniques, support a better narrative surrounding why they work. We want our patients to feel more empowered by feeling better following thrust manipulation, not to feel dependent by feeling better. So I think changing that narrative requires the learning of techniques and ability to execute the techniques well. That way the patient is actually interested in what you have to say. If you can't do the technique and you tell the patient that the technique doesn't work, a lot of patients are going to leave feeling like, well of course they think that, they're not able to do it. So I really don't think we can win any sort of battle of decreasing the dependence on things like spinal thrust manipulation without being experts ourselves in doing it.

SUMMARY
So team, that is just kind of the overarching thoughts on that article. It just jumped out to me that It was really nice to see the conservative care on the whole did really, really well. But I was just disappointed because I feel like I would love to carry more of the load alongside of our chiropractic colleagues and not leave them out there to fight this battle on their own. And I think a decent amount of professional infighting creates challenges surrounding actually learning these techniques and then utilizing them on patients. And I think we have to stop the professional infighting. We have to stop arguing over the deck chairs on the Titanic and just accept the fact that the ship is sinking. And it doesn't matter the orientation of those chairs. We have got to quit arguing over these factors and we've got to get to where we can actually do these techniques to people that are in pain so that we can help the chiropractic profession start to reduce a lot of those long-term costs that get associated with also not just costs but worse outcomes for the humans in front of us. You can criticize it all you want, but at the end of the day, what we're trying to avoid are things like opioids, things like injections, things like advanced medical imaging. These things, not just within 12 months, create a lot of expenditure and a lot of disability, but within the rest of that person's life, they do the same thing. So that's all I've got for you this morning, team. Let's tackle this problem together. Let's get out of the way. As far as the profession is concerned, stop arguing over little things and start to add these valuable interventions to our patients with acute pain. Hit me up if you have any questions, comments, or concerns in the thread here. I'll be checking it all day. Happy to further the conversation. But that's all I've got for you this morning. Take it easy and have a good Tuesday, 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.

Dec 4, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick as she wraps up her series on postpartum depression. In this episode, she will focus on first line of defense treatment for PPD including including medication, psychotherapy and exercise. As well as how to support someone with PPD as a friend or healthcare provider. She concludes with some important resources for emotional and mental health support that are free and extremely helpful to share with someone who is postpartum.

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

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

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

EPISODE TRANSCRIPTION

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.

APRIL DOMINICK
Hello and welcome PT on ICE. My name is April Dominick. I am part of the faculty for the ICE pelvic division. And today's topic is all things treatment support strategies and helpful resources for postpartum depression. This is the final episode in my three part series on postpartum depression. So I am excited to dive in. But first I wanted to remind everyone of our array of course offerings in our pelvic division. Our first few live courses of 2024 are in Raleigh, North Carolina. That's going to be January 13th and 14th. And then Hendersonville, Tennessee, January 27th and 28th. And let's not forget about our not one, but two online eight-week course offerings. The level one cohort is going to start January 9th, while our brand new level two advanced concepts course will take place April 30th. If you've got someone asking you for some gift ideas or asking you to let them get you a birthday present, if you have a winner birthday, then have them help you out with some courses for ICE. That would be such a great gift of learning. And you can head over to ptonice.com to secure your seat in one or all three of those offerings, which is what is needed for our brand new ice pelvic certification.

TREATING POSTPARTUM DEPRESSION
All right, let's dive in today to the treatment section of postpartum depression. So one of the most common ways to treat postpartum depression is with antidepressants and psychotherapy. For those who are lactating, the conversation may include discussing the benefits of breastfeeding and known risks of antidepressant use during lactation. A lot of folks have concerns with the side effects that can occur when starting antidepressants. These concerns are totally valid and really excellent questions to bring up with their physician. For some, not being on the medication and leaving symptoms left untreated from a medical management standpoint could be just as risky in terms of their mental health and emotional health as well. For those who are concerned about the interactions that breastfeeding would have with antidepressants, or for those who would not prefer to take antidepressants, Psychotherapy is actually the first line of treatment. When looking for a mental health provider, we want to remind our clients, if possible, you want to find one that lists some sort of training in or special specialization of perinatal health as they will be really well-versed in the unique challenges that a postpartum individual faces. 

EXERCISE AS A FIRST LINE TREATMENT
Now, Let's talk about a treatment that is within our PT scope of practice, and that's going to be exercise. So exercise is a great alternative or supplement to treating postpartum depression. Now, as a postpartum person, finding time to exercise while caring for a newborn, as well as taking care of the rest of life's demands, including chores or a job, That can be incredibly difficult and is a huge barrier for many to either return to or begin exercise in the postpartum period. When I was searching on the American College of Obstetrician and Gynecologist website, just seeing what all they have in terms of resources and recommendations, they didn't really have exercise as readily mentioned on their main pages when they were discussing how to address postpartum depression symptoms. And rather, they had like the medication and the mental health therapy, which was the greater focus, which is wild given that it Exercise is an excellent treatment offering that's conservative, it's generally accessible, and non-pharmacological. Not to mention, some of the forms of exercise can be cost-effective. And this may be a gap that we as rehab providers can remind our physician colleagues on the latest research that we know about of the effects of exercise and depression. and reminding them that, hey, we're those musculoskeletal experts in your community, and we are willing and able to help guide their clients in starting or continuing exercise, as we know, improving the postpartum individual's physical well-being and directly supports their mental health and well-being.

THE EFFECTS OF EXERCISE ON DEPRESSION
So what do we know about the effects of exercise in general on depression? Exercise helps to increase levels of endogenous endorphins and opioids, all of which have positive effects on mental health. And the team from Singh et al published a paper in 2023 on an overview of systematic reviews on physical activity for improving depression. they found that physical activity had medium effects on depression compared to usual care. So specifically, they suggested that aerobic resistance and yoga exercise was the most beneficial and exercise with higher intensity was associated with greater improvements. And then there was another study that was published in September of 2023, and this one was by Zhao et al. And they aimed to determine the association between seven lifestyle factors and lots of other body functions to see what their impact was on depression. They studied data from 290,000 individuals across nine years, with about 13% of those individuals developing depression. We love that length of time for data collection. Some of the seven healthy lifestyle factors that they found were associated with a lower risk of depression were healthy sleep, about seven to nine hours, that reduced the risk of depression by 22%. Frequent social connection that reduced the risk of depression by 18%. it was the frequent social connection was the most protective against recurrent depressive disorder. And then the other two of the seven healthy lifestyle factors was regular physical activity that reduced depression risk by 14% and then low to moderate sedentary behavior. When it comes to our postpartum population, we have to recognize that seven to nine hours of sleep is extremely unrealistic for most, but we can offer suggestions for improving the quality of that sleep, curating the best environment with maybe the control of limited noise. Can we make the room colder when we are going down for two to three hours, start to nap, uh, darker, uh, light or like less light and then cooler temperatures. Um, So those were some of the studies that looked at the effects of exercise and lifestyle behaviors on depression overall. What about the role of exercise in prevention and treatment of the postpartum population with depression? A little more niche. When it comes to aerobic exercise, there was a qualitative systematic review from 2023 by Xu et al. And it actually just came out last week. And it was studying the efficacy of aerobic exercise in preventing and treating postpartum depression. They found that compared to standard care, aerobic exercise, particularly 30 to 45 minutes of moderate intensity, three to four sessions a week, had a significant effect in treating postpartum depression with a greater emphasis on prevention. Many of the studies we have on exercise effects on postpartum depression, look at aerobic exercise. But what about resistance training? So in a study by Le Chemin et al. from 2019, the group examined the influence of resistance training in women during postpartum depression. They found that compared to a stretch-based program, those who engaged in resistance training reported a significant decrease in their depressive symptoms four months postpartum. compared to when they measured immediately postpartum. We also have data from our very own ICE faculty, Dr. Christina Prevett, who did a study that looked at the impact of heavy resistance training on pregnancy and postpartum health outcomes. And compared to the national averages, those who lifted heavy showed lower rates of perinatal mood disorders as well. So there's quite a bit of heterogeneity in the method sections of these studies that these systematic reviews are looking at when it comes to exercise and depression. This makes it difficult to specify any sort of intensity or specific type of exercise or timing frequency domain for what is best practice, what is most effective for using exercise to help with reducing depression. The SHU article was one of the first that I had run across giving a specific time and frequency domain for exercise in the postpartum depression period. It would be interesting if researchers could look at the effects of exercise alone, as many of the studies look at the combination of the treatment of psychotherapy, medication, and exercise. I'd also be curious about, hey, does it matter the specific time that someone returns to exercise postpartum. As in, is it most effective if someone returns to movement within two weeks, four weeks, six weeks? What makes the most difference? So while we're waiting for more dialed-in research in the clinic, If you're going to create a program or suggest a rehab EMOM for someone with postpartum depression, make sure that you're including a mix of aerobic exercise, resistance training, and mobility, as well as some sort of reconnecting with their breath and body, just to help tap into that downregulation of the nervous system and hit those preliminary time guidelines from Shu et al. of 30 to 45 minutes, three to four sessions a week. So to sum up treatment, while there are multiple options to address postpartum depression currently, our first treatment approach is usually a combination of the treatments of antidepressants, psychotherapy, and exercise. So that was treatment.

SUPPORTING PATIENTS WITH POSTPARTUM DEPRESSION
Now I want to talk about how do you support someone who has postpartum depression as a rehab provider or a friend. Overall, validation, education, and reassurance and psychosocial support go a long way in helping someone experiencing postpartum depression. Making the new mom feel taken care of. Everyone has shifted focus to the baby, so how about asking how the mother is doing, checking in with their needs or whoever the postpartum person is. So there are so many ways to support a new parent and these are just going to be a few suggestions for how providers or friends and family can support that person. As a friend and provider, highlighting and celebrating the wins is key. Small, big. How they have made a huge impact on caring for their child and supporting their family. How their baby needs them, the postpartum person, to be consoled and that that person is able to console the baby and how they are learning what their baby needs are and recognizing the needs for comfort, for food, for diaper changes. As a friend, if you're looking for a way to help them that may not have as high a financial ticket as some other ways that folks can help, offering to drive the postpartum person to their appointments or to sit in the stay with a baby so they can get out of the house or get in some exercise without being interrupted by the baby waking up. Or as a friend, offering to help them with some chores. Bonus, you'd get some quality time together. And then another option as a friend is just communication. A simple message can make someone's day offering consistent check-ins, text messages, phone calls, FaceTime, snail mails. You can share something funny about what you just experienced or maybe you just thought of them and wanted to share that with them. As a provider, brainstorming with the postpartum person, how they can ask for help from their support system and help offload their mental and physical demands. Um, maybe they could create a meal train or ask, um, friends to set up a grocery delivery or, uh, ask for some gift cards to a favorite restaurant or self care services like physical therapy, um, a massage, a facial or a haircut or a babysitter. Obviously those come with a little bit higher price tag, but just options to, um, suggest for the, uh, postpartum person to tap into their support network. And then as a provider, reviewing and sharing some resources with the client that are particular to postpartum depression, such as phone support lines, community groups, or even providing them with some postpartum depression related pamphlets so that if it's a hard conversation that they don't want to have, then they could read it on their own time.

RESOURCES FOR POSTPARTUM DEPRESSION
So I'll go over some resources now and put them in the caption for you to reference. That is my cat. She is joining and also wants to hear the resources. So the first one is the Postpartum Support International website. It is one of the best resources overall that I've encountered. It is good in that it is going to be helpful for connecting folks with local resources in their region, offering emotional support during pregnancy and postpartum. with online support groups and they also have live phone sessions every Wednesday and I think they're capped at about 15 to 20 people. They also have perinatal trained medication providers or therapists or community groups and tons of blogs with others sharing their stories and so Folks can also use the Postpartum Support International's directory of trained perinatal mental health providers on folks who are specialized in postpartum anxiety, postpartum depression, and they have a director specifically for those humans, which I think is awesome. The next resource is the National Maternal Mental Health Hotline. They provide free conventional support confidential support resources and referrals from professional counselors to help pregnant and postpartum individuals facing mental health challenges. And this is also available 24-7. They also have interpreter services that are available in multiple language, which is huge. The third resource is the 988 Suicide and Crisis Lifeline. It provides free and confidential emotional support to help people in suicidal crisis or emotional distress. This is also available 24-7 and individuals can call, they can chat, or look up all the different educational information on their website. The fourth resource is the Postpartum Progress website. It is just chock full of information on the postpartum period in general, with a big section on postpartum depression, They have a provider list, including a black mental health provider list. And, uh, one of their extras was a Spotify playlist, uh, called warrior moms, which I love the strength and energy behind that. And then finally another, um, uh, resource, which is on the ACOG website. Uh, it is an infographic on anxiety and they do a beautiful job of, um, pretty much going through all of my, uh, podcast series, but for anxiety. about the prevalence, what is postpartum anxiety, and what are some treatment methods, what are some resources, just kind of sharing information because it's helpful to know that other folks are going through the same thing and that there's help out there. This pamphlet is a great idea to put up in the clinic, put up in bathroom stalls, maybe even have on your clinic website, but making one for postpartum depression. So we as PTs, we are perfectly positioned to help break the silence of folks with postpartum depression who may also be unaware that they're even dealing with this condition. We can make a difference in these clients' lives. Combined with educating ourselves, we need to be educating the birthing individuals, their support system on what postpartum depression looks like and ways to prevent it. then actually informing the individual on a number of treatment strategies available to them, including the combination of medication that is right for them, psychosocial mental health therapies, or alternative therapies like aerobic or resistance training exercise, whichever of those treatment strategies makes sense to them. And of course, speaking with their medical provider for the medication and psychotherapy piece. Oftentimes finding the right care support and gradually adding in movement, physical movement, aiming for good quality sleep, which is so tricky with this population and addressing nutrition can be huge steps in treatment of postpartum depression. But there's so much more. The essential pieces are asking someone about their current ecosystem in their postpartum world, allowing them space to share the tough things and knowing when to refer out for postpartum depression. as well as encouraging them different ways that they can lean on their support system or offering them the free resources such as the support groups or hotlines I talked about. And those are available in the caption. So treatment for postpartum depression, remember it's not a one size fits all. And individual specific situations, their preferences, they all have to be taken into account. If you miss the other two episodes in this series that go over the prevalence, risk factors, how to screen and what to say to someone who you suspect has postpartum depression, check out episode number 1553 and number 1572 to learn more. And thank you so much for your time and attention today. And I hope you find some brightness in your day. And as a bonus, if you have anyone who is recently postpartum, send them a warm message and let them know that you are thinking about them. Take care, everyone.

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.

Dec 1, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses one of the most effective and efficient ways to improve VO2max/fitness/endurance/conditioning both in the gym as well as in the clinic for your fitness athletes (and all clients).

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

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

EPISODE TRANSCRIPTION

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 h 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.

GUILLERMO CONTRERAS
Okay, live on YouTube and live on Instagram. Good morning, everybody. Welcome to the PTI Daily Show. My name is Guillermo Contreras. Happy to be here with you on the best day of the week, Fitness Athlete Friday, talking all things fitness athlete and improving overall fitness in the individuals that we work with on a daily basis, in our clinics, in our gym settings, et cetera. Before we dive into the topic at hand, Let's go ahead and talk a little bit about the fitness athlete courses coming to your area as well as online. Fitness Athlete Live is going to be on the road over the next three months, quite a bit. Next weekend, we're going to be in Colorado Springs, Colorado, the weekend of December 9th and 10th. The weekend, and that's it for 2023, right? But 2024, we jump in right back onto the road. January 27th and 28th, we're going to be in Portland, Oregon. February 10th and 11th, Richmond, Virginia. And then February 24th and 25th, we will be in Charlotte, North Carolina. So plenty of options, whether you're in the mountains on the West Coast or on the East Coast, we're going to be traveling throughout those areas in the next three months or so. So feel free to check out the website, ptinex.com to find out how you can sign up for those. As a reminder, courses in price at the end of this year. So if any of these courses look like something you can get to, you want to get to, you can travel to, you're going to make a plan to get to. Snatch that course up now because right now courses are $650 and they're going to be bumped up to $695 in 2024. So take advantage of the lower price now. Get yourself signed up for those courses and then find a way to get to these courses but just check those out on the website for where those are going to be. And then fitness athlete level one online. The next cohort is going to start up on January 29th. Currently in the middle of a cohort right now. Started finishing up week four right now. So four more weeks there, a little short break, and then we kick back up on January 29th. And then fitness athlete level two, or what is formerly known as advanced concepts, that kicks off on February 4th. Those courses always sell out. We rarely have anyone that wants to get into it that can't get into it after they sell out. So if it's something you've been looking to do, if you're looking to become certified in clinical management fitness athlete through that certification process, then you need to be able to take a one, take the L2, take the live course. And again, that L2 only comes twice a year. So if it's been on your bucket list, something you want to take, sign up now sooner rather than later, because as I mentioned, those courses, All right. Um, so that is the introduction there. That is what we have on the docket. Um, as I mentioned, again, my name is Guillermo Contreras. I'm a physical therapist, uh, over here in Milwaukee, Wisconsin, and a part of the fitness athlete team here with the Institute of Clinical Excellence.

THE ASSAULT BIKE FOR VO2MAX DEVELOPMENT
The topic today, uh, the title, uh, is VO2 assault or assault on your VO2. I don't know why I wasn't too creative today, but there's there's a reason we're talking about it is The assault bike or the echo bike or like any air bike right we're talking about like this this beast This beautiful thing we have back here the assault bike I have here in my office Is one of the best tools that we can use to work with individuals in the clinic out of the clinic in the gym trying to improve overall cardiovascular conditioning, fitness, metabolic stress, like all these different factors that we can improve upon using a simple piece of machinery. This piece of machinery costs anywhere between $700 for the Assault bike, the standard or the original, I believe is what it's called, up to $840, $850 for the Echo bike, which you can get through Rogue, the Rogue Echo bike. It can go as low as, if you're really just kind of want to pinch pennies there, a couple hundred dollars, maybe $100, $150, or a Schwinn Airdyne. And those Schwinn Airdyne bikes, right, those are, like we used to have one of those from like the 90s that still worked like it was new. They last forever. they work forever, easy maintenance if you just take care of the chain with the rope echo bike a little more expensive because it's belt driven and again that lasts forever very little maintenance so they're just really really nice pieces of equipment to have. The weight limit then on them is around 300 for the soft bike 330 pounds for the echo bike and probably sure a little bit less for just your standard twin airdyne but they make like the airdyne pro that i'm sure has a 300 pound weight limit as well. last and survive through the apocalypse. That's how good these things are. Not only that, but in the clinic space, they are fantastic for working three limb conditioning. If you have any a knee injury, a hip injury, something that does not allow them to do something like running or standard biking or skiing or rowing, right? They have a limb that they cannot use. You can rest that limb and work the other three in a very effective way that increases conditioning overall. And the reason I'm saying all this, and the reason I'm touting up the Assault Bike, the Echo Bike, right, is because there is no reason that we should not have a piece of equipment like this within our clinics. And if we have something like this, there's no excuse for us not using it with our patients. Especially if you work with an athletic population. When you look at the NFL right now, how many people are getting injured? How many injuries are you seeing on a weekly basis? You've seen an excessive amount of Achilles tears, knee injuries, high ankle sprains, all those things. And one of the biggest things you hear when an athlete comes off of what they call the injured reserve is that, are they in game shape? Like they have the strength back, they have their motion back, they can handle the stress on whatever was injured, but are they truly in game shape? Do they have the ability to withstand rep after rep after rep on the field? And honestly, when it comes to conditioning, there is no better device. in a more efficient way than this behemoth, this beast right here, this monster, this thing we love to hate in the fitness athlete realm, in the CrossFit sphere, and in pretty much anywhere you see this bike.

EFFICIENT RESULTS WITH THE ASSAULT BIKE
This is proven in a wonderful study where it took 32 individuals and it put them in three different groups. The control group was given moderate intensity cardiovascular training. 30 minutes of 75% heart rate max, cardiovascular cycling, 30 minutes rate of 70, 75% of heart rate max. Group number two was given what we know as a Tabata or a half Tabata. They had to do 10 seconds sprints, five seconds of rest for eight sets. They then rested for two and a half minutes and repeated that whole cycle three total times. Group number three was given a standard Tabata, three sets, of eight repetitions of 20 seconds of work at 10 seconds rest. That is your standard Tabata 20 on 10 off eight rounds. They had to do that three sets with a five minute rest between each uh three set round you call it there or each eight set round I'm sorry eight round set. All in all the modern intensity cardiovascular training group did around three The 10-on-5-off group did around 72 minutes of work per week, so around an hour, a little over an hour. And the standard Tavada group, that three, or the eight rounds of 20-on-10-off, did around 144 minutes of work, or just over two and a half hours, sorry, around two and a half hours of work per week. What they found at the end of the study was that there was no significant difference in improvement across all three of them. All three showed improved time to fatigue, improved VO2 max, improved conditioning, and improved ability to create force, improved MET, M-E-T-S, M-E-T-S. But the big picture here, gang, right? Like what we see there is like, okay, like that means we can pick any of those and get someone more cardiovascularly fit. Yes, that is true. You can kind of pick your poison whichever way you want to do it. What we're talking about here is that the short group, the 10 on, five off, 72 minutes of work per week, one hour of work per week, that group was 250% more efficient in the use of their time to improve their cardiovascular fitness, to improve their conditioning, to improve their power output, to improve their time to fatigue than the other two groups that doubled and six times the amount of work. And how we can apply that is like when we're looking at individuals in the clinic, we probably don't have six hours of week to add to their program, to their plan of care, to get their conditioning up. They might not have six hours additional per week to jump on a bike and do 30 minutes of work three times a week as well. And if we want to get someone more conditioning, better shape, better heart health, improve health markers, blood markers, all those things, while also improving pain, reducing pain, improving function, increase in range of motion, whatever our plan is or whatever our goals are for them in the clinic, this device, the AssaultBike, the EchoBike, a nice quality Schwinn Airdyne bike, that is the way we can do it in a very effective, efficient manner. If you can do the same If you can have the same results in less time, people are going to buy in. If you can show somebody, hey, we're just going to do 8 sets of 10 on, 5 off before we start the session. I'm going to jack your heart rate up. I'm going to get your blood flowing. We're going to not only improve your overall cardiovascular fitness, we're not just going to improve your overall health markers. We're not going to just improve your conditioning, which again, if you're looking at working with athletes, whether it be in professional sports, amateur sports, high school sports, whatever it is, you need to build up their conditioning space or their conditioning ability.

SHORTS BOUTS; GREAT RESULTS
But across all populations, we can all benefit from this. We can all benefit from having better heart abilities, better cardiovascular fitness, better VO2 mass to be able to stand and do things for longer with less fatigue. So by using this device, using short sprint intervals, things like you see behind me, things like 10 on, five off, or eight rounds, three sets, two and a half minutes rest, or simply one set, one set of eight repetitions of 10 on, five off, right? We can have these small things that can affect individuals. It's also something they can easily do for a home program. if conditioning is an aspect they need to work on. If we're trying to get their VO2 max up, we can give them, hey, I want you to jump on the assault bike, jump on the echo bike. I want you to do 10 rounds. Just go as hard as you can. Rest five seconds. Do that eight times. Do that a few times a week. When you're looking at individuals who have Achilles tears, knee injuries, something where they cannot use that limb or it's uncomfortable to use that limb, they can still get after it with three limbs. They can use left leg and both arms and get after it on a soft bike. Again, effort is what matters here. Intensity is what matters. And when we're talking about working with individuals, trying to give them the most effective, efficient way to get better, get stronger, get healthier, and we're thinking of a fitness-forward approach to everything we do, this device, these tools, these strategies, these techniques, in doing that. and nauseam about getting people fit or getting people strong, using intensity as the way to do that. And if you're curious how it works and if it works for you, simply get on an assault bike, get on an airdyne bike, push yourself hard for 10 seconds, work a five seconds rest, repeat, rinse and repeat for eight rounds and see how you feel after that. See how the improvement comes upon there. Hope to see you on the road, gang. Hope to see you online. Thank you for tuning in. Have a wonderful weekend and we'll see you next time on the PT on ICE Daily Show.

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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