Info

The #PTonICE Daily Show

The faculty of the Institute of Clinical Excellence deliver their specialized content every weekday morning. Topic areas include: Population health, fitness athlete management, evidence based spine and extremity care, older adults, community outreach, self development, and much more! Learn more about our team at www.PTonICE.com
RSS Feed
The #PTonICE Daily Show
2024
June
May
April
March
February
January


2023
December
November
October
September
August
July
June
May
April
March
February
January


2022
December
November
October
September
August
July
June
May
April
March
February
January


2021
December
November
October
September
August
July
June
May
April
March
February
January


2020
December
November
October
September
August
July
June
May
April
March
February
January


2019
December
November
October
September
August
July
June
May
April
March
February
January


2018
December
November
October
September
August
July
June
May
April
March
February
January


2017
December
November
October
September
August
July
June
May
March
February


2016
December
November
October
September
August
July
May
April
March
February


All Episodes
Archives
Now displaying: 2023
Nov 23, 2023

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Officer Alan Fredendall discusses the "golden triangle" or the foundation of personal & professional success where time, money, and autonomy overlap. Alan shares research supporting a direct relationship between money earned & happiness, as well as the importance of respecting time & autonomy in the workforce.

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.

ALAN FREDENDALL
Team, good morning. Welcome to the PT on ICE Daily Show. Happy Thanksgiving. We hope your Thursday morning is off to a fantastic start. We're here on Thursday, Leadership Thursday, talking all things small business management, practice ownership, that sort of thing. Thursday, Thanksgiving Thursday, still means it is Gut Check Thursday. This week's Gut Check Thursday is a little bit of a tradition around here at ICE. We are gonna do a hero workout called Burp. This is a very long bodyweight workout. Starts with 50 burpees, a 400-meter run, 100 pushups, a 400-meter run, 150 walking lunges, a 400-meter run, 200 air squats, a 400-meter run, and then now we're going to come back down that pyramid. 150 walking lunges, 400-meter run, 100 pushups, 400-meter run, and then finally finishing with 50 burpees. So, very long workout. This is gonna take most human beings about an hour to finish. Obviously, you can tell a lot of redundancy in there with the running, the lunges, the air squats, and then the burpees and the pushups. So, if you do not have an hour today to work out, scale this. Cut all the gymnastics reps in half. Maybe cut the runs down. If you know you're a better biker than a runner or something like that, sub out a rower or a bike for the run. Obviously, the more you reduce the volume, the less time it's going to take. This workout is not for the faint of heart. This is going to make your upper body and lower body sore between all the lunges, squats, pushups, and burpees. But it is challenging. We love how simple it is. You don't really need to warm up or really have any sort of particular skill or range of motion to do this workout. So that's why we love Burp. Courses coming your way, I don't want to bother you with those today. Check out p10ice.com, click the Our Courses tab, and see what's coming your way. We do have a couple more weekends of live courses starting back up again next weekend before we take our final holiday break over Christmas and New Year's. So check out ptonice.com and click on our courses if you're interested in jumping into a live course before the end of the year.

THE GOLDEN TRIANGLE
Today I want to talk about a concept that I call the golden triangle. Talking about when folks reach out and they describe maybe an employment situation that they are not happy with. This is kind of how I evaluate what I think of the three pillars to success when you are not only working for someone else but just working in general. Even if you are self-employed, even if you do run your own business, carefully managing the three sides of this triangle, I believe is really important for your own personal and professional success, but also for those of you leading others in charge of others, I think even more important to fundamentally understand these concepts. So those three concepts are money, time, and autonomy, and we're gonna break each of those down here in a little bit. I want to start here though first, and this may be a weird place to start, but I promise we'll bring it back around again. I want to talk about what is the role of the human brain. A lot of us may think the human brain is for high-level computations and calculating the physics of a black hole, but that's not how most people's brains work. That's how very few amount of people's brains work, but for most of us, Our brain is a survival mechanism. It is a comparative analysis engine. And it's really good at making comparisons. Your brain is making one billion billion calculations per second. That's a one with 18 zeros. That is a million times faster than today's standard cell phone laptop or desktop computer. We call that an exaflop. It is the most powerful processor on the planet. It is always gathering data, both internally and externally, and making comparisons. Am I hot? Am I cold? Am I hungry? Am I thirsty? Am I not making enough money? Is my coworker making more money than me? Is my boss doing better than me because I noticed that he just bought a speedboat? Those sorts of things. Yes, very basic survival mechanisms, but also higher-level stuff. And that kind of brings up the next point of Maslow's hierarchy of needs. If our brain is this comparative analysis engine, what is it really focusing on? Well, psychologists would say it's focusing on comparing ourselves on this pyramid, this hierarchy of needs, where at the base we have our physiological needs. Am I hungry? Am I thirsty? Am I tired? The next level up is safety and security. Do I have a safe place to rest and sleep at night? Do I have a place maybe that in my mind when I compare to others I call my home? The next level up, the third level, love and belonging. Do I have friends? Do I have a family? Am I raising children? Not only do I have them, but do I feel like I'm thriving in those relationships? And now as we get to the top of that pyramid and we approach that peak, the fourth level is esteem and the last level is actual actualization, self-actualization. So do I feel like I am doing something meaningful, and do I feel like I'm doing something meaningful very well basically You know what is my life's work, and how am I doing at that? And now the brain is always comparing both to environmental factors and to other human beings where we sit on that hierarchy. Trying to chase the top tiers before addressing the bottom, I think is the cause of a lot of dissatisfaction in our daily lives. So shelving that for a little bit, the brain is a comparative analysis engine and hierarchy of needs. Let's get back and talk about the golden triangle.

MONEY
The first I want to address is money. Money is uncomfortable for some people to talk about. It's often a pain point for almost every single one of us. I think really understanding that about three-fourths of people live paycheck to paycheck and about half of all people now work two or more jobs. really helps us understand that we're not alone in being concerned about money. Most people are concerned about money, but also that it's okay to be concerned about money, right? That kind of sits at the base of that pyramid of those physiological needs, that safety and security. We do need money in modern society to do things like buy food and pay the rent on our apartment or the mortgage on our house. There's often an adage of don't focus too much on money because money can't buy everything or money can't buy happiness. And I would refute that. I would say that that is categorically untrue. We have some really interesting research from the 90s and 2000s that found money and happiness do correlate. There seems to be a plateau, at least in the earlier research, of around $100,000. Research from the 90s and early 2000s found that if you make about $100,000 a year, The more money you make. beyond that doesn't really seem to increase your happiness. Now, the thing to recognize is that if you're not making that, there is room for happiness between that and $100,000. New research, specifically from this year, an article from Killingsworth, I love that name, Dr. Killingsworth and colleagues, this year, March 2023, from the Journal of Psychological and Cognitive Sciences, titled, Income and Emotional Wellbeing, a Conflict Resolved. Strong title, I like it, let's talk about it. These folks repeated the studies, some of it their own research from the 90s and 2000s, and they're looking specifically at the relationship between income level and happiness. What they found this time is interesting that folks tend to fall into categorization buckets. Hey, we know all about that in physical therapy, right? What are these buckets? Well, human beings tend to fall into three different buckets. The first bucket is what they labeled as the least happy group. These were folks who kind of demonstrated the same results as the initial studies, where these folks seem to have a happiness plateau at about $100,000. What does that tell us? That tells us this group of people is probably motivated enough by money that once those initial levels of the pyramid are met, they're able to feed themselves every day. They're no longer worried about their next meal or making the rent or paying their bills. Beyond that, they don't seem to get any more happiness from an increased amount of income, right? So this could be somebody who, I imagine these people is the folks from the documentaries that have to you know free climb El Capitan or summon a mountain or something of that's really what drives their brain and kind of their intrinsic motivation and having enough money to do that stuff gets them to the level of happiness where they can pursue other things. The next group of people they labeled, the researchers labeled the medium happy group. These folks had a linear increase even beyond $100,000 a year with happiness and income. And then the highest happiness group had an exponential increase with income beyond $100,000. They could not seem to get enough money. Money on the opposite side of the least happy group, these folks seemed to be almost entirely intrinsically motivated by accumulating wealth, right? So these are our oil barons and our real estate moguls, our Warren Buffets maybe, folks who have a high value on money and its worth in their life. And then most of us are probably in that medium happy group. As we continue to make more money, we're able to buy nicer things, but it doesn't necessarily define us, but we do like to have that money. All that being said, there is a direct relationship between money and happiness. It's really important we recognize that paying people well, of feeling like the work that you do is rewarded with the amount of money that you place value on, is recognized both yourself personally, but also when you're leading others. What I found over my career Keep in mind, I've been working full time since I was 12 years old for about 25 years, is that the folks who tell you there isn't money for a raise, there isn't money for bonuses, or even that they maybe need to take money away from you, are telling you that because they don't want to give you more of the company's money, right? There is always more money, especially in the context of physical therapy, for an increase in your wages. We all have what we would refer to as a revenue-neutral position, which means the revenue you generate from the work you do is creating more wealth than what you are taking back from the company. I can't imagine a situation where a physical therapist would be getting paid more than what the clinic is collecting in revenue for those patients being seen. So it's really tough to talk about. I recognize that it can be awkward. It can be weird. It can be upsetting to personal and professional relationships, but I promise you when you draw a firmer line than the sand around what you're paid, when your comparative analysis engine is telling you, you're not being rewarded for the time you're putting in. That can be a pain point for dissatisfaction and the research would support that you are not wrong in believing that the money you're currently being paid and the money you think you would like to be paid is creating a happiness gap. It literally is, right? Killing's worth 2023. Messing with people's money on the leadership side is a recipe for disaster. It is never okay to cut someone's pay, to inflict some sort of monetary penalty aside from something catastrophic, right? Dave accidentally drove his car into the clinic and destroyed the clinic. Okay, Dave, you got to pay for that, right, man? But aside from really rare, unbelievable, catastrophic stuff like that. There's no reason to inflict a monetary penalty on someone or to take their benefits away. An example I have of this is my time in the army where if you messed up, if you were late to duty, If you didn't shave, you could be punished monetarily for that, right? It was called in Article 15, it is non-judicial punishment. That means usually you have to work extra duty and it usually means that they cut your pay that month. And that really puts a strain on people, especially in the context of the military where they're not already making a lot of money. And I fondly remember watching people have half their paycheck, all their paycheck taken away, and just instantly how it ruined that person, it ruined their career trajectory. So without a doubt, as a leader, that's something you do not want to mess with. We saw that mess with a lot during COVID-19. We saw pay being cut, and we saw benefits being removed, and then not returned. And it's no surprise that now, several years removed, we have the era of time that we now live in, what we call the Great Resignation, where folks are more than happy to say, give me a raise or I'm leaving, and they will literally leave, right? And for us as practice managers and owners, that's devastating. Attrition is one of the highest costs you can encounter, and you need to avoid it at all costs. When someone leaves, it's going to cost you $3,500 for every $10,000 that person makes. That's money you won't get back on maybe trading you did with them, time you spent with them, money and time you're now going to need to spend trading somebody else. And then of course lost revenue because that person is no longer working for you generating revenue. So keep that in mind when you're thinking, I'm going to withhold raises, I'm going to withhold bonuses, I'm going to otherwise inflict some sort of monetary penalty. It never goes well. And again, it's okay if money is a pain point for you personally, and if it's a pain point for the people underneath you that you're leading. Pay should always increase over time to match inflation at the minimum. I have said this a thousand times and I will say it a thousand times more. Every year you do not get a raise, you are taking a pay cut because everything in your life now costs more money to buy. So keep that in mind. I will beat that dead horse until we're all on the same page about that. And finally, I think this is something no one wants to hear. Both those of you who are maybe unsatisfied with your position because of the money and those of us leading others it is okay for people to leave a position if it's not working out for them financially, right? You cannot feed your kids with the promises of potential future money. Your landlord will not accept the ambitious dreams of your clinic owner and payment for your mortgage. and you cannot get any sort of retirement return on zero dollars invested. So it is okay to move on if this is a pain point that doesn't seem to be addressed. So money is the first part of our golden triangle.

TIME
The second part is time. Time is a finite resource that we're all running out of. I think every day now the moment I turn 37, I am statistically halfway dead. And statistically, every day beyond that point is that much time left I have on Earth. Time is interesting. Some folks don't feel the value at all. Some folks tend to place a great emphasis on it, maybe even more so than anything else. Humans are the only creatures that can perceive time, so I think it's unique that we're able to perceive the flow of time, and we're kind of aware of moments where we have maybe too much time that we might call boredom, and moments where we feel pressed for time. A lot of us, the majority of the human race, will spend most of our lives using our time to generate money and then trying to use some of that money to buy some of our time back. And that's the way it is, even if it is a little bit sad. But I think recognizing that that's how most of us are going to move through life is important. For some people, time will always be more valuable than money. It does not matter how much you offer someone, how much you may offer them for overtime, whatever, their time doing other stuff is important. There are those people, the clock strikes five, they're out of there and we need to understand and respect that that is one of their values and work around that in whatever way we can. Very few people though, even folks who maybe don't seem to value their time a lot, very few people do not like to have their time wasted for no reason. And this happens a lot in life. It happens a lot in day-to-day life. It happens a lot in the workplace. Think of every situation where you've shown up early or stayed late for a meeting or some other event that was canceled delayed or rescheduled even without notifying the people currently sitting and waiting there for that to happen. Every time someone schedules a meeting with me and doesn't show up, that's a strike in my mind against that person. Very few of us have the tolerance to have our time completely wasted in that manner. but it happens a lot and it happens a lot in the context of the physical therapy workforce. Think about how many times you've come to work and the first two patients on your schedule have canceled or rescheduled, right? And you're thinking, what the heck? Why didn't anybody text me or call me, right? I could have gone to the bank or I could have sat and had breakfast with my kids at home or any, literally anything else would have been a more valuable use of your time. We also, are often asked to work in situations where we know it's not a good use of our time, right? I think of every time I have been asked in the past to work on Christmas Eve, right? Especially in the context of patient care. I know as soon as I'm asked to work on Christmas Eve that no one is going to come to their appointment on Christmas Eve. I remember it's burned in my brain, I spent one Christmas Eve with a completely wiped-out schedule, laying on a treatment table, and I watched all six Rocky movies in a row, right? I watched like eight hours of Rocky movies and did not see a single patient. What a monstrous waste of my time, and the clinic's money, just a bad situation for everybody. The Japanese have a term for that. It's called "Isogaghii" is the act of pretending to be busy. Even when you have nothing to do, we hate that. That is not something that we should encourage. If you don't currently have something to do, don't be here. I live my life by that model. When I catch people sitting in the clinic and they're just kind of pushing buttons on a computer, I always ask, what are you doing here? Oh, you know, I'm, you know, final, I'm like, okay, go, go home, right? Go away. No "Isogashii". We do not need you to sit at your computer doing nothing until 9 pm just to appear busy. So that's money. That's time.

AUTONOMY
The last part of the triangle is autonomy and independence. It's important to know that we developed this very early, and we all have a strong sense of it, even if we don't voice that it's one of our values, right? I think of my son, he's about to be 11 months old. A couple of months ago, we were hand-feeding him, already he has that sense of autonomy. Now when I go to feed him, he slaps the food out of my hand, and then he grabs it and feeds himself, right? He's already expressing, hey, I'm not a baby. I don't need you to hand-feed me. I can feed myself, right? And that's already present in very, very small children, right? Those of you with toddlers, you know, that independent streak starts and doesn't stop. Those of you, especially with teenagers, you know, it gets more aggressive. And then obviously all of us as adults, have a very strong sense of autonomy. Again, even if we don't express it explicitly as one of our values. Just like time, autonomy is violated on a very regular basis in very unfortunate manners. This happens a lot in the workplace. A lot of you work for employers who control how you're allowed to dress. how you're allowed to speak and talk with your patients, how and when you're allowed to perform very basic physiological functions about when you can eat food. Some of you work for employers that don't let you eat or drink at work. You have to leave the building and eat outside by the dumpster like an animal because you're not allowed to eat in the building because the owner or the manager doesn't like the possibility of crumbs. That is a huge autonomy violation. We also see this in our workflow as well. A lot of us are performing unnecessary documentation so that someone can check our work, right? So that someone can audit our notes just for the purposes of having a checklist where they audit our notes, right? It serves no actual purpose as it relates to helping the patient by documenting what we did with the patient. And for those of us who take insurance, create a claim that goes to the insurance company. There is no point where it's required that all of these extra processes that we add to our workday are mandated. Nonetheless, many of us work for an employer who has all of this extra work, all of these extra checks on our autonomy just to have extra checks. That's very insulting and it creates a lot of redundant work that also simultaneously affects our time. So we are getting a one-two punch of time and autonomy when we're doing a bunch of busy work that doesn't respect our time. It doesn't respect that we're independent clinicians who have often been working a while with a bunch of advanced education. The final thing I'll say here is that what you'll unfortunately find is that leaders who micromanage more, and who place more limitations on autonomy are often the same leaders who have minimal or no restrictions on their own autonomy, right? The person who is a stickler about a dress code is often the person in the office in shorts and a t-shirt and sandals working on the computer, right? So be mindful of those things. As you are maybe seeking out a new position or evaluating your current position, there's no double standard on autonomy.

THE GOLDEN TRIANGLE AS A ROBUST BASE FOR SATISFACTION
So the golden triangle, the interdependence between these three things builds a very robust base personally and professionally. However, I think it's very important to note that if we take our comparative analysis engine in our brain and compare it to Maslow's hierarchy of needs, What some of us are doing is trying to aim for the very top of the pyramid, aiming for esteem, aiming for self-actualization, and trying to become the best physical therapist that can be when those other bases of the pyramid are not being met, right? We don't have our basic needs met because we don't have enough money coming in. We don't have control over our time. We don't have control over our autonomy. We talked last week about the pitfalls of social media, trying to make you think that the reason that you're unhappy is you're not buying enough stuff or consuming enough content. With that stuff in that content, mainly being focused on trying to push you to the top of the hierarchy of the needs when really what you need to do is address the base, meet those basic physiological needs, safety, security, love, Make sure that time, money, autonomy are on board before you consider purchasing that $10,000 self-help retreat or the mentorship program or the mindset program. I think a lot of our perceptions of concepts like burnout or imposter syndrome are really just the result of our comparative analysis engine and our skull recognizing differences and asymmetries between what we're doing every day and the results we're either achieving or not achieving compared to other people. And when we look and step back and look at this golden triangle, we see, okay, I am not making the money I think I should, especially compared to my peers. My time is not being respected. I'm working more than I think I should to make the money I'm making. And oh, by the way, I'm being treated Like an infant at work by having a dress code and having all of these extra redundant Processes at work that I need to do that consume more of my time and we are always again It is part of our survival. It's hardwired in our brains to make these comparisons. We're always consciously aware of the time and the work and the money and the autonomy compared especially to other people and kind of comparing again back to that hierarchy of needs. And that if we allow one or two or all sides of this triangle to be violated, that's where we find a lot of frustration, and trying to jump your way to the top is not going to get you there. You need to address that base. When folks reached out and they described their appointment situation, I used to be a lot more polite with my thoughts when people emailed us and said, what do you think? I'm seeing 20 patients a day. I'm making $62,000 a year. And every month that I see more than 250 patients, I get a $500 productivity bonus. What do you think? I used to be a lot more polite when answering those emails. I am not polite anymore, right? A lot of the dissatisfaction, a lot of the burnout, I hate that term, a lot of the burnout, though, can probably be addressed if we're a little bit more firm and reinforcing and adhering to our values of Again, money, time, autonomy, are all of those things in place? Okay, now we can begin to look more up that hierarchy, begin to pursue maybe specialization, become the best physical therapist we can be, or even if that's not something you value, the best whatever you see yourself becoming. But again, we can't get there if we don't address the base. Doing anything else is just addressing the symptoms. It's not addressing the root cause, right? We need to address the root cause first. We can't just keep treating the symptoms by buying stuff and taking vacations and that sort of thing to try to solve the unhappiness that we're perceiving. We need to know that it's all related and that we need to address it first before we can begin to kind of reach beyond the top of that pyramid. So I hope this was helpful. I would love to hear any feedback or comments you all have. I hope you have a wonderful Thanksgiving and we'll see you all tomorrow. We're gonna talk about rowing.

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.

Nov 22, 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 how to balance infusing patient care with hope with the reality of their recovery. Take a listen or check out the full transcript with show notes on our blog (www.ptonice.com/blog) or on your favorite podcast app.

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.

JEFF MUSGRAVE
Welcome to the PT on ICE Daily Show, my name is Jeff Musgrave, Doctor of Physical Therapy. Super excited to be here on a Geri Wednesday. Geri on ICE is what we like to call Wednesdays, all things older adults. So today's topic is going to be all about a question I got this weekend while on a live course. So I had a student raise her hand, the reality of clinical practice here, and ask, how do we balance providing hope for our patients while still setting realistic expectations? How do we balance providing hope while setting realistic expectations? This is a reality of clinical practice for older adults when treating older adults. Lots of factors, and lots of things to dig in there. Before we get into that, if you're looking to see us on the road in 2023, your last opportunity is on December 2nd. That will be in Candler, North Carolina. Our other December offering already sold out. So that's your last shot in 2023 to see us on the road. Otherwise, we're coming out strong in January, team. We're going to be all over the map. We're going to be in Florida, California, Missouri, Ohio, and South Carolina in 2024. So we'll be coming in strong if you're hoping to see us live on the road. L1, previously called Essential Foundations, the next cohort is going to be on January 10th. then advanced concepts will be on January 11th.

BALANCING PROVIDING HOPE WITH SETTING REALISTIC EXPECTATIONS
Okay, so the question at hand is, how do we balance providing hope while still setting realistic expectations? important that we get this right. This is especially crucial for older adults. I want you to think about their history, and what their interactions are typically like in the medical system. A lot of people don't really give them the time of day. Their visits are rushed. People are throwing $10 words like idiopathic non-diabetic peripheral neuropathy that's what's wrong with you all right get out of my get out of my office kind of thing but we have a lot more time with our patients in comparison to a lot of other providers in the medical system and want to really leverage that time well. So as I've been chewing on this question, I gave the short answer during the live course, but I'm doing this podcast to give you the long answer for those that are interested. So it's like trying to find the narrow path, walking down a tightrope. We think about this journey with our patients from beginning to end. And the two factors that we're trying to balance here, if you can kind of imagine someone walking across a tightrope, they usually have this big pole that they use to balance.

HOPE VS. HARD FACTS
I want you to imagine on one end of this pole, we've got hope and this positive outlook, Because we know as physical therapists treating older adults, there's a lot we can do. A lot of people leave things like fitness and strength training, and power training. They have not incorporated any of those things. They need us. We can give them a lot of value. We can really do a lot of things to change their life. So we've got hope on this one end. And then we've got the hard facts. the realities of what's coming if they don't change, the reality of what is going to happen to them if they continue down this path. And we're trying to balance these two factors as we're walking with our patients down this path to recovery. So, long story short, the balancing act we're trying to do is we want to give a crap, make it clear that we care, we want to help, and we can help, without going so far that it sounds like we're full of crap. It's like, yeah, that's not possible, and exaggerate too much. But we want to be very clear that words matter. And if we go too far, too far on the hard facts, we can really shoot ourselves in the foot when it comes to recovery for older adults. You know, just a quick overview of some of the research. So Rebecca Levy, a researcher out of Yale, has done a lot of really interesting studies where she's looked at the power of positive beliefs in our belief systems, what we believe about aging, whether that's negative or positive, and how that may change our health outcomes.

HOPE AS A POSITIVE TREATMENT FACTOR
So she has done multiple studies looking at things like recovery from injury, like people that are hospitalized, if they are able to recover fully or not and she's found that people that are 50% more likely to recover to prior level function if they have a positive outlook on aging, talking about older adults here specifically. She did another study where she looked at people who had a predisposition for dementia if they had a positive outlook, even though they should have had an exponential increase in risk that should have led to them going on to have dementia if instead, they had a positive outlook on aging, they did not go on to get dementia as much as the rest of the cohort that all had that same predisposition. So there was an isolating factor of hope. And we think about when we have hope, we're gonna make different choices. If we believe we're in control and we are the ones charting our course in life versus life is happening to us. So hope is a very powerful tool. To summarize this, there's a great quote from Dr. Justin Dunaway out of our persistent pain course. And he says beliefs and expectations are the foundations on which outcomes are built. beliefs and expectations are the foundations on which outcomes are built. I love that. There was another really interesting study that came out of Harvard in 2007 and what they did, was they had several females, it was I believe it was about 45, don't quote me on that. It was somewhere around 45 to 50 females who had a very active job. They all worked in a hotel system where they were the people who were cleaning and turning over rooms. So they're moving all day. and we would say that they were physically active, they weren't getting fitness in, they weren't hitting ACSM guidelines, they weren't hitting Surgeon General's guidelines for fitness and lifting heavy things and hitting high intensity like we would recommend to truly be healthy. So they split this group to figure out if half of them were told that they were meeting the Surgeon General's guidelines and half were told they weren't, would there be any changes to their actual health measures? So they measured things like the hip-to-waist ratio. They also measured their BMI, their blood pressure, their body fat, and their overall weight. So they told one group, hey, the work you're doing, it hits the Surgeon General's guidelines. You're doing everything you need to do to be healthy. You don't need to exercise. And they told the other half, you're not meeting the Surgeon General's guidelines. You really need to exercise. This is not enough for you to be healthy. And what they did is they met back in four weeks and repeated all their health measures. They found that the placebo group had physical changes. They improved their weight, they reduced their body fat, their BMI was better, their blood pressure was better, and their hip-to-waist ratio was better. The power of words was tremendous for this group. None of them changed their behaviors. They were just told by a trusted source they're doing what they need to be doing and you should expect good things. Really incredible stuff. So we want to keep in mind providing hope is very important, especially to our older adults. They don't typically get a message of hope and we need to provide that because we have valuable tools. There are mountains of evidence showing that resistance training can help people get stronger in the early and late stages of sarcopenia. It's very important to provide someone with some hope. We don't want to take that too far and be completely full of crap, right? We don't want to tell our patients, oh yeah, you know, you can do these adductor ball squeezes, these leg kicks, and you're gonna be fine. You're gonna be prepared and protected for what life has coming at you. We know that is not true, and we're not suggesting that you grossly exaggerate, but we do need to give a healthy dose of hope.

CONTENDING WITH REALITY
So on the other end of the spectrum, we still have to contend with reality. What is a reality for our patients? What's the reality of the recovery going to look like? How much time should they expect the recovery process to take? And then we need to take a really honest look at what part of the journey we're going to be able to take them through. If you are an ICU clinician, if you're in an acute care setting, you may only see someone once or twice. You're going to give them hope and hopefully help them chart a path. Like, hey, this is going to go from here to home health. You need to find a good outpatient clinician. I know this great team. As soon as you're safe to get there, you need to get there. They will get you hooked up with a gym. And if you really want to change your life and stop coming back to the hospital, you can do that. You have every ability to do that. People have done it before. I've seen them change their lives. If you want to be another person to do that, you're going to have to commit for the next year. But then the decades to come are going to be way different than how your life has been the last month. Those adventures, those fun things you are planning to do, those can happen. That can be a reality for you. And that 45-second conversation could change someone's life. It may not always be, okay? We're not going to wear the rose-colored glasses, but your job is to plant those seeds. You still have to plant those seeds and let them know. Throw them a rope. They're still going to have to climb out of that hole, okay? So, we've covered the hope piece. We've talked a little bit about that scaffolding, but you need to create some scaffolding with reality in mind, okay? We know that there are tissue healing timeframes. that are on a range. We need to scaffold this up, that we need to know that we can get better but it's going to take X number of months and then inject yourself as to how far you're going to be able to take that journey. And day one, plant the seeds for what happens after. What happens after PT, after acute care, subacute, or if you're an outpatient clinician? What are their fitness options? You need to have these people on speed dial so you can bridge the gap, okay? And let them know. Just give them the whole story. Our older adults can handle it. They're used to getting tons of bad news. This is probably, even with a healthy dose of reality, some of the best news they're going to get because it's clear you care. There's hope. There's a path for them. But they need to know the realities and be prepared. What's coming ahead? So use science. Use the realities of tissue healing time frames to help them know, hey, this is how long this journey is going to take. Let's start thinking about these transitions moving along. Team, if we give too much reality and not enough hope, we're going to crush them. We're going to be kicking them while they're down. They're already maybe at a really pivotal point in their life. We give them no hope in all reality. They're going to quit. before it's time to get started before the real work begins. So based on the research that I just covered, based on the realities of being a human being, I would give a healthy dose of hope, and get them started, but we gotta balance that out just like you're walking that tightrope. You go too far either way, you're gonna fall off the path. We're gonna lose therapeutic alliance with our patients. They need enough hope to be ready that they're gonna have to struggle, they're gonna have to work hard, and it's gonna take a while. But there is hope they can truly change, that you've got the skills that you can provide, you know the people to make the transitions, and I think that is what's gonna lead to the most success for our patients, is balancing out science realities with tissue healing timeframes, knowing the person in front of you, and giving them a scale based on how much buy-in they're gonna give you. Are they willing to come into the clinic twice a week? Do they have a plan that supports that? Do they have the financial resources to support that? Or do we need a completely different plan where they're now motivated to do it at home and we need to spread this out and stay connected because we don't have good resources in the area? Alright team, I wish you the best of luck with your older adults managing those two factors, balancing hope and reality to get the best outcomes possible for our patients. I'd love to hear your thoughts in the comments. Have a happy Wednesday and I will catch you next time.

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

Nov 21, 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 the concept of "DUDS" and "STUDS" when working with patellofemoral pain syndrome. 

Mark describes three outdated treatment paradigms or "DUDS" including an overemphasis on imaging, patellofemoral tracking, and VMO specific-strengthening. 

Mark encourages listeners instead to focus on the four "STUDS" of patellofemoral pain treatment: assessing current work demands on the knee vs. current tissue capacity, addressing power & not just strength of the knee, working in motor coordination & skill training especially when reintroducing functional movements like jumping, running, or squatting, and finally, ensuring load distribution across tissues is as equal as possible by working on range of motion.

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
All right, what is up PT on Ice Daily Crew? Dr. Mark Gallant here, Clinical Tuesday, coming at you the Tuesday before Thanksgiving in 2023. So first off, I want to say super grateful to have the opportunity to be on this podcast, rapping to you all and going around the country talking about these topics. So thank you all very much to anyone who's listened to this podcast or anyone that's caught us on the road. But before we dive into today's topic, last couple opportunities to catch the extremity crew crew on the road for 2023, we've got Cody is going to be in Newark, California on December 2nd and 3rd. So so a nice West Coast opportunity. And then Lindsey is going to be in Windsor, Colorado, December 9th and 10th. So those will be the last two for the year before we we take a little break and then we will kick off the second weekend of January for a full slate in 2024. So if you're trying to catch us on the road this year, those are your last two opportunities. And then make sure you grab those seats for 2024, because courses are selling out now and hitting max capacity. So make sure that you get those sooner than later. In addition, tonight on our Vice, so if you're signed up for the Vice program, our virtual ICE, Paul Killoren is gonna be on talking about peripheral dry needling. If there's any topic that pairs well with what the extremity crew is typically saying, it would be the ICE dry needling department talking about peripheral dry needling. So definitely catch that one tonight around 8.30 Eastern Standard Time.

DUDS & STUDS FOR PATELLOFEMORAL PAIN SYNDROME
All right, for today's topic, what we wanna talk about is duds and studs when it comes to patellofemoral pain syndrome, or what I would prefer calling kneecap pain. So what are the things that we've known over the years or we've tried over the years with kneecap pain that the research really does not shake out very favorably for? And what are the things with kneecap pain where it's like, Ooh, that that's something that we definitely want to pay more attention to. So I'm going to list all the duds and all the studs off, and then we'll break each one of those down individually. So for the duds, we've got imaging to the kneecap as a dud specifically for chondromalacia patella, patellar tracking and trying to impact patellar tracking would also be a dud, and then specific strengthening or specific loading or an attempt at specific loading to the VMO or the oblique fibers of the vastus medialis. So those are our duds and our studs are going to be building work volume capacity or looking at that person's work volume compared to their current capacity and making adjustments in their training. We have specific strengthening or building capacity to that anterior knee with both strength, endurance, and power. We have skill training or motor coordination, and then we have mobility towards the anterior knee and surrounding structures. So those would be the three duds, the four studs.

DUD #1 - IMAGING OF THE PATELLA
Now let's break each one of those down individually. So for most body parts, We now know that when we take asymptomatic folks and we image that region of the body, we're going to find as many tissue changes as we would for those folks that are symptomatic. Historically, we've called these abnormal tissue findings. Again, these are fairly normal findings for asymptomatic individuals, again, in every single region of the body. What we see with chondromalacia patella, so softening of the cartilage of the posterior patella, What we see when we look at that is if we take a bunch of asymptomatic individuals and symptomatic individuals, run them all through the MRI tube and say, who's got signs of tissue softening to that cartilage of the back of the knee, that number is equal or close to equal for both the symptomatic group and the asymptomatic group. So it would be hard to say that the finding on the image of chondromalacia patella is driving kneecap pain in any considerable way.

DUD #2 - PATELLOFEMORAL TRACKING
The second dud is patella femoral tracking. So there was this theory for a long time that the lateral structures of the patella or the structures that attach laterally to the patella are pulling that patella off track or creating some level of tilt or compression to the patella that is driving that anterior knee pain. What we now know is that this is not the case typically. The other thing with that was that the VMO was weak and not allowing that even force. We now have studies, it's a pretty cool study, where they took a group of 14-year-old women, they asked them all about their knee pain, how much pain are you in, and then they used imaging to track how their, to look at how their patella was tracking. So they got all that data at 14 when those individuals were at their peak symptom level. They then followed up with those individuals four to five years later, so now they're 18 to 19 years old, All of these individuals had significantly reduced pain. So the patella femoral pain or the kneecap pain had relatively worked itself out. And then they re-imaged and retracked how that patella was tracking. What was interesting is most all of them had a full reduction of symptoms. the knee was tracking the exact same way. So they found no difference in how the knee was tracking, yet that person had significantly reduced symptoms, which again, hard to say that that knee tracking is one, are we even able to intervene on it? And two, does it mean anything if all of the symptoms become reduced despite that knee tracking changing?

DUD #3 - SPECIFIC TRAINING TO THE VMO
And along those lines, the third dud, is specific training to the vastus medialis oblique fibers. What we now know is it's incredibly hard to isolate those fibers. When we activate the quads, we're getting the whole quad, all of the heads of the quad. And even if we did attempt it, we have no proof of correlation that those specific fibers are driving the symptoms. So our three duds, looking at imaging to drive treatment, specifically with Chondromalacia patella, being overly concerned with with patella tracking and trying to impact that patella tracking with the one thing that we've shown the good research that impacts patella that that would be theoretically impacting patella tracking is that medial knee taping mcconnell taping what we now know is that is much more of a symptom modulator and has no long-term impact on that patella tracking. And then VMO, specifically training the oblique fibers of the quad. What we now know is getting the quads more robust and resilient is the way to go, being far less concerned about those very specific fibers that are very hard to isolate anyway. So those are our three duds.

STUD #1 - WORK VOLUME VS. TISSUE CAPACITY
Our four studs are going to be looking at that person's overall work volume compared to their capacity. So this weekend is a prime time example. We're going to have tons of folks going out for turkey trots. We're going to have a lot of folks going out and playing backyard football with their family on Thanksgiving. They may not have been doing any training over the last four to six months to prepare their anterior knee. for that capacity. Family members might say, hey, I'm jumping into this turkey trot, and then Bill says, you know what, I'm gonna jump in with you, even though I haven't run since 1968 when I was training for Vietnam. That individual may encounter some anterior knee pain because the capacity of their anterior knee is not matched to the work that it's about to do. So anytime we've got one of these pain symptoms, syndromes, kneecap pain, looking at, okay, what is it you're doing? and what is the capacity of the knee currently, and trying to figure out where those gaps are.

STUD #2 - TRAIN POWER, NOT JUST STRENGTH
Along those lines, the second stud is can we increase the load capacity, the capacity to handle speed or power, and the capacity of that anterior knee to handle endurance. What is your ability to produce load or to tolerate load in knee extension or squat? What's your ability to sustain that over long periods of time for high repetitions or high time intervals? What is your ability to generate power with those things? Dustin Jones came on here a couple weeks ago and talked about how we may have named the wrong enemy when it comes to deconditioned older adults that it may be more power instead of strength is the problem that a lot of folks actually have load capacity tolerance to their tissue. What they lack is the ability to handle that load while generating high speeds or force. We see the same thing when it comes to kneecap pain. We're getting better at getting people stronger to build that load capacity. We also need to make sure they can handle that at fast speeds. Our box jumps, our broad jumps, our cleans, our snatches, or sprinting, those sort of activities, we need the same sort of intention to build the tolerance. So building the local strength capacity or building the local tissue capacity of the knee.

STUDF #3 - MOTOR COORDINATION & SKILL
The third stud is skill or motor coordination. The law of specificity has reigned true in strength and conditioning since it was looked at. If you want someone to get better at running, train them in running. If you want to get them better at squatting, they need to train the squat. If you want their step up to look better, they need to be working on step up variations. So this has a very much skill component like any other skill in life. It takes repetition, It takes breaking it into chunks, it takes slowing it down, speeding it up. If we want their step up, or their step down, or their running, or their squatting to look better, making sure that we break those things down individually and look at it in addition to the first two components.

STUD #4 - RANGE OF MOTION
And then the fourth piece that's a stud is range of motion. What is the range of the tissue surrounding the anterior knee that's gonna dictate how much force is going through that knee? So a couple of the big ones are, what is ankle dorsiflexion like? If that person significantly lacks ankle dorsiflexion, we know those forces are going to go up the chain, often landing on that anterior knee. So attempting to impact or offload dorsiflexion will help with that anterior knee pain. What is the length of the rectus femoris? What is that quad length like? If that tissue is super gummed up and tonic, we may want to work some eccentrics to improve the mobility of that tissue overall. And along those same lines, what is that individual's hip extension looking like? If that person lacks significant hip extension, again, they may encounter more force to the anterior knee.

DUDS & STUDS FOR PATELLOFEMORAL PAIN
So again, for our studs or duds, looking at the three duds, looking at imaging or being overly concerned with imaging, specifically chondromalacia patella, being overly concerned with patella tracking and trying to impact it, and being overly concerned with the VMO. Those would be our three DUDs that we want to spend less time addressing or no time at all. Our four DUDs are going to be looking with the patient at what is their overall work volume compared to their current capacity. What is the ability of the anterior knee to tolerate loads from a load capacity or strength perspective, from an endurance and from a powers perspective. What is their skill in the movement that they're trying to perform? Do they need to become a better runner? Do they need to get better at squatting? Do they need to get better at step ups? Looking at that specific motion. And then finally, looking at any range of motion deficits of the lower quarter. Specifically, what is that quad length like? What is their ankle dorsiflexion? And what is their ability to extend their hip? Hope this helps. Hope you all have a wonderful Thanksgiving and get some good relaxation and time with your families. Lindsay and Cody will see you on the road in early December. I'll see you on the road in 2024. Hope you have a great week.

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

Nov 20, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses the anatomy & physiology of phonation, the mechanics of breathing, and the relationship between the pelvic floor & the demands of speaking/singing. In addition, April covers unique considerations for professional singers & speakers and implications for physical therapy treatment.

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 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.

APRIL DOMINICK
What's up PT on Ice fam? This is Dr. April Dominick from the Ice Pelvic Faculty Division here today to talk about the pelvic floor and its role in breathing and voicing today. I have a feeling it'll take your breath away. But first, some updates from our pelvic division. First, we have our last live course offering of 2023. It is happening December 2nd and 3rd. with Christina Prevett, and that is gonna be in Halifax, Nova Scotia. And let's not forget about not one, but two of our online eight-week course offerings. Level one is going to kick off next year on January 9th, and the brand new level two advanced concepts are going to get rolling on April 30th. So head over to ptonice.com and secure your seat in one or all three of those offerings. So we wanted to hop on today to outline what we know about the pelvic floor and its essential tasks and things that you've probably already done today like breathing and talking.

THE PELVIC FLOOR & PHONATION
I'll discuss the essential anatomy and then the structures that are involved and then we'll unpack the complex physiology of breathing and voicing with a special focus on what the literature supports right now in terms of what the pelvic floor's role is in phonation. Spoiler alert, there's not a ton. And when I say phonation or voicing, all those terms mean talking. So we need to understand what normal function is in order to identify dysfunction during pelvic floor assessment, especially when it comes to an individual complaining of any bladder issues or bowel dysfunction, leakage, pelvic heaviness, or pain during tasks like breathing and talking, or yelling and singing, This can happen to anyone. Think about the last time you were in a really loud bar or at a concert and you're yelling at someone or trying to talk to people and your voice gets a little fatigued. Maybe there's some fatigue in the pelvic floor as well. This can also happen with other occupations that primarily use their voices. So I'm thinking about teachers, maybe chefs in a busy kitchen or coaches, professional singers even. Another point to bring up is breathing and more recently phonation have been used in the clinic by physical therapists to treat pelvic floor dysfunction. Yet we lack robust evidence to support these clinical practices. So when it comes to breathing and voicing, I want you right now to think of some body parts or structures that are involved. I'll give you three seconds or you can pause.

THE ANATOMY OF PHONATION
Most of us probably thought of the obvious structures like the nose, the mouth, the lungs, and maybe even the diaphragm. And those are great starts. And we're going to run through the other important players for breathing and voicing. Breathing and voicing work in a closed system, which involves the interplay of three regions. with different diaphragms. So the cervicothoracic diaphragm, the respiratory diaphragm, that's the diaphragm that you think of when we talk about the diaphragm, the dome shape, and then the pelvic diaphragm. So when it comes to the cervicothoracic diaphragm, the major surrounding structures of interest are the oral and nasal cavity, the larynx, which is also known as the voice box, and that houses the vocal folds, the trachea, and then there's supporting musculature. There's paralangeal musculature like the SEM and scalenes, as well as the intercostal muscles. From a nerve standpoint, we cannot talk about the pelvic floor or voicing or breathing even without talking about the vagus nerve, as well as the phrenic nerve that runs along this area. The vagus nerve innervates the vocal folds and the phrenic nerve innervates the diaphragm. So that's the cervicothoracic region and diaphragm. Then we've got the respiratory diaphragm. That's going to separate the thoracic cavity from the abdominal cavity. And the diaphragm at rest, it's that dome-shaped muscle And it's got many origins, the xiphoid process, some of the lower ribs, the lumbar spine. Indirectly, it also attaches to the psoas and QL or quadratus lumborum. And then in that same region, we have the abdominals and they aid in power production for respiration or phonation. We're talking the internal and the external obliques, the rectus, and then the transverse. Then we have the pelvic diaphragm, our third area. The pelvic floor muscles are actually the floor of this entire closed-core canister system. Its three layers involving the levator ani, the coccygeus, piriformis, optorenus, and ternus are all muscles that span from the pubic bone back to the coccyx, and then from the ischial tuberosity to the other ischial tuberosity. Functionally, the pelvic floor is involved in so many things, abdominal and pelvic support, modulation of intra-abdominal pressure, postural and respiratory support, bowel, bladder, sexual function and arousal, and reproductive function. When those pelvic floor muscles contract, they close off the urethral, vaginal and anal openings. When they relax, they open those openings so that if we need to, we can urinate or poop or do any of those things. So that's the anatomy piece.

THE PHYSIOLOGY OF PHONATION
Now I want to go into the relevant physiology when it comes to pressure generation and management. So breathing is the transmission of air into and out of the lungs. Sounds simple. Right? No, not so much. We're going to go through how each region that we just discussed supports respiration in two forms, inhalation and exhalation. For the cervicothoracic diaphragm, the vocal folds are there and they march their own drums. So during inhalation and exhalation, those vocal folds stay open, and that's to allow airflow in and out. In terms of the intercostals, during inhalation, the external intercostals are going to elevate the ribs and go upwards and outwards, which expands the thoracic cavity, and then they'll relax on exhalation. The SEM and scalenes are going to assist in the inhalation portion as well as provide some postural support for the head and neck. So that was a cervicothoracic diaphragm.

THE MECHANICS OF BREATHING
Now we're going to go into the respiratory diaphragm physiology and mechanics of breathing. So during inhalation, that dome-shaped muscle contracts and changes from dome-shaped and then flattens as it descends towards the abdominal cavity. This is going to create a vacuum that pulls air in. And then during exhalation, that flat diaphragm passively relaxes and returns back to its dome shape. Then we have the abdominal muscles. They are a little more straightforward. On inhale, they're going to relax and expand outward. On exhalation, they're going to contract and draw inward. Then we have the pelvic diaphragm. So during inhalation, the pelvic floor muscles relax and elongate. Then on exhalation, in the presence of now increased intra-abdominal pressure, the pelvic floor should contract and lift, which closes those openings, preventing any unwanted leakage or prolapse symptoms. And we have a few confirmations of this happening in the literature. In 2011, there was a group Telus et al, and they confirmed that these pelvic floor movements are happening with respiration during real-time dynamic MRI. We love some of that research. We also have other studies that show, hey, via EMG activity, there's actually some pelvic floor activity prior to resisted expiration. And this is cool because it demonstrates that maybe the pelvic floor has some sort of neural pre-planning during the expiration phase. So I know that was a lot of information, so I'm going to put it all together for you in terms of respiration, what's happening from head to floor. During inhalation, the vocal folds are open to allow the air to flow in. The external intercostals are going to elevate the ribs up and out. The SCM lifts the sternum. and clavicles, the diaphragm contracts and descends downward, the abdominals expand outwardly in response to the displaced organs, and then the pelvic floor elongates inferiorly. Whereas exhalation is more of a passive process of the muscles relaxing. But it can be a forced process as well, like during exercise or playing an instrument, or if we're under any stress, So now I'll run through the muscle responses during passive expiration, which is essentially inhalation in reverse. The respiratory diaphragm and inspiratory muscles relax, the pelvic floor and abdominals, synergistically contract, and there's this beautiful parallel lift of the pelvic diaphragm and the respiratory diaphragm upon exhalation. And then finally, those vocal folds, remember they stay open. so that air can exit the body. So that is respiration. It is the foundation and the power source when it comes to phonation or talking. As far as phonation goes, the entire body is a vocal organ. So the next time someone asks you at a party, hey, do you play any instruments? Be sure and tell them, heck yeah, I play this little thing, the voice. So next I'm going to detail the symptoms or systems involved in voice production. And I'll point out the differences in function of the two major muscles between respiration and phonation. As I said, the voice is a highly complex instrument involving many different body parts.

THE FOUR SYSTEMS OF PHONATION
And so we're gonna think of phonation as comprised of four major systems. And these systems are like a four-legged stool. When they're all working in sync, that stool or the voice is nice and stable. When one leg of the stool is a little off, then your whole stool is wobbly and your voice is a little wobbly. Another key thing to remember is that phonation occurs during the exhalation portion of respiration. So the first of the four systems is the air pressure system. It's going to manage pressure and flow. It sets vibration in motion. We can liken that air pressure system to a musician's breath as they are playing the saxophone. In the human body, the structures that are involved in the air pressure system are the trachea, the chest wall, the lungs, diaphragm. Then we move on to the second of the four systems, the vibratory system. It's made up of material that can vibrate when activated. So if we're thinking about the saxophone, we're thinking about the reed as the vibratory system. This creates pitch. In the human body, the vocal folds, are what create pitch. They open and close, and that lets short puffs of air come through the glottis at high speeds. And the number of vibrations per unit of time is what creates pitch. Low pitch is the result of the vocal folds shortening and vibrating more slowly. Whereas high pitch is created by lengthening the vocal folds and vibrating more quickly. Loudness is determined by the subglottal pressure which is generated by the abdominals and modulated by the pelvic floor. And then we have our third system, the resonators. They are going to amplify the vibrating sound. It's the actual physical saxophone itself. They affect the richness of the vocal tone. In the human body, that's going to be the throat, the oral and nasal cavities. This is what is going to create someone's recognizable voice. Then the final and fourth system is the articulators. They are unique to the human voice. So there is no analogy for an instrument here. Articulars add quality and timbre. They modify sound shapes as they leave the mouth, which creates recognizable words. And these are the tongue and the soft palate, the lips. So in summary, for phonation or voicing, the voice is produced via the interaction of those four systems. Subglottal pressure creates sound pressure and intensity, via rapid oscillations, the vocal folds produce sound pitch. Via the vocal tract, the glottal sound is articulated, adding in someone's unique voice timbre. And then intra-abdominal pressure is controlled and generated with the rest of the core canister. And that's going to be mostly the pelvic floor and abdominals helping out with that piece. So during phonation, the primary muscles and their actions involved in the inhalation portion remain the same. So prior to speaking, we usually inhale and then we talk, talk, talk. The exhalation portion of respiration is like I said, when we phonate.

COMPARING EXHALATION TO ACTIVE SPEAKING
So I'm going to talk about the two differences between quiet exhalation and actual phonation or speaking. One is that the vocal folds don't stay open like they do in quiet exhalation. During phonation, they are doing the vibration, opening, and closing through the different frequencies to produce pitch. Second, when it comes to the pelvic floor, there's very little research on what it's actually doing when we are phonating. Aliza Rudofsky is paving the way in these uncharted waters when it comes to research on the pelvic floor, phonation, and the voice, A study she published in 2020 looked at the glottis and the pelvic floor via bladder displacement. So they used 2D ultrasound imaging and folks without pelvic floor dysfunction. She had participants in a standing position. We love that because most singers stand or most people when we're talking, going about life, we're either sitting in an upright position or likely standing. And she had participants, she cued them to do a pelvic floor contraction, to do a pelvic floor strain, as if they had to go to the bathroom. And she also gave them some cued phonation tasks, like saying, ah, for three seconds at different pitches. She also had them take a note and go from low to high. And then she had them do some grunting. She found that during the pelvic floor contraction, the bladder moved cranially, or upwards, and during straining, the bladder moved caudally, or downwards. This is what we would expect. Interestingly, for the phonation tasks, she found that the bladder displacement was significantly different than that that she saw with the pelvic floor contraction. And remember, with pelvic floor contraction, we tend to see more of a cranial displacement, but with these glottal tasks, she found there was more of a caudal displacement towards the feet. And again, that's different from what we normally see with expiration. So this was some novel information about what's happening with the pelvic floor during phonation. She also recently did, and Aliza did an interview in August 2023, and she talked about some of the research she's currently conducting, still doing data collection, but she's having folks without pelvic floor dysfunction say on one exhale, one, two, three, four. And what she's finding is there again is a tendency towards pelvic floor lengthening that's happening and there's also this buoyant nature of the pelvic floor with a specific up and down response to each of those numbers. So again, that's early data collection, but really cool to hear about what could be happening that's a little different than what we would likely hypothesize with the pelvic floor and phonation. And to me, that buoyancy kind of likens to running. So in running, we know that with repeated impact, the pelvic floor is responding like a trampoline. It's going up and down. It's automatically doing this. And so this sounds to me very similar to that. Quiet respiration requires much lower subglottal pressure than phonation. So per Aliza's work, in those without pelvic floor dysfunction, as subglottal pressure demand increases, with the task of voicing, the pelvic floor has an overall tendency towards lengthening and then potentially going up and down with each voicing. Clinically, we can use these results to coach and educate patients, maybe those who are pre-abdominal or pelvic surgery or during pregnancy. We can talk to them about what may happen to the pelvic floor if it's unable to support those higher subglottal pressures that occur with certain phonation, like yelling or even singing. The pelvic floor system may give way in the form of urinary or fecal incontinence, pelvic pain, and feelings of heaviness. especially in that immediate phase, postpartum, vaginal delivery, or cesarean section because we just don't quite have those muscles or that muscular support to help with managing the intraabdominal pressure. And now I want to wrap everything up because that was a lot of information. So in terms of respiration and phonation, We can agree that those are both very complex systems of the body that use a number of body structures that start from the glottis and make their way down to the pelvic floor. Respiration is the process of inhalation and exhalation. During inhalation, the vocal folds, stay open, the SEM and external intercostals lift, the diaphragm contracts, and descends down, the abdominal slightly expands, pelvic floor elongates. Exhalation is either passive or forced, and generally the reverse process. When it comes to phonation, there are four main pressure systems in place. The air pressure system, the vibratory system, the resonators, and the articulators. They all work together to create unique vocalization. During the exhalation portion of phonation, everything stays the same with the exception of those vocal folds, moving back and forth, opening and closing, and then the pelvic floor showing a tendency towards lengthening with a potential buoyant response to each individual vocalization. The inability to support the intrabdominal pressure generated by these tasks with higher sub throttle pressure, such as phonation, may result in pelvic floor dysfunction. Clinicians can use this data as a preliminary sounding board for blending the intricacies of the vocal respiratory and pelvic floor systems, especially when they're treating someone who's coming in for pelvic floor and or vocal dysfunction, as we eagerly await even more research for these systems. Thank you so much for listening. And if you all celebrate Thanksgiving, have a wonderful week.

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

Nov 17, 2023

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel introduces the concept of an off-season for runners in order to focus on physical recovery, mental recovery, strengthening, and rehab. Rachel lays out a structured off-season approach for clinicians to use when working with runners.

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

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

EPISODE TRANSCRIPTION

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.

RACHEL SELINA
Good morning, everyone, and welcome to the PT on Ice Daily Show. Okay, I'm happy to be here as your host today. My name is Rachel Selina, and I'm a TA within our Endurance Athlete Division. So I TA for our Rehabilitation of the Injured Runner, both our live and our online courses. Our online course starts again on January 2nd, so if you're hoping to get into the next cohort of that, registration is open now, you can jump in online. It'd be a great way to kick off your new year Um, so we'd love to have you there again, January 2nd is when we start that next cohort. Um, so today, today we are going to dive into some running related topics.

THE RUNNING OFF-SEASON
I want to talk about the running off season and kind of what it is, how it could be structured and really at the end of everything, like why we should take one or why we should encourage our runners to be doing an actual off season and what that could look like. Why do we need this? It's a big missed opportunity. I don't think many of our runners are taking an actual off-season, even though in almost any other sport, we see an off-season that has a particular structure that looks different than our typical in-season, pre-season kind of training. But we don't often see that in running. And here I'm mainly talking about our recreational runners. So not our elite, elite, highly competitive, like they're getting paid to run. Um, but our everyday person that has goals has things they're trying to achieve with their running. Um, but again, not quite that high end elite athlete. Um, and it's really not what I see people doing. Okay. So what I often see. And I live in Michigan, so this is a bit skewed for kind of our timeline, but the same kind of like concept applies. I live in Michigan, so most people end up having like a fall goal race. And that might be a like a marathon or a half marathon. But they train a lot over the summer, building up to that race. It happened in the fall. And maybe they're using that race as a like a they're going for a goal. They're going for a PR or they're using a lot of people are trying to qualify for Boston. OK, so either way, that that fall event is something that someone is really training for, has a specific time goal, and is pushing, usually pushing their limits to get there. After that, right, event happens, and then people usually take one to two weeks off totally, like no running. And then usually I see it as people kind of taking that totally off of like anything. And then after that two week period, I kind of jump back into running, back into training, maybe slightly less volume, right? Long runs aren't going to be quite as long, but I typically see people kind of jumping back into the same type of schedule, like training five to six days a week. I'm still usually working in some like sprints or hill work, track work, something like that. Um, so really not a, apart from those two weeks immediately after not a clear, like differentiation from what their training was prior to that race. On the flip side, I see some people where they do the race and then they're just done running. Like I don't want to run in the winter. Um, so I'm, I'm not going to run it all after my goal race until spring. Can I argue both of those probably are not our ideal situation. So I think, like I said, it's a missed opportunity and I think it's missed because there's a lot of benefit in doing an off season. Primarily four reasons we're going to cover. So I'm going to take this down a little bit.

PHYSICAL RECOVERY
I think the first one is physical recovery, right? Someone typically, if they're building up to a goal race, has just spent the last three or four months, like progressively overloading every single week, building, building, building mileage, right? It's a continuous training cycle that adds up to a lot of fatigue. Some runners, right, we can encourage to take recovery weeks during their training, which can be helpful to like mitigate a little bit of that fatigue. But for the most part, people are constantly building their mileage, increasing their mileage and intensity over that three to four month period. So by the end of it, right, that's been a big stressor on the body, whether someone feels like recovered after their one to two weeks off of running, right? There's probably a little more going on underneath that the body is not actually fully recovered where they could jump back into full-on training and expect to do well. Okay.

MENTAL RECOVERY
So physical recovery and then also mental recovery. Training to that extent, having to put in that amount of mileage and time into running to train well, right? Means we have to say no to a lot of other things during that time. We maybe have to say no to some family obligations or time with friends or just other activities that we like doing that aren't running, kind of everything takes the back burner. So it can also be really just mentally fatiguing and draining. So coming off of that, being able to have a period of time where we can be a little bit more flexible, be able to do different activities, not have to say no, and also be able to prioritize sleep. or like how many people are trying to fit in their running around a work schedule, family schedule, right? So often we compromise on sleep to be able to make that happen. So having a period of time where we can really build back some of those recovery practices is huge. And I think what we miss. And then it also gives us kind of that third point.

STRENGTHENING
It gives us an opportunity to really help our runners do a full on strength training cycle, like intentionally trying to build strength. Um, we talk about this in the running, our live running course about trying to have runners incorporate strength training into their train, like into their endurance training, um, separate sessions, but concurrently meaning they're, they're doing aerobic training and then they're also in a separate session doing strength training. And we want that because it can help reduce the risk of injuries, but it can also help improve their performance. However, in that in-season cycle, that preparing for competition, most people aren't able to load to the intensities needed to really build strength. And it kind of takes second place to the running training. So having a two to three month period, where we can switch that narrative and make strength training the focus can be super helpful to actually help someone build the capacity in their tissues, right? Here's a two to three month period where strength training is going to be kind of our priority. We can actually build the capacity of your Achilles tendons, your quads, right? Your glutes. And make sure that when you go into that next training cycle, you're actually coming in more resilient, ready to train. Your tissues can tolerate more load.

ADDRESING REHAB & PREHAB NEEDS
Sweet, and then our final thing I think that we could use off season for is really having a period of time where we address nagging injuries, right? Oftentimes we're seeing people come in, they're in the middle of training, their goal is to do this race. So we might let some things go or people might avoid addressing some issues because they want to finish their race. So having, again, having a period of time where we can fully address that injury, not just kind of do what we need to do to reduce symptoms and get someone to the starting line, um, could be a really helpful thing so that it doesn't become this chronic, um, you know, it goes away when I stopped training a little bit, but then it comes right back because I've never actually addressed it. It's also a good time to address our running mechanics, right? Sometimes when we're in the middle of like a really high volume training, We might want to make some changes to mechanics, but those mechanics, when we change them even a little bit, can have a big impact, which can be good, but it's also hard when the volume is so high. So having a period of time where our volume is lower lets us adapt to that new running pattern, whatever the changes that we're making in the gate mechanics, without it being such an overload because the volume's lower. Right. So we can kind of ease into that new pattern when we go back to our like building cycles for running, we're able to kind of already have that, um, but like internalized and have our body adapted to it. So it's kind of the, like the, the big pillars of what it could be, but then what that would actually look like, like, okay, that's great.

STRUCTURING THE OFF-SEASON
How do I actually help my runner to structure an off season? If we go back to that initial goal race, race happens. And then we do want to encourage people to take that next one to two weeks off of running, but that doesn't have to mean off of all activity. So I'd encourage runners to focus more on active recovery, not running, but maybe they're doing some light cycling, swimming, yoga, anything else that kind of helps them to recover. But then also really focusing on refueling, right? Making sure we're sleeping enough in that time, just kind of replenishing the body after everything we depleted it from, from that baby vent. So that would be like one to two weeks. And then having another one to two weeks of a reverse taper, which is where we go from not running in those two weeks off and kind of gradually build the running volume back up, um, to kind of just a moderate level. So if we think of an actual taper before a race is the opposite where we're, we're at a higher volume, we kind of drop over one to two weeks. Um, and that purpose is to allow the body to be fully rested going into a race. So that would put us about a month out from a goal race, a month after it. And then I would encourage you to ask your runners to take two to three months after that of an off season. Okay. And that would look like keeping the volume at like no more than 60 to 70% of what they were previously running. Like as their, like their top training weeks or kind of their, their average volume week over week. So if someone was training 40 miles a week in preparation for, say, a marathon or half marathon, having them drop down to where they're not doing more than 24 to 28 miles a week. And that might look like going from training five to six days a week, running training, to dropping that down, running only three or four days a week. And that extra time, again, it doesn't have to be Like you just have to rest. Um, but filling it in with other activities that someone likes to do strength training, maybe it's CrossFit or swimming or yoga or climbing. Okay. And then finally, the intensity of this time should also be dropped down. Okay. We don't want, this isn't the time to like be working on our hills, our hill repeats, our sprints, our interval work, our track work, right. Keep the pace. low enough that it's like easy running. Okay. And then when the body is actually fully recovered, we can enter into that next cycle, ready to go, ready to push again and actually see benefit because the body's recovered and able to adapt to that new training stimulus. So the, the only other, um, It's kind of different situation here. Like what I've been talking about is someone who running is their main thing. Like they like to run year round, they're maybe doing a couple of different races in a year. If we have someone who's a true like multi-sport athlete, where they'll run during say like summer and fall, but then in the winter they switch, maybe they switch to skiing. Okay, that person's going to maintain their aerobic training, from the skiing, and they might not really wanna run at all, which I think we also need to have a bit of caution there, using that other sport as the off season, because running has such a different training load, right? It has that impact that differentiates it from any other activity. So we don't want someone's tendons and tissues to become unadapted to that stimulus of loading and running. So even if someone is taking their off season to pursue a different sport, still encouraging them to get like two to three, at least exposures to running or plyometric training. And it doesn't have to be long, right? Maybe it's asking your runner to do like, can you give me two 20 to 30 minute runs a week, right? Even with your other like skiing training. If they're like, nope, I don't want to run at all. Can we at least get some plyometric training? Can we work a little bit of jump rope in there? Can we work some just other kinds of jumps, box jumps, drop jumps, anything like that to still get exposure to impact loading? And I think like a lot of that can be more coming from a coaching perspective, but I think it's also important in the clinic, especially if we think that most people, when they have a running injury, they don't come to us until it's a big deal. That's kind of our typical pattern, which usually can look like someone coming to us shortly before a race, right? So our focus there to help them meet their goal has to be a little more on kind of like putting out the fire, helping them get to the starting line for their race. But if we can set patients up with the expectation, hey, this is going to help you get to your race. But then afterwards, like I want you to come back and see me. so that we can really address what's going on, right? I want you to take, especially if someone's dealing with an injury, I want you to take this off season afterwards. We're going to work through to make sure you're 100%. We're gonna drop your running down a little bit, make sure you recover so that when you go back to that next cycle, you are actually ready to go. This issue is no longer nagging you, you're stronger, you've had adequate recovery. So I think it's a big point for in the clinic, just the same as it can be outside as we're thinking about maybe our non-injured athletes. Perfect, I would love to know your thoughts, so you can throw them in the comments. Let me know if you're taking it off season, if you encourage your runners to do so, or just any kind of thoughts you have around the topic would be great. So thank you for tuning in, have a great weekend, and we'll see you next time.

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

Nov 16, 2023

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

In today's episode of the PT on ICE Daily Show, ICE Chief Operating Office Alan Fredendall discusses how and why behind more carefully curating the digital & social media content you consume on the internet.

 

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.

ALAN FREDENDALL
Team, what's up? Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day's off to a great start. Glad to have you here on the PT on ICE Daily Show. My name is Alan. I'm happy to be your host. Currently, I have the pleasure of serving as the Chief Operating Officer here at ICE and a lead faculty member in our Fitness Athlete Division. Leadership Thursdays, we talk all things practice management, small business ownership, and general leadership tips for all of you out there who are leaders in your own way. Leadership Thursday also means it is Gut Check Thursday. This week's Gut Check Thursday couldn't be more challenging but also simpler than getting out there and hitting a 5k run or if you can't run hit a 5k row. Great aerobic test. As I get more into endurance running, I would argue I've been learning to hate 5Ks the most if it's a really uncomfortable distance to settle into kind of a longer, slower pace of, you know, you're setting a good pace on the first mile. Dang, I'm almost a third of the way done. Second mile, third mile. can be quite an aggressive distance. It's the most commonly programmed CrossFit workout if that surprises you. I've posted some benchmark times as far as percentiles for both the 5k row and the 5k run to kind of compare yourself to where I stack up against the general population. So have fun with that one. It's good to test that at least once a year and see how your 5k has changed, especially if it's a goal for you to get your aerobic, your longer energy system a little bit more efficient, and specifically to get better at maybe 5k runs. Some courses coming your way. Before we talk about these courses coming up before the end of the year, I want to challenge you that if you are in the market for an ice course, and you're able to purchase a course before the end of this year, you should do that. Wink, wink, wink, right? There might be a change being announced soon that would make you regret not purchasing now. So you'll see that maybe an announcement coming soon. courses before the end of the year we're almost done we have some courses this weekend but that's probably too late for you we'll be off next weekend for Thanksgiving and then we have just three weekends left of live courses in 2023 December 1st through the 3rd that weekend you can catch Paul up in Bellingham Washington for dry needling upper body You can catch Zach down at his home base at Onward Tennessee for cervical management. Christina will be up in Halifax, Nova Scotia, A for Pelvic Live. Ellison will be down in Tampa, Florida for dry needling lower body. Cody will be on the road for extremity management out in California in the Bay Area in Newark, California. Brian Melrose will be in Helena, Montana for lumbar management. and Julie Brower will be on the road in Candler, North Carolina for Older Adult Live. That's right outside of Asheville. The weekend of December 9th and 10th, we have Fitness Athlete Live. That's your last chance to catch that course this year. That'll be with Mitch Babcock out in Colorado Springs, Colorado. You can catch Extremity on the road again, this time with Lindsey Huey in Fort Collins, Colorado. And Older Adult Live, your last chance this year will be in Portland, Maine with Alex Germano. And then our very last course of the year, of course, we expect nothing less than a person of Paul's caliber to be the last person working this year. He will be in Salt Lake City for dry needling his upper body. That'll be the weekend of December 15th, 16th and 17th. That's a three-day course. So if you're in a state that needs a lot of hours like Washington, or Maryland, that'll be a chance to catch a three-day version of that course. A course is coming your way from us here at ICE.

YOUR TRIBE DICTATES YOUR VIBE
Okay, let's talk about today's topic. Your tribe dictates your vibe. You've often maybe heard the other way around. Your vibe attracts your tribe. How you carry yourself, your personality, your values, kind of attract the people around you that are maybe in your friend group, your colleagues at work, that sort of thing. I want to talk about it from the other angle your tribe dictates your vibe, of the people you choose to follow, whether they're actual in-person people or specifically today's topic, of the people you follow on social media can really dictate not only how you feel about yourself, care yourself, but of what you might begin to spend your time and money on for the worse or for the better. So I really, really, really want to stress that social media, I think, is destroying our society for the worse. Certainly, it has value in things like this and sharing information and education. from one person to a large group of people. But I think overall, we can begin to follow people who appear really relevant to our lives. But actually, if we do a really deep dive, we understand they actually have very little in common with us. And then ultimately, at the end of the day, we're in charge of who we follow. Many of us are not on social media against our will. And so that the emails you subscribe to, the social media accounts you follow, all of this digital content that you consume can have positive or negative effects on you. And to really stress, if you take nothing else away from this episode, to be really diligent in the streams and feeds that you begin to curate as you begin to follow email newsletters, social media accounts, and the like.

THE PITFALLS OF THE INTERNET: TALKING TOUGH & SOUNDING SMART
The first point I want to make today is The pitfall of the internet, as it's always been since its inception of consumer-based communication, is that it's super easy to talk tough and sound smart on social media. We live in a very impatient, rapid-fire, fire-and-forget type of world now. You may not know, but certainly, if you work at all in customer service, you experience, that the average expected response time to an email or social media message is now 10 minutes or less by the average customer. That's a study from Forbes from this year in 2023. I could say a whole bunch of crazy stuff right now on this podcast. I could say it in a social media post and I would have almost no side effects come to me because our society now is so rapid-fire, so fast, so consumable that you would consume this. Maybe what I'd say you would resonate with, maybe it would make you upset. It doesn't matter because you will forget about it in three minutes when you scroll on to the next piece of content. on your social media feed or the next podcast episode that you queue up. The only regulation on what we say is from you all, from the consumers. What's noticeable on social media is that the people who tend to be the most aggressive and make the largest blanket statements are often those who do so without any sort of evidence or support. They're also not the people who tend to engage in the stuff that they create, right? They're very aggressive. They fire something out there. They know it might make you upset. You might actually make a comment. And that's kind of their goal, right? That drives their engagement up. That shows their post to more people. Maybe it further upsets people. It gets more comments. And what we need to realize is that cycle is kind of what fuels those people to have large follower bases, to be able to advertise different things to you. Hashtag, you know, ice barrel, try out your hashtag toe spacers, right? Those people are trying to strike a nerve on purpose to get more engagement, more followers, more followers, engagement equals I can make more money selling sponsored things to you. So we need to be aware of that trap that is out there for us on social media and be aware of the pitfall of the internet and social media itself of this very consumable temporary transient content and recognize if you're falling for that trap of if you are getting upset and making comment or if you're following people who make kind of outlandish, unsupported statements. If that makes you upset, again, the whole theme of this episode is why are you following accounts like that.

YOU HAVE NOTHING IN COMMON WITH THE MAJORITY OF PEOPLE YOU FOLLOW
The second point I want to make of why are you following accounts like that is that you have nothing in common with the majority of people that you follow and obtain content from. You're making less money than you want to. You're working more hours than you want to. You're not feeling as physically well or as fit as you want to. You're not happy with how your body looks. Maybe you're not happy with how your marriage is going how you're raising your kids how your sex life is going, and how your postpartum recovery is going. You name it, you're being told that whatever is wrong with you, X is Y with you. Y is the solution, right? You are not having a good life because you don't wake up at 4 a.m. and do a 6-hour morning routine. You're not having a good life because you don't wake up and do a gratitude journal, use toe spacers, do yoga, meditate, do a cold plunge, or a sauna, or any of these other things that you're told are the difference between this apparently very successful person and you. But often when you do your research, when you look behind who are these social media influencers, you're often being sold solutions by people that are usually millionaires and who are usually millionaires, not because of the stuff they're telling you that they do, but because they're convincing people like you to buy the stuff that they're selling. And that's how either they are making their money or they're maintaining the level of income that they already have, right? Or maybe they started out in life and mom and dad footed the bill for college and for grad school and for their first house and they don't have a lot of debt and so they have a lot of extra time, they don't need to work as much to become this social media influencer and begin to sell you supplements and Toast Facers and all this kind of stuff. And the more you listen to those folks about what's wrong with you is that you're not consuming this stuff, the more money they actually make and the bigger that asymmetry actually comes. What's not said is that a lot of those folks have made their money by living what they're doing right now, which is a very imbalanced life of working more than you want to in order to try to pull yourself up the socioeconomic ladder. You're told that you're burned out or whatever and really the cause of their success is doing what you're doing right now and eventually getting to the point where their success comes to a level where they no longer need to work as much and maybe now they have more time to show you a video of them working out on the beach in Bali. And by the way, use my promo code Stephen10 for 10% off, whatever. And again, the more you consume that, the richer that person becomes. But at the end of the day, you do not have a lot in common with that person, yet you are trying to model your life after them, even though that's not how they currently live their life. And maybe that's not how they ever lived your life. These people are happy, healthy, and fit because they don't have to go to work anymore. Or maybe they never had to go to work. They can wake up and do their morning routine and go surfing because they're able to afford a full-time nanny to take care of their kids. Or maybe they don't even have kids and they get 12 hours of sleep because they have a night nurse. Or again, maybe they don't even have kids. And you get my point that they are living a very different life than you and maybe they never lived the life that you did. So it doesn't make sense for you to spend a lot of your time consuming their content and buying the stuff they're selling to somehow try to fix your life. Follow people who represent you, who represent your values, who are honest about where they made their money or how they got to the level they are at. I tend to follow people who are very upfront about how they got where they're at by pulling themselves up from being very, very, very, very poor, working a ton, and pulling themselves up the socioeconomic ladder. Is that ideal? No, but sometimes that is life, as true as it can be. And I resonate a lot more with those people who say like, look like this was the way that worked for me. It may not work for you. And I appreciate those people who are honest that look, it was a lot of years of 100-hour work weeks, working multiple jobs to pay off my debt to afford a house, to raise kids, and kind of get to where I'm at now. And I really, really appreciate that transparency, especially more as life goes on. So, what can we do about this of recognizing that Social media is meant to be fire and forget, instantaneous, consumable? It's meant to sell you things. It's meant to show people who maybe have nothing in common with you that you want to see yourself become only if you buy these products. If that's the way it's designed, what is the solution?

CUT THE CORD
The solution is to cut that cord, right? Take a serious examination of the accounts you're following, of the newsletters you subscribe to, of in general the content you consume digitally via social media, email, whatever, and stop following stuff from people who make it seem like the only reason you're not obtaining the fulfillment you want is that you aren't buying enough of the stuff that they're selling. Stop following accounts that tend to speak on best practices, but speak so dogmatically. Manual therapy sucks, it has no value. On the other side of the continuum, manual therapy cures diabetes, right? Stop following that stuff if you don't actually believe that stuff. Some of us follow that stuff just to watch the comments and watch people argue, or maybe you're even that person, spending your time that could be spent better elsewhere, arguing with people on the internet. I'll be very honest, I used to be that person. If you knew me a decade ago, I was that person. I was that person yelling at people on Twitter. and Instagram and all the other social media platforms, and I've talked about this before, one of the biggest shifts in my life was meeting Jeff Moore, our CEO, who one day sent me a screenshot of all these comments I was making, all this time I was spending on the internet, on social media, and just said, is this the best use of your time to advance the field of physical therapy? And of course, if you really ask yourself that question, then the answer truly is no. So stop following that stuff. Stop following those accounts. Stop following people who tell you that the way you're treating patients is wrong. If they are people who maybe don't currently treat patients or have not treated patients in a long time, five years, 10 years, 20 years, or maybe people who have never treated a patient ever, right, that person who went from PT school, maybe right to a Ph.D., or a consulting job, or to work for an insurance company as an adjuster, and has no actual real-world experience. Why are you following content like that? Knock that off. Follow people who are in the clinic every day, who are trying to make it all happen, who are trying to blend manual therapy, patient expectations and beliefs, and fitness-forward lifestyle, getting people loaded, getting people addressing their sleep and diet. Follow people who put out content like that, not content that maybe just makes you upset at the end of the day. Follow accounts that make your life easier. Follow accounts that give you resources that you can provide your patients so you don't have to work as much making that stuff yourself, right? Follow, obviously, I'm biased. I can't not have any bias here. Follow us, right? Go to PTonICE.com, click the resources tab, and look at literally an endless list of ebooks, workshops, of patient resources already created for you to make your job in the clinic easier so that hopefully you don't have to spend as much time making the money that you're currently doing. You don't have to work as hard doing it. Follow people in a manner that sees you working less and making more and not just buying more gadgets and $10,000 mentorship programs.

THERE'S NOTHING WRONG WITH YOU
And I think finally, what I want you to resonate from today's episode is to recognize deep down that there's nothing wrong with you. If you work more than you want to and get paid less than you think you should, you are not damaged. You are a normal American, right? 77% of Americans live paycheck to paycheck. Half of all Americans work two or more jobs. It is totally common to work more than you want to, to try to get ahead. Again, some of us are trying to pull ourselves up a huge deficit, right? We're trying to close a large asymmetry. We're trying to go from the poor person who grew up in a trailer park to maybe the first person in your family to finish middle school or high school or undergrad and grad school and be the first person to own your own home and be the first person to maybe have a retirement account and actually be able to think about retiring. We're trying to pull ourselves up multiple rungs. And I think for most of us, we believe that working a bunch is not how we get there. And I think when, again, we follow people who are more transparent in how they have their success. You'll find that's how they also got there, right? They didn't toe space and cold plunge their way from the trailer park to owning their own home starting a family paying off their debt and being comfortable in retirement. So recognize that there's nothing wrong with you.

CHALLENGE YOURSELF TO CURATE BETTER CONTENT
Okay, challenge you. If you look at my social media account, if you look at my Instagram, you'll see I have tens of thousands of followers. I don't know who most of those people are or why they follow me. Yet, look at that ratio. When you look at the ratio of people who follow to followers, it is my belief that you should only follow people that you want to see content from. What you'll see when you look at my account is that I only follow a couple hundred people, right? I follow close friends and family members. and people that I want to see content from. Again, my goal with social media is to curate a feed that makes my life easier with different tips and tricks about physical therapy, coaching, leadership, business, about all the different spheres I'm involved in. That's how I curate my social media feed. I don't follow people back who follow me if I don't think they post any content, that's certainly possible, or content directly relevant to me. And I think it's okay if you have to unfollow those people. Some people may think that means they follow you. Well, hopefully, they follow me because they find value in what I post and I think it's okay to not reciprocate if you don't feel the same way. I'm sure the people who follow me that I don't follow are nice upstanding people who treat their spouses and their children well hold the door for people to pay their taxes on time and leave a nice tip at the restaurant for the waitstaff, right? Not saying there's anything wrong with them. It's just I don't believe that the content they create is beneficial to me, and otherwise, it just becomes an endless blob of noise that maybe as you start to follow and compare yourselves to, you start to feel bad about yourself. So take a step back. Why am I following these people? Is it beneficial to me? It's okay to unfollow people, I promise you. I'm giving you permission, I'm giving you the blessing to do so. Cut that cord, recognize that you don't have as much in common with most of the people that you follow, as you think you do, and recognize that a lot of those people are relying on showing you this grandiose awesome life in order to sell you stuff so that they can continue to live that awesome life of working out on the beach in the Caribbean and living in their mansion in Costa Rica and using dye-free detergent and eating organ meat and all the stuff you're told is the reason that you're not doing as well as you need to. Consider, that your tribe dictates your vibe. Who you follow can really make your day or ruin your day. It can make you feel bad about yourself. You could get caught comparing yourself. So just knock it off. Cut that cord. Hope you have a fantastic Thursday. Have fun with Gut Check Thursday. We're going to be at a live course this weekend. Enjoy yourselves. I'll be back here on Thanksgiving Day. So I'll see you all on Thanksgiving Day. If you won't be joining us, I hope you have a wonderful Thanksgiving. Have a great Thursday. Have a great weekend. Bye, everybody.

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

 

Nov 15, 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 as she discusses that the problem with patient education lies in the tendency of healthcare professionals to overwhelm patients with excessive recommendations, mistakenly believing that this approach is effective. They often act like a "fire hose," bombarding patients with information without considering whether it is truly understood or has a positive impact. This ineffective method of simply talking at patients, providing detailed explanations, or presenting long to-do lists is often learned from clinical instructors and perpetuated without recognizing its limitations. To enhance patient education, healthcare professionals should adopt a three-step framework. This framework involves "show and tell" by combining education with action and intervention, clarifying and recapitulating information to ensure comprehension, and following up and following through with patients to establish mutual accountability. By implementing this framework, healthcare professionals can avoid overwhelming patients and ensure the effectiveness of their education.

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.

JULIE BRAUER
Welcome to the Geri on Ice segment of the PT on Ice Daily Show. My name is Julie Brauer. I am a member of the older adult division. Excited to be here with you all on Wednesday where we jam on all things older adults. Excited to be talking to you all this morning about patient education. Our topic specifically is patient education finish the drill. All right, so what we are going to talk about this morning is the problem with what many clinicians perceive to be effective patient education. And then I'm going to unpack a three-step framework that you all can use to level up your patient education interventions. And I'm going to then share a few really detailed examples of how you can implement this going forward using clinical scenarios that many of you all experience pretty frequently. The goal here is that we just walk into the rest of our week doing 1% better, okay?

THE PROBLEM WITH PATIENT EDUCATION: THE FIRE HOSE
All right, so what is the problem with patient education? The standard. Too often, we act like a fire hose. We flood our patients with too many recommendations, and we think that it's effective patient education. Team, we cannot fool ourselves. that simply talking at our patients, right? So explaining the very detailed pathophysiology of their condition or explaining their fall risk profile after running your outcome measures or giving them a 10 item to-do list of safety and lifestyle recommendations that they have never heard before and assume that we are making a positive impact. Many times I think this comes from the fact that we didn't really learn in school how to be effective at communicating to our patients and providing education. And then we just kind of followed what our CIs did, right? I am so guilty of this. I remember as a new grad going into a patient and you're so excited because you want to tell them everything in your brain that you know, you want to share your knowledge. And I remember I would just fire hose, fire hose for 10 to 15 minutes and I would walk out of that room and be like, man, I crushed it with Dolores. Like she just learned so much. I just did an awesome job. And then I would sit down and write literally a paragraph of all the things that I educated my patient on. And for some reason, because I wrote an entire paragraph of my educational interventions, that must make it good, right? Like I perceived that I did this awesome thing. So I think that's a scenario that we find a lot. The other scenario, which I've also been here, and many of you have probably been here too, is that you constantly have this productivity being shoved down your throat, or you are just so freaking burnout and so exhausted, you look at your clock and you're like, I gotta get this last patient in. I gotta get this last patient in. I'm exhausted. I don't have a ton of time. I don't know if I'm going to get a second set of hands to get them up to do any exercise interventions. So what am I going to do? I'm going to go into this room and I'm going to sit there and I'm going to educate. I don't even know if I can stand up to do it. So I'm going to just stay in my chair, educate and type as I'm there. I know a lot of us had been there, right? I know a lot of us have been there, but are we really helping our patient? Do we really think that just by sitting there and telling them a bunch of stuff, it's going to cause any positive impact? We have to really start to dig in there. So I want to offer you all a solution. I'm going to explain this three-step framework. So what does finish the drill mean? It means one, we're going to show and tell, Two, we are going to clarify and recap. And then three, we are going to follow up and follow through. So let me unpack each of those.

SHOW AND TELL, CLARIFY & RECAP, AND FOLLOW-UP & FOLLOW-THROUGH
Show and tell. Are we pairing our education with action on our part, an intervention, a demonstration? Are we facilitating action on our patient's part? Show and tell. Next, clarify and recap. Are we ensuring that the education that we are giving, the literal words, the process, the steps that are coming out of our mouths is actually being understood? Are we ensuring that the message we are sending is being received in the way that we intend? Are we asking the patient to recap what they heard? Are we asking questions to clarify misunderstandings or gaps in knowledge transfer? And then lastly, follow up and follow through. Are we following up with the patient after we make those recommendations? Are we following through with a caregiver or the next provider? Are we holding ourselves accountable and the patient accountable? That is what it means to finish the drill. Show and tell, clarify and recap, follow up and follow through. Okay, let's go through a few scenarios to give you guys a very detailed, clear example of how you can implement. I have a massive list of these, but I'm just gonna give you three here this morning, okay? All right, for you acute care clinicians, You have Dolores on your caseload. She has just had a lumbar fusion surgery, and you go in to evaluate her. Instead of just telling her, Dolores, you have movement restrictions. No bending, lifting, or twisting, right? We all know the BLT restrictions. What we know is that restrictions can cause a lot of fear. A lot of patients never discharge them and they walk around like they're in straitjackets for a really long time. So instead of just telling Dolores what she can't do, let's show and tell. Let's show Dolores how to hip hinge safely. and distinguish that from actually bending and flexing at the spine. So how do we do that? If many of all have been following ice for a long time, you know this awesome hack. You can take the toiletry bucket that is in Doris's room. You can go take some towels, roll them up, soak them in water and put them in the toiletry bucket. You can put that toiletry bucket on an elevated surface like the bed or the chair, and you can show Dolores how to safely hinge. Let's clarify and recap. Let's ask Dolores, hey, Dolores, do you have any questions about moving your back safely and rebuilding its strength? Let's have Dolores recap the points of performance of that hinge motion and demonstrate it for us. Lastly, let's follow up and let's follow through. If you are lucky enough in acute care to see your patient twice, let's say it's the very next day, or maybe it's later in the day, on the same day, you can ask, Dolores to set the environment up. Show me how to pick this up. We are checking for Dolores's ability to have those points of performance and be able to form that hinge movement. Let's follow through, which is very hard to do as an acute care clinician because many times you have no communication with the next provider. You don't ever get to see Dolores again. How can we do it to the best of our ability? We can follow through by talking to Dolores, maybe putting it on her phone or on a piece of paper. I need you to show this to your outpatient PT. And what does it say? Can you please teach me how to deadlift? Right? We are planting a seed, passing the baton, trying to make sure she stays in that fitness forward lane because we don't want her back on our caseload. Maybe we even take it a step further and we actually recommend to Dolores a specific fitness forward PT in the outpatient setting who we are going to want Dolores to go to. Finish the drill. Okay. Let's talk about a home health example here. So let's say you have Dolores in home health. We know that her visual acuity is impaired, right? Maybe you have done an acuity test. You know that her prescription on her glasses are really outdated. Let's not just tell Dolores about the importance of vision, helping her balance to prevent a fall. Let's not just tell her to make that eye appointment with her doctor and then walk out the door and hope that she does it. Let's show her how to send a message via MyChart. Guys, systems are starting to charge patients for MyChart messages. Let's start to show them how to send appropriate messages via MyChart, right? Let's make this actionable. What if we call the doctor, put them on speakerphone with Doris, guide Doris how to schedule her own appointment to increase her self-efficacy? Let's clarify with Dolores by asking, are there any barriers that you can perceive getting to this eye appointment? Let's follow through by contacting a caregiver to schedule with them. Hey, this appointment, Dolores has a eye appointment this day, this time. Are you going to be able to take her? Let's make sure it's on both of your all's calendars, right? Or maybe we plan ahead with a service like Go Go Grandparent so that we know that the transportation piece that was a barrier is now something that is facilitated and that we have taken care of that. Okay. Lastly, let's talk about an outpatient example. All right. You're working with Dolores, an outpatient. She lives with her partner at home. She's got some balance issues. She has had a fall. So you are treating her. Let's not just tell Dolores to take up her rugs and put nightlights around her house. How often do we give that cookie cutter recommendation of let's remove all your rugs, right? Instead, How about this? How about we make this actionable and we get Dolores or Dolores' partner or a caregiver to get a video walkthrough of the pathway from Dolores' from the edge of her bed into the hallway, into the bathroom, into the living room, out her front door, whatever her normal pathway is for the day. What if we get a video so that we can actually see what her home environment looks like? And then we can say, okay, Dolores, that rug, that one, the one with the tassels that you know she's probably gonna trip over or she has tripped over. Can we get rid of that rug, Dolores? Why don't we clarify by asking, Dolores, are you willing to get rid of that rug? She may, older adults, we know this guys, right? It's really hard to tell them to get rid of rugs. They may be really resistant to that. So Dolores, are you willing to get rid of that one rug? Because you have gone through and you've triaged out of all of the rugs, that's the one that's gonna cause us the most problem. What if we ask Dolores, what are your feelings surrounding getting rid of your rubs? And you dig a little deeper there. Let's follow through with talking about how we're going to actually get this done. Because maybe Dolores may not have the capability to get down on the ground and remove her rubs. So what if our follow through is calling nephew Johnny to ask him, Hey, will you, within this week, come over to Dolores's home and help her take up her rubs? Right? What if, We don't just tell Dolores to have those lights throughout the home. Now that we have the video, we say, Dolores, the lights would be most helpful if you put them here, here and there. Here is the Amazon link of some cheap but effective ones to buy. Let's put it in your cart right now. That is how we follow up and follow through and make this actionable, right? Then we can say, Dolores, here's your follow-up. Bring in a video in the next week and show me what your pathways look like now. So you are able to see that we have followed through with this recommendation. The nightlights are where they're supposed to be and the rugs are taken out. Guys, this is what it means to finish the drill with our educational interventions. Show and tell, clarify and recap, follow up and follow through. I would love to hear you all take this framework into the rest of the week. And while you're with your patients and you're starting to just fire hose and spew out those recommendations, I would love for you to pause take the pause and really think how you're going to finish the Drew. How are you going to show and tell, clarify and recap, follow up and follow through? All right, team, that's all I got for you today. Lastly, let's talk to you all about our courses that are coming up. We have some sold out courses, which is wild to have at the end of the year. November, we have a sold out course in Illinois. In December, we are sold out or we're very near sold out in Portland, Maine. And then we have another chance for you all to catch us on the road in Asheville, North Carolina. In January 1st of the year, we are going to have both of our online courses, our Level 1 and Level 2, formerly known as Central Foundations and Advanced Concepts, that are going to be starting up on January 10th and 11th. You know where all that info lives, ptinex.com, mmoa.online. Hit us up if you have any questions. Go out there and start to make those educational interventions. Just 1% better team. All right, 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 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.

Nov 14, 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 various approaches to promote system-wide healing. One key aspect highlighted is the importance of education in the healing process. Lindsey emphasizes the need to educate patients about their condition and what to expect during their recovery journey. This includes providing information about tissue healing timeframes and milestones for progress. By equipping patients with this knowledge, healthcare professionals can help them understand their recovery process and make informed decisions.

Mindfulness is another approach mentioned in promoting system-wide healing. Lindsey suggests that practicing mindfulness techniques can help reduce stress and promote a calm mind. This can be achieved through activities such as breathing exercises, journaling, or spending time outdoors. By incorporating mindfulness practices into their daily routine, patients can support their overall healing process.

Exercise is highlighted as a crucial component of system-wide healing. Lindsey emphasizes that exercise should not be limited to traditional rehabilitation exercises but should also include activities like walking programs. For instance, in the case of total knee surgery, she suggests starting with a 10-minute daily walking routine and gradually increasing it to reach the recommended 30 minutes per day. Engaging in regular physical activity can improve overall fitness and support the healing process.

Diet is also mentioned as a factor that can promote healing, especially after a trauma such as surgery. Lindsey emphasizes the importance of nutrition in supporting tissue healing. Specific dietary recommendations may vary depending on the type of surgery and individual patient needs. However, healthcare professionals are encouraged to promote a healing-focused diet that provides the necessary nutrients for recovery.

Lastly, sleep is highlighted as a crucial element in promoting system-wide healing. Lindsey acknowledges that getting enough sleep can be challenging during the early stages of healing. However, they suggest providing patients with sleep hygiene tips, such as turning off electronic devices before bed or maintaining a cooler room temperature. By facilitating good quality sleep, patients can support their body's healing processes.

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.

LINDSEY HUGHEY
Good morning, PT on ICE daily show. How is it going? It is clinical Tuesday. I am Dr. Lindsay Hughey from Extremity Management. I led that along with Dr. Cody Gingrich, Dr. Mark Gallant, and Dr. Eric Chaconas. So happy to be with you all on a clinical Tuesday. It's been a little while. Today I'm gonna talk with you about fitness forward post-op considerations for extremity management. It's a topic that often gets asked about on our weekends and our weekends don't actually have the bandwidth to hold those questions. So I'm gonna start sharing on PT on ice a little bit more here. So I'm excited to talk with you about that. But before I do, I want to share some upcoming courses that Mark, Cody, and I have because there are only a couple more opportunities left to catch us this year. And for those courses, we are getting close to 30 for each. And so spots will run out. So if you're on the fence, consider purchasing that in the next couple of weeks. So Fremont, California, Cody will be there on December 2nd and 3rd. And then the final opportunity this year is at CrossFit Endure in Fort Collins, Colorado, on December 9th and 10th. And that one's going to be a blast and numbers are growing. So please sign up now. If you miss those two opportunities just because family stuff's going on, know that we have offerings early in January as well. So Mark in Richmond, Virginia, on January 13th, and 14th, that same weekend, we're also offering a course with me in Louisiana. So please check out our calendar. We hope to see you on the road soon.

A FITNESS-FORWARD APPROACH TO POST-OP EXTREMITY CARE
So today's topic at hand, we're going to dive into what a fitness-forward approach looks like when we are managing extremities post-operatively. So I want to first just talk about the framework generally, and then use an example. And the example today we'll talk about is total knee replacement. But there are five underlying pillars that I see that are required if we really want to have an all-inclusive approach that is fitness forward for these folks. So number one, we have to be really familiar with tissue healing timeframes of that condition and what to expect and not expect for that patient along their healing journey. So we have to be intimately acquainted with what's normal and what's not, and then be willing to educate the patient about that. So that second pillar is really education. So letting the patient know in whatever surgery they have, whether upper or lower quarter, what's really gonna facilitate healing? What are the expectations for recovery in regards to milestones that they need to hit by certain times and what milestones allow them to progress? There are certain timelines that we can't violate and range of motion precautions based on that specific surgeon. So really make sure we educate the patient and they are fully aware of those precautions. As Zach Morgan said in one of his podcasts recently, we have to catastrophize rest. I'm really letting someone know that rest will never be the thing here post-operatively. Yes, we might have to rest that directed limb, at times, but our body needs movement. It needs blood flow. And so really getting that message early that just because you just have surgery doesn't mean you'll just be sitting and laying around. We actually need to move to promote blood flow and healing to that extremity. Number third pillar is the protocol. Really being intimately aware of whatever protocol the surgeon gives knowing the timelines and actually reviewing them with your patient. Not all surgeons will have a protocol, right? Every surgeon's a little different, but find an evidence-based one based on that surgery and compare a couple of them if the surgeon isn't giving you one. It is really important to kind of sit down with the patient and briefly review that so they really understand, again, what's normal and what's not, knowing what safety precautions are on board from a range of motion and active range of motion versus passive range of motion perspective, and then again, those milestones. Pillar four, system healing. How do we promote system-wide healing? Well, I already mentioned a little bit about our education, about how we're going to catastrophize rest, right? We are going to keep our humans moving, but here's where meds will come in again. And if you've heard me on the podcast, you know, or even seeing my reels, you know, meds is something I'm really passionate about. Mindfulness, exercise, diet, and sleep. And really unpacking what each one of those is for your patient, right? So mindfulness, something that kind of soothes their stress and mind or soothes their soul, helping that connect them with that, exercise, keeping that human moving in whatever way possible, diet, promoting nutrition that promotes healing, especially after a trauma, even though it's a controlled trauma, surgery is traumatic on all of our tissues. So make sure the diet matches that, and I'll unpack some of those things that promote healing as we talk about our total knee example. And then sleep, really helping facilitate ways to help a good deep sleep, that seven to nine hours, and it's so hard in those early healing stages, but giving the tips that you think will help. And it could be as small as turning your phone off an hour before bed, right? Or keep the room a little bit cooler, around like 65 degrees to help them sleep, just giving them those sleep hygiene tips. more on that as we talk about the total knee example. And then the final pillar when we're thinking about fitness forward postoperative care is capacity rebuilding. And what I mean by that is considering all tissues involved in the surgery. So think muscle, think tendon, Think ligament if that's on board. Think skin integrity, right? Because there's an incision on board. And think bone. All of these are challenged. Their capacity is challenged because there is a period where there needs to be some precautions and rest on board. And there needs to then be a period where we gradually build up that capacity as it's going down. And it is our job to prevent loss of capacity as much as possible, and then also build it up as efficiently and safely as we can. And so there are three subsets in this capacity rebuilding phase. So consider when we're thinking about like the muscle, intend and think working locally, but then also think globally right. We don't want to be just so focused if it's a shoulder surgery just on the shoulder right. We also want to be thinking about scapulothoracic muscles. So local and global considerations are key. The second subset is nervous system offense. I think unless someone complains of numbness, tingling, and vague pain sensations, we kind of ignore the nervous system. But consider the nervous system is extensive, and our muscles, ligaments, bones, and tendons are all mechanical interfaces of the nervous system. So we can use the nervous system to promote intraneural healing and blood flow offensively. So consider using your nerve glides early more for tissue healing blood flow and intraneural nutrition. So thinking about it offensively prevention. In addition, consider central sensitization prevention, right? Again, this is a controlled trauma. And we know that folks who have surgeries or injuries are more predisposed to getting injured again. So consider that things like two-point discrimination training, laterality training, and pain pressure threshold are something we should both check on and possibly train if we see impairment side to side. And I'll tell you, in those initial early stages, that four to six weeks, there is definite nociceptive pain damage on board, but consider as we get towards the end, halfway through to the end of our care, we have to make sure central sensitization hasn't occurred in those tissues or become widespread. So check and then train if necessary. And then finally, the third subset of capacity rebuilding is functional pattern training. So consider we want healthy full body patterns. And what I mean by that is initially thinking of getting someone independent in their ADLs and IADL functions. Initially, they might need some assistance, but then eventually we want to normalize those patterns so they don't need any kind of assistance, whether that be a brace or an assistive device. And then we want to prepare humans not just for daily living, normal daily living, but think of job and sports demands. ultimately functional patterns will train those good functional patterns without assistance but then think about preparing for the unknown as well because things in life and sports will happen right maybe our older adult after total knee prepare for falls right think about our person after a meniscal repair like pray prepare for unstable landing. So that's what I mean when I say prepare for the unknown, right? Prepare for real life, which we'll do in a multi-segmental compound way. So to summarize, The five things. Tissue healing time frames. Two, educate your patients. Three, know the protocol and review it with your patient. Fourth, give a meds education for system-wide healing. And then five, think about how you're going to build up capacity in muscle, tendon, ligament, bone, nervous system, and then full body capacity. I wanna briefly take you through a total knee example, how we'll apply these five pillars, just so you can consider how you can apply this really to any post-operative condition. So let's think about someone with a total knee replacement, uncomplicated.

TISSUE HEALING TIME FRAMES
So tissue healing timeframes, considering just the timeline of care initially, it's gonna be anywhere from four to 12 weeks. And we're really usually seeing them right for those two to three months. letting the patient know, that that's a realistic timeframe. And that there are multiple things on board, right? We have an incision to heal, a muscle to heal, and then bone. And so that four to 12-week timeframe really encompasses that and lets that human know that this is just not a quick rehab process.

POST-OP EDUCATION
In regards to our education for someone with a total knee replacement, considering our first education strategies really need to be about signs of infection, right? And anybody postoperatively, this needs to be on board, but specific to this total knee replacement, right? If there is red, hot, and warm redness that is spreading outside of that incision. Here's where we make that circle around, we see that redness, and if it spreads outside that, that becomes an emergent thing that they need immediate medical assistance for. Consider letting them know the systemic temperature. If they're running a fever greater than 101 Fahrenheit, they need to, again, get to their doctor quickly. These are things we don't wanna mess with when we think about infection associated with the prosthesis. If there are dramatic increases in pain that are debilitating, another coinciding sign of infection. So that needs to be a part of our initial early stages of education. And then obviously we're educating about our HEP and its importance, but then we need to get into some of that nitty gritty of what facilitates healing. And I can't keep echoing Zach Morgan enough that we need to catastrophize rest, that letting that patient know that they shouldn't be sitting or laying around more than 30 to 60 minutes at a time. They need to keep moving so that systemic healing can happen. Giving them specific movement HEP parameters about exercise, and we'll talk more about the specifics on this in the med section for holistic wellness, but walking, a walking program, or cardiovascular program is crucial with someone with total knee replacement because we know of the underlying metabolic disease that coincides those. that are getting a total knee replacement. And then again, in our education bucket, expectations for recovery, which includes the protocol, and then just specific functional milestones.

POST-OP PROTOCOLS
That third pillar is protocol. When we think about our total knee replacement, there aren't the very hard and fast range of motion precautions we would have in like a meniscal repair. But there are some must-have range of motion milestones achieved, like in that first year to two weeks, things like there should be independent mobility and getting in and out of the home. That should be all independent or modified independent, right, where they're using an assistive device. In that two to six-week mark, they should be at zero degrees of knee extension, right, to promote that terminal knee extension in gait. Anywhere from zero to about 105 degrees of flexion is that goal in the first two to six weeks. around the five to eight-week mark, we should be progressing past 115 degrees of knee flexion. So using these as buoys and goals is something that we not only want to have in our mind but also help encourage the patient that these are like milestones we want to achieve to keep them progressing. And then when we're past that eight-week mark, we should really be close to within normal limits for range of motion. Now we know not every case goes perfectly like this, but these are overall goals. And by the end of our time in therapy, so think that 12-week mark and this is where you can really set up the patient, here's where we're headed, is a normal step through gait pattern, right? That doesn't require an assistive device ideally. Reciprocal stair climbing, step over step, unrestricted standing, and walking to complete life tasks. If this is an athlete, getting them back to their athletic demand because we do have some of our total knees are in fact, athletes. So don't hold them back if they are, but consider them for our everyday human that just wants to get back. Let's think about Betty getting back to her, taking care of her grandkids, and gardening. We need to make sure that she can get on and off the floor, that she can kneel on that prosthetic, and feel confident in that to get up and off the floor for her grandkids. So consider those timelines. when we think about system-wide healing for the person with a total knee. And this part also applies to anyone who's had a post-op or has had an operative condition.

TAKE YOUR MEDS (MINDFULNESS, EXERCISE, DIET, AND SLEEP)
Mindfulness, I already mentioned, right? Some kind of stress relieving strategy, whether it's breathing, journaling, or maybe it's just sitting or walking outside, but giving them something that kind of soothes the soul and the brain. Exercise. This is not just the HEP, right, working on specific impairments. It's not just about quad sets and straight leg raises. This is actually working through a walking program for someone with a total knee. You know, in the beginning stages, it might just be in phase one, working on a 10-minute walking daily. But then we want to eke our way to that 30-minute mark, right? Because we want to meet that minimum of 150 minutes a week of daily activity. Again, think about underlying metabolic disease. The person with a total knee replacement has to build up to this to help fight systemic implications. And so whether that is, ideally it is walking, getting their walking tolerance up to that, but it could also be biking. Think cycling and or swimming. Nutrition. So when we think about diet, that D in meds, we're thinking about nutrition that promotes healing. Make sure they're eating enough protein to heal that incision and help heal the trauma associated with the surgery. They're getting hydrated enough, half their body weight in ounces. that they're eating foods rich in collagen. Think bone broth, sardines, and organ meats, because collagen has been associated with improving healing. Things that are vitamin C rich. Think of citrus fruits like oranges which are cruciferous. Veggies like broccoli Brussels sprouts and tomatoes are another good source of thinking about vitamin C. Bromelain, eat pineapples. This helps reduce pain and swelling. Assuming this is okay with their doctor and nutritionist and their pharmacist, right, not interacting with any meds, all of these natural foods will help boost healing. So just giving that general knowledge, can be really helpful in the healing process. And then I already mentioned sleep, the importance of seven to nine, hours of sleep, giving sleep hygiene. And you can see past podcasts that talk about sleep hygiene tips, or even just message me and I'll send you some. But in the person with total knee, it's not just about how to get them to sleep better, but it's giving them some education like, don't put a pillow under your knee so your knee is flexed all night. And then you're fighting to walk into that terminal knee extension we've been fighting for with the quad set multiple times a day. If you're going to put a pillow under the leg, make sure that the knee is straight, right? Think about maybe talking to them about a wedge pillow so that they're elevating that limb above the heart to help with the swelling that is ongoing in that total knee replacement, but that doesn't put that knee in a flexed position. So when we're thinking about sleep hygiene for the person with total knee, it matters how you sleep, those positions of rest. and don't fall asleep with the ice machine on. This is asking for ongoing stiffness. And if it's cold enough, possibly even does some damage to the local skin tissue. So we don't want that. So, your education on sleep is a little bit different from that person with total me.

REBUILDING TISSUE CAPACITY
And then finally, because I'm running out of time, and this is a topic that is rich and I don't want to take any more, but capacity rebuilding after this last point. So think about, the muscle, tendon, bone, and nervous system. So when we think local, think about skin integrity and prescribing scar massage as soon as that incision is healed, really working on scar massage, think working along as a T and an X, and then specifically focusing on that distal one-third of the incision, it's going to be really paramount in care and getting that knee moving. For local exercise or local muscle, we're thinking of exercising the quads and hamstrings, right? For global, we're thinking above and below the knee. Think about working the glutes, glute max, glute med, but also your hip flexors and to work on your stairs, and then think below also your plantar flexors. For stair climbing and think ankle mobility for squats, When we think about nervous system offense, this is one where I think it's an untapped source, but for that intraneural healing and blood flow, think about using sciatic nerve glides for all that posterior tissue tightness and or those folks that actually have complaints, right, of pain going down the leg. Often it's a secondary result of just an antalgic gait pattern, but get them doing that early so that doesn't become a problem. Even some of our folks have some femoral nerve or saphenous issues. So think about doing some femoral nerve gliding if there are medial and lower leg issues, just that on-off pumping. And then in regards to preventing central sensitization, just consider checking and screening our two-point discrimination, our pain pressure threshold, and our laterality training as we get further out in our rehab and closer to discharge to make sure that this isn't impaired. And if it is, then we train it. And then finally our functional pattern retraining for someone with a total knee. We in the early stages will teach them in a modified way to be independent in their ADLs and IEDLs. But then we wean off of that, right? We want to normalize their gait pattern. Think we go rolling walker to cane to independent ambulation. Even in our sit-to-stands, initially, we'll allow that kick out, right, when someone's going to sit down, but eventually, we want them to use that knee flexion. So we'll have them keep that leg in place and no longer kick out that leg. So consider a functional pattern changes throughout the healing process, but eventually, no matter what, we build up. squat pattern, deadlifts, we prepare for falls by fall training and we prepare for that human to kneel as soon as that incision is healed and they feel comfortable. This is how we train in a multi-segmental way for life after total knee I have usurped my time on the PTL Night Show 21 minutes in. So this is just one small example of someone with a post-op extremity condition and how you can approach it in a fitness-forward way using the five-pillar framework. No, in a total knee, there are minimal precautions, but there are a little bit more precautions on board in other conditions. I appreciate how you can apply this in both the upper and lower quarters. Join me in a month, the day after Christmas actually, to talk about post-op incision management. I appreciate all your time to listen today about a fitness-forward approach to post-op care. Happy Clinical Tuesday, folks!

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.

Nov 13, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore describes pelvic varicosities & varicoceles. Rachel breaks down the difference in how these present in both male and female pelvic physical therapy patients as well as how to conceptualize treatment in the clinic. 

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 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.

RACHEL MOORE
All right, good morning PT on ICE Daily Show my name is Dr. Rachel Moore I am here this morning. It is Monday morning. That means it is our pelvic day here on this podcast So I'm here with the pelvic division and I am super excited to talk to you guys this morning We're gonna be kind of diving into varicoceles and varicosities, vulvar varicosities, and the way that those are actually incredibly similar in our treatment approach, whether we realize it or not. Before we dive into that though, if you missed it, we've officially rolled out all of our certifications here at ICE. So we have certifications, we've had them before in the clinical management of the fitness athlete division and an MMOA, but now we have new ones. So we have orthopedic, we've got dry needling, we've got an endurance athlete, and then what we are super excited about in the pelvic division is we have our pelvic cert as well. So this is three courses, two online, a level one and a level two, and then one live course. If you're looking to get in on that certification, our upcoming courses, we actually have one this weekend in Bear, Delaware. That's going to be with myself and Alexis Morgan. So super excited about that. Still, time to hop into that if you want to buy yourself a plane ticket and get out there. And then we also have one on December 2nd. If you are north of the US border in Canada and Halifax, Nova Scotia, Christina is bringing those live courses to Canada. So we're super excited about that. Our next L1 cohort kicks off January 9th, and then our L2 you can already sign up for. So if you want to be in that first cohort of that L2, it kicks off April 30th. So if you're interested in getting that cert, all of the options are out there. Hop into one of those courses. We're excited to see you in them.

VARICOSITIES AND VARICOCELES
Let's dive into our topic for the day. So a lot of times those of us in the pelvic space if we are maybe majority see women a lot of us tend to maybe start there and then maybe branch off into seeing men but if we are in this kind of blinders-on situation where we're like no no I only see women sometimes we may be uncomfortable or unsure if somebody gives you a call and asks about a certain diagnosis or maybe you have a friend or somebody that you know that is struggling with something and asks for advice on the pelvic space and you're trying to figure out how to get them into your clinic. And so I wanted to draw a parallel this morning between two diagnoses that we see as fairly common that actually are very similar in the way that we treat them. So that is going to be varicoceles and varicosities. So in utero, the reproductive tissues of males and females begin developing similarly. If you guys remember that from PT school, when we were learning about the brief amount that we cover these types of topics, once testosterone starts being released, that's when the reproductive organs shift and either develop into male organs or continue on the path of female organs. And so if the testosterone is there, then the tissue that is becoming the scrotum becomes the scrotum. But if the testosterone is not there, then that tissue continues on to turn into the labia. So when we think about our tissues and our anatomy, we often talk about how male and female anatomy really aren't that different. It is similar parts arranged differently and maybe to different sizes and proportions. But when we look back all the way in utero, we can see that developmentally these things start the same and there's a certain point where things branch, but we have these kind of analogous, um, uh, tissues within males and females. So, We know that the tissues are similar between the scrotum and between labia. When we're talking about varicosities, this is important for us to know because these are two diagnoses that we tend to see come up fairly frequently.

VARICOSE VEINS IN THE PELVIS
So before we dive into the specifics of varicose veins in the pelvic area, let's talk about what varicose veins are. Varicose veins, if you're not familiar with them, are enlarged twisted veins. So oftentimes this comes from damage to the valves in the veins. So our veins have one-way valves that help push blood up and prevent backflow back down. If there is damage to the inside of the vein and the valves are damaged somehow or maybe are not operating at the capacity that they need to be operating, we can see kind of a backlog of blood and that can lead to this kind of inflamed or swollen look to the veins and that blood just kind of pulls in there. The causes of the damage, quote-unquote, Inside of the vein can be known. So this can be something like high blood pressure or it can be unknown Things that increase your risk for developing varicosities are gonna be things like being female So that's always fun when gender is one of the top things can't control for that genetic predisposition so if you have a family history of varicosities then this might be something that you're really keeping an eye on and older age as we get older maybe those valves within the vein become a little bit less competent increased body mass and then in pregnancy we'll dive into that here in just a second and then also interestingly having a history of blood clot that's really important to kind of keep in mind on our radars not only in our post-surgical patients but we're starting to see blood clots kind of popping up more and more um and so if you have somebody who might be not hitting any of these other risk factors but has a history of blood clots it's still something that we want to kind of keep on our radar varicose veins aren't a medical emergency by any means but they can cause some like uncomfortable unpleasant symptoms like heaviness aching pain and then swelling.

VARICOSITIES
Let's dive a little bit deeper into varicosities of the pelvic region so in our biologically female counterparts we see vulvar varicosities this is varicosity that develops on the vulva so anywhere along the outside of the vagina so that tissue of the vulva It can happen on labia majora, labia minora. It can be going towards the inner thigh, more into that groin area. Really just kind of depends on the area that is affected. The risk factor for this specifically is pregnancy. So we see this come up in pregnancy for a few different reasons. One reason is that we have an increase in blood volume during pregnancy in order to support the baby. So that increase in blood volume means that our veins have to work harder to push more blood up. we also know that we see relaxin circulating and that does have an effect on all tissues and then we have an increase in pressure so we have increased pressure from both the weight coming down of baby placenta amniotic fluid and all the things but then if we also think about like the anatomy of a pregnant belly as people progress through pregnancy get into this maybe anterior pelvic tilt their belly maybe drops low it can cause some congestion or some backup within that system which then leads to less efficient drainage. This is something that we see pretty often in the clinic really and you might be familiar with this if you're in the pelvic space. but what we tend to not really think about is how this parallels varicose seals. So a lot of times we're pretty confident and comfortable with vulvar varicosities, but then somebody comes in with a little bit different anatomy, and we kind of get thrown for a loop. So a varicose seal is a varicose vein that's located within the scrotal sac. This can actually develop during puberty because blood flow to the genitals increases during puberty. As those tissues are maturing things can just get a little thrown off, but it can also happen as a result of surgeries So think about vasectomies even though those are like minor office procedures surgeries vasectomies or trauma to the scrotum They're surprisingly common, especially in the adolescent puberty side of things. And just because you have a varicocele doesn't necessarily mean you'll even know it, aside from feeling it, potentially. So the biggest way or hallmark of this is called the bag of worms. because within the skirt sack that varicocele feels like a thick ropey worm and so as people are feeling around checking testicles for different things then you might feel that bag of worms type sensation or that that feeling with your fingers and other than that you may not have any idea However if you have a varicose seal that is causing problems We can see swelling pain and heaviness as I talked about earlier and if this is left alone and becomes severe it can actually impact fertility in men because it can lead to decreased sperm in the ejaculate and so it can be something that if it happens in adolescence and somebody is trying to conceive later on in life with their partner and they're struggling, it's an area to look at. Just like vulvar varicosities, we see an increase in symptoms when we're standing for prolonged periods, but uniquely to this population, we can see potential pain with ejaculation. So with vulvar varicosities, we might see pain with intercourse because of the pressure on the outside of the vulva during intercourse. But with this population, it's going to be more so during ejaculation that there is pain.

WHAT TO DO ABOUT VARICOSITIES AND VARICOCELES
We have our person in front of us, male or female, who comes into your clinic, some varicosity of some sort going on. What are we supposed to do? Jess actually did a really fabulous episode on this topic. It's episode 1198, so if you want to go back and listen to that, she talks specifically about varicosities during pregnancy, and those same concepts can be applied to varicoceles in men. So I highly recommend giving that a listen. We're going to dive in just really briefly touch on some of those topics and then I'll let you guys really dive into justice. External support can be a game changer for these folks, especially those with varicose heels whose anatomy is already putting things in a gravity, um, disadvantageous position for drainage. So giving some type of support, whether that is like when you're getting up and moving using your hand to support or getting some type of support garment. There are specific support garments that are made both for males and females for varicosities. soft tissue massage and when we think about this we're really thinking like mimicking lymphatic drainage I talk about this all the time with breast tissue and engorgement but the same thing we're thinking about this like congestion within the pelvic region and so we want to think about clearing more proximally up Towards the iliac vein so that we can kind of promote that drainage and then work our way down Rather than coming down to the bottom and just shoving everything up and causing more congestion Superiorly, so we're starting closer to the midline Draining quote-unquote that area. So if you're watching on Instagram, we're saying we've got a guy in and he's got varicose heels maybe we're starting here and then we're working lower and then working lower and until we get to that most distal tissue. From an exercise intervention standpoint, the pelvic floor muscles, of their functions are a sump pump. So when they contract and relax, they push fluid out of areas. So teaching our patients how to do pelvic floor contractions, how to lift up and contract into the attic, relax down and go into the basement, get that pumping mechanism going, and then teaching them belly breathing on top of that to help facilitate that as well. Finally, from a positional standpoint, we can have our patients if at the end of the day, they're super symptomatic and they're feeling rough after being on their feet, laying on their back, propping their legs up on the couch, or on a wall to get some passive decrease in gravity pressure on the pelvic region, and we can even take that a step further, have them plant those feet on that surface and do some bridging where they're squeezing their glutes, maybe adding in that pelvic floor contraction, layering that in, so we've got gravity coming down, we've got our muscles contracting and relaxing, really everything helping to push that fluid up and out into the drainage system to go bring that blood back to the heart. So, if you have somebody come in your clinic tomorrow, and you are a pelvic floor PT who traditionally treats females, and a guy walks in and he's like, I have a varicose seal, I don't know what to do. I hope that you can put your cap on, thinking cap on, and realize like, you got this, you know what to do. At the end of the day, we have to remember that our males and our females, although the anatomy is arranged a little bit differently, and proportions are a little bit different, they are similar tissue. So keep that in mind. You guys are rocking it out there. Have a happy Monday. Thanks for having me. Bye.

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

Nov 10, 2023

Dr. Megan Peach // #FitnessAthleteFriday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses the importance of cadence in running, variables that may affect a runner's cadence, the relationship between cadence & speed, and finally the "optimal" running cadence.

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

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

EPISODE TRANSCRIPTION

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.

MEGAN PEACH, PT, DPT, OCS, CSCS
Alright, Instagram. Here we go again. YouTube, we're on. Okay, finally. Sorry about that a couple minutes ago. I think I actually got it to work this time. Okay, we are live on Insta. We are live on YouTube. I am Megan Peach, probably the most technologically challenged person next to Jason that we have in this community. So, I apologize for the previous live feed that didn't actually work. Again, I'm Megan Peach and this is PT on Ice, your daily show. I'll be your host today. I am one of the lead faculty for the endurance division and specifically in the injured runner course, both the live and the online courses. And although our courses have wrapped up for this year actually, We are super looking forward to next year. Over the next couple of months, Jason and Rachel and I are basically doing like a big revamp of Rehab of the Injured Runner online. And so that course is going to look entirely different come January than it does right now. If you haven't taken that course and you've taken the live course already, or even if you haven't taken the live course, this is going to be a great time to hop onto that course, just because the material is going to be really complimentary to the live course, even more so than it has been in the past. And then if you have taken Rehab of the Injured Runner online already, it will be a really good time just to check in because it's going to look entirely different in terms of the material and what's in there. Remember, if you've taken that course already, you have lifetime access for as long as that course exists. And so check in with us in January for a full revamp, full update. We're super excited about it.

RUNNING & CADENCE
Okay, so to get to today's topic, I wanna talk about cadence. And cadence is something that I think if you treat injured runners at all, if you have in the past or you've taken one of the courses, This is a topic that's pretty familiar. It's a running gait retraining tool that we use probably more than any other tool that we have in our gait retraining toolbox. And it's used for a variety of different injuries. We could use it globally for injuries like patellofemoral pain or IT band syndrome. exertional compartment syndrome. There are even prospective studies that have looked at healthy runners and the risk factors for their injuries. And they've seen that low cadence is a risk factor for things like bone stress injuries, things like medial tibial stress syndrome. So we can use it not only to treat injuries, but then potentially as an injury prevention tool as well when somebody has a really low cadence. And then we can also use cadence retraining as a way to treat really specific gait abnormalities or mechanical faults after we've done a running gait analysis. And so typically when we are using cadence as a gait retraining tool, we're increasing the cadence by at least 10%, at least that's the goal typically. And when we increase somebody's cadence, what we typically see are first, changes at the knee joint. At least those are the most prominent changes that we would see in a runner. And the changes we see at the knee joint are things like increased knee flexion at initial contact. We see a decrease in stride length, or a decrease in foot to center of mass, in terms of where the foot falls in relation to the center of mass. We also see changes at the ankle joint, not as prominent as the knee, but we still see them there. We see with an increase in cadence, we see a relative increase in plantar flexion. So whereas we might see a lot of dorsiflexion with a very slow cadence, we see relatively less or more plantar flexion as that cadence increases. Or you could look at it as less angle of inclination as well. We also see changes at the hip. Again, not as prominent at the knee, but they're still there. With an increase in cadence, we will see increased hip flexion also at initial contact. Not only do we see kinematic changes, but we can see kinetic changes while somebody's running as well. And so some of the kinetic changes that we'll see are decreased vertical loading rate with an increased cadence, as well as decreased vertical center of mass, which can then translate to decreased overall loading for that runner with each foot strike. And so while some of those kinetic variables aren't always accessible to us in a clinical setting, typically they're just lab-based variables. we can still use cadence retraining and still make some of those assumptions that it is going to affect some of those kinematic variables as well. So we can not only use cadence as a gait retraining tool to treat specific injuries, we can use it to treat kinematic variables, but we can also use it to treat kinetic variables.

VARIABLES INFLUENCING HABITUAL CADENCE
What I want to talk about and spend the rest of the time today talking about is some of the variables that might influence somebody's habitual cadence that we don't normally discuss or sometimes don't even consider when we are using cadence as a gait retraining tool. And so somebody's habitual cadence, it just means that the cadence that they're running at normally, without any outside influence, without anybody saying, you should run at this cadence, or you should run at this cadence, or you should increase your cadence. It's just their normal everyday cadence that feels good to their body. And so some of the variables that might influence that are leg length, running experience, BMI, as well as speed. So leg length plays a role in that somebody with a shorter leg length, typically has a faster cadence, and somebody with a longer leg length typically has a slower cadence. Okay, now there's obviously a very wide range of a spectrum there in terms of cadence and leg length, and so these variables are typically related to cadence only at, or I guess more strongly, at the ends of the spectrum. So somebody with either very short legs or very long legs their cadence is likely a little bit more related to their leg length than somebody whose leg length sits kind of right in the middle or maybe that like middle 50% range. And so none of these variables are going to apply to everyone, obviously. The next one, so running experience can play a part as well. Somebody who has less experience running, so like a novice runner, typically has a slower cadence. I've definitely found this to be true in clinic versus somebody who has a lot of experience running or who is a very high level runner, maybe even a professional runner, typically has a very high cadence, upwards of mid 180s, upper 180s, maybe even low 190s, depending on that runner. I've definitely found that variable to be true within clinic, but again, Take that with a bit of a grain of salt because the ends of that spectrum in terms of novice versus experience tend to ring more true with a relationship with cadence than the middle of that spectrum for experience. BMI can also play a role in that somebody with a greater BMI tends to have a slower cadence versus somebody who has a lower BMI tends to have a bit faster of a cadence. That one, clinically, I really can't speak to that one, but that's what's in the literature.

SPEED & CADENCE
All right, and speed is the last variable that I wanna talk about because I think intuitively, we know that speed is related to cadence, and that's true to a certain respect. And intuitively, if we think of as somebody speeds up their pace, then their cadence is going to speed up as well. And that's true, but only to a certain extent and really only to higher speeds. And so for most people, their cadence is going to speed up only as they approach sprinting or a very, very fast run. And so when we think of speed and we think of running pace, We have two different strategies that we can use to increase our running pace or our speed. And one of those strategies is to increase the stride frequency or increase the cadence. So we increase the number of times our legs turn over, and that alone can increase the speed. The other strategy to increase speed is an increase in stride length. So rather than increase the stride frequency, we can also increase the stride length. And when we increase the stride length independent of any other changes, we can actually increase the speed even when we're maintaining the same stride frequency or cadence. So if we are using these variables independently and considering them independently, most humans are going to take the stride length strategy first up until they get to a point where they're almost sprinting. So a very fast run, a very high intensity run. And at that point, then they're going to employ more of a stride frequency or a cadence tactic to increase their running pace or running speed. So let's think about when you have an injured runner on a treadmill and you're choosing to use a cadence gait retraining tool to address either their running-related injury or certain gait mechanics, and you get them back on the treadmill, and you're having them run at their 6.0 mile per hour, whatever they did their running gait analysis at, and you say, okay, I want you to run at this new cadence, and you've increased their cadence, and now you have it on a metronome, and you put the metronome on the treadmill, and they hear that click, click, click, click, click when they're running, and the first thing they do I think you've all experienced this. If you have treated injured runners before, the first thing they do is that they increase the speed on their treadmill, right? So why we don't want them to do that is that if they increase that speed on the treadmill, chances are they're also going to employ this increased stride length strategy to increase the speed. They may also increase their cadence as well, but we have to remove some of those variables. If we keep them at the same speed that they did their running gait analysis, which should be a fairly comfortable speed for them, something they would run just an easy run, or even a moderate run, but let's say we have to keep them at that same speed that we use for the running gait analysis while we're using that increased cadence, then they have no choice but to increase the cadence rather than increase their stride length. We don't want them to do that. If they increase their stride length by increasing the speed on the treadmill, what's going to happen is that they're likely going to reach out further, meaning they're going to increase their over stride, which is definitely a variable we don't want to influence negatively. We want that over stride to reduce. They may get increased knee extension at initial contact, which again, not a gait mechanic that we want to encourage. We want to encourage more knee flexion at initial contact. We also want to encourage more or less dorsiflexion at initial contact, more plantar flexion, relatively speaking, which is likely also going to increase in the negative direction if we increase the stride length by increasing the speed on the treadmill. All of these variables are very much related in terms of the gait mechanics and the speed of the treadmill and which strategy they employ to actually increase that running gait speed. But if we take out the speed component and just leave that pace at the same pace on the treadmill, then they have no choice but to then change their cadence to match the cadence that you've chosen. And in turn, what we're hoping to see is a positive change in their gait mechanics.

"OPTIMAL" CADENCE"
Now we often get a question in both courses of what's the optimal cadence for a recreational runner, and really there isn't like a set in stone, everybody's gotta run at this cadence. It's a range, anywhere from mid 170s to mid 180s is typically what we kind of range for for a recreational runner. It may go higher than that. For a more experienced runner, I find that they can tolerate higher cadences, for a very novice runner, generally sometimes they don't even tolerate like a mid 170s and so although it might be a goal, it's something that we may have to work up towards in the future and with different gait retraining strategies. Okay, so I hope that helps. I hope that clears things up for some cadence questions that we commonly get in both the rehab online and the rehab of the injured runner live. I hope you have an awesome Friday and a great weekend and we'll see you next time.

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

Nov 9, 2023

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

In today’s episode of the PT on ICE Daily Show, ICE faculty member Christina Prevett emphasizes the crucial role of understanding statistics in making clinically relevant decisions. While staying up to date with the literature and being evidence-based are often emphasized in healthcare, Christina points out that it is not enough if one lacks the ability to comprehend the meaning of statistics and their application in a clinical setting.

Christina acknowledges that interpreting statistics can be challenging, even for individuals with a PhD and experience in the field. This understanding leads the host to empathize with clinicians who may find statistics intimidating. It is recognized that being evidence-informed and evidence-based requires clinicians to possess the skills to understand and interpret the data they encounter.

To make statistics more clinically relevant, Christina suggests utilizing systematic reviews and meta-analyses as tools for interpretation. Specifically, she delves into the interpretation of a forest plot, which graphically represents the results of a meta-analysis. By understanding how to interpret and analyze the data presented in systematic reviews and meta-analyses, clinicians can determine if the findings are significant enough to drive changes in their practice.

Christina also highlights the importance of considering clinical relevance when interpreting statistical findings. The concept of the minimum clinically important difference (MCID) is introduced, which refers to the smallest change in an outcome measure that is considered clinically meaningful. An example is given of a statistically significant improvement in a timed up-and-go (TUG) test, but it is explained that it may not be clinically relevant if it does not meet the MCID for the TUG.

 

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.

CHRISTINA PREVETT
Good morning everybody and welcome to the PT on ICE daily show. My name is Christina Prevett. I am one of the lead faculty in our geriatric and pelvic health divisions. So usually you’re seeing me on Monday and Wednesday, but today I’m putting on my PhD research hat to talk a little bit about statistics, which I know sounds really boring, but I promise I’m gonna make it really exciting. But before we do that, we have a couple of courses that are coming up across our divisions. So MMOA is in Wappinger’s Falls, NY this weekend. Extremity Management is on the road in Woodstock, Georgia. And Cervical Spine is heading to Bridgewater, Massachusetts. And so if you are looking to get in some Con Ed before the end of the year, we still have a couple of opportunities across all of our different divisions. And so I encourage you to go to ptinice.com and take a look at some of those opportunities. Okay, so a little bit about my kind of hat outside of working with ice is that I recently finished my PhD at McMaster University at the end of this year. I just announced that I’m doing a part-time postdoctoral fellowship at the University of Alberta looking at resistance training and its interaction with pregnancy and pelvic floor function.

BUMPING INTO STATISTICS
What that means is that I am bumping into statistics all the time. And I’m going to like kind of start this off and say, I’ve been asked to do some webinars and things around statistics for the ice crew for a while. And to be honest, it’s been really intimidating for me to do that, despite the fact that, you know, I have a PhD and I’m interacting with this stuff all the time. Um, statistics is hard and, you know, discussing statistics in a way that makes sense is also challenging. And when I reflect on that and the fact that you know, I feel uncomfortable sometimes with interpretation and you know, I did a part-time PhD for seven years and I’m in a postdoctoral position. I recognize how challenging it can be for clinicians. And, you know, we get told all the time, like, you know, stay evidence-informed, like it’s important to be evidence-based. It’s important to stay up to date with the literature. But your ability to stay up to date with the literature is only as good as your capacity to understand what it is trying to tell you. And I mean that in the best way possible, that it is so tough for us to gain insights from what the statistics mean into what is clinically relevant for us to understand and be able to bring into our clinics. So today I’m trying to take our statistics and make them clinically relevant to you.

SYSTEMATIC REVIEWS WITH META-ANALYSIS
One of the first ways that I want to do that, and if you like this type of podcast please let me know, and I’ll do more, is around the systematic review and meta-analysis and then trying to kind of deep dive into interpreting a forest plot. So when we’re thinking about a systematic review, this is the highest level of evidence when we have a systematic review of intervention or prospective studies. When we take a systematic review, we ask a very specific question. And I’m going to use the example, I’m working on a systematic review right now on resistance training and pregnancy. And I’m going to take some of that to make this relevant to how this happens. This is where we’re trying to get an idea of the state of the literature. So we use a PICO format, which is the population that we’re trying to look at. So in this case, it’s individuals who are pregnant. The intervention is what you are trying to see if there’s a positive or negative benefit or whatever that exposure may be. And that for me is resistance training. The comparison group is to usual obstetrical care. And then the outcomes, we are looking at fetal delivery, pregnancy, and pelvic floor-related outcomes. So we’re looking at the investigation of resistance training on incidents of gestational hypertension and preeclampsia, gestational diabetes, rights of cesarean section, the size of babies, and babies more likely to be too big or too small. What does their birth weight look like? How long are they pregnant? And then are they at increased risk for things like urinary incontinence, pelvic organ prolapse, diastasis recti, or pelvic girdle pain? So that’s kind of the format of a systematic review we’re trying to answer a very specific question. From there, we go to the literature and we want to make sure that we encompass as much literature as we can. in our search strategy. So that is usually why you’ll see a list of PubMed and OVID, CINAHL, Sports Discus, like these types of different big searching platforms that are looked at. And then you’re going to get a Prisma plot that you’re going to see in the first figure. And that kind of describes a person’s search strategy. So how many hits were given when this search was done? How many were excluded because of duplicates? How many were excluded from the title and abstract because they were done in rats instead of in humans? Or they were looking at an acute effect of resistance training versus being on a resistance training program like you’re going to have a lot of those that are excluded. And then you’re going to have kind of what is included in your systematic review, and then what is included in your meta-analysis if a meta-analysis is indicated or possible. When we’re looking at a systematic review, we’re looking at a qualitative synthesis. And what we mean by that is that we’re trying to figure out, you know, where the state of the literature is. And when I’m reporting on something like the systematic review portion of a paper, You’re seeing things like, you know, how many studies were done in resistance training in pregnancy? How long were those interventions? Were they done in the same cohort of individuals? What was, how many of them were statistically significant? What was the dosage of that intervention? Those are things that kind of come under the systematic review umbrella. But I would say really now the emphasis is being placed on the meta-analysis and that is the quantitative combination of these studies and that is what gives us this forest plot. So when we are going through and doing a meta-analysis, there are a couple of things that we need to make decisions on very early on. So the first thing is on a random or a fixed effects model. This is kind of getting into the weeds, but almost all papers are going to be a random effects model, which means that we’re going to expect some variability in the population that we are working with, and we’re going to account for that variability in the calculations that we’re using for our forest plot.

PRIORI SUBGROUP ANALYSES
The second thing that we are looking at is a priori subgroup analysis. And so I’m going to use my research study to describe this. Before going into this meta-analysis and putting this forest plot together, we have to brainstorm around where possible sources of skew or bias would come into a forest plot. For example, in the resistance training intervention, it would be very different when we have resistance training in isolation versus resistance training as a component of a multi-component program. And so one of our subgroups analyses a priori we discussed was that we were going to subgroup studies that were only resistance training compared to our big meta-analysis, which included our resistance training in isolation or as a multi-pronged program. Another example in our systematic review is that some of our studies were on individuals with low risk at inception into the papers versus those that were brought into the study because they were diagnosed with a complication like gestational diabetes. we could think that the influence of resistance training on a person who has not been diagnosed with gestational diabetes versus those who have could be different. And so we did a secondary subgroup analysis where we looked at the differences between studies that looked at only individuals with gestational diabetes versus those that didn’t. And so when you are looking at a forest plot, you will see the big analysis at the top, including all of the different studies. And then after that, you will see different subgroups where there’s a repeater of what was in the main group, but it’s a subsection of the included studies. And that’s what we see. And then we try to see, you know, is resistance training and isolation positively associated with a benefit? versus multi-component or is there no difference and that gives us a lot of information too? So that’s that subgroup analysis. Then you go into the results of the paper and there is a forest plot that is there and this forest plot has a bunch of different names of studies It has the total number of incidences and the weight. It has a confidence interval with a number around it. And then on the right-hand side, there’s like dots with lots of lines and then a big thick dot at the bottom. I’m trying to explain this to our podcast listeners so that you can kind of understand. And I hope you’re kind of thinking of a study in your mind that you have seen in the past. But we’re going to kind of explain each of these different things. Okay, so when we’re looking at what we are trying to find, it is going to depend if we are looking at a dichotomous variable like did gestational hypertension get diagnosed or not? And if it is a dichotomous variable, what we’re looking at is an odds ratio with a 95% confidence interval. So if we are thinking that no difference between usual care and resistance training is one, then a reduction in risk for gestational hypertension with resistance training would be an odds ratio that is less than one. When it is less than one, it becomes statistically significant when the 95% confidence interval encompasses all numbers less than one. When the confidence interval, say for example, our odds ratio is 0.8, we can say that there is a 20% reduction in risk, because a one minus 0.8, of getting gestational hypertension because of resistance training. I’m making these numbers up. But that is only statistically significant if the confidence interval is 0.7 to 0.9. then we can say there’s a statistically significant reduction in risk for gestational hypertension with resistance training in this systematic review of this meta-analysis. Where we cannot say it’s statistically significant is if the odds ratio is 0.8 and the 95% confidence interval is 0.6 to 1.2. That crossing of one means that there is a higher likelihood that there is that variation is because of chance and not because of a true difference. And so what you see is that when you’re looking at the odds ratio, the combination of all of those odds ratios from the individual studies are then pooled in that bolded line at the bottom of the forest plot to give us the confidence that we have based on all of the studies combined, that there is a true effect of resistance training in this example on gestational hypertension.

I-SQUARED HETEROGENEITY
The other kind of statistic that we’re looking at is the I-squared statistic or the amount of heterogeneity. So when you’re looking at that forest plot and you’re seeing all the dots and those lines, the heterogeneity is basically saying how close are those dots? How much spread is there in those dots? And so if the heterogeneity is low, we can say that not only did we have a statistically significant result, but across all of the studies, we tended to see a trend in the same direction. So it allows us to have more strength and confidence in the results that we are getting. If we see a high amount of heterogeneity, so like there are some that are like really favoring control and saying that resistance training is bad for gestational hypertension, and then some are having really positive effects of gestational hypertension on resistance training, that I square statistic would be high, and then we would probably have to be doing more evaluation, and that’s where we would rely really heavily on the subgroup and say, Well, is there certain subpopulations of this group that are skewing the data in one way or the other where their results may be different than the results of other individuals? And so that gives us a bit more information. So the odds ratio is when we’re looking at the presence of an event and it’s a binary variable of yes, this exposure exists or no, this exposure didn’t. When we are looking at continuous variables, we are looking at like a time on an outcome measure, like the time to up and go, we are looking at a mean difference score between resistance training and a control. So the mean difference is going to be in the measurement of the outcome measure that we are looking at. So the target would be seconds. So then from the pool, it would be plus, Six seconds or mine I guess minus six seconds would be in favor of resistance training and that your tug score is six seconds less in a resistance training arm than a control arm or if it goes against resistance training it would be plus six and Again, we’re looking at that 95% confidence interval. That average, that mean difference is also something that we would push against what our clinically relevant difference is. So we may see something that’s statistically significant at a two-second improvement, but we know that the MCID for the TUG is four seconds. So while yes, it’s statistically significant, it may not be a clinically relevant finding. So that’s kind of where we build in clinical relevance. And then again, we look at that 95% confidence interval, see what that spread looks like, and look at that I squared statistic. Where it gets a little bit more complicated is when we have things that are measuring the same thing, but measuring it in a different way. So an example in the systematic review that I did on resistance training and lower extremity strength is that there are a lot of different ways for us to measure lower extremity strength. Some people may use an estimated one rep max, and Some people may use a five-time sit-to-stand as a conduit for functional strength training. Some people may use a dynamometer for knee extensor strength. There’s a lot of different ways for us to do that. We can still do a meta-analysis on this, but what we have to do is transform all of those variables into one type of measure. And that’s when we would see something called a standardized mean difference, an SMD. And in that SMD, we’re essentially taking the impacts of all these different types of measurements that are telling us the same information and putting it into an effect size. And so the effect size gives us the amount of confidence that we can see in the influence of the intervention resistance training on the outcome of lower extremity strength. So an effect size using Cohen’s d statistic would be that less than 2 is no effect, 2 to 5 is a moderate or minimal effect, 5 to 0.8 is a moderate effect, and 0.8 and above is a large effect. And so in my systematic review on lower extremity strength and resistance training in individuals with mobility disability, we saw a standardized mean difference of 3, which means that we can be really confident there was a large influence of resistance training on the development of lower extremity strength. So kind of pulling this all together, I know I threw a lot at you. When you were looking at the forest plot, you were looking at trends in the data that are pooling all of the different intervention studies, looking at the same construct and looking at the same outcome. When we are looking at the odds ratio, this is a binary variable. There’s going to be a 95% confidence interval. And the pooled odds ratio that we look at with respect to making decisions is that bolded number at the bottom. Our I-squared statistic gives us an idea of the spread of the data and the results that we see. When we are looking at continuous variables, you’re going to see either a mean difference or a standardized mean difference. The mean difference is reported in the measurement of the outcome measure that we’re talking about. So it could be seconds, it could be points. A standardized mean difference is an effect size where we are transforming multiple different outcome measures into one output that’s pooling these things together, but we have to do it in a standardized metric that looks at the magnitude of the effect of that outcome. So how do we think about this clinically? Well, the first thing is that we need to understand where these effect sizes are and if they are significant. And then we have to put it through the filter of, is this clinically relevant? When we have something that isn’t statistically significant, the next thing to do is go into the methods and say, you know, was this dose appropriate? Was this done in the way that I would do this? And can I be confident that the interaction between what I would do in the clinic and what was done in these studies is significant enough for me to drive changes in my practice? All right, I hope you found that helpful. I’m at 18 minutes, I knew I would. But if you have any other questions about statistics and how to interpret them, please let me know. It’s really important that we know how to understand the data that we’re being presented with because that’s how we’re gonna change our clinical decisions based on what we are seeing. All right, have a wonderful afternoon, everyone. I promise hopefully I didn’t stress your brain out by talking about math too much and hopefully, this was helpful and we can do it again sometime.

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.

Nov 8, 2023

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

In today’s episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment.

Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum.

Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels.

She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame.

Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear.

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

CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we’re gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don’t need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you’re interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you’ll see is slightly less because we are making it equivalent to the Canadian dollar. So if you’re wondering why that course is at a different price, it’s because we’re creating an equivalency to the Canadian dollar. And so if you’re interested in catching us before the end of 2023, those are your last two opportunities.

EXERCISE IN THE PREGNANT & POSTPARTUM SPACE

Okay, let’s talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don’t have an abundance of literature. And I made the argument that it isn’t. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who’s looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I’m gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn’t doing CrossFit at that time so my body was not used to the impact of running and So I didn’t feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn’t feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn’t do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn’t get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I’m sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don’t have any evidence to say that Riding a horse is bad, but we just don’t want to minimize the risk of falling But here’s the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones.

BECOME A PRO AT PUSHING THE BOUNDARIES

As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals’ risk tolerance may be different than ours. And I’m talking about kind of pushing the extremes of exercise, but I’m also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You’re going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it’s the same thing.

THE RISKS OF NOT EXERCISING DURING PREGNANCY

Our division is adamantly against the six-week blanket statement that we shouldn’t be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it’s going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it’s important for us to be able to make informed decisions, which includes the fact that early movement, and I’m not talking exercise, I’m talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that’s something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they’re at.

REFRAMING RISK TOLERANCE

And so why is this reframe around risk tolerance so powerful? we don’t have a movement problem, which means that we need to push our recommendations within a person’s risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person’s risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don’t have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients’ wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don’t know to the yes within these kinds of buoys or navigational obstacles that we’re going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we’re asking it to do. It doesn’t it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there’s obviously some big risks or red flags, we are going to educate on that. But most of the time, it’s our own discomfort because their risk tolerance doesn’t match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client’s perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can’t believe I’m already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client’s, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don’t have any justification for that kind of shifting or that moving away from a person’s own tolerance zone. And I really challenge individuals to not make individuals feel bad. There’s a lot of shame in the perinatal space that is unfounded. And I think it’s really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It’s a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We’ve been fielding questions. We just love the interest that we’ve seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will 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.

Nov 6, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett delves into the need for a shift in the perinatal space, moving away from a fear-focused message and towards one of empowerment.

Christina emphasizes the significance of understanding and respecting individual risk tolerance when it comes to making decisions about exercise and healthcare during pregnancy and postpartum.

Christina argues that healthcare providers should not impose their own risk tolerance onto their patients, but rather support and empower them in making informed choices that align with their own comfort levels.

She also highlights the presence of unwarranted shame in the perinatal space and encourages listeners to critically evaluate their own risk tolerance zones, challenging any beliefs or practices that contribute to this shame.

Christina underscores the importance of evidence-informed practice and the facilitation of movement and exercise, rather than creating barriers based on fear.

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

CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of our team within our pelvic health division. And if you have been catching all of the news coming out of the ice world, you know that we just announced our pelvic certification, CertPelvic. And we are so excited to bring this to you all. One of the missions that we have been kind of on this journey for over, you know, the last four or five years has been to try and flip the script in pelvic health and really create a fitness-forward approach to pelvic health, just like we are trying to do in the orthopedic spaces. And so our cert pelvic is our next Step in that trajectory. And so we are going to have three courses in our cert pelvic curriculum We have our two-day live course and then we're gonna have two eight-week online courses level one and level two if you have taken Our live course that is going to count as your cert pelvic The only additional piece is that there is going to be an added skills check to the end of our second day. If you are interested in becoming CertPelvic, you will have to find a time when we are near your area to be able to take that skills check for the end of day two. You don't need to take the course again. You do not need to pay a fee for the skills check. We just have to get that from you for individuals who have already taken our live course. And if you're interested in catching our live course one more time, or getting in before the end of 2023, we have two opportunities left. Alexis is gonna be in Bayer, Delaware on the 18th and 19th of November, so in two weeks. And then at the beginning of December, December 2nd, and 3rd, I am gonna be in Halifax. And that course you'll see is slightly less because we are making it equivalent to the Canadian dollar. So if you're wondering why that course is at a different price, it's because we're creating an equivalency to the Canadian dollar. And so if you're interested in catching us before the end of 2023, those are your last two opportunities.

EXERCISE IN THE PREGNANT & POSTPARTUM SPACE

Okay, let's talk about exercise in the perinatal space. You know that we have been on a huge journey to reframe the idea around Pregnant and postpartum exercise it is no surprise to any of you who are listening and have listened to our division that we are very pro pushing the boundaries and that we believe from a fitness perspective that the answer should be yes For health promoting behaviors instead of flipping to the no and proving it I did a podcast episode a little while ago where I said is it ethical, you know to remove resistance training in a pregnant individual and because we don't have an abundance of literature. And I made the argument that it isn't. Until we have safety data to take away a health-promoting behavior, we should start with the yes. And so this kind of goes into this reframe. I was talking to Sinead DeFore, who is a Ph.D. who's looking at diastasis recti and pelvic girdle pain literature, and she created this idea around risk tolerance within my brain and it has really helped me to solidify our thoughts and feelings about exercise our sparks notes a very first thing is that We are going to have individuals who are going to have their own Risk tolerance and I'm gonna give you a couple of different examples. So everyone is gonna have their own risk tolerance when it comes to exercise. Personally, when I got pregnant with my daughter five years ago, I was a national-level weightlifter. A barbell was an extension of my hand. I knew where it was going to go. I knew what it was going to do. I could make finite, tiny little details and I would be able to manipulate my technique. I felt extremely confident moving around a barbell during my pregnancy. Was not a runner. I had done CrossFit but I wasn't doing CrossFit at that time so my body was not used to the impact of running and So I didn't feel that good running after about 18 or 20 weeks of pregnancy And so I removed running from my exercise routine I was not running that much to be good with but I removed it and I kept Olympic weightlifting all the way up until delivery and That is my risk tolerance. I decided what felt good for my body and I made decisions within that. That does not mean that I do not have individuals that I have seen that were running right up until delivery and then a heavy squat or squatting below parallel just did not feel good for them. It didn't feel good on their pelvis. So many people have their own risk tolerance. we are starting to see people push the boundaries in almost every stretch from a pregnant and postpartum fitness perspective. We are seeing individuals, part of my postdoctoral work is some of our team members are talking about contact sports, for example, and contact sports are contraindicated during pregnancy. People are told to not do equestrian, for example, during their pregnancies. And then you have some equestrian riders who feel extremely confident with the horse that they are working with and may continue to ride. Even though right now our data says that maybe we shouldn't do that on the chance that somebody falls off a horse. I treated an individual who was snowboarding, 17 weeks pregnant, fell so hard she broke her collarbone, baby ended up being okay. Another one of these decisions would probably not have been within my risk tolerance, but individuals are starting to push the boundaries. We are starting to see changes in the military with respect to flying restrictions. We were being told that when you found out that you were pregnant you were grounded with respect to flying hours. Yeah, right. Someone says, I grew up showing horses and you couldn't get any of those ladies I knew at the barn to get off that horse. Absolutely, right? And that is, again, literature that we are basing off of a lack of understanding. I'm sure that there are so many examples exactly like that, where individuals feel so confident with their horse that they are not worried. We don't have any evidence to say that Riding a horse is bad, but we just don't want to minimize the risk of falling But here's the thing if we kind of take this back and talk about risk tolerance as grown-ups We can decide it for grown-ups or not But as grown-ups we are taking risk every single day every time we walk out of our house We are deciding if it is snowing and we decide to jump into a car. We are making a decision and we are calculating We are creating risk thresholds. When we are even talking about health-promoting behaviors, we are talking about stacking the deck in our favor or away from it, right? We are health-promoting or we are taking things that are going to increase the risk of an adverse event. But none of these things are guaranteed, and everybody is going to have their own risk tolerance zones.

BECOME A PRO AT PUSHING THE BOUNDARIES

As physical therapists who are working in the perinatal space, it is time for us to embrace that risk tolerance, embrace the fact that individuals' risk tolerance may be different than ours. And I'm talking about kind of pushing the extremes of exercise, but I'm also talking about allowing individuals who do not feel safe continuing to do certain exercises to be allowed to step that back if that pulls them within their risk tolerance zone. We do not have a movement problem in our society. We have a lack of movement problem. All of our divisions are screaming this from the rooftops. You're going to hear me say this in geriatrics. What that means though and what we see is that during pregnancy and postpartum exercise goes down and we see that fewer individuals are hitting the exercise guidelines despite the fact that our guidelines during pregnancy from an intensity and a Duration perspective mirror that of the general population what I mean by that is we are still trying to accumulate 150 minutes of moderate-intensity exercise during pregnancy and moderate intensity resistance training are Recommended but what we see is that during pregnancy for a whole slew of reasons Not just the fact that individuals are pregnant and getting scared away from exercise though. That is a component We are seeing that individuals are less active so Then we go into the postpartum period, and it's the same thing.

THE RISKS OF NOT EXERCISING DURING PREGNANCY

Our division is adamantly against the six-week blanket statement that we shouldn't be doing any exercise, and we are 100% against the five in the bed, five around the bed, five in the home type of rhetoric. The reason is that it's going to increase our risk for blood clots, and it is unrealistic for so many individuals who do not have a village that allows them to be able to do that. If you are trying to bond with the baby and that is something that you want to do, excellent, but I also think that it's important for us to be able to make informed decisions, which includes the fact that early movement, and I'm not talking exercise, I'm talking about getting out of bed, is really important for the management of postpartum complications. risk tolerance is going to be different. We see a lot of individuals who want to go to the gym two weeks postpartum. Are they jumping into a CrossFit workout? No, but are they becoming around their village because they feel really lonely and sad and their hormones are all over the place and somebody is going to take their baby and tell them and have an adult conversation and that's something that they want to do completely. their risk tolerance is going to be different. Do we have some individuals who adamantly want to wait until six, eight, 10, or 12 weeks, who do not have the mind to go in, who are struggling with sleep, who are having trouble with hormones? Absolutely. And so we are going to meet them where they're at.

REFRAMING RISK TOLERANCE

And so why is this reframe around risk tolerance so powerful? we don't have a movement problem, which means that we need to push our recommendations within a person's risk tolerance. And the message needs to be around facilitating movement, not creating barriers to exercise, right? As physical therapists, our job is to help facilitate movement. And when we create fear in the perinatal space, by moving or shifting a person's risk tolerance down beyond the level that they want to accept. We are not providing evidence-informed practice, right? One, we don't have the evidence to show that there are things that are adverse, and many of these things are mechanistic based on theory and are starting to be disproven. But the second thing is that we need to be taking our clients' wishes and hopes into perspective and that is an equal part of the triangle of evidence-informed practice and then obviously our clinical experience. Our clinical skilled care is where we can move those buoys, and give individuals ways for them to navigate exercise so that they know what they are listening to their bodies for, in order for us to be driving change in this space. When we accept this model of risk tolerance, we get to move from the no or I don't know to the yes within these kinds of buoys or navigational obstacles that we're going to be able to keep individuals within. We need to think that we want to move individuals away from being more sedentary out of fear in the perinatal space and move them to more empowered movement of their bodies in order for them to feel strong and empowered. We are starting to see over and over and over again that Individuals who maintain strength during their pregnancy have a much easier time postpartum from a muscular physical reserve perspective. We see this across everything in rehab. Our body needs to be strong enough to handle what we're asking it to do. It doesn't it breaks down. There are overuse injuries if the tensile strength of our bone does not match the force at which we hit the floor We have a fracture we see this in orthopedics the same is true in the perinatal space like our body needs to be able to respond to the stress is on their body in the pregnant and postpartum period and if we are deconditioning our pregnant individuals we are not setting them up for success and so we need to be able to have a shifting and moving risk tolerance to meet the risk tolerance of the person that is in front of us and then if there's obviously some big risks or red flags, we are going to educate on that. But most of the time, it's our own discomfort because their risk tolerance doesn't match our risk tolerance. And then we are making recommendations that are not serving them, but making us feel more comfortable. And so my call to action for you all today is to push your comfort zones. Really reflect, is there a discrepancy or difference between your risk tolerance and mine? And if there is, is that because of my own experience in this space? Is it because of my own lack of experience with somebody with this type of risk tolerance? And then how do I marry those two things to respect where the evidence is, but also where my client's perceived risk is? And then how can I bring my own clinical practice to help marry those two things together to serve the person that is in front of me? All right, I went off on a soapbox. I can't believe I'm already 14 minutes in. I hope that you found that helpful. This idea of risk tolerance and being able to see this as a moving target, I think is going to shift us away from a fear-focused message in the perinatal space towards more one of empowerment. And if your risk tolerance is less than your client's, that is not bad, but it is not our job to project our risk tolerance onto a patient, especially when we don't have any justification for that kind of shifting or that moving away from a person's own tolerance zone. And I really challenge individuals to not make individuals feel bad. There's a lot of shame in the perinatal space that is unfounded. And I think it's really important for us to really think critically about these risk tolerance zones and where ours exist. All right. If you have any other questions, if this is something that is a reflection point for you, I want to hear about it. If you want to see more of the research and get more of the news coming out of our pelvic division, cause geez, things have been moving really fast in our divisions. I encourage you to sign up for our ice pelvic newsletter. It's a research-focused newsletter that comes out every two weeks on Thursday. Our last one went out last week. If you have any other questions about our ice pelvic cert, please reach out to us. We've been fielding questions. We just love the interest that we've seen in our certification and we are so excited to show it all to you. Otherwise, I hope that Alexis sees some of you in Bayer or I will see some of you in Halifax. Have a wonderful rest of your Monday, everyone, and we will 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.

Nov 3, 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 the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad".

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

ALAN FREDENDALL

All right. Good morning, folks. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. We're here a little bit early in the garage. We're going to be talking about some double unders today. Welcome to Fitness Athlete Friday. My name is Alan. I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at the company, as well as the Division Leader in our Fitness Athlete Division. We love Fitness Athlete Friday. We would argue it's the best day of the week. On Fitness Athlete Friday, we talk all things relevant to the CrossFit athlete, Olympic weightlifting, powerlifting, bodybuilding, anybody that's recreationally active in the gym. We also talk about our endurance athletes, whether you're running, rowing, biking, swimming, triathletes, If you have a person that's getting after on a regular basis, Fitness Athlete Friday has a topic for you. Some courses coming your way from the Fitness Athlete Division. We have a couple live courses before the end of the year as we get ready to close out 2023. This weekend, as in tomorrow and Sunday, November 4th and 5th, both Mitch Babcock and Zach Long will be on the road teaching. Mitch will be down in San Antonio, Texas, and Zach will be in Hoover, Alabama. Even though it's last minute, both of those courses still have some seats. And then your final chance to catch Fitness Athlete Live will be the weekend of December 9th and 10th. That's gonna be out in Colorado Springs, Colorado, and that will be with Mitch as well. Online from the Fitness Athlete Division, our entry-level course, Clinical Management Fitness Athlete Level 1 Online, previously called Essential Foundations. The next cohort of that class begins November 6th. We love that class. That is a great entry-level experience into all of this stuff if you have not taken it yet. We take you through the very basics, back squats, front squats, deadlifts, presses. We get into some basic gymnastics with the pull-up and introduce you to Olympic weightlifting with the overhead squat. Along the way, we have case studies relevant to athletes with those particular issues that we discuss with those movements. We talk a lot about loading and we get you introduced to basic programming, both for injured athletes and also how to recognize CrossFit style programming, strength style programming to better prepare you for those folks who want to continue on to our level two online course, previously called Advanced Concepts, who really want to drill down into programming, advanced gymnastics, advanced Olympic weightlifting, and truly become the provider of choice for athletes in their region through the clinical management fitness athlete certification. So that's what's coming your way course-wise from us in the CMFA division.

WHAT ARE WE DOING WITH THE DOUBLE UNDER?

Today we're going to talk about double-unders. This is personally an issue I've struggled with for a long time and probably maybe aside from pull-ups and handstand push-ups, one of the more basic movements we see in the gym that still a lot of your membership base will struggle with, maybe you personally struggle with, and I want to talk about what are we actually trying to do with the Double Wonder, some tips and tricks and cues to think inside your mind as you're going through them. I want to spend some time talking about the equipment involved in jumping rope because I think there's two sides of the equation, people with very basic equipment and people with maybe equipment that they don't need that's maybe too expensive, too advanced, And then I also just want to talk about how to begin to better practice double unders so that you can work towards achieving them and being able to complete them during a workout, in large sets, when the CrossFit Open comes up, or just in your regular workouts at the gym. So first things first, with double-unders. When I ask a lot of athletes in the gym when I'm coaching, when they say, oh my gosh, I just did five double-unders in a row, I say, great, great, what were you thinking about? And overwhelmingly, the majority of the people say, I don't know. I couldn't tell you what I was thinking about. And that strikes me as very different from a lot of stuff that we do in the gym. People usually have maybe one cue or maybe even a couple cues in their mind when they're setting up for a heavy deadlift, when they're setting up for a clean and jerk or a snatch or a handstand pushup. They often don't kick up upside down or go to max out their snatch and tell you that they had nothing going on in your brain. But something about the double under, people think it's just magic, how you learn these and how you get better at them. And unfortunately, it's not magic. Fortunately, it's just physics. So I want to talk about really at a base level, at a nerdy physics mathematical level, what are we doing with the double under? We are translating linear force. We are creating force across the lever that then transforms into rotational force where your jump rope handle meets the bearing.

FIX THE SET-UP

If your jump rope is nice enough to have a bearing. So a lot of times the setup, even with just the handles is wrong of looking at a jump rope. Again, it's quite a basic piece of equipment. It's got some handles. you to hang on to in a rope. Even a cheap moderate jump rope of $20 should have some sort of bearing set up so that it spins a little bit. We are trying to create force at the end of the handle that as we flip that jump rope it turns into rotation through the rope and that by doing it both hands at a time with that flicking motion we spin the jump rope. What we're not trying to do is physically spin the rope ourselves with our shoulders, right? We're trying to create rotational force through a flick. So the first thing is making sure that you are even handling your jump rope appropriately. If you are cinched down with a full grip, right where the handles meet the bearing, first of all, you can physically block the bearing if you're not careful. If you hold right here with a depth grip, that bearing cannot spin anymore, right? It's going to be extraordinarily difficult to easily create rotational force here and you're going to naturally be that person who has to spin your arms to spin the jump rope. That's exhausting. It's not a great way to do single unders and it's an even worse way to do double unders. So first things first, where are you grabbing the handle? You should be grabbing further down the handle, ideally with a loose grip, as low on the handle as you can get, right? The longer the lever, the more force amplification we have, right? The more force is going to be transferred and transformed into rotation down here versus the higher we grab up towards that bearing. So a nice loose grip, thinking about flicking, creating linear force at the bottom of the handle that creates a spinning force for me up at the bearing. So that's number one of making sure that you're even using the jump rope correctly. The next thing is making sure it's sized correctly. I always laugh when I see people in the gym who I know are taller than me, which is not very useful because most human beings are taller than me, but I know someone is a couple inches taller than me and I see them using a rope shorter than a rope I would use and I think What the heck, why are they using such a short rope? It makes sense why trying to do double unders, they're bringing their knees up to their chest and bending their knee to try to clear the rope because the rope is so short. How do we sign the jump rope? We take the jump rope, we hold both handles, we step one foot, we try to even it out as much as possible, bring it towards our body, and the length of that rope should be at our nipple or maybe a little bit higher. If it's down at our stomach, it's too short. You're gonna have to do some really unnatural jumping things, like piking your hip, or kicking your legs back, or both, just to be able to clear that short rope. Likewise, being a little bit longer is okay, but this thing up to my chin or above my head, I have a lot of slack behind me now. I'm moving a lot of extra weight I don't need to, and that's all the more drag factor on the rope that's gonna mess up my timing as I try to learn double unders. So making sure we're holding the handles in the appropriate place and making sure that we understand how to measure our jump rope. A really nice jump rope will have maybe a nut or a screw here to adjust. This is a typical, what we call a class rope. This is just a $20 rope from Rogue. You'll often see these in the wall at a gym for everybody in class to use. These can't be adjusted. They go based on your height. There should be a table or a chart or the coach should know what color you should be using based on your height, assuming that you know what your own height is, to make sure that you're using a jump rope that is long enough with maybe a little bit of extra slack, but is not extraordinarily short or long. So that's first things first, using linear force to create rotational force, making sure the rope is sized to us correctly, and making sure we're holding the handles in the right spot so that we're not hampering ourselves from creating that rotational force.

SOMETIMES IT'S THE WRENCH

We have a saying, with jump rope, with most things in life, it's usually not the wrench, right? It's not the equipment, it's the mechanic. But sometimes it is the wrench. A lot of folks start trying double-unders with maybe the class rope they have, and I think that's a great place to start. Now the issue is a lot of folks will start trying double-unders, they'll look at people in the gym who are really great at double-unders, and not recognize that that person probably started with the class rope, and they'll immediately go out and buy a $200 competitive CrossFit game speed rope. There's a couple issues with the wrench itself of making sure you have the right wrench. We've already talked about length. A really nice jump rope, again, will have a way to adjust the length that you can undo a screw or a nut and make it longer or shorter and get it really dialed in. These ropes, again, are a fixed length but making sure the length is exactly correct. The next thing that most people don't consider is that this jump rope has some weight. Yes, the handles have weight, but that's going to be relatively fixed based on the brand that you have. So not considering the weight of the handles, what is the weight of this rope? This is a class rope. This is about 2.5 ounces or so, which I would call a medium weight rope. When we are doing jump rope, In learning double-unders, the best thing you can do is use a rope that's a little bit heavier.

null: Why? Two reasons.

SPEAKER_01: When you spin a heavier rope, you can hear it slapping on the ground in the gym, even over the loud music. That helps your brain learn the timing. A heavier rope also forces you to develop wrist speed. When we're doing double-unders, it's not about how fast you jump, it's about wrists. And a really light rope doesn't force you to learn that speed because it costs you almost no energy to go through that movement pattern. So for a lot of folks, they're trying to purchase the most lightweight rope ever, and I'm going to show you some different ropes here in a second, when in reality they should probably be working with a heavier rope. Again, this is a class rope. This is maybe two and a half to three and a half ounces, somewhere in the middle. What's going to help a lot of folks Smartgear brand rope. You can buy this from Rogue or from RX Smartgear directly. You can see just by looking at these two ropes, significantly thicker, right? This is a 4.1 ounce rope. The handles are different. Yes, they spin a little bit better. They have a little bit better hand grips. You can see here different spots to put your thumb along the handle. But most importantly, the cable is heavier. This is going to teach hand speed, this is going to build up endurance with the double under, and it's also both the sound and the feeling of this rope is going to help learn timing a lot better for our jump rope. So making sure that we have the right rope. Again, almost everyone trying to get good at double unders immediately goes and buys the $200 speed rope, when in reality they should probably buy this. Now the nice thing about these ropes, as you can see, I'll bring it up really close, is this is just a keychain type carabiner. When I'm ready for a lighter rope, the most expensive part of a jump rope are the handles. The cable is usually cheap or sometimes even free if it gets frayed. If you fray your actual rope, you can email Rogue, you can email RxSmart here, they'll send you a new cable that you can reattach to your handles and you can use the same handles forever. So as you get better, you can detach, put a lighter cable on, make it easier and more energy efficient as you actually start to string together double-unders. But early on, you're going to want a heavier rope, something around four ounces. That's the biggest recommendation I can make to folks who are trying to learn double-unders, and especially to those folks who have 19 different speed ropes at home. They've got a second mortgage on their house full of jump ropes just to pay for them all. and they're going lighter, lighter, lighter, thinking they need a lighter rope, a faster rope, lighter handles, diamond grip handles, when in reality they just need a heavier cable. So when in doubt, go heavier. Again, four ounce rope compared to maybe a two and a half or three ounce rope. Once you can start to turn over bigger sets of double unders, 25, 30, 50, you're able to start doing them in workouts, your efficiency, your endurance with them improves, now you're ready for a cable itself is basically non-existent. This is aircraft grade aluminum. This is about eight tenths of an ounce. So almost 500% lighter than that heavy rope I just showed you. This weighs almost nothing. It is very hard to feel when you jump rope with this cable and it's very hard to hear as well, especially if you're in a CrossFit style gym in the middle of workout with loud music playing. What's different about this besides the cable weight? The handles are so much nicer. They are diamond grip. My thumbs can lock on. I can hold very low on the rope. Again, I want to have as much time for that force to build up and transfer along the length of the handle as I can. I can hold just my index finger and my thumb and really develop that flicking motion. What's also very nice is look at the spin on this handle. right? That thing spins forever. Very, very, very efficient for large sets of double-unders, but only once you can actually do them. So this is kind of the in-stage progression of somebody who looks at a workout that has a couple rounds of 30 or 50 or maybe even 100 double-unders and says, no problem, I got These ropes are about $200. And again, the most expensive part arguably is the handle. If the cable frays, you can replace it. But a very, very, very high quality jump rope intended for folks who have already learned how to do big sets of double unders, ideally using a heavier, cheaper rope. So that is what we would call a speed rope. So that's the wrench.

BUT IT'S USUALLY THE MECHANIC

Now let's talk about the mechanics. because there are a lot of things we can do, a lot of cues we can give that can very quickly make double unders a lot better. The first thing is understanding, again, in a double under, what changes is my hand speed. Jump, spin, spin, jump, spin, spin. It is a double spin of the rope. It is not an increase in my jump rate. A lot of folks, off the ball of their foot. Because in a single-under, we're only clearing the rope once, we can get away with a very small jump and just clear that rope once. We see a lot of boxers do this. You see a lot of people in the gym who have jumped rope a lot in the past do this with single-unders. They can crank out 150 single-unders in one minute with that very fast, low jump. That's not gonna cut it for a double-under. Why? The rope has to pass twice. A lot of athletes in the gym will ask me, I have no problem getting it over the first time, but it gets caught the second time. The answer is yes. The rope has to come back around again twice and you have to be in the air the whole time. That's why it's called a double under. You're trapping the rope on the second time through, which is why you're not getting your double under. How and why are we trapping the rope? Most commonly, is we do not increase our jump height, we just now try to jump even faster. All we're gonna do there is trap the second pass of the rope that much more quickly. We're just getting more efficient at bad double-unders. We need to consider a smaller, taller, slower jump. We should practice single-unders on the ball of our foot, and we should practice a little bit taller jump, but not try to pick up our legs not jump speed. If you correspondingly increase your jump speed, you're going to trip because you're now trying to basically get in rhythm and jump twice for two rope swings. That doesn't make sense. Keep your jump speed the same. Stay tall, vertical on the ball of your foot, and jump a little bit higher. Practice single-unders that way. When you can begin to turn over 50 or 100 single-unders like that, now you know you have the jump height, the jump speed, to be able to begin to turn over double unders. Remember, wrist speed, not jump speed, and stay on the ball of your foot. A lot of folks will do some really dramatic stuff to get that rope over twice, and they will land on their heel. Again, the rope has to pass twice. If you land on your heel, there is no physical way that rope can pass under your foot for its second time through. You're going to track the rope underneath your foot. So small, short, sorry, tall, vertical jump.

PRACTICING & DRILLING DOUBLE-UNDERS

Make sure we're practicing wrist speed. A penguin drill is a great drill to give people, to have them practice maybe what's a new jump height and cadence for them. And at the top of their jump, have them slap their thighs twice to imitate the double flick of the jump rope. You'll find a lot of athletes who think they should be able to do double-unders, struggle a lot with that drill. They're used to that short, very fast jump cadence for single-unders. Asking them to slow down and jump a little bit higher wrecks them. It also messes them up mentally when now they have to focus on actually doing something with their hands. You'll find they're probably not as ready for double-unders as they thought they were. So double-unders, not magic, just physics. We are creating force across a lever, the handle of the jump rope. We're holding it as low as possible. We're trying to create rotational force where the rope meets the handle at the bearing. We're holding it as low with as loose of a grip as we can. We're thinking about flicking the wrist, not spinning the shoulders. Sometimes it is the wrench. Make sure the rope is the correct length. Make sure newer athletes who are beginning to experiment with double unders use a heavier rope, something three, four, maybe five ounces, and that we reserve those speed ropes for once we're actually able to string together bigger sets of double unders with a heavier rope.

PROGRESSIVELY OVERLOADING DOUBLE UNDERS

The final thing is how to progress these. A lot of folks want to be able to do more unbroken sets, Can you just practice more sets of double unders? Yes. The key thing though is that we practice that. We don't try to do it in the middle of the workout under an extreme amount of cardiovascular fatigue and that we consider double unders no different than a back squat or a clean and jerk or a deadlift. That we take principles of progressive overload and we carry it over to our body weight, cardiovascular stuff, especially higher scale, like double unders. How do we do that? Things like a Zeus Rope. or a drag rope are great. A drag rope is literally climbing rope with handles. It has, you can see the same handles as some of the other jump ropes I've shown you. The only difference now, there is no handle spin. The only way I'm going to rotate this rope is by being really aggressive and really fast with my hands. This is a nine ounce, I guess you'd call it cable. Again, it's technically just a length of climbing rope. This is nine ounces. So this is 900% heavier than the speed rope. So if I want to get better at double unders where I can look at a workout that has a couple rounds of maybe a hundred double unders and it has some other stuff in there too that's also going to make me tired from a cardiovascular perspective, how do I know when that workout shows up that I can blast through those with my speed rope? Well, when I go back and take class workouts that maybe have small sets of double unders 20 or 30 at a time, I bring my drag rope to class. And I do smaller sets with a heavier, slower rope that continues to progressively overload my double-unders so that when big sets do show up in different workouts, I can handle those no problem with my speed rope. So it takes practice, intentional practice. Folks are always disappointed that they don't magically learn double-unders 18 minutes into a 20-minute AMRAP. That's not how it works. Sometimes it does, but it usually doesn't. Practicing this stuff at home with a cheap jump rope from Rogue that's 20 bucks, practicing 10 minutes a couple times a week is really going to go a long way. I always tell folks when they're practicing double-unders the same way I tell them when they're practicing things like pull-ups. When you're learning to kip, when you're learning that motion, forget about getting your head over the bar. Just learn the rhythm. That's the most important thing you can do. I say the same thing to folks who are going to be going home and practicing double-unders. Don't focus on actually getting the double under. Focus on doing the mechanics correctly. Use a timer so that you're not just in your garage for an hour and you're breaking stuff because you're so frustrated or the neighbors are worried because you threw your jump rope into the street. Set a timer, do as many as you can, and then take a break for two minutes and do a couple sets of that. Make sure that you aren't treating it as a workout, but that you're treating it as practice and that you use different methods once you actually can do double unders. to continue to progressively overload your double unders. So double unders, not magic, physics, make sure your wrench is set up, but make sure your mechanics are dialed in as well. And make sure if you want to get better at these, that you actually spend diligent time to practice and make sure that it's actually practiced and it doesn't turn into a second workout that day. I hope this was helpful. I hope you have a fantastic Friday. If you're going to be at a live course this weekend, we have 10 of them going on, I believe. So I hope you have a fantastic weekend. We'll see you all next time. Bye everybody.

OUTRO

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

Nov 2, 2023

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

In today's episode of the PT on ICE Daily Show, ICE CEO Jeff Moore discusses the idea that moving into a leadership role requires a shift in mindset from focusing on individual accomplishments and deliverables to prioritizing the building of culture and guiding the team. Jeff emphasizes that one of the hardest things about transitioning into a leadership role is separating your sense of worth from the tangible outcomes of projects. Instead, leaders need to concentrate on steering the team in the right direction and creating an environment that fosters productivity and engagement.

Jeff describes that a true leader's job is not to solve every problem or complete every project themselves. Instead, their role is to provide guidance and support to the team, ensuring that they stay on track and between the "buoys." This means constantly having touch points to build culture and considering where the team should go, as well as where they should not go.

Jeff also highlights the importance of reframing what being productive looks like in a leadership role. It suggests that leaders should focus their energy on three main areas: culture building, organizing and strategizing, and problem-solving. Culture building is described as the leader's top priority, as they need to create an environment that people want to be a part of. Organizing and strategizing involves evaluating when to intervene and when to let capable team members come to their own conclusions. And problem-solving requires knowing when to provide guidance, but not getting caught up in completing the task oneself.

Overall, Jeff suggests that moving into a leadership role requires a shift in mindset from individual achievement to team success.

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

JEFF MOORE

All right team, what's up? Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Moore, currently serving as a CEO of ICE, and always thrilled to be here on Leadership Thursday, which is always Gut Check Thursday. Let's get right to brass tacks. What's the workout this week? It is ascending squats, but of decreasing challenge, and then the reverse for our gymnastics. So it's gonna look like this, kind of an interesting workout. So it is for time, You're gonna open up with nine overhead squats. That barbell prescribed weight's gonna be 135, 95, so scale accordingly. Paired with 21 pull-ups. Then you're gonna increase your squat number 15, but moving to front squat, same barbell weight. gymnastics going to 15 chest-to-bars and then 21 back squats and then 9 muscle-ups. So you got kind of this 9, 15, 21 climbing a number of a decreasing complexity on the squats and then the opposite 21, 15, 9 as your gymnastics get more challenging. So should be a very interesting workout. Just one time through that for time. All right, regarding upcoming courses, it is all about the certifications this week. So if you have not heard, we launched our entire brand new suite of new and renovated certifications over on ice. So we've got our brand new pelvic certification. We've got our dry needling certification now. The group has launched that advanced course. We have our brand new ortho certification, the endurance athlete certification. on top of a tremendous amount of renovation and facelift on all the other ones. So if you have not browsed our new certification offerings, go to PTOnIce.com. That certification tab is right on the top. Jump in there and look at all those different search. Remember, One thing that separates ice certs from everybody else is live testing is involved in every single one of them. So regardless of which one of those you jump into, there is live testing. We believe that is really what holds the standard. So just know that you will be examined in person to make sure you indeed have the goods before we throw that stamp of approval on your work. So that is what's basically, involving all of our worlds this week is getting all the certifications launched. Hope those really improve not only your skill set next year, but your ability to market effectively that you're a specialist in these areas and really take over your geography and serve your community. So enjoy those certifications, check them out. All right, it is Leadership Thursday.

BREAKING UP WITH DELIVERABLES

We are talking about breaking up with deliverables. A challenging but necessary conversation. Challenging because… There's very few things, especially for really high performers, that is more satisfying than completing a really big project, right? Something you've been working on and chipping away on, very few things feel better than putting a bow on something like that, crossing that off that to-do list that you've been looking at for months as you kind of worked your way through the project, not to mention just delivering a beautiful deliverable. Nothing feels better. The bigger leader you become, the better leader you become, the less you will get to experience this. If your leadership trajectory really takes off, you will literally never, again, get to experience that wonderful feeling of wrapping up a project. The reason for this is it almost never makes sense For you to finish anything, right? Once your job is getting the train on the tracks, your job is approving the project. Your job is saying, you know what? That makes sense to put resources towards that. Considering all the other options available, your job. is figuring out the right combination of people that will maximally effectively take over that job and really bring it to completion as fast as possible and be able to scale it. So is it the right gig? Who are the right people to do it? What resources do they need? How can I collect those in the most cost and time effective manner? Those are your jobs. But once that train is on the tracks, proper delegation should always bring it to the finish line. It would be very rare, very rare, that a task needs your personal involvement end to end. Just because you want it to, doesn't mean it does. In almost every case, your job is going to be saying, yep, that's the right thing that we should do with our resources. These are the right people to make that happen. And here are all the resources they need to be freed up and made available so they can execute properly. Those are all of your jobs. The actual doing of it, the execution, the part you want to do, right? Cause it just, again, feel so wonderful to be a part of creating and finishing something like that is something you should almost always hold yourself back from. Now, I know what you're saying. You're saying, but that's what makes it feel like I've accomplished something. Like getting something to the finish line is what feels rewarding. You have got to reframe if you're truly moving into a leadership role. Like you're going to be organizing and strategizing a number of people that are in your circle and your job is kind of commander in chief. If you're heading in that space in whatever your division might be, you've got to reframe what being productive looks and feels like. You gotta reframe this, and you gotta think about three big buckets where your energy is gonna be going, and none of them are gonna be about bringing a project to execution.

CULTURE BUILDING

The first one is culture building. Your number one job, right, is that glue that keeps everything together, that makes the energy of the organization feel like something that people who are a part of it want to be a part of. Number one is culture building. In every single touchpoint, with another individual in the group is culture building. It doesn't need to accomplish anything, right? These touch points, these little moments of interaction don't need to finish anything. They don't need to accomplish anything. What they accomplish is you understanding each other just a little bit better. What they accomplish is you seeing where the other person's coming from, is a little bit of trust building because you had that moment of connection. They accomplish that. No, it's not finishing anything. This is an infinite game. Culture never has an end point. You never win culture, right? You nurture culture. And it's with every single touch point that you do so. So one of your biggest buckets as a leader is gonna be culture building. And culture building has no conclusion. So you'll never get that feeling of finishing.

INNOVATING

Number two, energy bucket number two is innovation. Time spent pondering solutions is one of your most important jobs. And here's the rub, here's the really uncomfortable part. 90% of your time will be considering solutions that you don't move forward with. You certainly can't finish anything you never start. And 90% of your time is going to be exploring options that don't wind up being the right call. But that is a critical part of your job. There's no way that you can rule down where your resources should go if you don't consider all the options and say no to most of them. So because so much of your time is going to be spent evaluating possibilities that literally never get off the ground because you decide they shouldn't, obviously you won't have any sense of completion there. But yet, if you're not in that role, you will never allocate your resources properly in a way that allows the company to move forward efficiently. Innovation, and namely deciding what shouldn't get off the ground, is a huge spend of your time and has no completion.

PROBLEM SOLVING

And finally, number three is problem solving. One of your key roles as a leader is evaluating when should you intervene. Oftentimes, my number one recommendation there is to restrain yourself, right? To let very capable, high-performing people come to their own conclusions, but be evaluating it from a 30,000 foot view. But you do need to sometimes say, you know what? I'm gonna jump in here. A little bit of restraint is always a good thing, right? But knowing when to jump in is very important. Now, here's the key. When you jump in, you jump in with a couple pieces of information or a little bit of guidance, again, to get the train back on the tracks. What you don't do is follow the train. Right, that's falling right back into that temptation of wanting to get something to completion. That's not your job anymore. Your job is, ooh, this isn't going in the right direction. Watch it, study it, think about it, find your moment, and then jump in and say, team, can I ask that we look at one thing a little bit differently? What are your thoughts here? Okay, now you jump in, you change the energy of that environment, of that project, you get people chiming in as a group, you decide, Oh, this is the one change we've got to make. And then very importantly, you get back out because you've got to go do that somewhere else. If you stay on that ride, you're not getting back over and solving that same problem in seven other spots. The people can handle it. Your job is just to steer, just to get them back in between the buoys and then get out of there. One of the hardest things about truly moving into a leadership role is you've got to divorce your sense of perceived worth from deliverables that you're a part of. Your energy needs to be in constantly having touch points to build culture. Your energy needs to be spent thinking about where should we go and maybe more importantly, where should we not go? Your energy needs to be in and out of different projects when you see an area that your experience or wisdom can nudge people in the right direction and get their momentum built back up before you remove your energy from the scenario. These things never feel done because they never are done. None of those buckets even move closer to a perceived finish line. You just keep nurturing and spinning those plates at all times and never ride any of them to the end.

DIVORCE YOURSELF FROM DELIVERABLES TO IMPROVE THE EFFICIENCY OF YOUR BUSINESS

You have to divorce yourself from deliverables, otherwise you're never going to take the true position of an effective leader. Give that some thought. I know you're high performers. I know you love finishing projects. I know for many, many, many years that has filled your cup, but it's killing your team. Try to reframe it. Let me know if you have any thoughts. PTOnIce.com. Thanks for being your team. 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.

 

Nov 1, 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 difference between sarcopenia (the loss of muscle mass) and potentiapenia (the loss of muscular power). Dustin reminds listeners that performing functional outcome measures & then creating a treatment plan based on functional deficits uncovered during assessment is the most important thing in ensuring patients receive the individualized care they need: "Assess, don't assume." Dustin also discusses the utility of using functional outcomes to assess & track progress so that insurers like Medicare will continue to pay for treatment.

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

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

EPISODE TRANSCRIPTION

00:00 - DUSTIN JONES

All right, welcome y'all. 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 as we call MMOA. We're going to talk today about a really interesting topic. We're going to name the enemy and that is potentiopenia. We're going to name the enemy particularly when we're working with older adults and that is potentiopenia. This is brought to you by a listener question, a commentary that they wrote and I want to dive into the topic of power, strength, Sarcopenia as well. What should we really be focusing on? How can we screen? Before we get into the goods, I want to mention about some upcoming MMOA live courses. MMOA live is a part of the cert MMOA curriculum. Part of that curriculum is a live course. Also our MMOA level one online course, which was formerly called MMOA essential foundations. And then MMOA Level 2, which was formerly called Advanced Concepts. You complete all three, you get your cert MMOA. We have three upcoming weekends where you can go to that live course. We're gonna have Annapolis, Maryland and Central South Carolina. This upcoming weekend, November 11th, we're gonna be in Wappinger's Falls, New York. And then right before Thanksgiving, November 18th, that weekend, we're gonna be in Westmont, Illinois. So if you are looking to get some Con Ed before the end of the year, be sure to check us out. PTOnIce.com is where you can find all that.

POTENTIAPENIA

All right, so naming the enemy, potentiopenia. So this is a term you probably have never heard about because it's not been coined, it's not been researched, it's not been agreed upon in literature. This is a word that was made up by Dr. Ronald Michalak. So Dr. Michalak is an orthopedic surgeon that's been practicing for roughly 20 plus years that has quitting his surgical practice to go back and pursue his PhD in Rehabilitation Science. Dr. Michalak is an avid listener to the PT on ICE Daily Show, so I want to take the time to shout out to him, but also for all of y'all that listen to this show that aren't our typical physical therapy crowd, right? The OTs, the speech-language pathologists, the other healthcare providers. I know we have some PAs, some NPs in here, but we're really grateful for y'all tuning in because we're starting to see we have a fitness-forward army clinicians that are trying to solve the same problems. This is one example. So Dr. Mitchell like you know 20 plus years doing orthopedic surgery you start to see some patterns right? You start to see the issues with focusing on the tissue, right? Of focusing on, oh, that bone-on-bone, we should probably just go ahead and replace that whole joint, and that will solve all your problems, right? There's some issues to that, that when we focus so much on the anatomy, the structure, that we apply surgical interventions to non-surgical problems, that creates issues, right? And so over his career, he started to see, man, the biggest issue is not the quote-unquote bone-on-bone, it's the fact that these folks are deconditioned, they're weak, they're not able to do the things that they want to do and it leaves them susceptible to some of these medical situations that I'm often performing surgery on. What can I do to prevent them from even having surgery? And so we started to dig into the research and science and what he has come to the conclusion of is we are really missing the boat to where we're focusing on the wrong things and what we need to focus on particularly with this population is their lack of power. hence the term potentiopenia, the lack of muscular power. So, I want to give some context for this discussion because I think it's really interesting of how much progress has been made in this area, particularly in geriatrics and geriatric rehabilitation.

SARCOPENIA

So, sarcopenia, you've heard us talk about this so many times on the PT on ICE Daily Show. If you've taken any of the MMOA courses, you've heard this term. Sarcopenia was first coined in 1989 by Dr. Rosenberg, and at the time, the definition, the accepted definition of sarcopenia was age-related loss of muscle mass. That we thought, oh man, these folks are losing muscle mass, therefore, they are losing their strength, they are losing their ability to do what they need to do. This is a big issue. It's age-related, but we may be able to do something about it. As this was studied more and more, and just this whole concept, was being critically you know thought about that the term of sarcopenia or the definition of sarcopenia was missing a little bit right because you can have someone that is losing muscle mass but may still be really strong or you may have someone that does have a good bit of muscle mass that is rather weak or they're not able to produce their force quickly aka they have low power So, in 2008, Dr. Clark really started to push against this definition of sarcopenia and say, hey, this isn't the issue. The issue is the lack of strength, the age-related loss of muscular strength. And he coined the term dynopenia. That was a back and forth, back and forth. And now in terms of the term of sarcopenia, what we're seeing is that it's starting to incorporate some of the things that Dr. Clark really was pushing for. And now you're often going to see sarcopenia defined as the age-related loss of muscle mass and strength. That's what we speak to in the MMA course. And so a lot of the screens that you're seeing of being able to identify folks that have sarcopenia are mass related screens of actually measuring muscle mass and having cutoffs based on certain age groups and so on and so forth. But then there's also functional measures, right? Gait speed is one, grip strength is another one, the SPPB, the short physical performance battery test can indicate that someone is at risk of sarcopenia. Sarcopenia has changed a ton over the past few decades. Now, what's interesting is that the amount of research, which is so massive in this particular topic, that we have really good evidence to show, man, if this person scores below one meter per second, for example, on the gait speed, that this individual is at risk of sarcopenia, also a host of negative health outcomes. It's very predictive. We have a lot of data to show that poor performance on some of these outcome measures is a big issue and very predictive and warrants medical treatment or physical therapy, if you will, or occupational therapy, some of these rehabilitation-based services. Now, here's the issue. Here's what I think Dr. Michalak is going towards, is a lot of these screens that have been used to say, hey, this person has sarcopenia, age-related muscle mass and strength, that these screens may not actually be measuring what we think, right? If you think about gait speed, normal gait speed, for example, is that a measure of strength? Not really, right? Is it a measure of, let's say, power, the ability to produce that strength quickly? Potentially, right? Definitely, if it's a fast gait speed, or if we're looking at gait speed reserve, the difference between max gait speed and normal gait speed. Think about the 30 second sit to stand test, where we're standing up and sitting down 30 times. Is that a measure of strength? You can make a strong argument that, no, not necessarily, but it's more of a measure of how people can use that strength quickly to perform that transfer. Same thing could be said for the five times sit to stand. And so these outcome measures that are often tied to quote-unquote sarcopenia, the age-related loss of muscle mass and strength, isn't really measuring that. We can say that those tests are very predictive of some of these negative health outcomes. That's not what we're talking about. What we're talking about is do these tests actually measure, indicate what they're saying that they measure, right? Now, here's the, I think the important part about this is that if I am performing a five-time sit-to-stand test or a 30-second sit-to-stand test and think that, oh, this indicates that this person has impaired lower extremity strength and I focus on strength-based interventions, right, I'm just worried about getting them stronger, not necessarily trying to help them get stronger, produce force quicker, aka power.

THE NEGLECT OF POWER-BASED TRAINING

And so what Dr. Michalak is really proposing is that our focus on age-related loss of muscle mass and strength, the focus on strength has resulted in the neglect of power-based training. We need to really think differently about these terms and ultimately what they result in. I think we should have a new term, potentiapenia. That was his argument. This is all in a beautiful commentary that I loved reading that I'm going to link in the notes. So here's our take on this. I agree that… we have really dropped the ball on power-based training, right? That we often neglect that in this population for many reasons. One is just we haven't named the enemy as one. Two is that we often have ageist assumptions about what people can handle, right? That, oh, that's too intense for them or they will get hurt. It's not as well studied as strength-based training. There's a lot of reasons that go into that, but I do agree that we have really dropped the ball there. A new term, creating a new term, and everything that's associated with that, I don't know if that's the answer, but I do think we need to continue to be critical of the term sarcopenia and what that actually represents. It's already changed to age-related loss of muscle mass and strength, which is lovely, and I would love to see that conversation continue to include power as well. Clinically, here's what I think is really important for us when we think about some of these deficits that folks are undergoing and we're throwing around some of these terms.

STRENGTH VS. POWER TRAINING

I think the big thing that needs to be focused is we're diving into the weeds of strength versus power and you know reps and sets and volume and all that type of stuff that when first one is when we're working with individuals that are relatively sedentary or inactive and Movement is king. I don't care what they do. The fact that they are moving is ultimately important, right? We got to get people moving first and we need to be less picky of what that looks like, especially with sedentary and active individuals. That's the first thing. The second thing is we need to really think about our assessments and challenge our assumptions with this. This is why in our courses we always say assessments over assumptions. It's very easy for us as clinicians, when you're doing an assessment, you're doing the five-time sit-to-stand test, 30-second sit-to-stand test, to assume, oh, this person needs to do more lower extremity-based strength training, right? That's a very common thing for us to correlate. Now, that test may not be and probably isn't testing pure strength, right? There's other ways to do that. One rep max testing, estimated one rep max testing. We can use dynamometry as well. There's other methods to test strength. These functional and very practical outcome measures may be more a testament to someone's power ability. So when we use these tests, particularly the 30 seconds sit to stand, five times sit to stand, I think is a great example. that we need to be thinking probably about strength training, but we also need to be thinking about power training. Can they produce that force quickly? Because it ultimately is an indicator of power, the ability to produce that force quickly and do that transfer. So what your outcome measures tell you, we need to be very careful of how that informs the intervention, right? And ultimately what we're often going to find, I think this is not an or conversation, strength training or power training, in the realm of ice, you will hear this so often, it is and not or, right? Probably both, strength and power, we can do both. In reality, when we do get people stronger, you often see, especially in folks that are untrained, you are gonna see an improvement in power production. You could do specific power training, where you're doing force movements quickly, you're probably using lighter loads, and you're probably gonna see an improvement in strength, right? That's gonna happen with a lot of untrained individuals. But I think in the context of rehab, in the context especially of One Rep Max Living, that we probably want to do both. Heavy loads are really good. Heavy loads provide an amazing stimulus to promote muscle mass, our strength, but also the strength of our bones, also our soft tissue remodeling. It makes us more resilient individuals. But fast loads are really good too, right? They give us that type 2 muscle fiber stimulation to prevent some of that preferential decline. in those fibers. That quick speed is so practical for so many things that we do in the real world and also in high-risk situations. It's an and conversation. We want to do both. Now, Dr. Mitchell, I had two specific questions that I also wanted to hit on. Could referrals be written or phrased better from the physician end to encourage PTs to try to help get these individuals moving toward fitness? Now, I want everyone to listen here, and by and large, the PT on ICE Daily shows largely physical therapists, physical therapy assistants. Think about what this physician just asked. This physician is basically saying, where are my fitness forward clinicians, right? Where are my fitness forward clinicians? Where are the people that I can trust with my patients? I love this question. I think from our angle, from kind of the rehab fitness side of things, Let it be known. What are you about? Lock arms, lock shields with us, the ICE tribe, the ones that are really pushing this fitness forward message because there are healthcare providers looking for you. Now, Dr. Mitchell, from the physician's standpoint, I do think it is helpful to make it clear as a physician that you have that fitness forward approach. And oftentimes, we don't see that on referrals, right? It's the diagnosis and treat, which you love as a PT, to be honest, but if you do run a 30 second sit to stand and acknowledge that it is under or below a particular cutoff let it be known and let it be known what you are thinking about that it is a potential loss of power production potential right and let the PT do the job of assessing to determine is this a bigger power issue or a bigger issue of just producing force of strength.

FUNCTION-FORWARD HEALTHCARE PROVIDERS

But let it be known, I love it whenever I see another healthcare provider perform some type of screen, like a 30 second sit to stand, a timed up and go is another one, that tells me that this is a function focused healthcare provider. And we're speaking the same language, especially when we're coming from the MLA tribe. We speak function, we speak that fitness forward mindset, include some of that information and that's really going to get the point across particularly to the fitness for clinicians. I would also say Dr. Michalak is go to PTOnIce.com, look at the find an ice clinician map and build relationships with that person that is local. The second question that he asked was, are there any insights into Medicare billing or reimbursement that would allow them to do so and actually get paid for their expertise? So the question here is mainly looking at, he's interacted with some PTs where he sent the referral that was not pain based, where these clinicians said, I can't get this covered, right? I treat pain, I get paid to treat pain. That is not correct, right? So you can definitely get reimbursed to have the fitness forward approach when you use appropriate outcome measures. When you can demonstrate medical necessity through the performance of these validated outcome measures that we cover extensively in our MMOA level one online course, and a little bit as well in our MOA live course, when we're using those outcome measures to demonstrate, hey, this person has a score, which based on the literature is showing that they are at a higher risk of whatever, negative health outcome, usually it's a fall, that that warrants your services. It is medically necessary. So we can have fitness-forward physical therapy. This is what we often see in the context of home health. We treat more function than pain in the context of home health. Outpatient, not so much. It's more of a pain driver, but you can still have a fitness-forward approach in the context of outpatient. These outcome measures are absolutely key because they demonstrate medical necessity. Multiple outcome measures I should say great conversation. So what I want y'all to do if you like this topic I want you to come to Instagram and I'm gonna drop a couple links. You could also send me a direct message At Dustin Jones dot DPT and I'll send you the links as well because it's a really great conversation. I think by and large Yes, we need to get people stronger We're already really pushing forward with that and I love that but we may need to take it to the next level of power based training In terms of a new name, potentiopenia, I don't know. I'll let the really smart people debate that and discuss that, but I'm going to keep pushing the message that we need to build people's resilience. We need to end one rep max living and really show that people may be quote unquote old, but not weak. Also that they may be quote unquote old and not slow. Y'all have a good rest of your Wednesday. I'll talk to you soon.

OUTRO

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

Oct 31, 2023

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry as he discusses the reverse hyperextension exercise as the go-to exercise for the low back. The reverse hyperextension provides a decompressive effect on the spine, often reducing symptoms, while simultaneously allowing for strengthening & mobility through the full range of motion of spinal extension & flexion.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

JORDAN BERRY

Good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management Courses. Coming at you on Clinical Tuesday, we are chatting today about why the reverse hyper is king. We love the reverse hyper when we're either building strength in the back, trying to modify symptoms and pain in the back, but we're gonna talk about today about all the different exercises and machines, equipment that we have in the clinic when we're talking about the lumbar spine, why the reverse hyper is king. Before we get into that, just a couple upcoming courses. We've got a few spine courses left before the end of the year. So if you're trying to catch cervical spine management, you've got two options left this year. You've got November 11 and 12 is going to be in Bridgewater, Massachusetts right outside of Boston. And then we also have December 2nd and 3rd out in Hendersonville, Tennessee. So two options left for cervical spine. If you're trying to catch lumbar before the end of the year, you've got three options. You've got Fort Worth, Texas coming up November 4th and 5th. And then two options, December 2nd and 3rd. We've got Charlotte, North Carolina, and then Helena, Montana. So a few options left before the end of the year. We've got a ton of dates on the books already for 2024. So hoping to see you at one of those live courses either before the end of the year or maybe sometime in 2024. So let's dive into the content today.

THE REVERSE HYPEREXTENSION

So again, chatting about the reverse hyper and why the reverse hyper is king. So let's define king to start with. So when I think about an exercise, ideally it would do three things. So it would do a combination of reducing someone's pain, improving the mobility in the lumbar spine, and then building strength and endurance in their back as well. Like if I had one exercise that could do those three things, that's what I would consider king. So reducing pain, improving mobility and building strength and endurance all at the same time. And so yes, there are multiple techniques and exercises that we have that are incredible for reducing low back pain. but they don't do an awesome job at improving someone's mobility or strength. And then we've got exercises that are awesome for range of motion. However, they don't do a good job at reducing pain. And then of course we have some awesome exercises for building capacity and building strength in the lumbar spine, but maybe they don't do a lot for improving range of motion. What I'm saying is the reverse hyper is the king of all three of those if you package that up into one exercise. And so to start with, If you're not familiar with the Reverse Hyper, I would say YouTube it or look it up or try to find one even better and test it out in person. But if you're not familiar with that machine, there's a, essentially you're laying on a platform. So it's elevated a few feet in the air, almost looks like a GHD machine, but you're laying across it and you're holding it with handles in the front. So your torso's laid out on the area. and then your legs are essentially hanging off the side of it. So the pad that you're laying on hits right around the hip crease, legs are laying off the machine, and then it's plate loaded. So you have this pendulum underneath that you can load with weight, load with plates, and then the strap goes around the lower leg. And the exercise is essentially just contracting the posterior chain. So you're lifting the legs up and down, And then it's taking your lumbar spine through full flexion and full extension. And again, hard to explain verbally, um, on the podcast, but look it up on YouTube, um, get out to a gym that has one and test it out. But I want to talk about the three reasons why I think this exercise is king.

STRENGTHENING THROUGH THE FULL RANGE OF MOTION

So the first one is it's strengthening through full range of motion. Now, if we're just talking about building capacity and strength in the lumbar spine, no argument, the deadlift is king. The deadlift is an incredible exercise for building strength and capacity in the posterior chain. However, the deadlift doesn't utilize a lot of range of motion in the lumbar spine. Like, when we coach the deadlift, what we want to see is essentially straight lines. Straight lines or strong lines. So, we coach it to have a neutral spine position throughout, so the lift is more efficient, right? But, we're not actually utilizing a lot of range of motion for the lumbar spine. And we would never treat another joint like this. So, you know, if you're only utilizing hip hinge type of movements, then you're missing a ton of range of motion. And think about treating an Achilles tendon or rotator cuff. We would never utilize just a very small amount of the range of motion. We always talk about strengthening through the full range of motion. So why is the spine any different? So the reverse hyper, as you kick those legs up and down, right, you're taking the lumbar spine through full flexion and full extension. and you know an exercise similar to the Jefferson Curl in a way where we're utilizing a lot of range of motion of the spine but Jefferson Curl is much easier to cheat on because if you have really good posterior chain mobility then you can essentially do one massive hip hinge on the way down. And it looks like you're really utilizing lumbar flexion, but you're not. The reverse hyper, because you're locked in laying on the pad, it's much harder to cheat. And so we love this exercise for strengthening through the entirety of the range of motion.

DECOMPRESSIVE EFFECT

Now, second, there's what we call a decompressive effect. So on the actual reverse hyper machine, not a variation on the actual machine, you have this pendulum weight underneath that is plate loaded. And as you lift the legs up and down, that plate swings pretty far under. And so as you're flexing the low back, because the weight is underneath and has some momentum to it, you almost get this decompressive traction like effect. Now, why this is so awesome is this exercise can work for someone who has almost any levels of irritability. So, for high levels of irritability, like when someone's back is really jacked up and they have a lot of pain, it can sometimes be challenging to find an exercise that relieves symptoms and feels really nice. And you'll be surprised to find that for those individuals that can't tolerate other forms of exercise, they will really like the Reverse Hyper. And even the heavier you go on it, the better it feels sometimes because it's more weight underneath that is almost tractioning the spine. And in my mind, what I think is happening here is we're essentially creating a pump. So when we have that pressure gradient that we're creating, when you contract and relax and contract and relax, And that pressure gradient is going to essentially pump fluid and water into the lumbar spine. And I think about the couple of research articles that we referenced in lumbar management, they're both from Paul Beatty, 2010 and 2014. And he's looking at diffusion weighted MRI. And in the first study, we're looking at interventions like prone press-ups and lumbar PA mobilization. Second study four years later, lumbar spine thrust manipulation. But what they found in both studies is the individuals that had a significant symptom reduction, so a massive pain reduction, following the intervention, we saw an increase in hydration, the diffusion coefficient, in the discs in the lumbar spine. So essentially the discs brought in fluid, brought in water content, and that matched up to who had a significant reduction in pain. What do I think is a massive, massive pump that we could utilize in the clinic? It is the reverse hyper. So I can't prove that there's no research for that, but I would love to see something like that in the future. But I really believe that's what's happening is one of the ways that we're reducing symptoms is the diffusion coefficients. We're creating that pressure gradient is drawing in fluid to the lumbar spine and helping to reduce pain. I think that's why some individuals they have pretty high levels of pain, pretty high severity, are able to tolerate that type of exercise.

SCALING THE REVERSE HYPEREXTENSION

And then lastly, the third reason why the reverse hyper is king is it's easily scalable. So yes, the actual reverse hyper machine, the official true reverse hyper machine is a bit harder to find in commercial gyms, but there's a scalable option for pretty much anyone. You know, you could regress it anything from a GHD machine where you're on the backside of it. So you're holding with your hands where the feet would go and lifting the legs up and down. You could throw a band around the bottom of it and have some banded resistance. We could utilize just a bench. We could either lie on the bench and so the end of the bench would hit the hip crease and have our legs hanging off. Or we could go on top of a physio ball on the bench to get more of the curve in the lumbar spine that mimics the true machine. Or something as simple as just holding something at home. Like sometimes in the clinic for my clients that don't have a lot of equipment at home, I'll have them just lay across our coffee table or a bed or some sort of table that they have where the edge of the table hits the hip crease and they can just lift their legs up and down in its simplest form. It's an awesome exercise for, again, not only increasing range of motion, reducing pain, but also building strength and endurance in the lumbar spine. So there's pretty much a variation for anyone where you can mimic this type of movement.

CONS OF THE REVERSE HYPEREXTENSION

The pushback with the reverse hyper over the last few years has really been two things. Number one is the cost. The traditional reverse hyper machines were a couple thousand dollars and they took up a significant amount of space. So if real estate is an issue in the clinic, a lot of the old reverse hyper machines took up the space of about a squat rack. And so because of that, not a lot of gyms and not a lot of physical therapy clinics utilize that. But thankfully, a lot of companies are solving that issue. A couple companies like Rogue and Titan and a couple smaller ones are now making reverse hypers that are not only significantly cheaper, but are more compact as well. Some of them even fold up. So they take up pretty much no real estate in the clinic. So because of that, That is why we think the Reverse Hyper is the king of exercises for the lumbar spine. So again, there are exercises that yes, might be best for pain, might be best for building range of motion, might be best for building strength for any N equals one. But I'm arguing if you gave me one exercise that could do all three, I'm taking the Reverse Hyper all day. That's what I've got team. Thanks so much for taking a few minutes to listen. I would love to hear some thoughts on this. So if you're utilizing the reverse hyper, either in your personal training, um, just from a performance standpoint, or if you're utilizing it, um, in the rehab setting, I would love to hear comments, how you're using it, what you think about it. Um, drop those in the comments and, uh, and we'll chat about it. But other than that team have an awesome Tuesday in the clinic. Um, if you're coming to a cervical or lumbar course in the future, I will see you soon. Thanks team.

OUTRO

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

Oct 30, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses simple, but often overlooked interventions for treating patients with symptoms of pelvic prolapse including the Kegel, unilateral hip strengthening, and proper breathing & bracing.

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

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

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

EPISODE TRANSCRIPTION

00:00 - JESSICA GINGERICH

Welcome to PT on Ice Daily Show. My name is Dr. Jessica Gingerich and I am on faculty here at Ice with the Pelvic Division, which means that it is Monday again. We are getting super close to Halloween. I'm really excited. I'm definitely a Halloween girly. Today we are going to talk about what may be missing during the plan of care when it comes to prolapse. So this is another hot and relatively scary topic for a lot of mamas, but also for a lot of clinicians in this space. So we're going to talk about a few housekeeping items before we get started. We are currently in our last cohort of the year for the online course. This is something we are gonna put the pedal down come January. We've got a lot of exciting things coming up. So if you have not signed up for this course, head over to ptonice.com, just sign up. We also have a few more courses, live courses, to round out the year. So, if you're looking to dial in your internal assessment with that kind of higher level population, that athletic population, head over to PTOnIce to sign up there as well. My hope after this podcast is that you guys want that. You want to sign up for that live course. You want to dial in your internal assessment, dial in your interventions, and just guns a-blazin' out in this population. For those of you in the ICE Students Facebook group, you will hear more about the revamped certifications from Jeff tonight. Otherwise, stay tuned to Hump Day Hustlin' emails for details. So if you haven't signed up for Hump Day Hustlin' emails, again, that's all on the website. It's free. We just want to get out as much information to you guys as we possibly can. So we have some really fun new certifications coming up that Jeff is gonna dive into later tonight. So as we begin our PT careers, a lot of us prefer a specific population, right? We want to treat the older adult, the pregnant person, et cetera. We want to dial in our skills. And we love to see that, right? Like that, I love that. I want to get really good at that one thing. I want to go to the provider that is that provider. I am the person that you want to see if you are experiencing X, Y, and Z. We hear that a lot as faculty, especially in the pelvic space is, you know, well, I only want to kind of treat this type, this, the urinary incontinence or, you know, low back pain. And as a faculty, we've all kind of experienced those same thoughts and feelings. Again, it's intimidating when you get into this space. Well, we quickly learned that you can't just pick and choose. If you have someone that's experiencing urinary incontinence, they also are likely experiencing something else as well. If you are in the pelvic space, you're going to see all things.

PELVIC PROLAPSE

The ones that are at the top of the list, at least that we hear about as faculty, are the ones that are scary are pelvic pain and prolapse. So today we're going to focus on treating prolapse and specifically what we may be missing in our plan of care. It is going to be outside of the scope of this podcast to talk about the assessment of, um, like the subjective or objective assessment of prolapse. So if you are unfamiliar or you feel like you're just kind of shaky on this, again, that live course is waiting for you. Once we know the pelvic floor is strong or weak, or that it's a timing issue, or that they may or may not be tender to palpation internally or externally. And when I say externally, I mean hips as well. And that they may or may not have objective signs of prolapse. we then get to develop our plan of care. Now notice that I said may or may not because these clinical patterns are not identical. You will see so many different clinical patterns when it comes to symptoms of prolapse. So let's just say your patient comes in with feelings of heaviness, pressure, or dragging, and it feels like they may be sitting on something. That's something how they're describing it. When they're in the shower, they feel, as they're bathing, they may feel something physically. The heaviness gets worse after they have a bowel movement, void, go to the gym, or have been on their feet all day. So what's your next plan of action? Well, first and foremost, we wanna encourage you guys to stop focusing on the biomechanical components of a prolapse. Of course, there is that person or that type of prolapse. We're maybe talking about surgery. That does happen, but it doesn't happen without needing that pre-physical therapy, the stuff that they're doing beforehand, getting stronger, learning how to poop and pee. learning how to brace. So all of this stuff is still happening, even if surgery is part of the discussion. So first and foremost, let's stop focusing on the biomechanical components. Let's start focusing on the symptoms. So understanding what makes the pressure heaviness better, what makes it worse. Can we, part of their plan of care, ramp up the things that make it feel better and ramp down the things that make it feel worse? That has to be followed with this is not gonna be your forever. This is not gonna be you never doing that thing because it ramps up your symptoms and always having to like sit and be immobile because it ramps down your symptoms. We have to think about this on an irritability scale just like we do with pain. We have to be able to bring down their irritability, so then we can make them better by loading them. So now that we know that, I'm gonna give you four points to go home with today that are great points to start with. When you have that person come in with a script that says pelvic organ prolapse, or doesn't say that, it says pelvic pain, but then you start asking them questions and you're like, hmm, they may have symptoms of pelvic organ prolapse.

REMEMBER THE KEGEL

We have to remember the Kegel. This is number one, the Kegel. It has gotten so much hate over the past few years, especially on social media. I don't think that was anyone's intent to just say never do Kegels, but it matters. Teach your client how to do a Kegel. Lift and squeeze, shut off the holes, come to the attic. But we have to remember the relaxation component to the Kegel. Teach them how. to relax. Have them focus on this. A lot of times people feel like they can multitask a cubicle. If they are new to this and they don't know and they didn't even know they had a pelvic floor, they need to go in a room where it's quiet with no kiddos running around and focus on the up and the down component of a cubicle. Something that I love to say in the clinic is the relaxation component of a Kegel is sometimes more important than the contraction. Everyone always thinks we need to go up, up, up, up, up. And when I say everyone, I mean typically our clients. And they forget that this actually has to happen as well. Or, not that they didn't forget, but they think that they may be in that relaxed position and they're not. and that's where that internal palpation can be golden. Again, people tend to focus on the contraction, so being constantly contracted can also lead to symptoms of heaviness. So maybe their symptoms of heaviness are coming from this versus actually symptoms of prolapse.

UNILATERAL HIP STRENGTHENING

Number two, single-sided hip strengthening. get their hips stronger, always, but even here, get their hips stronger. And I don't mean with a TheraBand. Throw it out. If you want to warm them up with it, great. But we've got so many options. Step downs, step ups, we've got single leg RDLs, we've got variations of that. We have Core stuff that we can do, like the options are endless. We can do side planks, we can do hip thrusters. Don't forget about strengthening their hips.

INSTRUCTING THE BRACE

Number three, teach them how to brace. Symptoms of heaviness can happen due to faulty bracing strategies. Bracing is not only for lifting heavy either. We need to prepare mom for the demand of life. And mom is holding Johnny who has a runny nose and she's trying to wipe his nose and he's flinging his head back. She's going to be bracing her core and she's not even gonna think about it. So let's prepare her for that. Number four is find and encourage frequent rest positions that ease or make their symptoms go away. This could be lying on their back. This could be seated, this could be laying on their stomach, it could be leaning over the counter, anything that makes their symptoms ease. Again, follow this up with this is not forever, this is a for now, we wanna get those symptoms, the symptom irritability down. And once we get those symptoms down, what can we do? Everything that we just talked about in one through three. So to recap, find the symptom aggravators, find the things that make their symptoms go away or ease. There may be multiple clinical patterns to prolapse-related symptoms. Prolapse can be scary to a lot of women. It is, if they've Googled it, they are gonna come in wide-eyed, or if the doctors told them that, there might be tears. But it can also be really scary to clinicians if we don't know how to treat this. You have four places to start. The Kegel. Gets a lot of hate, but we need to start using it. Don't forget about the hip. The hip muscles are gonna be supporting structures to the pelvic floor. Bracing is not only used for heavy lifting, and using positions that ease symptoms to lower irritability, which will increase our loading capacity. That is it. Start there. So team, I hope this helps. I hope you have a great week and enjoy your Halloween and we'll see you next time.

OUTRO

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

Oct 27, 2023

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Mitch Babcock discusses how to approach setting up at a competitive event, including looking the part, preparing to capture leads, and knowing what is possible in the context of a short session with a potential patient.

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

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

EPISODE TRANSCRIPTION

00:00 - MITCH BABCOCK

All right, here we are. Good morning, everyone. Welcome to the PT on ICE Daily Show. I'm your host on Fitness Athlete Friday. I'm Mitch Babcock, lead faculty in the online Essential Foundations Level 1, Level 2 courses and our live Fitness Athlete course on the road where we do all things barbell in your hands all weekend long. I'm pleased to be joining you guys this beautiful Friday before Halloween here, October 27th. And my apologies for nine minutes behind the clock as our CrossFit hour this morning was jamming and ran a little bit long. Today's topic is something that we derived off the ICE Students page. So shout out to all of you that are active on the ICE Students Facebook page. We always appreciate the engagement, the questions, the comments, the thought. It spurs topics like these. You don't even know what kind of good info may come from a question that you pose on the ICE Students Facebook page. So thanks for being a part of that to everyone.

01:18 - THE ART OF THE 10 MINUTE EXPOSURE

The topic today is the art of the 10 minute exposure. We're talking about, hey, someone posted a question of, I have an opportunity to set up at a local CrossFit gym or a CrossFit competition that's going on. And I want to know what should I do? Should I treat for free? What should I be doing? How long should I be doing it? And so we want to talk around that concept today of like, let's say you have 10 minutes with a free prospective client and you're trying to win them over in that fitness athlete space. What are some things that you need to be doing and doing well? And so that's going to be our topic of discussion today. And just before I dive into that, I do want to let you know that next weekend November 4th and 5th. Both Zach and myself are gonna be out on the road. Zach's gonna be in Hoover, Alabama, and I'm gonna be in San Antonio, Texas. Team, we are running out of dates to catch the live course at the end of 2023, so if you were hoping to wrap up that cert, or you wanted to hit that course and get dialed in on all your barbell dosage, treatment, refinement, everything, there's like a total of three weekends left at the end of the year. Anna Marie Island just sold out, so that one's off the map now in Florida. Shout out to everyone that's gonna be in Florida. We got Colorado Springs, we got Hoover, Alabama, and we got San Antonio, Texas. So if you want to catch us next weekend, we've got two dates. Check the PT Online's website and we will see you there at those courses. Okay, let's paint the picture. You are a newly minted business owner of your own. You've started your own practice, maybe in a CrossFit gym or near one. And you're looking to do this fitness athlete thing on the out of network side of things. And you want to anchor your ship tight to a CrossFit community in your town, which is smart. And you have an opportunity now to go to a CrossFit competition, market yourself, get your name out there, your business exposure, all of that. What should you focus on? I wanna start with looking the part.

05:07 - PHYSICALLY LOOKING THE PART

Aesthetically, physically, from a business perspective, from a clothing perspective, all of the above. That if you're gonna go into this environment, that you need to pull up on the right horse. I don't want you showing up to a biker rally on a scooter and thinking like, I don't know why I didn't blend in with this culture, this community, right? Humans still operate on that first impression basis. That is still a key component. Those first three seconds that someone looks at you, sees you, makes all these internal assessments on what your business is like, what kind of information they can gather from you, what kind of expert you are. We have to respect that first impression and we have to bring our best foot forward. So let's start with your setup. your nice pop-up table, right? Whatever that is, they're cheap on Amazon, you can get a nice brand new table for 100 bucks, it's black top, looks good. Go on Vistaprint or Banner Buzz or one of these websites that will print out a nice custom fit tablecloth that will stretch over an eight foot pop-up table that has your business logo branded across the front of it. So you've got your treatment table and you've got a nice table up front that's going to hold all your brochures or anything else that you have on it. Marketing materials wise, that's a very nice printed stretch fit cover. You're going to invest a couple hundred dollars into having those things ready at any event you go to and market. 5k races, CrossFit events, whatever, right? Tent or not, really doesn't matter. Indoor comp, outdoor comp, you may wanna invest in a little pop-up tent, but let's just assume you're set up inside and you don't need to worry about that. You've got your treatment table, you've got a table up front. You need to personally look the part as well. And I don't just mean the clothes you wear, and yes, I do mean the clothes you wear, but I also mean physically. You need to physically look the part. If you're going in here and working with fitness-forward athletes, you should look the part like you train from a fitness-forward approach yourself. If you're not there yet, and you're trying to inject yourself into that community, anticipate a hard ramp up, right? You need to look like you work out, you train, you've exercised, you do CrossFit, you have some calluses on your hands, that you can speak to the expertise that these athletes are expecting you to have. That is just a cold truth that no one really wants to admit and talk about. If you can't tell the person in front of you how many burpees you do in seven minutes, you're probably not ready to set up at a CrossFit comp yet. Your personal expertise probably has some developmental work to be done on the back end prior to you setting up and going out there and being like, yeah, I can solve all your problems for you. I know exactly what you're going through. So get yourself dialed in from a physical perspective. Two, get your wardrobe updated, right? Do not roll into a CrossFit comp rocking that same polo that worked in the in-network setting and the khaki pants that you wore Monday through Friday. We're not in that setting anymore, right? So invest a few hundred bucks into a nice clinic wardrobe that looks good. Some nice athletic pants, joggers, whatever. Black always goes well. And get yourself a nice top and take it to your local screen printing place and have your business logo screened on the top of it. everyone's wearing the cotton freaking t-shirts with their low company logo on it but not everybody's wearing that that next level nice t-shirt whether that's lulu or whatever you go and you buy your stuff from you get that nice t-shirt you get your company logo on it it just stands out it just looks a little bit better a little bit more professional and a leg up on the competition you're going to business suspense that stuff anyways you might as well get a shirt you like you feel good you look good in and go get your company branded on the front of it So step one, looking the part. Both your setup, your table, your banner, your clothing, right? And physically looking like you train and you exercise and you know what you're talking about when it comes to this stuff. Two, Treat for free. Everyone's talking about should I charge people at these comps. I say that you're there to gain exposure. You're there to convert people back to your clinic. You want them to come to your operation. So you need to funnel everything through that filter. Everything needs to be geared around how do I get in front of people, show them I know what I'm talking about, and then get them to schedule an eval and come see me at my clinic. It's not about a transactional thing here. It's about giving things to the consumer in that environment where you're in front of hundreds of them, over delivering for free, and then converting on that at the end of the sale.

09:49 - CONVERTING LEADS

And that's a key part. You need some way to capture leads and convert leads. The best way to do this is having some sort of QR code available. Everybody's scanning QR codes these days. Having a flyer printed out on a little plastic flyer holder that when they walk up and it says right there, free 10 minute session with Dr. So-and-so. Scan here. Boom, that's easy. Boom, pull out my phone, scan it. It takes them to something, a lead generation on your website. That could be sign up for my newsletter, name, email, phone number, city, whatever. That could be put in your contact information. We're going to reach out after today and kind of be in touch with you. Whatever that is, whatever lead funnel that you want people to go to, that's where that QR code directs them to on your website. So they scan the QR code. Boom. That holds their place in line. And then you're calling the next person up 10 minutes at a time. Hey, I got 10 minutes. What's going on here? In that 10 minutes, your goal is to address the areas that most need addressing, to over deliver the best you can, and then to convert that individual after the sale. Give, give, give, and then ask. Give, give, give in that 10 minutes. Here's what I think is going on. This is common. These get blown up. This gets overworked. This is out of position. This is stiff. We need to mobilize this. Here's some things that I like to do. Let's get some needles in that area. Let's do some cupping. And at the end of it, say, hey, I would love to earn your business. If you would, please take my card. I'd love to have you call and set up an appointment. I can actually get you scheduled right now. This looks like something that needs some work. Would you like to schedule right now while I got a few minutes? Don't be afraid of the ask. You're giving free content, you're giving free knowledge, you're giving free experience, and you're giving your time and service to that individual. Do not be afraid for the ask at the end of it, right? Can I earn your business? I'd love the opportunity to work with you, get you in the clinic. My e-mail rate is this. Can I get you scheduled for next week? Convert those leads. We stink at this as a profession and something we definitely have a lot of work to do on getting better when that conversion, that sales conversion process kicks in, right?

10:43 - TRIAGE & TREAT

And then the last thing I have, if we're looking the part, if we are converting our leads is to know what works and deliver on that. Team, if they're at a CrossFit comp, they don't need pain science information right now. Okay? I'm not saying there's not a time and a place for that. What they need is something to help them recover. Their back is likely blown up. It feels like there's a hundred gallons of blood shoved right in their erectors right now. They want their back to loosen up and feel better. Their legs are probably imploded. They want their legs to feel better. Their shoulders are probably imploded. They want them to feel better. Right? Understand what these comps and these things are going to ask people to do. Lots of pull-ups, lots of squats, lots of deadlifts. Know what works for those things so that you're efficient in your clinical approach in those 10 minutes you have with someone. We're not trying to solve all their pain and all their problems in 10 minutes. We want to show them that we have tools that can help them. And if you give me more time, if you give me an eval, if you give me a couple sessions, I can get to the root of your problem. So you're having things at the disposal, ready to go for shoulder, like high-volume pull-ups, what am I gonna do to address the lats and the biceps? High-volume squats, what am I gonna do to address the legs and the quads? High-volume deadlifts, what am I gonna do to address the low back? Are you gonna bring needles and stim and hook people up and get them stimming? Cool, maybe get two treatment tables so you can get one person started on that and you get the other person on the table right after that. Are you gonna do some cupping on there, try to increase some blood flow? Great, get it set up, get it rocking, take a bunch of pictures. Another good thing to ask someone for is to have them take a picture and post about your company on social media. Remember, they're getting this for free. They're willing to do something in exchange. Scan your QR code? Sure. Post a picture? Sure, I can do that. Tag my business? I would really appreciate the exposure. We're just getting started. I love working in this community. I love working out in CrossFit. I'd love to be able to help athletes like you down the road. If you could post about my business, that would help me a ton. Thank you so much. They're thankful for your time, your service, and your free delivery of something to them, and they're willing to exchange that in terms of something else for your business. So there's some things for you guys to think about. The art of the 10-minute exposure. You've got 10 minutes in front of somebody. Treat them for free. Have some way of funneling and converting those leads. And don't forget to ask for the sale. Can I get your schedule? Can I get your book? Can I get your e-mail? Look the part. clothing, wardrobe, physically, and then your environment that you're set up, your tables, and your banners, and your marketing materials. And don't forget to ask for something on the tail end. Let's take a picture. Let's post about it on social media. Convert those leads, team. Get those people that you're there, you're giving your time for, for free. Convert those people into prospective clients that are on your books for the next week's following. I hope this was helpful. I hope you took something from it. that you know what works and that you're going to deliver on what works in that 10 minutes for that patient. Team, thank you so much. Shout out to anyone that's going to be at our courses to the end of the year. We're looking forward to wrapping up 2023 with a bang. Next weekend, we're in Hoover, Alabama and San Antonio, Texas. And still some spots for you to join us if you want to. And have a happy Halloween. I know we're rolling into it this weekend. Our gym has a Halloween WOD planned for tomorrow. So a costume WOD for tomorrow and then Halloween on Tuesday. So let me be the first to wish you a happy Halloween weekend, team. Thanks so much. Go kill it in clinic today. Have a great one, 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.

Oct 26, 2023

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

In today's episode of the PT on ICE Daily Show, ICE COO Alan Fredendall discusses different ways to use band tension to make bench pressing easier for those dealing with pain, weakness, or stiffness, as well as techniques to add accommodating band resistance to improve bench press performance.

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

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

EPISODE TRANSCRIPTION

00:00 - ALAN FREDENDALL

Good morning, everybody. Welcome to the PT on ICE Daily Show here on Instagram, here on YouTube. My name is Alan, happy to be your host today. Welcome to Technique Thursday. You may have seen this the last couple weeks. We had Paul on here and Ellie on here last week talking about some dry needling techniques. We're happy to bring techniques back. They used to be on Tuesdays, but now they're on Thursdays. So the goal of Technique Thursday is to show you some sort of manual therapy technique maybe a variation you've never seen before and likewise to maybe show you some tips and tricks with a certain exercise. The goal being something hands-on that maybe you could use in the clinic later today in front of your patients. So if you're joining us on the podcast and you're just listening to my voice, you're not going to get a lot out of this episode. So go on over to the Ice YouTube channel and find this episode so that you can watch the video. Before we get started today, it's Technique Thursday, which means it is Gut Check Thursday. This week's Gut Check Thursday, five rounds for time, a 400 meter run, 50 double unders, and 15 burpees. Much more cardio focused, body weight focused than last week. So last week we had an EMOM of calories on the bike and some bench press. So if strength and power is not really your thing, then maybe some lighter, long-duration cardio this week is your thing. You're thinking maybe 3-5 minutes around there, a relatively fast 400, ideally an unbroken set of double-unders or single-unders, and then a relatively fast pace on those burpees, trying to get that workout done, maybe somewhere between 15 and 25 minutes. Courses coming your way today, I wanna highlight our Extremity Management Division. The last three courses coming your way this year are coming up in November and December. So the weekend of November 11th and 12th, we're gonna have Mark Gallant, aka Mark Gallant, aka Mark Lanz. He'll be down in Woodstock, Georgia, the weekend of November 11th and 12th. And then the weekend of December 2nd and 3rd, you can catch Extremity's newest Lee faculty member, Cody Gingrich. He'll be out in Newark, California. That's gonna be in the San Francisco Bay Area. And then Lindsey Huey, the very next weekend, the weekend of December 9th and 10th, she will be out in Fort Collins, Colorado for the very last extremity management course of the year. So if you're looking to catch that course, check one of those three courses coming your way in November and December.

02:29 - BANDED BENCH PRESS TECHNIQUES

Today's topic, we're going to talk about some banded bench press tips. So you might be thinking, Alan, this seems like a topic for Fitness Athlete Friday, and you could be correct. But I hope by the end of today's episode that I get you some buy in that bench press is really appropriate for almost all of our patients. And today we hope to explain why and show you how you can introduce this movement to everybody. So when we think about bench press, we mainly think people who are already active, who are in the gym, either bench pressing, recreationally because they like it, they like to have a big puffed up chest, maybe they're doing it competitively, maybe they're a powerlifter or a strongman type athlete, and bench press is one of their events. And bench press does show up occasionally in CrossFit, so we do, not as often as powerlifters or strongmen, we do bench press in CrossFit as well. What's really cool about bench press is it's one of the four primary movement patterns of our upper body. If we think about our shoulder and chest complex, our upper body in general, what movement patterns can it fundamentally do? It can move things vertically. We can vertically pull, right? That's our pull-ups, our muscle-ups, our toes-to-bar, that's getting out of the pool functionally, jumping over a fence or something like that, some sort of vertical pulling pattern. We can press things overhead as well. the turnover of a snatch, things like that, moving weight overhead in a vertical pressing pattern. But then probably the more neglected patterns across fitness, recreational or competitive, is horizontal movements. We have our horizontal pulling, things like bent over rows. And finally, we have our horizontal pressing, things like bench press, but also more functional movements like pushups and burpees, right? Getting off the ground. So we like to use bench press here a lot with our older adults. It's a great way to load the shoulder complex, especially somebody with a painful or stiff shoulder that maybe can't even begin to initiate vertical pressing, maybe not even prone with body weight on the table, maybe not even in a landmine press, they have a really hard time due to stiffness, due to pain, whatever, even lifting any sort of weight vertically overhead. We know there's some carryover from horizontal pressing to vertical pressing. We're working primarily the pecs with the bench press, but we are getting some delt as well, and we're able to lift in a horizontal press pattern to maybe 115 degrees. So this is a great way to reintroduce load to the shoulder complex, even if we can't vertically press. Now today, I want to show you some ways to make the bench press easier for folks, whether strength is limiting them, range of motion is limiting them, or pain is limiting them.

04:57 - MAKING THE BENCH PRESS EASIER

So we're going to show you two techniques to make the bench press easier, and then we're going to show you a technique to make the bench press harder. So the easiest way to offload a bench press is a banded bench press like I have set up here in the rig. So I have two bands, half-hitched over the pull-up bar, the upright of the squat rack. onto the bench press in the center of the barbell so that I can still grab whatever grip width I want and now the bands are offloading that barbell for me. if I have pain maybe above a certain percentage I'm already bench pressing in the gym this can make bench press feel a little bit lighter so that it's more comfortable and tolerable and I can still get into the gym and maybe I can't bench at 75 or 80 or 90 percent of my max like my training has me doing but I can go in the gym at 60 percent with some bands on the bar and maybe I can move some weight at 60 percent so at the very least I'm maintaining or maybe a little bit incrementally increasing my strength as we calm pain down and build tissue resiliency back up. So pretty simple, half hitch the bands, put them over the barbell, lay back down in your normal bench press pattern, and then what you're going to feel is with no plates on the bar, you're going to feel almost like you have to pull the bench press down, and then the bands, if you have no weight on the bar, are really going to pull the bench back up for you. So you're able to really move through the movement pattern efficiently. So this can be great to train the bench press as well. And now we can put plates on there. What's great about this is we can get plates on the bar for maybe somebody who just the empty bar is challenging. By being able to put maybe even 10 pound plates on the bar, it helps them feel really successful, like they moved some weight around the gym. even if all they can normally lift without the bands is the empty barbell. So they get to go home and tell their spouse or their kids that they lifted a bench press today with the greens on or the yellows on, right? So it can help build success with that novice athlete. Folks who have pain or stiffness, we're now able to load at least in a partial range of motion of the shoulder, begin to strengthen within that range of motion that will hopefully now also allow us to transition to a vertical pressing pattern. If you don't have a way to set this up, another great tool is the slingshot. So this is from Mark Bell and colleagues. Anytime you've used a hip halo, maybe to do some monster walks, if you've used one of the official hip halos, that's also a Mark Bell product. If you have one of those, you probably recognize this looks very similar. So there's really no difference here and what I'm about to show you from what you get with the banded unloaded bench press, except now I don't need a squat rack with uprights to hang bands, but this is going to come up on my upper arm. I'm going to put both sides in. and now this is the slingshot. So now, as I sit down on this bench, there's going to be a tension that's created at the bottom of my bench press that's going to push me back out of the bench. So I'll lay back and show that to you all. If I were to pull a barbell back down, that band would stretch and help me out of the bottom. Now, what's great about the slingshot that you can't do with the barbell and the rig is I can translate this now and I can do push-ups or burpees with this on as well. What's really, really, really cool in the literature is how correlated maximal bench press strength is to push-up and burpee capacity. That is to say that the stronger your bench, it tends to track that you can do more push-ups. The reverse is also true. The more push-ups you can do, the likelihood is that you have a stronger bench press, and you can train one or the other to improve the other one. you can just do push-ups for a year and as long as you're progressing, how many push-ups you do, you're progressively overloading your push-ups, you will see an increase on your bench press and vice versa. So same thing, maybe somebody's not bench pressing at all but they come in and they have pain with push-ups or burpees, we can use the slingshot to offload that bottom position and make them feel more comfortable so they can continue to doing push-ups or burpees in their training program that we know that will translate down the road to bench press strength and vice versa. So two different ways to make the bench press a little bit easier, whether somebody's new, whether somebody needs to learn the range of motion, whether they have stiffness that prevents vertical pressing, or they just have a painful bench press and they currently can't lift as heavy as they would like.

07:53 - USING BANDS TO IMPROVE BENCH PRESS PERFORMANCE

Now we can also transition, we can use bands to make lifts a little bit harder. So now, instead of these bands over the barbell offloading, We're going to put these down on the floor to this pair of dumbbells you see down on the ground. Key here, really heavy dumbbells. I've got 50s here. If you try to do a banded bench press with like 25s, the resistance of the bands is going to pull the dumbbells off the ground. So keep that in mind that you need some heavy dumbbells to anchor for you. Setting these up, don't overthink it. Loop it halfway through, underneath the handle of the dumbbell, and then loop it up and over the barbell, right? You can see this is even challenging the 50-pound dumbbell. If I had even 45s or 40s, it would be lifting this dumbbell off the ground. Same thing on this side. Half loop on each side. up and over the inside. There we go. So now, the resistance is going to be coming out of the bottom. Because it's an elastic band, it's going to give us the least tension in the bottom, and it's going to give us increasing tension as we drive out of that bench press. Now, there's some criticism of this, of the weakest point of the bench press is the bottom, so why am I doing a training method that makes the weakest part, the easiest part to train with a banded bench press. The answer is that when I have accommodating resistance out of that bench press, I need to activate more and more and more and more and more muscle fibers to drive out of that bottom. So yes, It will never improve the dead stop where the bar is touching my chest at the bottom. The only way to train that is to go through full range motion bench press more often. But the benefit I'm going to get is I'm going to activate more muscle fibers, which in the future is going to translate to being able to recruit those more easily when I bench press in the future. And also I have to continually increase my velocity out of the bottom of the bench press to overcome the steadily increasing resistance from the band. That band is going to get tighter, tighter, tighter, tighter as I get out of the bottom. I'm going to have to continually increase my velocity out of the bottom or I'm not going to be able to go anywhere. That's really helpful for anybody that's maybe stuck at a certain weight at their bench press. They can go to the bottom and they can drive out, but it's really slow and grindy and maybe they're stuck at a weight like 315 and they said, hey, I haven't added weight to my bench press in a year. This can be a great way to break some plateaus. It can also just be a way to overload the bench press. If my max bench press is 315, I can put 275 on here. Yes, the bottom is going to feel easier, but as I drive out, it's going to feel as hard as 315 maybe coming up. And now I can get more volume in, in a way that my speed is maintained, that's going to translate into having an overall stronger bench press down the road. So pretty simple, bands on the barbell, on racket. A lot of tension at the top, right? This is super tough even with no weight. As I come down, easier, easier, easier, and now I really have to focus on increasing speed continually to get out of the bottom of the bench press. With an empty barbell, that would be pretty difficult for maybe even a set of five. So don't knock it till you try it. There's a lot of criticism about bands and chains. Obviously the most important thing is the weight on the barbell over time, but this can be a great way to just change up variance in your bench press, to break through a plateau, and even to overload your bench press, to be able to lift a weight Maybe you use a bench block, you come down to maybe 80% of the range of motion and drive out, and now you're working at a weight that's maybe heavier than your one rep max bench press. Again, the goal, recruit more muscle fibers and kind of overload that bench press pattern. So banded bench press, why? Folks who maybe have a lack of range of motion or lack of strength overall in the chest and shoulder complex, who maybe not right now are able to show you any sort of vertical pressing pattern. It is a great way to offload a bench press for somebody that maybe is already training the bench press that has pain, and then we can flip the resistance. Now we can give resistance as we drive out of the bench press. Why? Accommodating resistance, help improve our barbell velocity, help break through plateaus, recruit more muscle fibers. So play around with banded bench presses. I hope this was helpful. Have a fantastic Thursday. If you're going to be on a live course this weekend, I hope you have a wonderful weekend. Thanks for listening. 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.

Oct 25, 2023

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

In today's episode of the PT on ICE Daily Show, Modern Management of the Older Adult division leader Christina Prevett discusses that the fountain of function is muscle mass and estrogen in the aging female. Christina breaks down these two areas for function, and what we have physical therapist can do to help encourage both muscle mass and estrogen preservation.

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

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

EPISODE TRANSCRIPTION


00:00 - CHRISTINA PREVETT

Hello, everybody, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the team within our Modern Management of the Older Adult Division. In our division, we have three courses in our geriatric curriculum. We have our eight-week online Essential Foundations course. We have our eight-week online Advanced Concepts course. And we have our two-day live course. We have a couple of courses that are left in the remainder of the year. We have a course coming up in November in Chandler, North Carolina. We have another course coming up in South Carolina. And we have a course coming up in Texas in December. So if you are near those courses or you are looking to get in some content before the end of the year, I encourage you to check those courses out. and you'll be able to get in with some of our faculty before, you know, we ring in 2024.

01:18 - THE FOUNTAIN OF FUNCTION

Today I'm going to talk about the fountain of function. And so this is a reframe that I think is really important. And we're going to talk about what those fountains of function are. You'll notice that I did not say fountain of youth. We have this idea in our society that youth is the goal, to not feel like we're getting older in any way, to not show signs of age on our faces. And don't get me wrong, I see my aging face, I was like, oh, my face doesn't look like I am 21 anymore, and I look at the wrinkles on my face, and I have those emotions. But the idea for my life is not to try and get younger. It's to try and optimize my reserve and try and live the way that I want to live with the most amount of function possible into my 30s and 40s and 50s and 60s and hopefully all the way up to 100. Because at MMA and within ice in general, Aging is a privilege. It is something that I am very thankful for because the alternative is not that great. We're not gonna be able to reverse back time, but we can have a really successful aging process, especially when we put in the steps to live the way that we want to live, whatever that filter means for us. So I'm not looking for the fountain of youth. I am looking for the fountain of function. And so the two types, the two areas that are the fountain of function in aging women, so I'm going to talk about female anatomy, is muscle mass and estrogen. And these two things, especially when taken together and optimized to the best of our capacity, is going to allow us to have more function towards the end of our life. So let's talk about muscle mass. You have not been following the Institute of Clinical Excellence in any ways if you don't know that LODE is our love language across all of our division, across all of our faculty, and that is absolutely true in the geriatric curriculum as well. And I love it so much that I did an entire PhD on the influence of resistance training in an aging body. When we look at resistance training, we are accumulating a growth and a continuation, a plethora of education and research that looks at the impact of resistance training on health outcomes. And I just posted a paper that was a narrative review from Stu Phillips, who is one of my committee members on my PhD.

04:18 - THE COMING OF AGE OF RESISTANCE TRAINING

And he talked about the coming of age of resistance training and how we are starting to see some accumulation of evidence that is mirroring and is just as strong as literature that we're seeing in aerobic training to prevent stave off different chronic diseases, including some cardiovascular diseases. And so there means that there, as of course, we're going to target the aerobic system. This is not to say to not do cardio in stead, just do resistance training, but it's showing that there is a continual and persistent growth of literature talking about the impact of resistance training on health outcomes. So what we see is that those who have more muscle mass tend to have lower all-cause mortality. They are less likely to develop cardiovascular conditions. They are better able to manage diabetes. They're less likely to get diabetes. We know that muscle mass is protective around things like osteoporosis, right? Tensile strength of the bone is important and we need impact, body weight movements, resistance training across the lifespan in order to optimize that. We see that individuals who are stronger or less likely to have sarcopenia, right? Sarcopenia is clinically relevant amounts of muscular weakness that are preventing a person from completing their day-to-day tasks. It's a totally important output of frailty. Fried's physical phenotype of frailty talks about physical reserve and physical capacity as an output of individuals seeing these constellations and signs and symptoms that lead to vulnerability to external stress. That external stress includes things like hospitalizations and being able to withstand different stressors with respect to immune system insults, including things like COVID-19, pneumonia, and the flu that allows individuals, while they are sick, to have that reserve and resiliency to lean back on in order for individuals to be able to get back to baseline or improve past baseline, post-hospitalization, or acute insult. All this to say, we know that individuals need to be trying optimize their muscle mass in their earlier life and then hold on to it for as long as possible. If you are in a setting where you are not working with individuals who have optimized their muscular mass, we also know that muscular mass can be developed and we can see improvements in physical function with resistance training at any age when we start including in our 90s. The mechanism at which strength develops is a little bit different. We're looking a lot more at neuromuscular efficiency. However, we can absolutely see that it can improve function. And so whether you are 30 or you are 85, muscle mass is a fountain of function and it allows us to withstand stress.

12:24 - ESTROGEN FUNCTION & MENOPAUSE 

Now let's kind of talk about this second piece, which is estrogen. I've done several podcasts on menopause, but I want to talk about the influence of estrogen around female physiology, because I think this is really important. So when we are going through the menopausal transition, on average, individuals will start menopause between 50 and 51. Definition of menopause is when you've gone a full calendar year, 12 months without a menstrual period. That is your menopausal transition. But individuals can be experiencing perimenopausal symptoms that are indicators of dwindling or are coming down of estrogen status for up to 10 years prior to the transition into menopause. And so individuals who are in their early 40s can start to see the influences of loss of estrogen on their body. And then that influence is persistent as individuals get older. When we're talking about menopause, we often are putting this into two camps. So we have vasomotor symptoms, which are these symptoms that occur because of an acute withdrawal of estrogen. These are things like night sweats and hot flashes. As individuals transition through menopause and we get into our later life, into our 60s, 70s, 80s, and beyond, those symptoms tend to decline. So those vasomotor symptoms that occur as our body transitions to reductions in estrogen status they tend to go down as our body gets used to this new state of equilibrium that occurs without estrogen. In the opposite direction, the second kind of camp that we speak about when individuals are going through menopause is genitourinary syndrome of menopause or GSM. And that is signs and symptoms across the female physiology that are responding to losses in estrogen. and anywhere where there is an estrogen receptor within our body, they are going to experience changes when individuals transition through menopause. And we oftentimes will, in the pelvic health space, talk about changes to our reproductive anatomy, which are unbelievably relevant, but we have to also extrapolate that out and talk about different areas where estrogen is influencing female physiology and how, if you are working with an aging female, they are experiencing changes because of that change in estrogen status. And so within the reproductive track, we see that there is changes in ligamentous stability around the pelvis. And I hate that word stability, but it's a change in the turnover of the way that our ligaments are restructuring. So we have a little bit more ligamentous breakdown than buildup, right? That turnover rate is different. And so we have this shift between static support in the pelvis to the requirements or dynamic support around the pelvic floor. We see that individuals start to have vaginal atrophy. We see that the vaginal microbiome starts to change. We don't have the same cervical mucus secretion. And so things like chafing and redness can be more prevalent in a person who is postmenopausal. We can see fusing of the labia minora and majora. and this can lead to increased risks for pelvic floor dysfunction. So when we are in estrogen low states, rates for pelvic floor dysfunction go up. This includes anal incontinence, urinary incontinence, pelvic organ prolapse, dyspnea, or painful punitive intercourse, and other aspects of the reproductive tract. We also see, because of this change in the vulvar anatomy, that we have an increased risk for things like urinary tract infections, that increased risk for urinary tract infection also influences individual's physical function. We know that recurrent UTIs can be a cause of changes in cognitive status for our aging females. And so something that is extremely relevant for our aging women. Other things that we see is that as individuals go into an estrogen depleted state, increased risk of cardiovascular disease goes up. Individuals as they transition through menopause, we see that in general, men tend to be more impacted by cardiovascular disease. That is shifting for a lot of different reasons, but that risk profile increases when individuals are in an estrogen depleted state. We see a change in central adiposity where weight starts to increase. Adiposity accumulation can increase, especially visceral fat accumulation, which has a risk profile in and of itself for different chronic diseases. And then we see, for example, in our bone microarchitecture that the influence of estrogen allows for continual bone regeneration and that profile again starts to switch and there's an increased risk for things like osteoporosis in an estrogen deficient state. So there's a lot of things that get impacted, right? Our skin gets impacted, our breast tissue gets impacted, our urinary tract, all of our mucosal membranes, not just in our vulva, but across our entire body, and this has impacts. And so when we are thinking about working with these individuals, one of the things that is starting to become really recommended is topical estrogens. And there's a lot of debate about this because of a study that had been done a little while ago that looked at increased risk for sex-related cancers, breast cancer, endometrial cancer, cervical cancer, et cetera, with systemic estrogen. However, what we are starting to see now and many of our menopausal experts like Dr. Mary Claire and Dr. Rachel Rubin are really trying to have this public health approach to medicine saying that we are not doing our females a service when we are saying that there is a risk profile when subsequent studies have not been able to substantiate or replicate those findings. And so there's been a big shift in the last five years to the need for or the desire for many women who are really suffering with genital urinary syndrome of menopause to be able to take things like topical estrogens in order to really significantly reduce their symptom burden. And I'm not just talking about their pelvic floor, which is an extremely important part of their sexual health, also a vital sign of aging, but also, you know, all of these other physiological signs of estrogen deficiency that are impacting our outcomes, right? We see that individuals with that combination of muscular mass, we are seeing individuals with negative consequences of osteoporotic fracture. if we were able to be preventative in this approach where we are talking about estrogen supplementation when these symptoms start to arise, especially when they hit a threshold of bother, where there's going to be this spectrum, some individuals are very bothered and very impacted by the signs of vasomotor symptoms and genital urinary syndrome of menopause, and then some individuals are not, but for those individuals with bother, is this something that should be taken? Is this something that they can talk to their physician about? Is there this literature to support these topical estrogens? And we are starting to see this mounting of evidence that is starting to come up to help individuals in the aging process. So many of our aging adults are being told that this is just what they should be living with. This is because they're going through menopause. Deal. We saw this in the peripartum space where there's a lot of advocacy still happening with respect to not having this thought process that as soon as you have a baby that pelvic floor dysfunction is just something that you should live with. We're starting to see this rise up in our perimenopausal and postmenopausal population, where they are not accepting that this is what they should be doing. They're not being dismissed anymore for these symptoms, and it's super important. When we take this lifespan approach, this education becomes extremely relevant. Talking about the peripartum space, I truly believe that that is where we start to tell females that they are not resilient, that they are somehow fragile, that they need to be concerned for their organs falling out and all these different pelvic floor dysfunctions. And then they are not encouraged to be as resilient as they could be by taking part in heavy resistance training or impact activities or things at higher intensities. We start bringing that intensity down and the idea of, ooh, be careful or, oh, monitor this or, oh, if you have these symptoms, it's time for you to stop participating in those activities. We are seeing this shift and what this shift is going to do earlier in life is it's going to set up are aging individuals with this mindset that pelvic floor dysfunction one is not inevitable two that reserve is protective when it comes to muscular reserve and three they're going to be advocates for their own health and that includes their hormonal health and that includes not accepting that some of these symptoms of menopause are things that they just need to live with, but things that can be medically managed. Genital urinary syndrome of menopause is a syndrome condition. It is a medical diagnosis, and therefore it is something that we can be treating. As physical therapists, us being educators and conduits of that knowledge translation is extremely important. And then we are going to optimize function for these individuals. Last point that I'm going to make, because I ended up being a lot more long-winded than I thought I was going to be, is that we are now seeing this interaction between menopause, genital urinary syndromes, and long-term health outcomes. We are seeing that individuals with higher physical activity, combination, aerobic resistance, or both, are having a much lower GSM burden than those who are not. And so again, it comes back full circle, whether this health promotion is extremely important, that not only are we gonna optimize a person's muscular reserve, we're gonna make that fountain of function be extremely relevant, but we're also going to make the quality of that function a lot better because their quality of life is better because we are not allowing them to just live with these symptoms and be dismissed by our medical system, us included, that just expects this to be the way that it is. And so this advocacy piece is extremely important and it's something that we are going to be screaming from the rooftops. All right, everyone, I hope you have a wonderful week. I'm going to be diving a lot more onto my page and I'm going to be collaborating it with ICE and MMOA around hormone therapies for individuals with GSM. I am not a medical physician, so I encourage you to reach out to your urogynecologist and urologist in your area. Get that relationship with them so that you can start having these conversations and we can start talking about risk profiles. All right, have a wonderful week. If you are not on our MMOA digest, I encourage you to sign up for those newsletters. Otherwise, have a wonderful week and I will talk to you all again soon.

OUTRO

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

Oct 24, 2023

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant emphasizes the importance of having a well-coached and appropriately dosed set of exercises for patients. He stresses that these exercises should be ones that the therapist is extremely familiar with and knows exactly how to prescribe. By having a clear understanding of these exercises, the therapist can confidently explain to the patient the objective criteria and expectations for progression.

Mark acknowledges that sometimes our egos can hinder us, leading us to believe that we can come up with a better plan for each individual patient based on the information we have at that moment. However, he argues that research has shown that the human brain is a sensitive instrument that responds quickly to changes. Therefore, having a preset plan of exercises allows for consistency and efficiency in treatment.

Additionally, Marj suggests that having a set of exercises that can be progressed by increasing work volume, range of motion, load, or speed, while keeping the exercises relatively similar, can be beneficial. This approach allows the patient to become more efficient with the exercises and increases their buy-in. It also reduces stress for the physical therapist and ensures that enough time is given for each intervention to make a meaningful impact.

Take a listen or check out the episode transcription below.

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

EPISODE TRANSCRIPTION

00:00 - MARK GALLANT

What's up PT on ice crew we got Instagram here YouTube over here. I'm Dr. Mark Lantz coming at you here on Clinical Tuesday, lead faculty in the ice extremity management division, alongside Lindsey Hughey, Eric Chaconas, and Cody Gingerich. Happy to be here this Tuesday. Before we get rolling, a couple of housekeeping things. We've got a few more courses for the extremity division coming up here for 2023. I'll be in Woodstock, Georgia, second weekend of November. and then Cody and Lindsey each have opportunities early December, so check that out on the ICE website. More importantly, if you've been looking to get a certification through ICE and the overall ICE cert seemed like a bit much to chew off right now at this stage of your career, we are happy to announce that we've launched the Ortho cert. If you take the two spine management courses, cervical management, lumbar management, the extremity management course and total spine thrust manipulation, take a short test at the end of whichever the last of those four that you take, you can become ortho certified. So that is officially launched and on the website. So definitely head over there and check that out and we hope to see you on the road soon.

01:39 - INDIVIDUALIZED CARE

So today what I want to talk about is individualized care. your ego is killing our profession. And what I mean by that, or what we mean by that, is that when we go around the country and we mentor folks, or we help out and talk through cases with individuals, watch people treat, one thing that we're starting to see as a trend is that folks are jumping around quite a bit in their plan of care. So that patient comes in for one visit, they're given a certain set of manual therapy techniques, a certain grouping of exercises at a specific dosage, and then each subsequent visit that person comes in, the plan dramatically changes. They're given a new set of exercises, there's different manual therapy techniques done. They are getting a completely unique plan of care each visit. And what we're recommending is that there needs to be a plan, that for any given pathology, you have a plan of what this is typically gonna go like. With that individualized care of jumping around from place to place, visit to visit, what we believe is that it is a reaction to old school physical therapy, what we like to call physical therapy 1.0, where a person would walk into a clinic, they would be put on a new step or a bike for five to 10 minutes, the physical therapist would wave the ultrasound wand on wherever their area of pain is, and then they would be given an exercise sheet. And it would be very specific to, here is the foot and ankle exercise sheet. Doesn't matter what you have going on, here is your foot and ankle exercise sheet. Here's our shoulder sheet. And if you were lucky, you would have a tech that would take you through that. If you were not one of the lucky few, you would either be given that to go run through in the clinic on your own, or even worse, just sent home with this exercise sheet.

04:17 - INDIVIDUALIZED PLANS OF CARE

So we swung the pendulum hard to everyone gets an individualized plan depending on what they show up with the clinic that day. So if their pain has changed, if what the exercise is looking has changed, then we ditch the entire plan and then we're going to go to this very individualized thing each visit. The problem with this is it's hard for the patient to buy in if everything changes each visit. They're not sure what the plan is. Humans love to have a target in a bullseye. So if that person knows like, ooh, here's the plan that we laid out during the first couple visits. And here's where I am along that plan. It allows them to be more bought in. They're going to comply with the plan more. They're going to be more adherent to the plan because they can see the target they're shooting for. And they can very clearly see where they currently sit on that plan. In addition to that, if we're jumping from thing to thing all the time, we're actually likely not giving any one intervention enough time to do its thing. So we know with exercise, the research is fairly clear now that exercise for musculoskeletal pain is the most bang for your buck intervention from a cost perspective and from a getting the job done perspective. It takes time. If we're jumping from thing to thing every visit, then we're likely not giving those interventions enough time to actually make changes. And in addition, it takes people time to get used to doing an exercise. So if we switch to exercise each visit, we're not allowing that person to become efficient with that exercise. And then finally for us, if we're seeing anywhere, depending on what type of setting you're in, between six and 20 individuals a day, creating six to 20 unique plans of care. Every single visit for every single person becomes wildly exhausting. I've lived it. Everything that I'm saying here, I have personally done for many years. That type of physical therapy becomes exhausting. And it's likely part of the reason why we have such a high burnout rate in our profession. If the expectation is a unique individualized plan of care for every individual, every day. That becomes a lot for any one given physical therapist. Whereas if you know, for X pathology, for my rotator cuff related shoulder pain folks, I know that I can modulate their pain, decrease their symptoms with these three to four manual therapy techniques. I know that my bread and butter early on exercises are gonna be these four to five exercises that I can coach extremely well, that I know exactly how I want to dose, and that I have an expectation of when the person can do these, what the next group of exercises that I'm gonna move on to, and I can clearly explain the objective criteria to the patient of what that's gonna be. Now, our egos often get in the way of this, because many of us, myself included, I'm speaking to myself more than anyone, believe that for any given person that comes in, that we're going to be able to give them a better plan based on the information that's coming that day than the preset plan before that may seem more cookie cutter that we're afraid of. What we know about the human brain, now having a lot of research over the years, it is a very sensitive instrument and it's going to respond quickly and rapidly to what's changing in the moment. So therefore your plan or what that person is coming in can be highly deviated by anything that's happened to you that morning or that day. If you had a stressful interaction with your boss, if the kids were having a hard time getting ready for school, if someone called you right before the patient came in and gave you some bad news, that is all going to very dramatically sway what happens in that session and how you go about what you're going to do in that session. Even more dramatically, our patients are in pain. which means that their nervous systems are gonna be all over the place. And so their drama and their brains are gonna be very sensitive and that is also gonna shape those interactions. So we're leaving a lot of interpretation to that interaction. Whereas if we have a plan that we know if this is looking like this, I'm gonna go this way, if this is looking like this, this is how I go based on the plan for this pathology, we are far less likely to succumb to the sways of any given day. When we look at other professions, professions that have higher stakes than physical therapy typically, we see that they use systems and plans to deviate from those in the moment sways. Pilots are the easiest example to talk about. When you have a pilot, it doesn't matter if that pilot is on his second day of the job or if they have 36 years of experience. That pilot has a checklist for almost everything that could possibly happen on a plane. If the weather looks like this, this is our checklist of what we're going to do. If the wind changes this way before we land, this is what we're going to do. And that pilot follows the checklist, not what they're feeling in the moment based on their experience. So much so to the point where there's a second person there, the co-pilot. whose primary job is literally to say, hey, why aren't you following the checklist? We got to go back to the checklist. We know this works. 99.9% of the time go to the checklist.

09:30 - RECIPE REPETITION 

For those of you who have been following ICE for a long time, our CEO, Jeff Moore, spent a lot of time working in restaurants and kitchens. And if you were lucky enough to take a class with Jeff or got to spend some time with Jeff, we used to always get all these stories about his time in the kitchen. And a lot of those things I still think about to this day, the stories he told as far as patient care. And one of the main ones that stuck with me was a chef that he worked with, who now has a Michelin star, by the way, told Jeff that for any given recipe, you need to cook this 1,000 times before you start to deviate from the plan. Doesn't matter if you're the greatest chef in the world, you don't add salt, you don't add fat, you don't add any flavor profiles until you have cooked that recipe 1,000 times. Because that 1,000 times is going to allow you to see how this thing really responds, what could possibly go wrong, what could happen, how you really get the full breath by committing that much. That's the same with our plan of care. There is no way that we can confidently say to the human in front of us, for most people what we see, if you follow this plan, this is where we get to. If we're changing the plan all the time, we never get to experience that to show the patient and to say confidently. So we want to have the plan for any given pathology that we're going to give most people. Another example, is the 12-step plan in recovery. I am not in recovery myself, so if I'm butchering this, I apologize to anyone who is in recovery. But with the 12-step program, it's 12 steps. You run the steps, and people who have addictions all over the country have been using this 12-step program to help deal with their said addiction. And when you look at that plan, it's a simple, not easy plan, and you follow those steps to a T. Again, same as the co-pilot, they have a mentor or a sponsor who helps them work those steps. If that person is struggling or deviating, what that mentor's job is to do is say, hey, make sure you go back and are following these steps and are not deviating. So lots of examples of really solid professions and organizations that use a plan to get the job done.

12:07 - STICK WITH THE PLAN: MODULATE PAIN, INTRODUCE MOVEMENT, PROGRESS MOVEMENT

So what should the plan look like for us, for any given patient? When you have a pathology, rotator cuff related shoulder pain, plantar fasciitis, things that you need to know. Early on, what are the manual therapy techniques or exercises that you know can modulate pain and decrease symptoms for most people? Have a few of these that you know you can do effectively and work for most folks as part of your plan. Then have your bread and butter exercises. What are the exercises that are gonna be the main, let me back up for a second. Before you have your bread and butter exercises, what are the few exercises that you're gonna have that are for that irritable patient that you know before they can tolerate a lot of load that we're gonna give them? So your pain modulation techniques, your lower level exercises that are not gonna overstress the tissue while we're trying to calm this down. Part two, what are your bread and butter exercises? What are the handful of exercises that you know tend to work best for any given pathology that you can coach really well, that you can dose really well, that you can manage workload really well? And then finally, what is the criteria that that person needs to demonstrate to move on to their more advanced exercises? And then a final piece to have in your mind is what does this look like If the person does have a flare up or relapse, how do we coach them? What point in the program do they go back to if they are indeed not ready to progress? So again, what are the things that can modulate pain and that can calm symptoms down or exercises that are not going to require a lot of stress to the tissue while things are calming down? What are your bread and butter exercises for any given pathology? What are the most common things that you're going to give in most people's plans? And then finally, what are you going to have as your criteria to progress these people on and having a game plan if they do flare up or regress? What this is going to allow, it's going to allow the person to go, ooh, I know exactly where I am on Mark's plan of care at this time and where I need to go to take the steps to move forward. It's also going to allow you to not have to switch exercises so much. You're not going to have to get overly creative with your exercise prescription. And by doing this, what you're typically going to be changing is same exercises, but you're going to be increasing the work volume. You're going to be increasing the range of motion. You're going to increase the load on the exercise and you're going to increase the speed on the exercise while keeping the exercises relatively similar or the same so that the person can become more efficient with that exercise. It's going to allow the patient to buy in way more. It's going to take our stress way down as a physical therapist. And if there is that small percentage of folks who do indeed need a more nuanced program because they are actually not responding over time, or they're having a lot of trouble adhering to the plan, it's only a small percentage of the folks, which takes a lot off of the mental stress for us as physical therapists. Love to hear what you all think about this in the chat. Definitely hit us up. Love to see you on the road in Woodstock, Georgia next month. Cody and Lindsey have courses early December. Check out the ortho cert on the website. Have a great day in clinic today. Hope you all crush it. See you soon.

OUTRO

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

Oct 23, 2023

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic lead faculty Alexis Morgan discusses the research & practical approach to helping runners return to running beginning at 4 weeks postpartum. She references research that about 50% of postpartum patients begin reintroducing running at approximately 4 weeks postpartum, with varying degrees of symptoms. Alexis emphasizes utilizing the symptom behavior model to monitor symptoms, educating & encouraging patients that about 85% of all individuals have some sort of symptom(s) with running, and that volume is an important variable to have a successful return to running.

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

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

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

EPISODE TRANSCRIPTION

00:00 - ALEXIS MORGAN

Good morning, Instagram. Good morning, fellow ice people. Welcome to the PT on Ice Daily Show. Welcome to Monday. It is the start of another week. And we are so excited to be here. Really as we're wrapping up the end of this year, we still have a lot going on at the end of the year that I want to tell you all about this morning. And then we are really getting already very excited about 2024. And just want to talk to you all about some of the things that are going on. If you are in the ICE Students Facebook group, you've been to an ICE course or you were just recently added in because you just finished a course this weekend, welcome. You've seen some announcements in there as well a while back. And I just want to highlight a couple of things. So let's get started on that before we discuss four weeks returning to running, four weeks postpartum. So number one, we've still got three more chances for a live course, or you've got three more chances to hit us in the pelvic division at a live course. So this, not this weekend, but next weekend, if you're listening live, November 4th and 5th, we will be in Bozeman, Montana, and then a few weeks after that in Bexar, Delaware. And a few weeks after that in Halifax, Nova Scotia, Canada. That is the first weekend in December, December 2nd and 3rd. So those are your three chances to get into seeing this Pelvic Live course, experiencing it, having fun with us, learning so much about pelvic floor health. not just for pregnancy and postpartum, but in general, across the lifespan, men and women, pregnancy, yes, but also all things pelvic health. So those are your three chances, Bozeman, Bexar, Delaware, and Halifax, Nova Scotia, Canada. So if you're on the fence, go ahead and pop onto those. Second, thing that we i want to share with you all is about the pelvic level one course so our name is changing as you all have heard us talking about and we're actually going to be taking a little break through the next few months and our new level one cohort is going to start in january so Be sure, we've already got people signed up for that, gearing up, ready to experience the new content. Very regularly, we are always reading the research on a weekly basis. And once enough of it stacks up, we've got to reframe the way that we're teaching, particularly in the space, because it changes so incredibly rapidly. And so with that, we are updating that material. So that is coming up on, that will be on the website soon. Actually, that is actually already on the website. So that is on there. So a lot of things coming up at the end of this year, the beginning of next year. We've got even more announcements, so stay tuned. And we're gonna be announcing a couple more exciting things in our ice pelvic newsletter. So if you're not already signed up for the pelvic newsletter, go ahead and sign up for that because we've got even more things to discuss and share with you all.

04:31 - RETURNING TO RUNNING 4 WEEKS POSTPARTUM 

So all of that aside, let's go ahead and discuss this four week return to running. This is a topic that a handful of years ago really was not discussed. No way are we going to be facilitating someone running one month after giving birth. That's what we thought a handful of years ago. But fast forward, we've got several examples of elite level athletes which then trickles down to our recreational level athletes, we've got several examples of people returning to running. And it's actually even showing up in our literature. And when we are starting to see this, it's kind of interesting in the pelvic world, like we have all of these thoughts and beliefs and oftentimes you're you're gonna run into some strong opinions surrounding those, and a deep connection here. We've gotta have that connection with our beliefs, but also be willing to let that go once the evidence and once the, even the anecdotal evidence that your clients show up to you with, once that narrative begins, and it's maybe opposite of yours, we need to be able to let that go and to explore and ask questions and be curious about, well, what are some other possibilities? And that's exactly what we're seeing in this four-week return to running. So what we've seen is people aren't running. Runners will run, as we always say, in pregnancy and then early postpartum. And what we know is that the longer someone runs in their pregnancy, the sooner they're going to run in that postpartum phase. And in Shefali Christopher's study looking at returning to running and risk factors associated with musculoskeletal pain, she actually saw that it was close to half of those individuals, 46%, reported returning to running at four weeks. And so we've got some information to kind of digest, right, as therapists. And what we know, and again, in her research, what we know is that when runners return to running, we're seeing that musculoskeletal injuries or musculoskeletal pain does occur. And so that's the number one thing that we want to be educating our runners on and we want to be looking out for. But rather than waiting until they've hit certain guidelines, what we are proposing and what we are doing, what I am doing clinically, what a lot of our faculty is doing clinically is we're educating our patients. And we urge you to educate your patients as well. Based on this evidence, this is what we're seeing. We're seeing that when we're returning to running, we're actually, many people are experiencing musculoskeletal pain, about 85% of people. Not just those that are returning at four weeks. The median time returning at 12 weeks. So that's significantly before and significantly afterwards. We educate them. So we can, Educate them. They know that okay. There's a risk of injury. There's a risk of musculoskeletal pain Of course, just like with everything and what we tell them is when you feel something You need to let me know That visit is so much easier to discuss that if it's already been planned. So you schedule your person a couple weeks out. Go ahead and return to running and see how that feels. We're gonna control for the volume. We're not gonna go out and run five miles for the first time in eight weeks. We're gonna control that volume. Build up slowly and see how they feel. If you're experiencing some mild knee pain or some hip pain, we are gonna address that. All the while, absolutely, we're doing our basic hip strengthening, right? I say basic, not just talking about a basic squat, but also your accessory movements like clamshells to work on that rotation. Or better yet, some single leg standing you know, the standing variation of the clamshell or the hip abduction with your foot on the wall. That way you're working both sides. We love that accessory work to decrease the risk of pain. But even while they're working on that strength, they're still, everyone is still at a risk. And so the best thing they can do is talk to you about it as soon as they experience that. And tell them, okay, let's back down on that volume right when they're when they experience that let's say they bumped it up to a two mile total volume of running maybe they were doing one minute of running 30 seconds of walking and they had just bumped all of that volume and those intervals up experience that bit of lateral knee pain let's bump that back down. What were they doing last week? Let's repeat last week's volume. Let's repeat last week's running workouts and let's calm that system down. That's how we'll address it from that pain aspect. And then of course, we're going to be continuing to build that accessory strength training and coaching their running, looking at their running form. We're not afraid of them experiencing that pain. In fact, we know more than likely they're going to experience that. Again, 85% of runners are experiencing some level of pain, typically in the lower extremities, not necessarily their pelvis or pelvic floor. So we know we're gonna bump into that. So we educate them on the factors, and then we schedule a visit to where we're gonna follow back up on that. That's already in their calendar, they already know. That way we can discuss those itty bitty issues that they have, and we can address them before they get bigger. That's exactly the same thing that we want to do with pelvic heaviness, symptoms of heaviness, really fatigue, we've talked a lot about that on the podcast here and of course in our courses, but pelvic floor heaviness or fatigue is another symptom that we're going to address in the exact same way. We're gonna decrease their volume. We're gonna educate them about it first and talk with them when they experience it, but they are going to decrease their volume when that occurs. We're gonna continue to be building that hip accessory work. All the while we're working pelvic floor strength, but pelvic floor and hip accessory movement, that's what builds up strength and endurance for the run. Just like how we expect them to experience pain, what we're realizing is that we expect them to bump into some symptoms of heaviness as well. We, as the rehab providers, are not scared of that. Just like we're not scared of them experiencing pain. We know they bump into that and we get them to back off immediately. We know they're not gonna have an issue there. We know they're gonna meet all of their goals and continue to run. We know this with the symptoms of pelvic floor heaviness as well. Heaviness, in most cases, many cases can come on with a lot of emotional concern. And honestly, in some cases, pain can do that as well. You've all experienced that with your patients. Very similar with pelvic floor heaviness. I see it very, we all see it very heightened in that emotional response. But if we can educate them on this first, if we can tell them, Hey, You're gonna bump into this. This is a symptom of fatigue. What you're gonna do when you bump into it is you're gonna back down. You're gonna back down in that volume. You're gonna wait to return to your next running workout until those symptoms have died down, because your body is telling you that that's too much. But you're gonna return, and we're gonna talk about it on our next visit, and you are absolutely gonna run that 5K at Thanksgiving. or you're absolutely gonna run that New Year's Day 5K, whatever that may be for them. So, educating them about symptoms, whether it's pain, whether it's heaviness, of course, leaking. I feel like we as pelvic floor PTs have educated people so, so much on leaking, but similar conversation here. you're probably going to have leaking with some point of return to running. Again, it's muscle fatigue that often precedes that return or that leaking. So we're going to probably experience it. If that athlete is running to a fatigue level, that's okay. We've gotta understand where their capacity is and where that lies and where that threshold is for leaking or for heaviness or for pain. We figure out where that threshold is, we go down from that. We build capacity and we bump that threshold up. That's the name of the game in all things that we do. That is the name of the game in pelvic floor health, in returning to running, even when they're returning early, like at four weeks. Realize runners are gonna run. Many of them are already going to run at four weeks. So go ahead and have that conversation at your two-week follow-up. Better yet, go ahead and have that conversation in their late pregnancy. Prepare them for what they're going to experience in that return to run. Prepare them for it to decrease fear and to improve education and awareness. Education goes such a long way in this area, but we've also gotta have that follow-up. We've gotta have that action item, okay? When they experience the pain or the heaviness, what you're going to do is X, Y, Z. Decrease that volume, right? Maybe return to some, diaphragmatic breathing and regulate your nervous system if it's someone who's has a heightened level of concern, right? We're going to repeat last week's workouts after symptoms have resolved. Give them several action items that way they feel empowered to make those decisions for themselves. All of that and then have that follow-up appointment with them already scheduled a couple weeks out. And that way, you can address all of these issues that are small, and we ensure that it does not continue to grow. So that's a very different way of guiding someone in this return to running, where someone is starting to run early, we don't have the time to go through all these strength and all of these assessments, but we just say, hey, let's use our symptoms as our guide. Let's start small, 15 seconds of running, 30 seconds of walking. Let's start small and add that in and let's see how you do. That is an example of us coming alongside someone who's already going to be running. This is how we stay in their corner as opposed to, Hey, you're not ready to run. Person's like, I know I'm ready to run. I mentally am so ready to run. I'm not gonna go back to that person. I'm gonna go run. We lose people when we have this black and white yes and no and I am the boss. We gain people, we gain people's trust and confidence and their willingness to work with us if we come alongside them. So that's what we're advocating for this return to run. Absolutely, you're gonna work on strength, overall building capacity, calf. We're gonna work on coaching them and how do they look with running and running form and their cadence. And we're going to be addressing all of these factors. Let's do it by letting them run and coming alongside them. That's a bit different than what you might be doing. That's different than what we used to do several years ago. What do you think? Do you want to try it? Have you recently tried it? Or are you concerned? Think we might be missing something? I'd love to hear your thoughts on this. Have a wonderful Monday. Hope to see you on the road at one of our three courses at the end of this year. And we will talk soon. Thanks for being here, 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.

Oct 20, 2023

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

https://journals.lww.com/nsca-jscr/fulltext/2019/12000/validity_and_reliability_of_the_rear_foot_elevated.9.aspx

https://journals.lww.com/nsca-jscr/pages/articleviewer.aspx?year=9900&issue=00000&article=00300&type=Fulltext 

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Alan Fredendall discusses the research, physics, clinical context, and patient input that goes into deciding if mechanics with lifting are "good" or "bad".

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

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

EPISODE TRANSCRIPTION

00:00 - ALAN FREDENDALL

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 here on Fitness Athlete Friday, the best darn day of the week. I currently have the pleasure of serving as our Chief Operating Officer at Ice and a lead faculty member here in our Fitness Athlete Division. Fitness Athlete Friday, we talk all things CrossFit, power limping, Olympic weight lifting. recreational bodybuilding, running, rowing, biking, swimming, triathletes, marathoners, anybody who's out there getting after it on a regular basis, we address all things relevant to that population. Some courses coming your way really quick from the Fitness Athlete Division. Your last chance to catch us online for our eight-week online entry-level course, Clinical Management Fitness Athlete Level 1 Online will begin November 6th. So that's just two weeks away. That'll be our last cohort of the year. That class will take us right through the holidays. and then we'll take a little break. The next cohort after that will be available sometime in the spring. So if you've been hoping to join us for that class, November 6th is your last chance for the next couple months. Live courses coming your way between now and the end of the year as we get into the back half here of quarter four. You can catch Zach Long down in Birmingham, Alabama. That'll be the weekend of November 4th and 5th. That same weekend, Mitch Babcock will be in San Antonio, Texas. The weekend of November 18th and 19th, Mitch will be in Holmes Beach, Florida. Beautiful place, just actually took a vacation there a couple weeks ago. Wonderful place to get to, especially in mid-November if you're from the Northeast or the Midwest, Florida's a great spot that time of year. That class just has one seat left, so if you've been looking to get baby both to Florida and to fitness athlete, that is your chance. And then our very last live course of the year from the fitness athlete division will be December 9th and 10th. That will be out in Colorado Springs, Colorado. That course will also be with Mitch Babcock. So check us out online, check us out live. We'd love to have you here at the end of the year before we get into the holidays.

02:16 - DOES FORM MATTER?

Today's topic, we're going to take a deep dive into form and mechanics. Does form matter? How much does it matter? We hear this question a lot in our courses as we're introducing movements, instructing the basics of how to perform some of the most basic movements, your squats, your deadlifts, your presses. This may be a question that you get from athletes or patients in the clinic and for a long time and even right now this is kind of a very dogmatic campy approach to this topic of yes form is the most important thing or no form has no application at all we've even heard things like Sheer force is an artificial construct created by physical therapists to scare people away from moving. Physics doesn't matter as much as we thought it did. That movement, however it happens, is normal, natural, and that's how the human chooses to move, and there is no right or wrong way to move. So, where's the magic lie? Where's the evidence lie? What actually works in practice in the gym with real human beings? And what are some pearls to take away from the discussion on form? So often we get questions of does it really matter if the low back rounds during a squat or a deadlift? Does it really matter if the back hyper extends with overhead lifting? Who cares if someone catches a snatch with a bent elbow or they never reach full extension of the elbow at the bottom of maybe a pull-up? If someone presses their jerks or snatches out, is it really that big of a deal? So today I want to approach this topic from a couple different directions. I want you to go back and watch last Thursday's episode or listen to it on evidence-based medicine about making sure we're addressing all of the facets of evidence-based medicine when we approach a really hot topic like this that also has a room for a lot of interpretation one way or the other. We need to look at what does the evidence say, we need to look at what does our friend physics say, what does our clinical experience say as far as What is our anecdotal experience with clinical pattern recognition with actual patients and athletes? And then what does the patient say? What matters to the patient? Patient expectation and input matters. So let's start from the top.

04:42 - WHAT DOES THE EVIDENCE SAY?

What does the evidence say? As much as we don't want to hear this, we don't have a lot of strong evidence either way in this discussion about form. When we talk about what does the evidence say, we have nothing concrete or strong for or against poor mechanics and lifting. We have a ton of research out of the functional movement screen space that looks at movement quality and its association to injury. And time and time again, I have to declare my bias. I hate that test. I think that test is total garbage. I think the research supports that that test is total garbage. And when we look at does particularly unweighted movement transfer to predicting injury, we have stacks and stacks and stacks of research across a wide variety of populations, recreational athletes, tactical athletes, first responders, professional athletes, that shows the association between quality and injury prediction or injury risk reduction is simply not there. We do have some research that looks at the effects of lifting, and I'll put lifting in air quotes here for those of you listening on the podcast, that lifting with a rounded back does not seem to cause low back pain or make current low back pain worse with the caveat of when we look at that systematic review and meta-analysis from O'Sullivan and colleagues a couple years ago, that the papers they included did not have any patient lifting more than 25 reps across the span of a day at a weight heavier than 25 pounds. It's really hard to take research like that and extrapolate it to our population who might be deadlifting two or three times their body weight, cleaning or snatching their body weight, doing dozens or hundreds of things like pull-ups and handstand push-ups and double-unders, really getting a lot of load through their body, running, crossfit, lifting, whatever. That research really has no application. It's really hard to even call that lifting, right? Those are just kind of activities of daily living. We can't take research like that and extrapolate it to somebody dead lifting with a low back and say these are the same. They are just simply not. We also need to be mindful of the research that we do have. When you look at papers on deadlifts with low back pain, on the effects of lumbar reversal with lifting, what you'll find in those studies is that one of the variables that the research authors always control for is the lifting mechanics themselves. You'll often see, if you actually read the full paper, not to harp on that, but when you read the full paper, when you read the methodology, what you will find is that very often those folks are instructed how we would instruct a movement in the gym, which is to try to maintain a brace-neutral spine, modifying the load or modifying the range of motion to maintain that, to therefore reduce that as a variable in the research study. That if we cannot control mechanics, that's one more variable that maybe takes a little bit away from our conclusion when we look at the data. Of trying to standardize the mechanics as much as possible is how we can narrow down the focus of that research study on whatever the intervention is and whatever the outcome and feel really confident that the association there is direct and that other variables aren't at play. If we can't say deadlifts are safe, deadlifts increase low back strength, deadlifts improve low back pain, if we look at a study and there was no control on how the deadlift was performed or how the mechanics were performed through those deadlifts. One study does sumo deadlifts, another does conventional, one does trap bar, one allows back rounding, one does not. You'll see when you read those studies that controlling for those variables, controlling for those mechanics, is one of the ways that variables are reduced. And so it's hard to look at those studies as well and extrapolate to altered mechanics, what we might call a movement fault, and translate that to the population that we're working with. It's hard to take research and say, you know what? I'm gonna do everything this study did except change everything about it, right? That doesn't mean you're implementing that research and practice. You're taking the general idea and you're kind of going your own way with it. You no longer have that evidence base to stand on. From the research, we do know that symmetry can be objectively quantified, we can assess it, and we can intervene on it. Very often, physical therapists are very comfortable at calling out and identifying qualitative faults without really understanding what might be going on, how to assess it, how to measure it, how to track it, or how to change it. But if we look at some really nice research papers, a great one came out this year, I'm gonna butcher this name, I'm so sorry, Yuja Kovic and Sarah Bond came out this year, looking specifically at asymmetries and change of direction in basketball athletes and finding that there are ways that we can objectively quantify things like asymmetries, strength, speed, motion, quality, asymmetries, that we can also intervene on them. This study in particular sought to reduce the change of direction asymmetry by overloading the slower slash weaker limb with three times as much training volume compared to the stronger or faster side. That looking at an 11% or so difference in change of direction speed, able to reduce that down to just 4% simply by overloading the volume on the weaker, slower, basically problem area. In this case, it was the lower extremity. A very simple study, just using some lower extremity strengthening, three times as much volume as the contralateral limb. We know we don't need a biodex or some other form of fancy isokinetic testing or force plates in our clinic to have ways to objectively identify and assess maybe quality that is associated with asymmetry that is maybe the cause of pain, aggravating current pain, aggravating past pain and or limiting performance. Great study by Helm and colleagues 2019. wanted to validate the five rep max rear foot elevated split squat. Maybe you have heard of this as the Bulgarian split squat, but essentially kicking up that back leg, doing a five rep max on each leg. In this study, they used a barbell. In the clinic, you can use dumbbells as well, trying to find a five rep max per side, and then quantifying and objectifying the asymmetry side to side. Finding it's a very reliable, very valid way as compared to things like Biodex, and force plates to develop an idea of asymmetry from side to side. I would argue a paper like that we can extrapolate to the upper extremity, we can do something like a landmine press, we can do something with our lats or back with something like a bent over row and really start to think if we're seeing movement faults that we think are the cause of symptoms or some sort of performance issue to start getting more objective in how we assess, reassess, and intervene on these things. So that's what the evidence says. It doesn't say a lot. Besides that, we need to help people get stronger and we need to quantify where their strength is at as they're starting their rehab program and then reassess it as they're finishing in order to be sure that person actually got stronger and actually closed the gap on any sort of perceived or actual asymmetries that we found.

11:38 - WHAT DOES PHYSICS SAY?

What does physics say? This is something that we tend to ignore a lot, that we exist as human beings on a planet with things like gravity, and that we are subject to certain physical characteristics that we can't avoid. Physics would say that the shortest route between two points is a straight line, and anything else, any other extraneous movement is a force leak. Any amount of force leak doesn't matter what your sport is. If you're an Olympic weightlifter, a powerlifter, a crossfitter, a gymnast, a swimmer, a runner, The more inefficient your mechanics, the more extraneous movement, the more your leg kicks out into circumduction in your run, the more your lower back rounds and extends back and forth as you go through deadlift reps, the more you bend your knees or bend your elbow in your pull-ups, it doesn't matter. The more extraneous movement you have, the more you're leaking force out of your system, the more you're limiting your top end performance. I have yet to this day see anybody break the deadlift world record by doing a Jefferson Curl. Yes, under extreme loads we might see a little bit of low back rounding, but we don't see people intentionally initiating a 1500-pound deadlift with a Jefferson curl mechanic. They tend to approach the barbell over and over again in a similar fashion, either setting up in a conventional or sumo deadlift and really doing everything they can, again, to minimize extraneous movement, put the maximum amount of weight through the ground to lift the highest load up in the air. That is performance, that is physics. We have to remember, unless we can invent some sort of technology or better understand physics, we can't get around that. So that's the evidence, that's the math. What does our personal experience say? Our clinical experience, maybe some of you would say this is anecdotal, but remember, part of evidence-based medicine is our clinical experience.

13:59 - WHAT DOES CLINICAL EXPERIENCE SAY?

Our clinical experience would say that those folks in the gym that we see performing pull-ups, overhead movements with things like a constantly bent elbow, tend to be the people that we most often see over in the PT clinic for stuff like elbow pain. That the folks who rock up on their toes, catching their cleans, their snatches, because they lack ankle dorsiflexion, are the folks that we tend to see coming into the clinic with things like knee pain. That those folks who always quarter squats, no matter how much we try to help them get to a deeper range of motion, a greater range of motion, whether it's working on their mobility, elevating their heels, giving them a squat to target, whatever our coaching cues corrections are, those tend to be the folks in the clinic with things like knee pain and hip pain. And those folks who show up with lumbar rounding in the bottom of their deadlifts, as they're pulling the deadlift off the floor, the bottom of their squat, catching a clean, catching a snatch, those tend to be the people who come to see us for low back pain and hip pain in the clinic.

18:01 - WHAT DOES THE PATIENT SAY?

And that connects really well to the third part of evidence based medicine of what matters to the patient. We have to understand these folks are often aware of their faults, especially the more they've been training, the less faults they tend to have, and they're more acutely aware of the ones they have left, and they also know the association between the faults they have and maybe aggravation of symptoms, re-aggravation of symptoms with maybe a previous injury. Understanding as well that we don't just always work with the lead athletes, that our goal is to introduce movement to everybody who comes into our clinic. How hard is it to introduce movements, even basic movements like the squat or deadlift, to patients who maybe never done this in their life before? Not even with a barbell. Maybe we just hand Doris a kettlebell for a goblet squat, or we have Frank just deadlifting a kettlebell off the ground. How tough is it for that person who is a complete novice to this If our instruction is, hey, Frank, you know what? Mechanics don't matter. Points of performance are arbitrary constructs created by rehab providers and fitness professionals to scare people like you into purchasing more care than you need. How helpful is that to teach movement to somebody new? What are they going to say? Uh, okay. So like, is there a way I should do this? Is there a best way? Well, Frank, it doesn't matter. All human movement is good and natural movement. Just do whatever feels good. That's not very helpful, right? And you would never do that in the clinic with a patient. You would never do that in the gym with an athlete. If you do actually do that, I challenge you to film that and send it to me because my gut tells me that nobody actually does that because you know how stupid you would sound and how likely it is for the patient to be successful if that's your approach to instructing movement. Likewise, if we do have that more experienced athlete, what good does it do to tell that person who has extreme low back pain, when their spine rounds in the bottom of the squat, there may be somebody who's filming their lifts to try to figure out why do my squats bother me? And our answer is, hey, there's no evidence to support that your spine flexing is a source of your pain. Same issue, right? Same outcome, entirely different patient population, but same outcome. Okay, that's not very helpful. I can see my tail tucking here, and I notice that when that happens, that's when I feel my extreme low back pain. That person has already associated that in their mind. What good does it do to tell them that there's no evidence to support that that's what's happening? They're experiencing it firsthand, right? We need to be mindful of the way that we instruct this, both with new and experienced athletes, patients in the gym and the clinic, that mechanics do seem to matter. People seem to have a natural awareness that at least some sort of standardization of performing a movement seems natural and that some sort of association exists between maybe symptoms and faults. We always acknowledge the resiliency of the human body, that yes, it can develop tolerance in different positions, such as lifting with a rounded back, but we can also still do stuff at the same time to limit pain with lifting. We can modify the range of motion. We can modify the load, the volume, whatever, to a more tolerable level. We need to get a lot more comfortable living in the gray area. Yes, we can recognize injuries multifactorial. Yes, the body's capacity can be temporarily reduced by things like sleep, stress, illness, nutrition, but we can also still manipulate movement to be more comfortable and enjoyable and also help that person work on strengthening in a manner that we know is very evidence supported that's going to reduce the likelihood of future injury. I have an athlete on my caseload right now, very, very impressive athlete, been doing CrossFit a long time. every time she's under an extreme amount of cardiovascular fatigue, or she's doing something like a 10 rep max with a back squat or a three rep max clean or something like that. Usually under a high amount of fatigue, she demonstrates some lumbar reversal associated with that lumbar reversal is always extreme low back pain. She is aware of that. She's somebody that films her lifts. She knows every time she rounds her low back in the bottom of her squat, that is what usually will kick up an episode of low back pain that could last short term, a couple of days, or could really set her back weeks or maybe months. So she's very aware of her spine rounding, the association of form with the development of symptoms, and aware of how bad those symptoms can get. So what are solutions with that in regards to does form matter or not? Well, the first thing we can always do is help reduce that pain acutely, right? Of that person is an extraordinary pain in our clinic, regardless of what we're going to do with them in the gym, regardless of how we're going to address their form, we have ways to reduce their acute pain. We can modify those squats, we can do things like belt squats, we can do lightweight, high tempo squats, tempo squats at maybe 30 or 40% of her max where she's maybe taking three, five, seven seconds to sit down to that squat to maintain or continue to build strength in a way that doesn't aggravate her symptoms. We can do alternate movements if a squat pattern is not tolerable at all, hip thrusts, deadlifts, et cetera, to train lower extremity general strengthening. Yes, we can build up general strength and endurance of the low back, the legs, the posterior chain as we're getting more comfortable, but we can also spend some time working with that athlete on their mechanics of what's going to probably help you the most is that under extreme fatigue, you know how to breathe embrace, you know when to call it for the day when you know you're extremely fatigued, so you don't find yourself in this position again and again. And yes, the final step there is probably to layer in some intentional lifting in that what we would say poor mechanical position, right? Let's also add in some rounded back lifting so that we expose ourselves to the movement so the only time we encounter it is not under a 10 rep max on the 10th rep where we tend to encounter our symptoms. So let's do things like sandbag cleans and sandbag squats and yes, Jefferson curls and other things like reverse hyper extensions. Let's do all the things. We don't have to focus just on form but also form matters. We need to train in that position so that when we get into that compromised form position, it is going to have a less likelihood to be symptomatic and set that athlete back.

21:09 - MECHANICS & PERFORMANCE

And finally, we need to go beyond pain into performance. What does the evidence say? What does physics say? What do we say? What does the patient say? What does performance say? What can you possibly help an athlete with who comes into your clinic, who wants to pay you $150 an hour to improve their snatch, and you say there are no optimal mechanics to complete the snatch. We know that's not true, right? People who win gold medals in clean and jerks and snatches tend to lift a certain way. They tend to all show relatively the same mechanics. That tells us that mechanics seems to matter a lot in regards to high level performance. There's a reason those Olympic weightlifters tend to initiate their pull off the floor in the same fashion, going through their first pull, their second pull, their receiving position, the jerk overhead or the catching of the snatch. There's a reason that it looks pretty much textbook no matter who the athlete is, how tall or short or big or small they are or what their race or gender is. They all tend to show the same mechanics time and time again. It seems like it's physics at the end of the day. We don't see anybody breaking the snatch world record with a rounded back deadlift to a muscle snatch, do we? And I think that tells us a lot of now beginning to shift towards using mechanics to push performance. And again, as long as we can be objective about it, I think that is the way to go.

24:41 - SUMMARY

So what does the evidence say? We have nothing strongly for or against poor mechanics and lifting. is it relates to people actually performing resistance training not just picking up pins off the floor with a rounded back. We need to be mindful that research studies tend to standardize points performance for lifts such that everyone is performing the same thing the same way every time. What does physics tell us? It will always tell us unless something miracle happens with a change in physics that the shortest route between two points is a straight line Mechanics matter in performance. Straight lines are strong lines. What does our clinical experience tell us? That people who tend to move like crap, especially under increasing amounts of load and or volume, whether it's due to poor mobility, going too heavy, going too fast, those tend to also be the people who need a lot of healthcare treatment, right? Those folks who tend to move quite well tend to have maybe one particular fault, that they're usually aware of, and that they're usually also aware of being associated with their symptoms, and we need to be mindful of that. And what do those patients say? People who are already active are usually aware of that fault, they're usually aware of when and how they demonstrate it, and they are usually aware of that it's associated with some sort of symptom, development of a new symptom, re-aggravation of a previous injury, that sort of thing. We know the group of people we probably need to help the most are inactive patients. The other 90% of the population, right? The majority of the people in our caseload. Inactive patients, people who are complete novices to movement, can't learn things in a structured manner that they're going to be able to repeat them on their own in the gym or at home in the garage or whatever. if our approach is that physics, points of performance, faults, are just artificial constructs that we create to scare them and somehow fleece the general public out of their money. And then also finally, something to remember is that you'll be stuck on a hamster wheel in your clinic forever just treating people in pain if you're not able to transition people to the lifelong fitness and performance side of what we can offer them. At a certain point, mechanics do matter as it relates to top end performance, as it relates to goal setting. And you're crazy if you think, quote unquote, normal people don't want to increase the amount of weight they can snatch, or how fast they can run their mile. We need to be mindful that with top end performance, when people want to see their 5K time come down, or their one rep max back squat go up, that mechanics really, really, really do matter. So mechanics, do they matter? It depends, but there's probably more to be said for mechanics mattering for a performance aspect, for instruction aspect, and for overall higher quality and the ability to perform more movement more often, which is the goal. If we are aware of mechanics, but also being mindful that sometimes they don't matter, especially if we're not being objective about assessing them, reassessing them, and what we're doing to intervene on maybe trying to improve mechanics. Tough discussion, but I think it's worth one having. I hope you all have a fantastic Friday. If you're gonna be at a live course this weekend, I hope you have a great time. We'll see you all 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.




Oct 19, 2023

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

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses an alternate technique to dry needle the lumbar multifidus.

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

If you're looking to learn more about dry needling, especially dry needling with e-stim using the ITO ES-160 stim unit, take a look at our Upper Body Dry Needling course, our Lower Body Dry Needling course, or check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

00:00 - ELLISON MELROSE

Good morning YouTube and good morning Instagram. This is PT on ice daily show. I am Dr. Ellison Melrose and I am currently lead faculty with the dry needling division of ICE. So we are going to go over a alternative approach for dry needling the lumbar multifidus today. Um, before we get into that, I want to go over our upcoming courses. So this, the remainder of 2023, we have, um, a handful of courses. This weekend, Paul's going to be out in Anchorage, Alaska, and I believe that is capped. After that, he will be down in Seattle, Washington on November 3rd through the 5th for the upper quarter. I will be out in Rochester, Minnesota for upper quarter dry needling on November 18th through the 19th. We will both be teaching the first weekend in December. So December 1st through the 3rd, Paul will be in Bellingham, Washington, and he will be hitting upper quarter then, and I will be out in Clearwater, Florida, so opposite sides of the states, doing lower quarter. So if you guys have a chance to find us out on the road, or want to join us for the remainder of 2023, those are the courses. We have one other one also in Fayetteville, Arkansas, the second weekend in December, where we'll be doing lower quarter. out there. So if you guys have any questions about those courses coming up, feel free to message us here or yeah, stay tuned for those courses. And then 2024 we'll be starting out pretty hot with some more courses and our advanced course as well. It will be, will be coming, um, in 2024.

02:10 - COMMON APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS

So what I wanted to do today was to go over an alternative approach for, uh, dry needling the lumbar multifidus. So there, We are not gonna go over clinical reasons for needling the lumbar multifidus, but for those who have been taught how to needle the multifidus, there is one technique that is used fairly widespread across all educators, and that is the wrap-over technique. For demonstration purposes, I am going to be using my knuckle as the spinous process, and then we will be demonstrating it on a human body as well. For that wrap-over technique, so we have our spinous process here, Wrap over technique, we use two fingers to compress within a one centimeter gutter, just lateral to the spinous process. And we create a target window with our fingers and treating within that zone. In order to treat bilaterally, so both sides, you have to walk around the table to treat the contralateral side, which is fine, But when we're talking about clinical efficiency, it may be conducive to be able to treat or to needle staying on the same side of the patient. So we have an alternative approach for needling the multifidus where you are able to stay on the same side of the patient, and that will be your dominant side. So I am right-handed, so I'm going to be treating from the right side of the table treating the lumbar multifidus. I'll demonstrate first the wrap over technique and the alternative technique.

04:02 - ALTERNATIVE APPROACH TO DRY NEEDLING THE LUMBAR MULTIFIDUS

For that alternative technique, so instead of using that spinous process, our palpation hand, two finger, stepping over that spinous process and compressing into the gutter, what we are going to be doing is we are going to be using our palpation hand, index and middle finger to orient us to where that lateral border of the spinous process is. In the lumbar spine, we have about a one centimeter gutter where we can feel fairly confident that we're going to be directing our needle towards the lamina with a directly posterior to anterior approach. From there, if we go outside that one centimeter gutter, we need to angle the needle medially to ensure that we have contact with the lamina as we need that laminal contact to ensure that we are at the depth of the multifidus. We are going to stay within that one centimeter gutter for today's demonstration, but we will start with that wrap over technique and then the alternative approach. The alternative approach, instead of using that two finger digital compression, we are going to be using the spinous process and either our middle or index finger to find that lateral border. So, first we want to find the spinous process and take the mid pad of our palpation finger and palpate that lateral border of the spinous process. From there, we're going to take our middle finger or our index finger, depending on which side we are treating, and compress tissue down within that one centimeter guide. From there, we're going to create a treatment window between our two fingers and treating directly posterior to anterior. towards laminal contact.

07:19 - ALTERNATIVE TECHNIQUE DEMONSTRATED

So it'll make more sense when we're demonstrating it on the patient. So let's go ahead and do that. I'm just going to angle this camera down towards my patient. So here we have an exposed lumbar spine. I'm going to just orient myself to where we are. I am standing on my dominant hand side. From there, We'll just go over palpation. So spine is processed, we can palpate the lateral borders with our thumbs here. For that wrap over technique, we're going to take our pads of our palpation hand, stepping off, compressing tissue down, treating within that one centimeter gutter, okay? So let's start with that technique and then I'll show you the alternative approach after. So, palpating that lateral border of the spinous process, two fingers stepping off, compressing down into that gutter, keeping that needle angle directly posterior to anterior, so vertically, tapping, advancing the needle towards laminal contact. So in order to treat the ipsilateral side now, I would have to walk around the table and straddle that needle to do the same compression and same technique that we did on this side. So what I will demonstrate is the alternative approach and then we'll do another segment down below of the alternative approach just to show you how efficient this tool can be. So, instead of using those two fingers to hug the lateral border, I'm going to be using my middle finger on my palpation hand to palpate the posterior aspect of that spinous process. From there, I'm going to take the middle aspect of my pad and hug that lateral border of the spinous process. My index finger is then compressing into that gutter creating a nice treatment window. Again, we want to be aware of where that one centimeter gutter is and treating within that zone, directly posterior to anterior. So vertical, vertical needle approach here. So compressing down towards laminal contact. So there we have the alternative approach on that ipsilateral side. From there, thinking clinical efficiency, if we were going to set up multiple different segments in the lumbar spine, if we started proximally or superiorly and worked inferiorly, kind of like you're reading a book, that is going to be the easiest way to avoid some awkward hand positions with the needles. So we will needle the segment just distal to the ones that have needles in. So from there, Instead of using my middle finger to contact that lateral border, I'm gonna be using my index finger. We are treating the contralateral side from where I am standing. So again, we can appreciate the lateral borders of the spinous process. Take the pad of our index finger and hug that lateral border of the spinous process. Compress my middle finger now and create a treatment zone between my two fingers. Again, appreciate that we have a one centimeter gutter. Now we want to be treating directly posterior anterior to contact lamina. From there, I'm going to do a firm guide to compression, firm tap, advance the needle to laminal contact. And then we can do the same thing on the ipsilateral side. so middle finger palpating the posterior aspect of the spinous process wrapping to that lateral kind of hugging that lateral where it starts to curve creating a one centimeter gutter with my index and middle finger treating within that zone directly posterior to anterior towards laminal contact. So there we have, we went over the wrap-over technique and the alternative approach and just looking at the clinical efficiency that being able to stay on that ipsilateral side of the patient can do. I have a very small treatment room, so it allows me to not have to kind of wiggle my treatment table back and forth, and allows us to get a handful of segments within a couple minutes, which I think when we're thinking about using dry needling in the clinic, we want to save as much time as we have for using our electrical stimulation, as the new research is showing how beneficial that can be for treating pain, neuromuscular priming, also, um, recovery or hemodynamics, improving hemodynamics. So we want to get the needles in as efficient as possible as to allow for some optimal treatment time with the Eastern. So we, again, just to review with this technique, we are going to be using our index and middle finger. And instead of hugging the lateral border of that spinous process, we are going to be treating, um, with those fingers just off the lateral border, creating a one centimeter gutter between those two fingers, treating directly posterior to anterior and maintaining laminal contact to ensure we are at the depth of the multifidus. Thank you guys so much for joining me this morning, going over the alternative approach for dry needling the multifidus. And I hope to see you out on the road sometime this year or next 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.

1 « Previous 1 2 3 4 5 6 7 Next » 11