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
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: April, 2024
Apr 30, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division faculty member Cody Gingerich discusses the importance of focusing on the subjective exam during the first 2-4 follow-up visits to ensure patients are making appropriate progress.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

CODY GINGERICH
All right, good morning PT on ICE daily show. My name is Cody Gingerich. I'm one of the lead faculties with the extremity management. What I wanted to come on here today on our clinical Tuesday and talk about is when things are not going to plan. Specifically the subjective exam on visits two, three, four. Okay, so when people come in and they say, hey, you know, I don't think this thing has gotten any better. I'm feeling potentially even worse, or they had a flare up since the last time you saw them on that initial eval. And what then does that subjective exam look like when they come in on visits two, three, four? How do you dive into, do you need to make an adjustment on your plan of care? Do you need to make an adjustment on dosage? Do you need to make an adjustment on anything? Or do you stay the course and you dive into really heavily on what exactly happened? Okay, so that's what we'll talk about today. If you did a good, really good initial exam, right? And you're like, man, this thing presents like I expect. We're going after it. You choose a dosage and a diagnosis that you feel confident in what you have given that person leaving your clinic. And let's say they come back in in one week. Most of the time I'm seeing people on a once a week basis, but even if they come in later on that week and they come back in and they're like, ooh, you know what? We are not really feeling any better. They come back in, something happened, flared back up, and now you have a pretty difficult conversation, right? Because on an initial eval, if you felt confident, you probably provided that confidence to the patient of like, Hey, you know, I think we found this thing. This is definitely coming from your shoulder. Probably the more of those muscles in the back of your shoulder. And you know, if we do these two, three exercises over the course of the next couple of days, I really think things are going to get better. Right. And then they come back in and all of a sudden that confidence is not as high because they're like, Hey, you know, this is not getting better. And then what, where do you go? Where does that conversation lead you?

GATHER MORE INFORMATION BEFORE YOU ABANDON SHIP
So a big thing that I want to emphasize today is you need a lot, a lot of information from that person subjectively before you decide to abandon ship on what you were doing. Okay. And the reason being is there are so many variables that can happen in that time from when they left your clinic to when they show back up. Okay, and if you did that really good initial exam and you're thinking like, hey, I'm really on this thing, then your first initial thought when somebody comes back in, shouldn't always be a, oh, we did the wrong thing. More times than not, you want your curiosity to be, hey, okay, what did you, first of all, did you do the things exactly as I prescribed them? Secondarily, what did those couple days in between actually look like? A lot of times our patients have no real understanding of what actual movements can be their aggravating factors. When you did their exam, their subjective exam, and you asked for aggravators, then you did your objective exam, you found their aggravators. That does not necessarily mean that the patient understands then that those particular movements are going to aggravate them. They know the two or three that they told you, but there are so many other things in life that could potentially also be aggravating factors for them. And they're not going to be able to always put those pieces together. So go into that first conversation with curiosity and be saying, Oh, okay. You know, that wasn't exactly as I expected it to go. I thought we were really on the right track, but I want to dive into what did those couple of days in between here look like? Like, what, what did you get into? You know, what did you, um, spend your time doing? What did you do at the gym? If you were going to the gym, all of those types of things. Did you do those exercises we talked about as I prescribed them, or did you feel like you needed to do extra because they weren't hard enough? or did you not particularly do them? And that is going to start that conversation in a much better way than you just saying, oh, okay, in your brain, like, oh, okay, well we definitely did the wrong thing and we need to fully go back through an entire new eval and figure this thing out again. A lot of times those patients somewhere in that subjective are going to give you some clues on what actually was going on in their day-to-day life. A couple examples of that, okay? A big one, if we're talking about like a gluteal tendinopathy, okay? So think glute med tendinopathy. Potentially you've given them some kind of leg lift, maybe a side plank, some kind of glute, maybe side steps with a band, glute need, strength training, blood flow type of thing. Okay. Well, let's say that person also, you did not tell them, you didn't really even have this discussion of like other things that they potentially could be doing, or a lot of people try to manage their own symptoms. Okay. So if you didn't potentially give enough explanation of, Hey, this blood flow thing is the thing you need to do when you are hurting. I have seen many, many times where they are consistently stretching and stretching and stretching that glute med, bringing their knee across their chest into more of that like pigeon pose stretch. And if we're dealing with the true tendinopathy where irritability is fairly high, that can be a pretty significant aggravator to those tissues, even though the patient feels like it is helpful because it's tugging on the thing that is bothering them. Okay. So then they come in and you're like, man, they did the exercises. This is a pretty clear cut. Like this is glute tendinopathy. I don't know exactly what else it could be. Cause my hypothesis list, like we checked off, like we cleared the back, nothing's going on there. Um, but then they start talking about like, Oh, the only thing I can get relieved for, like, I spent all day just like yanking and yanking, trying to stretch. I'm stretching a bunch. And so then that has to be a, oh, okay. That conversation goes into, hey, I know right now that feels okay, but what we really need to do with those tissues is get some blood flowing to them. And what is actually happening is when you're sitting all day and then stretching, we're actually almost occluding blood flow and taking away more blood flow than what can get to it. And so all of those exercises that I gave you, although they feel like work, are also the thing that's going to make it feel better And you can use that as a symptom reliever. But we need to pause on stretching for the time being. And that language needs to be also relatively clear on this is a temporary pause. Temporary pause on this thing, it is not a you should never stretch your hip end of conversation, is a right now that is something that's aggravating you. So we still have a really good plan in place, but we need to control that variable and decrease that stretching time. Another thing that you'll start hearing is like, they'll be like, you know, I didn't do anything. If maybe your conversation the first day was around like gym movements and not life movements, um, You know, same type of conversation with the glute med temnopathy. I've had patients come back in where they were climbing a ladder all day. They were doing some housework, they were up and down on a, you know, a ladder and they don't really bring that up when you're saying, when you're going through your subjective, you know, what did, what did you do? And they'll say, well, I, you know, I avoided squats for the time being and I didn't do any deadlifts, but I did your exercises. So I just don't know why, you know, things could have flared up. But then you dive a little deeper. Oh, what did your weekend look like? And they're like, Oh, you know, I had a, I had a bunch of yard work to do. I was up on the, up on the house doing gutters and it was up and down standing on that ladder. And that position of the ladder has them essentially loading that glute, glute tendinopathy all day long, a ton of time under tension. And so now all of a sudden you're saying, okay, well now we need to pull back on that. Or over the course of this next week, you don't have any more yard work to do. So now let's go after this plan that we had in place. Okay, so subjective exam on days two and three or visits two and three when they come back in are vitally, vitally important to be able to really take a deep dive. Like that conversation may take an additional 10, 15 minutes if they are not moving in the direction because you want to be as curious as possible because you already did your due diligence on the initial exam.

CONTROL EVERY VARIABLE BEFORE YOU CHANGE YOUR PLAN
So don't immediately assume that you're in the wrong and have that patient conversation of what did exactly your day look like? What have you been doing to try and self manage this thing? And you know, what have you done in the gym? You've also can talk to people, they have no real understanding. I've had patients where they go to the gym and they did a rope climb, sandbag carry, Ski erg workout because they felt like it wasn't a shoulder heavy Exercises they were avoiding their shoulder because everything they thought sandbag was mostly back, you know Skis like core type of thing and rope climbs you're using your legs to pull yourself up. So you're not really pulling I And again, it's just one of those things where you have to educate those people significantly on like, look, I know you don't feel like it is, but the reality is you're using a ton of that shoulder, especially the posterior, your cuff on all of those exercises. And you are not really avoiding any of those aggravating factors. So be a little bit more explicit on your, what movements could potentially be aggravating. That's also when you learn the type of human you have in front of you and how much you need to give them reins or really pull back on those reins. Most of the time I try to err on the side of giving people a little bit more leeway. I don't ever like to tell people there's nothing that they can't do. It's just a matter of like how much and the volume and intensity and those type of things. Visits two and three is when you actually learn that person and how much reins you can give them. And you might need to start controlling more variables as a therapist for them, okay? And so that might be the time where you say, hey, this movement is out. I need you to really pay attention to when you're standing and when you're sitting and where that hip is in space. I need you to completely avoid this particular set of movements for these next two weeks to make sure we can calm symptoms down. That's when you learn if that person has an actual like throttle on them or not a self throttle Can they actually? Determine on their own what they can push through and what they can't and if you can determine that they come in and they are worse and they did a bunch of stuff that you would say, man, that was pretty reckless given the thing that you were dealing with. Now you as a therapist and the expert in the field can say, you know what, this is out, this is out, this is out. I need to make sure I'm controlling every variable in your life right now until this thing gets a little bit more calmed down. Okay. And that's where you need to put your foot down every once in a while with a few patients and say, Nope, that's not happening this week. You're taking this time off or you are going and doing more cardio based exercises or you are doing XYZ, not a, hey, I want you to pay attention to this and that. This could aggravate it or could not, but give them leeway and they come back in and it's worse. and you're like, man, that was pretty reckless. Now, as a therapist, you're saying, nope, we're doing this, this, and this. This is a temporary thing, but in order to get this under control, now I'm telling you what you're doing and what you're not doing, okay? Because that is your expertise now on the line. If you give them a bunch of leeway, and they come back in and they're worse, and you don't ever have that conversation of, you know what, nope, this needs to happen this way, then they just assume physical therapy doesn't work for them, right? Well, it's not physical therapy. It's not what you've chosen. It's all the other variables that you don't have control over. So you need to start having a little bit more control as much as you possibly can. You can't control everything, but as much as you possibly can on what's going on there. This is also the time where you ask about food, sleep, nutrition, and stress, okay? Hey, over these last three, four days, how did your sleep look? Were you getting good sleep over these last three days? What does your nutrition look like? Is it as you typically do or did it change at all? Did you go to any parties? Did you go to anything outside of the norm? Are you having any type of particular high stress environment right now? Do you have a deadline at your work that you're trying to get done? Is your kid sick? Is whatever the case may be, all again, factors in that subjective exam that need to be dove into if things aren't going well. Okay? These are all just making sure that you are on the right track and aren't abandoning ship too early. The other thing is if they come in and they're worse, you also want to be like, give them confidence in saying, Based on what we found the first time and based on the exercises that we gave and this thing that you did over the weekend or whatever the case may be, I can actually give you more confidence that we are on the right track. We just need to dial that in a little bit closer. We either need to cut the exercises that I gave you in half, like let's say all those variables have been controlled and they're still coming in like, man, I'm just really flared up. Well, then that was your fault on giving them a little bit more, not reading that the irritability quite as well. And that happens. I've done that plenty of times. That needs to be like, Oh, okay, cool. You know what? We're going to cut those exercises in half, or we're going to pull one of them totally out. That one was a little bit more than I think you were ready for. We'll bring it back in and maybe a week or two, but over this next week, now all of a sudden we need to just dial that one exercise in and make sure that that's not aggravating and your tissues can tolerate that. If everything else has been pretty clear and there wasn't anything out of the norm that you weren't expecting, then you just overdosed their tissue a little bit. Great. You know what? Sorry that you were a little bit feeling rough the last couple days, but I know that if we pull this back, we should be in pretty good shape moving forward. Okay. All of those things need to happen before in your brain you say, oh I messed up, we treated the wrong thing, and we need to fully switch gears and go to our second hypothesis. Until you have controlled all the variables, you have asked all of the questions related to nutrition, sleep, stress, plus what they did in their non-gym, just daily life, Have they done your exercises? You need to have all of that information, and it needs to be in your brain, like pretty much, hey, everything is pretty close to exactly as I would expect it, before you'd say, I think we should recheck this exam, and might go after that second hypothesis on our list. So that's the big thing, is trust your instincts first, whatever you found, if you did a really good initial exam, whatever you found, When they come in that second, third, fourth visit on those subjective exam, when they come in, make sure you're super curious. Go after all of those variables, figure out all of those variables. Once that's all been controlled and they're still not going as you would expect, that then is the only time where you would start to switch that hypothesis list. So overall, Be curious on make sure that that second, third, fourth visit, that subjective exam is is very stout and make sure that you are really doing a good job on understanding that person in front of you. Where's their headspace at? Are they able to tolerate what you've given them? Do they know how to pull back on exercises if they need to? Or do you need to be the one that says nope, you're pulling back on this thing you have you know, shown me that you don't have that ability. So for the next couple of weeks, I'm your boss on, you know, what you can and can't do. Always making sure that it's a temporary thing.

SUMMARY
Okay. So that's when things don't go as planned, right? Make sure that that subjective exam on the second through fourth visit is super dialed in and you know that you can, uh, have a good solid impact and still give your patient the confidence that they need moving forward. And it's not a, um, you know, hope, just hoping for the best and throwing things at it and, and hoping it sticks. And now your brain is all over the place. Okay, looking forward, extremity management. If you want, there's a couple seats left in Bellingham, Washington, May 18th and 19th, and then we got two courses running on June 1st and 2nd, one in Texas and one in, oh man, I just lost it. I believe it is. in Wisconsin. All right, Texas, Wisconsin, June 1st and 2nd. So jump on both of those. There are courses, there are seats open on both of them. So check us out. Find Mark Lindsay or myself on the road with extremity management and we will see you tomorrow.

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.

Apr 29, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Alexis Morgan discusses the concept of "fitness freedom" as it relates to helping patients & clients embrace the ability to "choose your hard" in customizing rehab & fitness exercises.

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

INTRODUCTION
Good morning, PT on Ice Daily Show. My name is Dr. Alexis Morgan and I am thrilled to be here with you all this morning. I am here in my Airbnb in Carson City, just coming off of the ice sampler and Wow, what a weekend we've had. We have had so much fun learning from all the different divisions here at ICE and learning from all the different instructors. And let's be honest, having a blast, having a blast with each other. It has just been an incredible weekend that we are still running high from. Today's topic is fitness freedom. And it really is fitting for today in reflection of this weekend, just because the 150 people that have been all together this weekend, of course, we're all different fitness abilities, right? We all have our different fitness goals.

WHAT IS FITNESS FREEDOM?
And as I was thinking about this topic that is fitness freedom, which comes from our street parking friends, Miranda and Julian Alcraz. As I was thinking about this concept of fitness freedom, to discuss with you all this morning. It was beautiful how really the last two days here at ICE, it was just laid out perfectly. And so I wanna talk with you all a little bit about what fitness freedom is, what it means, and where it came from, and how we can implement it in our lives, as well as our practices, ultimately for our communities all across the nation. So, as I mentioned, we just got off of Sampler, and over the past two days, we've had various divisions talking. We went through different labs, and when our pelvic division did the lab on bracing, Rachel said, choose your heart. We did pushups, and we worked on bracing within pushups. But for every single person, a variation of push-ups is going to be appropriate. For some people, we may need to do the push-ups on our knees. For other people, we may need to have weight on your back. I'm giggling because if you saw the reel at ICE, you saw Dave Finkelstein laying backwards on top of Zach Morgan as he was doing the pushups. So maybe your weighted pushups is a human. If you missed that little scene, watch the latest reel, because it was hilarious. But choose your hard. That was what Rachel told us. Choose your version of hard, because you're gonna get the best out of this lab if it is relatively difficult, Not too difficult to where you can't do it, of course, but also not so easy to where you can't get what we're needing out of this lab, which is a brace. We need to find that moderately difficult heart. Choose your heart. Then in extremity lab yesterday, we went through so many exercises for the shoulder and so many ways to improve our clients, ourselves, our overhead athletes shoulder capacity. And as we're going through these exercises, they said, pick your poison. They said, choose your own adventure. You choose the internal rotation option and you choose the external rotation option that works best for you. Choose your own adventure. The same concept. We're not gonna tell everybody to do the exact same thing because there's so many options here. Let's individualize it for that person let's let them have fitness freedom. The freedom to choose what is right for you and your body at this exact moment in time, which applies to your goals, which may be different than what you would have chosen a year ago and is probably going to be different than what you'll choose next year. Fitness freedom. Do what you need to do right now. And Mitch, at our group workout, running 150 people through a group workout, which did include barbells, and he said, I like to ask people, what is your seven minutes of burpee time? Reps, how many burpees can you get in seven minutes? It doesn't matter the score that you get. It matters that you know. He said, as we're working out today, it doesn't matter what your score is. It matters that you're here, that you're sweating, that you're working out alongside each other. That is what matters. That is fitness freedom. I did a different weight than the person next to me. We did a different, it's all freedom within and it's all fitness. We choose it differently based on our own goals, based on our own needs. Now this idea, this term, I did not coin, this term of fitness freedom, I use all the time. If you've been to our live courses at Pelvic, you've heard me say this, because as we're giving various exercises, various versions of squat and pull-ups, we say it's fitness freedom. Do what you need to do to make it hard for you, to make it easy for you. Maybe you need that, whatever that is, but you've probably heard me use their term fitness freedom. I'm going to read a quote from street parking from Miranda and Julian. because I think it just so beautifully describes not only their company and their vision and their values, but also something that I think you all will resonate with as well. They say, consistency is one of, if not the most important values here. Doing with fitness freedom, in parentheses, embracing the ability to customize and make the workouts for you. and more than nothing, getting rid of the all or nothing mentality. It is so beautiful. I've been doing for the last three months street parkings programming and when you sign up for their programming, you get their emails and I read almost every single one of their emails. Their wording to describe to people this fitness freedom, to describe to people how to get fit. And that is consistency before intensity. It is choose what you need to do for your fitness so that you will be consistent. Because we know that consistency is what drives changes in humans. Consistency is what allows for these individuals to make life changes. We're changing lives here, not back pain. We're changing lives here, not peed pants. What is it that will allow people to exercise, to feel the freedom to do what they need to do on a regular basis to ultimately change their lives? Let's help them find their freedom within that. It's a beautiful saying. We use it all the time. Live this, embrace this. As I've been doing this programming, I have really learned to understand exactly what they're talking about. They have four different versions of every single workout. You choose your heart. You choose your own adventure. Sometimes I'm working out at the clinic at Onward here in Hendersonville, and I don't have I don't have an echo bike. My echo bike is at home. So maybe for that portion of the workout, I'm running outside. Or maybe when I get home, I've got my echo bike and I've got a box, but I don't have barbells. So I'm gonna use the dumbbells. Use what you have. We're changing up the equipment. We're customizing it for ourselves. But the same can apply to that mindset. Maybe for my… pregnant mama who wants to exercise, who wants that fit pregnancy, but she's sick and she's low on energy. Maybe for her, that fitness freedom is just moving through without even touching any weight. We all know what ideal is. We all know where we want to go, but that's a goal. How do we reach those goals? We don't just start doing it. We don't just climb the mountain, right? We train to climb the mountain. Part of that training to climb the mountain, so to speak, is to just move your body through that workout for that individual. Don't even touch the weight. Have a no sweat day, where you're just moving through that exercise, but you're not even sweating. Any of these concepts to break that down, to allow them to feel The freedom to choose whatever it is, is such a beautiful thing. So many individuals do not have that freedom, or at least they don't know about it. They don't mentally have that freedom. They think that they have to do everything as hard as possible, or else it doesn't count. I have to do that RX way, or why even bother? They're saying to themselves. I have to do better than so-and-so. I always do better than them. And if I back off at all, they're going to beat me. Well, maybe for a time, that's okay. We would rather you show up and be consistent in your workouts than not show up at all and not do the effort, not do the work. Allow for that fitness freedom. If you come to ICE courses, you are definitely going to experience that fitness freedom. You're definitely going to experience that group workout at the end of every Saturday, every day one at ICE. We always do that group workout. You are allowed to customize that workout for you. You have that fitness freedom. We'll make suggestions, we'll make ideas, but at the end of the day, it's your workout, and we're just here to guide that. Embrace this, learn it for yourself, and ultimately teach your clients about that. Teach your clients to where they can, at the end of the day, take those baby steps all the way to reach their goals.

SUMMARY
Thank you all so much for being here and listening this morning. Just wanna do a quick little notification for you all who are listening live. Probably by the time you're listening to this on the podcast, next year's sampler will be sold out. So if you're listening live and you want to go to the sampler next year, which you want to go to the sampler next year, 91 people are already signed up. This just went live on the website, um, 24, 48 hours ago. 91 people are already signed up. We only have 59 tickets left. Today is Monday, April 29th and they will sell out today. So if you want those tickets, if you wanna enjoy this beautiful place that is Carson City right outside of Lake Tahoe, come join us, buy that ticket to where you can join us. Today marks day one of Pelvic Online Level 1 and Level 2 starting out. This is our very first cohort for Level 2 and we are amped to have so many people who are ready to provide this fitness freedom this fitness forward pelvic health to their communities in this level two. And we're of course excited about all of the folks who are joining us with the level one as well. Some people have taken the live course before, some people are brand new to pelvic, taking this online course to understand a little bit more about how they can help themselves maybe, their family members maybe, and their communities about pelvic health. So if you are interested in joining us, we've got some online courses coming up in a couple of months. They will sell out, they always do. Level one starts in January, level two starts in, I'm sorry, not January. Level one starts in July, and level two starts in August. So be sure to sign up for those, we would love to have you. And then lastly, if you want to join us in May or June for Pelvic Live, we are going to be in four different cities. We are gonna be in Kansas City, Missouri, Anchorage, Alaska, Highland, Michigan, and New York, New York. So we would love to have you join us for our live course as well. Thanks for joining me this morning. Enjoy your fitness freedom and hopefully we'll see you next year at Sampler. Take care.

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.

Apr 26, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete faculty member Guillermo Contreras discusses the why behind the footwear recommendations they make and why minimalist footwear may not be the best choice for many fitness athletes to start with as well as how proper footwear can have an added benefit of improved strength, hypertrophy and fitness

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

GUILLERMO CONTRERAS
Here we go. Good morning, fitness athlete crew. Good morning, PT on Ice Daily Show. Welcome to the PT on Ice Daily Show and the best day of the Fitness Athlete Division of the Institute of Clinical Excellence. Super happy to be with you here this Friday morning. fitness athlete footwear. And that's a little teaser there. Hopefully you get excited for that. Before I start jumping though, I want to say anybody headed to Reno, Nevada, in Reno, Nevada for the ice sampler, have an awesome time. Have an epic time. A little bit of FOMO not being able to be there, but hope you all have a wonderful time. Take so much out of that weekend. It's such a great weekend. So much to learn. So many to learn from. And I've done this topic in the past. I've talked about my shoe recommendations for fitness athletes, whether it be the Rad One Trainer, the Strike Movement Trainer, the Nano, the Metcon. I've gone deep dive almost too long into episodes with that in the past. And today's actually a more of a, let's call it a response, a response PT on this episode, discussing why we don't, or why I don't personally recommend barefoot in the fitness athlete, whether it's the level one or the live course, we get asked, hey, what are your thoughts on barefoot shoes? Or why aren't you recommending minimalist shoes to allow the foot and the ankle to naturally do what the foot and ankle should be able to do? And this is where we're going to dive into, right? This is the topic I'm discussing because we know there's different shoes out there, right? I have somewhere in front of me right here. This would be a minimalist shoe, right? This is a zero drop shoe. it allows the foot display so a really nice wide toe box. It allows the foot to move naturally, allows the ankle to move through a broad range of motion. Why is that foot, why is that shoe wear not something we recommend to the majority of fitness athletes? to explore that full, broad range of motion that we wanna see with squats, squat cleans, wall balls, air squats, you name it. Why is that? when we look at shoe wear, we know that there's aspects to it, right? There's the forefoot, there's the midfoot, there's the heel, and we have something called a heel drop. And the heel drop, essentially, I'm gonna grab another pair here, is the amount of drop a four millimeter heel drop from the back of the shoe to the front of the shoe. That means that when I put this shoe on, my heel is lifted up just a little bit, just about four millimeters difference. What that does for me as an athlete, when I am squatting, is that it gives something we like to coin a dorsiflexion buffer. on board so that when I squat, I have maybe a little bit more available ankle dorsiflexion range of motion for me to squat with. When we take that away, when we go into that minimalist where we have a flat, fully flat shoe, if I am limited at all in ankle mobility, ankle dorsiflexion, that shoe is not going to allow me to have as much anterior transition to that tibia. it's then going to reduce the depth with which I can get into my squat, or it's going to push me into some more funky motor patterns, what we call the immature squat pattern, where my shin moves forward, but then it stops, which means my hips can't go any further without me losing balance or falling backwards, which means my torso needs to dive much further forward, which leads typically to a significant increase in stress on the posterior We're going to increase the loading, uh, the, the, the, the torque on the hips and the posterior chain when we significantly limit that anterior translation of the tibia. We know that from research, right? We know that it's no longer recommended or should be recommended to teach to restrict amount of increased stress to the lumbar spine, the posterior chain, and the hips when we do that with a very minimal decrease in stress to the knee. If you look at the data from the research, it's about a 53% decrease in the knee. 1,000% increase in torque to the low back, hips, and posterior chain, right? That's a huge trade-off. Whereas if we allow that tibia to translate forward, that knee to move forward, it allows for a more upright torso, a more vertical descend into that squat, and improved motor pattern there. So all that to say, when we give minimalist footwear, and we don't know what the individual's mobility is like, or we do know, like, hey, I know this person has really stiff ankles, And what we see both anecdotally and pretty much everywhere is that the ankle is one of the most difficult joints in the body to create mobility. And it can take years to improve ankle dorsiflexion range of motion. If you don't believe me, you can talk to our COO, Alan Fredendahl, uh, who's been working on ankle dorsiflexion for darn near a decade now, probably. And he's, he's doing much, much better now, but it's, it's been a journey for him to try and improve his ankle dorsiflexion. that athlete's ability to sit deeper into that squat with that more mature vertical squat pattern. And when we're talking about CrossFit or fitness athletes, that means that we're limiting the squat, including the back squat, the front squat, the overhead squat, squat cleans, squat snatches, pistol squats, wall balls. There's all these movements where we want to have a vertical torso, a more upright torso when we're performing it or receiving And when we take away mobility from the ankle, we restrict that motion because we're saying you need to go barefoot at all times to really work on it. You need to work on your mobility. Okay, you're not gonna go to depth until you can have better ankle mobility. We are significantly reducing that athlete's ability. to improve, strengthen the knees, strengthen the hips, strengthen the trunk because they can't load that barbell as much. We're reducing fitness level because now they're doing less work in the same amount of time as maybe their counterparts in the same classes or following the same programming and such. So we use the shoe to allow for that dorsiflexion buffer to allow for a deeper squat. We also recommend TO Slide a pair of VersaLifts, of heel lifts underneath the insole, they sit in there. Now instead of a four millimeter, maybe they have more like, I believe VersaLifts are eight millimeter or so. So it'd be like a 12 millimeter, which is, it's pretty high up, right? But it gives so much more mobility in that ankle to allow them to sit deep into a squat with good mechanics, with good motor pattern, and really, really hit the deep ranges that are gonna allow them to train a greater amount of the glute max, a greater amount of their quad to a broader range of motion, right? powerful hip extender that most people don't realize only really gets targeted when we're hitting those deep ranges below parallel to the squat. Again, this is not me saying barefoot or minimalist shoes aren't for nobody, right? There are individuals who have fantastic mobility in their ankles, great mobility in their hips. By all means, if they want to wear a two millimeter heel drop like Vans or Chuck Taylors, or do you want to wear a New Balance Minimus or the, I think the Xero, X-E-R-O, whatever those are. Those are fine for those individuals if they have the adequate prerequisite mobility in their ankle, their hips to be able to perform these movements are really good quality patterns. But for those of us who might have a limitation in the hip or limitation in the ankle, we have should be recommended. right? The two I have right in front of me, right? The strength movement, his trainer, four millimeter heel drop. This is someone who maybe has pretty good hip mobility. Um, and they can make up for a little bit of lack in ankle mobility with that, but they still have more than like 10, 15 degrees of ankle dorsiflexion. Um, me personally, I have like 30, 35 degrees of ankle dorsiflexion. I have decent hips. These work really, really well for me. These are my favorite training shoe for They fit more true to size than they used to. This has, uh, the rad one trainer, um, has a seven millimeter heel drop. Uh, and it is much larger. It's different. The heel is really good for lifting. It's good for Metcons. I have a lot of people at our gym who love these shoes. Uh, really high recommend these for those who maybe need a little bit more ankle dorsiflexion buffer or limited in their ankle mobility because of that. And one I don't have with me right now, if you have more of Um, and you don't like your toes display a whole lot, uh, tier T Y R their tier one trainer has a nine millimeter heel drop. So the biggest heel drop and they just standard training shoe that you can find. And that is the one I recommend to my individuals who like, Hey, I have horrible ankle mobility. Um, I always struggle to hit squatting full depth without my either my ankles kicking in or my going up on my toes. What do you recommend? Um, that's uh that's tier one trainer um excuse me first ones are called oh i'm sorry these are the uh strike movement haze trainer strike movement haze trainer so there is a strike movement right there uh strike movement without any vowels in the movement um so the haze trainer uh good quality shoe really really solid uh great for med cons i love them for weight lifting as well um and again nice and like a wider toe box not too wide but not too narrow at all either so really comfortable i love these for So hopefully that answers your question. And if you're looking for the evidence, right? Like, oh, well, like you gotta be able to use your feet. You gotta be able to use your ankles. In 2022, a study from the Journal of Strength and Conditioning Research came out on the effects of footwear and biomechanics of the loaded back squat to exhaustion in skilled lifters. So these are people who are already lifting, who probably already have really good mechanics and strength and everything on board. And they made one group lift barefoot or minimalist as barefoot style shoes. One group had to lift in like heel elevated shoes. And what they found was there's no difference more in like a novice athlete or beginner athlete or maybe people who maybe don't have that same mobility but in these skilled lifters people have been doing it for a while there was no significant difference in that either shoe reduced joint loading or improved joint range of motion for them they already had the adequates on board so the reason I even always emphasize, more than anything else, in the level one, in the live course, when people ask about shoe wear, about are we going to restrict someone from squatting until they have adequate ankle mobility, do we give them a shoe like this, is this okay, or do we give them a minimalist shoe right away, and if they can't do it, do we let them do it? It's always and, not for. I'm going to recommend something like a Rad1, and if they need it, a Rad1 with a heel insert, a VersaLift in there, while they work on ankle mobility, while they work on their hip strength, to work on their squat, to continue being a part, a participant in their CrossFit class, in their group fitness class, without needing to worry about scaling every single time, without needing to worry about modifying every movement every single time, and then they are also going to continue working on their ankle mobility diligently to get to a point where maybe they can take that heel insert out and they feel really comfortable here, and they can move to something like this, and then they can move to minimalistic. That is their end goal. It's always and, not, or with this type of If you want to learn more, if you want to ask this person live and really have a debate with me one-on-one, we have courses coming up where you can meet us on the road, where you can talk all things shoe. Like I love talking shoes. I love talking footwear, worn them, almost all of them. Love doing it.

SUMMARY
But we have courses coming up. Our CMFA online level one just sold out. So if you've been looking to take an online level one course with Fitness Athlete, we are not having another one until fall of 2024, but you can sign up for that now. So if you want to register for that now, this course always sells out. We always sell out before we start the course. We have a course in the fall. You can sign up now. You can wait until the summer to sign up whenever you want to. Our next level one one if you've taken the live course and you just have the level two to finish up your CMFA cert or if you just want to continue down the path of that CMFA cert we have CMFA level two starting up in September uh on to a year. So again, if you're looking to get that certification, if you're looking to learn more about Olympic weightlifting, programming, modification, even some business type things, check out the level two CMFA course on September 3rd. That one also always sells out before it starts. So if you're looking to take that, sign up sooner rather than later. If you want to hit us up on the road, you're looking where we're at. CMFA Live is going to be on May 18th and 19th in two different locations. Proctor, Minnesota. I believe Joe Hnisko will be leading that one up in Proctor, Minnesota. And then that same weekend, I'll be hanging out with Mitch Babcock in Bozeman, Montana. That is, again, the weekend of May 18th and 19th. And that's all we have right now in May. And then June, on June 8th and 9th, you can hang out with the barbell physio, Zach Long, in Raleigh, North Carolina. And then on June 22nd and 23rd, we have the first ever annual Fitness Athlete Summit. You're going to see every single faculty and TA and every member of the fitness athlete crew. You have Mitch, Zach, Joe, myself, Kelly, Jenna, Tucker. We're all going to be coming together in Fenton, Michigan at CrossFit Fenton for an epic weekend, more fitness and fun and sweating and learning than any course you've ever done in your career. So we would love to see you at the Fitness Athlete Summit on June 22nd and 23rd. I believe it's about 45 minutes, an hour, something like that away from Detroit.

null: So quick flight in. You can also

SPEAKER_00: to fly into Flint, I believe, which is a shorter, even shorter drive from there. But we would love to see you there and have you join us for the Fitness Athlete Summit in June of, June 22nd and 23rd. Gang, thanks so much for tuning in this morning. Have a wonderful weekend. Again, if you are at Sampler, have an absolute blast. Enjoy yourself for me as well. And we will catch you on Monday for the PTNX Daily Show.

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

Apr 25, 2024

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 history of non-compete agreements, relevance of non-competes to PTs, and recent law changes banning non-competes.

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

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

ALAN FREDENDALL
Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. I hope your day is off to a great start. Good morning. If you're listening on YouTube, Instagram, the podcast, we're happy to have you. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions here on Leadership Thursday. We're going to talk about non-compete agreements today. But first things first, Leadership Thursday also means that it is Gut Check Thursday. So, Gut Check Thursday this week will be the Ignite Workout from our friends over at Forging Youth Resilience. FIRE, we team up with them every year. They support kids learning CrossFit, using CrossFit to help themselves with mental health, and other things they have going on in their life. So this year, they are doing the Ignite workout in the month of May for Mental Health Awareness Month. And we're going to do this workout this weekend at the Ice Sampler here in Carson City, Nevada. And so the workout, what is it? It is a two-part workout. It has a conditioning piece and it has a weightlifting piece. So it starts with an 18-minute running clock for the whole workout. So start at 18-minute clock and then work your way through 21, 15, 9. Thrusters at 95 for the guys, 65 for the ladies. Lateral burpees over the bar and then ab mat sit-ups. And then in whatever time you have left in that 18-minute window, you're going to max a complex of a power clean and a hang squat clean which must be performed unbroken. So cycling that power clean back down to the hip and then moving through a hang squat clean for a max load. Now this year at The Sampler we're going to do this in teams of three where three folks each do the workout at the same time. They have a combined time and then they have a combined load on their weight lifting piece. And what we're asking folks to do at the sampler, and we're asking you all to do as well if you hit this workout, is to consider donation to FIRE in whatever amount, one cent, 50 cents, one dollar, for every second you are slower, and every pound you are less on the complex than the team that FIRE has assembled of CrossFit Games athletes. So EZ Muhammad, Noah Olsen, and Sam Dancer have teamed up to represent FIRE. And the challenge to all of us is to try our best to beat them. And so we ask you all to consider donation in the seconds you are slower, pounds you are less on your lift. And then ICE will donate $1 per second and $1 per pound to any team whether you're here at The Sampler this weekend on Sunday or whether you're doing it at home in a team of three, we will donate $1 per second that you are faster and $1 per pound that you are heavier on your complex than that team of CrossFit Games athletes. So a little challenge flag for you all. If that is your team and you are not here at The Sampler, we would love to see a full video posted somewhere, shared with us, and then we'll make a donation on behalf of your team to fire. So that is the Ignite Workout. We're super pumped about that. Today on Leadership Thursday, what are we talking about? We're talking about non-compete agreements. So most of us are somewhat familiar with these. Some of us are unfortunately very familiar with these. We may have a non-compete looming over our head that we're worried about. So my goal today is to talk about the history of non-competes, the purpose of non-competes, and then talk about some recent changes to non-compete agreements that are really in our favor on the employee side of the equation.

WHY NON-COMPETES?
So first things first, when and why did these begin? These have been around for a while. These are becoming more prevalent in healthcare certainly, but these are primarily designed to limit the ability of somebody to leave a job and take not only their experience, but maybe knowledge of technology or systems to a competing company. So that is why they were created. So you might say, well, that seems like a pretty good reason. But in reality, what happened is that non-competes just became so prevalent that pretty much every person at every job, no matter what they were doing at that position, ended up being asked to sign a non-compete agreement. And what we've seen and what the government has done a lot of research on over the years is, is this good or bad for workers? And is it good or bad for the American economy in general? And what they have found over the years is that it is very bad for the economy. Why? Two reasons. It suppresses wages and it increases worker dissatisfaction. So obviously if you're working at a position and you're asking for a raise and you're not getting a raise, you're asking for a bonus, you're not getting a bonus, you're asking for a promotion, you're not getting a promotion, The answer when you have a non-compete agreement has always been too bad. You can't leave anyways, right? So we have no reason to help you further your career along. And now you can imagine how that part influences worker dissatisfaction of feeling like you are stuck, feeling like you have no mobility in your career, feeling like if you leave you might end up with a lawsuit, you might end up in a really bad position both personally and professionally. And the thing to know about non-competes is they are not in effect everywhere. There are some states that have never allowed them, and there are some states over the past couple years that have begun to ban them, either across the state or for specific workers. So a good example, California and New York, a couple other states have completely banned them. And then a lot of other states, about 25 states in total, have restrictions on who they can be applied to. And they can't be applied to specific professions or people making under a certain amount of money. And the whole idea is we cannot control the ability of people to have upward mobility in their career. That's obviously bad for the individual, but it's also bad overall for the economy. People who make less money, spend less money. People who make less money, pay less taxes. So the government is very interested in seeing what happens when non-competes are in effect and when they're not in effect. Your thoughts on California notwithstanding. California is a great example of what happens when non-competes are not allowed. They have been banned in California for a very long period of time. And you can imagine an area like Silicon Valley where all of our technology is essentially created and invented would simply not exist with non-competes because people would not be able to leave and have upward mobility in their career to join a different software company or something like that if they had non-competes in effect. And because non-competes are banned in California, we see higher than usual income for workers in California. Yes, unfortunately that's offset by cost of living because California has a really nice climate and everybody wants to live there. But that is the reason why wages are higher on average. And thinking about world economies, The United States is number one. We have about 25% of all the world's economic output happening just in our country. But not too far behind is the state of California itself. So if we look at largest economies in the world, United States is number one, China is number two, Japan is number three, Germany is number four, and actually the individual state of California is number five. And part of that is favorable worker laws like having non-competes banned. So that is the history of non-competes.

RELEVANCE OF NON-COMPETE AGREEMENTS TO PT
Why have these never really been appropriate for us as physical therapists and for healthcare workers in general? As physical therapists, we are not really using a lot of proprietary software or technology or systems that we could leave a position and move to a different employer and really have, you know, inside secrets. We can all agree there are really not a lot of inside secrets and technology and stuff like that inside of physical therapy that would offer a competitive advantage. The primary reason employers are upset when PTs leave is that they're now generating revenue for somebody else and not for them anymore. And when we think about what does it take to become a postgraduate professional, especially a healthcare provider, a physician, a physical therapist, a dentist, whatever, it takes a lot of time and it takes a lot of money. And non-competes for healthcare providers have never historically stood up in court anyways to begin with because it is so limiting on our career mobility to say that you cannot work for another physical therapy organization. You cannot create your own physical therapy company for five years within 50 miles of your current employer. All those restrictions that we see in non-compete agreements make it very, very difficult to continue to work. in physical therapy in general, let alone close to where you currently live. Some of them are so restrictive, folks either leave physical therapy entirely, or they have to essentially move very far, potentially out of state, to get around their non-compete agreement. And knowing that they're not held up in court, they're primarily used as a scare tactic of People don't want to be in court. They don't want to be sued. They don't want to potentially lose their license. So even if they've been told, don't worry about that non-compete, they worry about it. In our brick by brick course, our practice management course, this is one of the biggest concerns with people starting the course of, hey, I don't want to start my own business yet. I signed this non-compete for two years, three years, five years. We have met people who are working in fast food, who are waiting tables as physical therapists because they are so scared to leave a position as a physical therapist and work somewhere else. that they decide to just at least temporarily leave physical therapy entirely, which is devastating. That is a significant reduction in the income you could make as a physical therapist if you decide to wait tables or if you decide I have to move out of state to continue to work. And so they have never historically held up in court and they have primarily been used as a scare tactic, especially for physical therapists.


NATIONWIDE BAN ON NON-COMPETE AGREEMENTS ISSUED APRIL 23rd, 2024
So, the history of non-competes, the relevance of non-competes to physical therapy, what has happened recently as of this week that is a great change. On Tuesday, the Federal Trade Commission, the FTC, announced that non-competes were banned nationwide. And so they have been watching this issue for a while. They have been doing a lot of research on this issue for a while, and they have decided it's in the best interest of the American people and the American economy to ban non-compete agreements everywhere. So as of that issuing of that rule on Tuesday, April 23rd, 2024, Any current non-compete, so if you're sitting here right now and you're listening to me talk and you have signed a non-compete, it is invalid. It cannot legally be held up in court ever. And you cannot be asked to sign a non-compete moving forward. There are some exceptions here, but they largely don't apply to us as physical therapists. The one exception is that you can still be asked to sign a non-compete if you're a C-suite level executive who has ownership stake in the company that you work for and you make more than $151,174 a year. So some of you, depending on where you live, you might make more than that. However, unless you're a C-suite level executive who has ownership stake in the company you work for, then still you are exempt from being asked to sign a non-compete. So where do we think this will go? Well, we're not quite sure. Any party, public or private, has 120 days to challenge this rule. In August, it will become permanent, but we have about four months where private companies could sue and say, this is not allowed, you can't tell us what we can do with our employees. Public organizations such as state governments at the state government level can sue, and then other governmental organizations can sue. Because the Federal Trade Commission is an executive branch of the government, or at least an arm of the executive branch, the president also has the power to shut this down. Congress has the power to change this by passing a law about it. And then any individual organization, public or private, can elevate this to the level of the Supreme Court for the judicial branch to weigh in. So all three branches of government have chances, one way or another, to weigh on this issue. and either cement it, certainly if it's drafted into law by Congress, it becomes a much more solid rule, but if we don't see it challenged, then this will become permanent. And we really like this here at ICE. Again, in our brick-by-brick course teaching people to open their own practices and how to manage their own practice, this is a large concern. Over at Onward Physical Therapy, starting new clinics, starting cash-based physical therapy across the country, it's also an issue of people do not want to leave their current position and start their own business for fear of what might happen to them legally. So this was a great rule and that we hope this stays in effect and that nobody challenges it over the next four months. We'll be watching this issue closely because it's near and dear to our heart.

SUMMARY
As much as we love PT 2.0, we think part of PT 2.0 is also being able to run your practice really well or consider opening your own practice and not being limited by things like non-compete. So we're excited about this here at ICE. We hope you're excited too, especially again, if you're sitting here listening and thinking, oh wow, I have signed one. I've been worried about one. It's cool that it doesn't count anymore. So that's where we stand right now. And then we'll see what happens over the summer, what organizations challenge this, hopefully none, but we'll see how it goes. So non-competes, what's the history of them? Largely used to try to keep a competitive edge in business, but what we see happen is really just obviously very personal negative effects on workers, but also an effect on our economy in general. that they're not really relevant to physical therapists to begin with. They're primarily used as a scare tactic, but the good news leaving today's episode is that as of right now, they're not valid anymore. You can't be asked to sign one. If you had signed one, it's unenforceable and it cannot be legally upheld in court, but we're watching to see what develops over the next couple of months. So, that's PTN Ice for Leadership Thursday. I hope you get a chance to hit that Ignite workout. If you have time over this weekend, grab some friends and go for it. If you're gonna be coming to the Ice Sampler, we're looking forward to seeing you very, very soon. 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.

 

Apr 24, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Dustin Jones discusses helping patients better understand their osteoporosis diagnosis, including learning to read a DEXA scan. Dustin also shares tips on discussing prognosis with patients as well as using the data supporting their osteoporosis diagnosis to inform your treatment choices & plan of care development.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane, an online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

DUSTIN JONES
What's up team? Dustin Jones here. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Today we're talking about osteoporosis diagnosis, prognosis, and treatment. This is a big topic that so many of the folks, older adults that we work with, they will receive this diagnosis or have this discussed with them. And a lot of times it's not given a lot of context or they don't have full understanding of what this really means for them and what they can do about it. Most importantly, what they can do about it. All right, so let's get into this.

OSTEOPOROSIS: DIAGNOSIS
We'll start with the diagnosis piece, just really defining what is osteoporosis and then spend a little bit more time on the prognosis side of things and the treatment because I feel like that's where we have a lot of opportunity to really serve our folks well. So osteoporosis, we're going to review, go all the way back to your formal training when you learn some of these numbers. that we may have forgotten, all right? So when someone is, when that conversation of bone mineral density starts to come into play, usually it's for postmenopausal women or males over 50 years old, start to look at bone mineral density. And the way that we can measure, objectively measure bone mineral density is through a DEXA scan. You'll see that D-X-A or D-E-X-A, that's Dual Energy X-Ray Absorbed Geometry or DEXA. This is the reason why everyone calls it that. So you're basically looking at bone mineral density. And if for individuals that are over that kind of 65 year range, you're going to get a score. That score is going to be a T score. And so we're taking the measurement of the minerals in the bone in a certain area and comparing that to same sex and race norms for a younger population. So we're comparing it to a younger cohort, and that's where you'll get those T-scores. And so based on those T-scores, you will get maybe something from 0 to negative 1, and that is considered to be normal and healthy. Then that negative 1 to negative 2.5 is that osteopenic range or osteopenia which means the bones are a little bit weaker but not full-blown osteoporosis just yet and then below negative 2.5 and below they will receive that osteoporosis diagnosis. Typically, along with the DEXA scan, a physician is doing a FRAX screen. This measures the 10-year risk of having a fracture. There's some different lifestyle questions and it'll basically spit out a percentage of likelihood that that individual is going to have a fracture within the next 10 years. And so those two pieces of information really formulate the, or someone giving a diagnosis, but then also the treatment that follows. And then based on those T-score readings, as well as the FRAC score, the pathways are typically, there's gonna be some pharmacology involved, right? Whether we're preventing bone resorption or really encouraging more bone formation and remodeling. And then they're typically going to give some blanket generic recommendation of exercise of weight bearing exercise. All right. Now, the tough part about this diagnosis, it can come from a whole host of different providers. So you can see primary care physicians, you know, kind of leading the charge of, you know, looking into bone mineral density. Internists can as well. Orthopedic physicians can as well. And so there will be different doctors that will be kind of looking into bone mineral density. And then they will often refer out to someone like an endocrinologist, for example, for further treatment and so there's a lot of people kind of involved talking about this and what at least I have seen is that this has been a topic that has been brought up and a lot of fear has been revolving around this topic but not a ton of guidance of what it really means day to day to really influence bone mineral density beyond taking that pill and you know quote-unquote weight-bearing activities. I've just worked with so many people that did not understand that diagnosis and what it actually meant. So just understand that. I'm not saying that always happens, but in a lot of the folks that I work with, that is typically the case.

OSTEOPOROSIS: DIAGNOSIS
So they're given this diagnosis and now let's talk about the prognosis. In particular, what I want to speak to is the opportunity to really dive in to the DEXA scan that our patients receive. And I'm not saying it is our place to kind of give a medical prognosis per se. Well, I guess when I'm saying prognosis is what can they expect going forward and to give them context of that diagnosis. So I'm mainly working the context of fitness now at Stronger Life in Lexington, Kentucky, and it's a gym for folks only over 55. And we're about four years old now, and so over the past four years, we've had a lot of members that have had at least a couple DEXA scans at this point. And so I'll put a field out for folks to send me some of their DEXA scans, and this is something that, these are conversations I'll typically have with folks anyway, once they get their DEXA scan. This is something I want you all to do. I want you to ask some of your folks that have osteoporosis on their, you know, their chart, their diagnosis list. Say, Hey, can I see your DEXA scan? Or, you know, if you're in a medical system, look up their DEXA scan, because it's really interesting. And you start to look at a lot of these reports and you'll have some of them that are more kind of narrative based, um, that, you know, are basically just several paragraphs kind of outlining, um, you know, what to expect, what they found, something more along the lines of, a bunch of words if you're not watching I'm just holding up some of these DEXA scans but more narrative but then a lot of them will actually have graphs of T-scores when they had that DEXA scan and where. So the most common areas are going to be the lumbar spine, the neck of both femurs, bilateral femurs, and then they'll kind of zoom out a little bit and look at the total hip as well. And so get those DEXA scans and look at some of those numbers. And when you start to look, what you're often going to find is variation amongst the different sites. So you can have individuals that may have that negative below negative 2.5, negative 2.5 or below, let's say at the neck of the left femur, for example. And then the neck of the right femur may be negative 1.7, osteopenic. The lumbar spine may be negative 1.5, for example, osteopenic. And so technically that person has osteoporosis on the left, on the left side, right? The right and the lumbar spine does not have osteoporosis, osteopenic, still a concern, right? But not as bad as that left side. That message is often missed by many of our patients. Now, I believe they're getting that message, you know, when they are getting these reports and having conversations with some of the physicians, but they're probably getting all kinds of recommendations. They're getting that diagnosed and all kinds of things that, you know, we only may only hear half of what is actually being said. But a lot of folks I work with, they will receive that diagnosis of osteoporosis that in reality is only in their lumbar spine, for example. and they will take that and own it as if every single bone in their body is brittle and about to combust under any type of pressure or load. They embrace that diagnosis as it's this global systemic osteoporosis. Every single bone I have is tremendously weak without acknowledging that there's some variability in different areas of the body. That piece of information for folks can be really eye-opening and very empowering. Oh my gosh, are you saying that I only really have this in this particular area of my body and not everywhere else? That's a sense of relief for a lot of folks. A lot of folks will take this diagnosis and view it as almost like a death sentence. everything. I am so weak. I'm so fragile. I need to be very careful. I'm going to break something, any bone I need to be very, very concerned about. Right. And that's not necessarily what's happening. It's usually in kind of one, maybe two areas that are a concern, particularly folks that are initially receiving these DEXA scans. And the cool thing about where I'm at now, working with folks for over four years, this individual, she's had a DEXA scan every two years. She was on a negative slope, negative three in 2017, negative 3.1 in 2019, negative 3.4 in 2022, and her most recent scan a couple months ago was negative 2.8. This is at her lumbar spine. and when you are able to give context to the diagnosis but then also be able to see over time you'll be able to spot trends and then hopefully be able to potentially reverse trends or slow down trends and we're seeing this at Stronger Life and I know many of y'all don't have the luxury of working with folks consistently you know three times a week over the course of several years but man if we can apply some of the interventions I'm going to talk about here in a second over the course of years you can have a significant influence in a lot of these DEXA scan readings and we're definitely seeing that and you can too. But I think that conversation, the prognosis, them understanding the diagnosis, where in particular that may be, that they understand every single bone in my body is not going to combust under pressure. This particular area may be more concerned, but I'm doing okay in these other areas. It's really good for them to hear that and that can be a more empowering message.

OSTEOPOROSIS: TREATMENT
Now the most important thing I think is that we take the information from this DEXA scan and then we use it in our plans of care. And so if I have someone that has maybe normal osteopenic in terms of the DEXA scan in their bilateral femurs, neck of their femurs, but then they're kind of borderline osteoporosis in their lumbar spine, for example, as a physical therapist, That gives me something that I can focus on, that I can give targeted interventions to give specific forces and stressors to that area in a very progressive manner, keep in mind, to stimulate a change in that bone mineral density or increase the odds that we can see change in their bone mineral density. So we take that information, use it for our plan of care. Some folks, you may be focused, all right, this left hip, let's load up this left hip a little bit more, do some unilateral stuff, staggered stance type things, not neglecting the other side per se, but if there's a big difference, we may want to give preference to one side or the other. If it's a spine, lots of loaded carries, deadlifts, those types of things where we're getting that axial compression, getting those forces through the spine. We can give target interventions. that's gonna encourage those bones to remodel, to get stronger, or potentially slow down, decline. So we take that information and take it into our intervention piece. Now for the intervention piece, you know, this is a 15, 20 minute podcast. We have a whole week on this in our NYA Level 2 course. But what you need to know is there are three things that are really, really important if osteoporosis is on board. One is balance training. This doesn't directly impact bone mineral density, but if we're able to improve people's balance capacity, I would even go as far to say their fall capacity as well. Do they know how to land? Do they have the balance capacity to even prevent the fall? That whole conversation of falls prevention and falls preparedness that we speak to, particularly in our live course, is really helpful for these individuals. Because if we can prevent a fall or even teach people how to fall in a more efficient or safer manner, you can potentially prevent an injurious fall or an osteoporotic-related fracture. So that's the first thing. Second thing is progressive resistance training. Bones really like progressive resistance training, where we're working up to relatively higher percentages of a one rep max, 70, 80, 85%. We're not going to come out the gate hitting that, but it'll take some time. But there's some really promising studies showing that, man, if people are able to regularly train at those higher intensities, they get really strong. They improve in a lot of the functional outcome measures that we care a lot about, but also their bone mineral density as well. Lyftmore trial is a great example of one group that's been able to show that. And then probably one of the more neglected things that we can definitely implement that can be intimidating for a lot of folks, but I found a lot very empowering for patients once they're able to do these things, and that is impact training. Weight-bearing as well. Loading the bones, but really thinking about the rate of loading. Progressive resistance training puts a ton of force, a bunch of load through that skeletal system that gets really good results. But bone can also respond really well to rapid loading. So think like plyometrics, stomping, heel stomps. step-ups, maybe a plyometric push-up, for example, or a quick bearing of weight through the upper extremities, something along those lines, where we're getting those increased ground reaction forces, we're getting those impact that can give the bones a signal to remodel. You take balance training, you take falls preparedness, sprinkle in some progressive resistance training, and then sprinkle in some of that impact training, and you stretch that out over years, And I will put my money that you're going to see some solid results when your patient comes back and says, Oh my gosh, Alan, look at my DEXA scan I just got. Remember the previous year, about a couple of years ago is like right when we started working together. And then man, I just had this DEXA scan and I've reversed my osteoporosis. We've seen that. Not to say it's going to happen every time, but people have the capacity to change and we often don't perceive that with this particular diagnosis. It is not a death sentence. There's a lot we can do. So understand the diagnosis, but then also understand that prognosis and give your patients context. Get that DEXA scan, look at it, analyze it. It's going to give you a lot of helpful information that they may not have comprehended and it can ease their mind of a lot of concern and worry, but it can also give them, something that they know they can do. And we can take that information and give a targeted intervention to a particular area that may be more troublesome than others. But man, if we combine that balance training, falls preparedness, progressive resistance training, and impact training with folks over a long duration of time, we can see some really significant results. All right, y'all. I appreciate y'all taking the time to listen. Let me know if you have any thoughts, questions, or your experiences working with folks. I do want to make sure I'm not saying everyone's going to get better. Everyone's going to improve their bone metal density. That is not the case. But man, if we can try without causing more harm, I think that's a good thing to pursue. And oftentimes, we can see some improvement.

SUMMARY
Before I go, I do want to mention our MMOA courses. I already mentioned that level 2 where we talk a lot about osteoporosis. Our online level 1 course is starting May 15th. Our level 2 course is starting May 16th. These are both 8 weeks long, about 2 hours a week, so you'll get 16 CEUs for PT, OT. and we equip you all to be the go-to clinician to best serve older adults in your community. It's likely gonna make you a very, very busy clinician serving these folks. And then our live course, we're gonna be in Bismarck, North Dakota, in Richmond, Virginia on May 18th and 19th. I'm gonna be in Scottsdale, Arizona, the beginning of June 1st and 2nd, and then we'll be in Spring, Texas, June 8th and 9th. We'd love to see y'all on the road or see y'all online. Y'all have a lovely rest of your Wednesday and go check out those Texas games. See 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.

Apr 23, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses details surrounding velocity changes and fatigue in both metabolic and cardiovascular systems when loading the spine.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Thanks for watching! Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account.

BRIAN MELROSE
All right, good morning, PT on Ice Daily Show. My name is Brian Melrose, teaching both cervical and lumbar courses in the spine division, and just here to kind of round out another clinical Tuesday, talking about loading the lumbar spine in a comprehensive program. Today, the aspects that I want to talk about is kind of loading the spine at different speeds and different fatigue levels. If you can do those two last things, I think you've really built a comprehensive loading program for either your patients or your athletes that you're working with. So a couple of weeks ago, you know, we've talked about all things at this point, barbell isometrics. Last time we were talking about leveraging different planes of motion. And not just sticking in the sagittal plane, loading into kind of side bend into rotation. And so if you miss those episodes, check those out, because all those rules still apply. But the last thing that we need to talk about is different speeds and fatigue levels. And so where this thought process really comes from, is kind of, you know, again, I was sitting at extremity, and I was thinking about loading the rotator cuff. And again, we can't just sit down here, we got to get in different positions, we have to load with variable resistances at different speeds. And I thought to myself, why would the spine be any different. And so that's really where I started messing with some of these things in the clinic. And so If we want to start leveraging some of those concepts for the back, we have to take something like the deadlift, and then start loading folks at different variable speeds, as well as fatigue levels. So just like last time, I made a partnered post here, it should be on our Instagram, it'll be in the reels. Again, that kind of outlines everything that I'm going to talk about for the next couple minutes. There's gonna be a lot of exercises I mentioned. And so again, there's visuals there if you want to check those out after listening to the podcast.

WHY SPEED?
And so when it comes to speed, the first question is, is like, why? Like, why would it matter? And that really comes down to something as simple as different muscle fiber types. We have type one and type two fibers, and those do different things. And so if you're only doing something like power lifting and lifting heavier loads, at lower speeds, you're going to really leverage type two type fibers. If you're moving lighter speeds quickly, again, you're going to be more oxidative, you're going to challenge different energy systems, and you're going to utilize a different kind of muscle fiber type. So if we want our comprehensive loading program to include both of those, you got to have lighter loads, you also got to have heavy loads to train both of those systems and move those kind of weights at different speeds. And so when I think about loading the lumbar spine on a spectrum, there's really a lot of different speeds that we can mess with. The first one you would have to kind of really begin with would be the barbell isometric where the barbell or the weight really isn't moving at all. And so we talked about some of the nuances of that weeks ago, but you can get that barbell underneath those J cups and have a very consistent pull with max effort without any movement. And so the first speed would be no speed. And you can set that at different kind of heights for something like the deadlift. Things really begin there and they can then swing the direction of normal movement. So looking at something like the deadlift, you could do something like a touch and go rep where the barbell is touching the ground and then you're almost using that momentum of hitting the ground and that reaction to pull the barbell back up. And so it's a faster movement and therefore typically a lighter load. We can compare that to something like a heavier deadlift where you're maybe again slowly getting that barbell all the way to the top of the rep. And a lot of athletes use different things to look at speed as a parameter. And so a lot of the powerlifting athletes that I end up working with use a barbell accelerometer. It's a thing that kind of sits on the ground, it's got a cord, it attaches right to the barbell. And as it's lifted from the ground, the device allows you to kind of record how fast you actually pulled it. And this can be a great way to use an objective measure to look at someone's kind of difficulty level. Are you programming it properly? Are they working in the right range? We love using things like reps in reserve, RIR, or RPE, Raiders Perceived Exertion. And we know that those subjective measures are actually pretty good at helping us vary load for our patients. But something objective can also help as well. And so those barbell accelerometers, I'm sure they have a bunch of cute apps that do it too, can really be a helpful thing in the clinic to kind of dial in your speed when you're working with those different athletes. The only other concepts I want to kind of throw out there would be leveraging different speeds with the concentric and eccentric portions of a lift. And so for the deadlift, again, as you're pulling that concentrically from the ground, you could do a fast pull up, and then a nice, slow, controlled lowering. You could also change that. You could do a slow, gradual pull up, and then a fast drop towards the ground, where either you come to a rested point right before the barbell hits the ground, or actually contact the ground. And so that's leveraging speeds within the lift to, again, challenge different muscle groups in different systems at those different speeds. The last thing is kind of what I call a reactive speed drill. And so, again, in my post, if you check that out, it'll have a band just looped around the barbell that's gonna accelerate the barbell down towards the ground each time I pull it. And so that can, again, really change your ability to slowly, eccentrically control a lift. A really cool way to, again, just leverage speed in a different position. Now, if you have access to chains, that's another thing you can put on the barbell. As those chains come off the ground, it increases the weight. So again, typically in the easier part of the lift, you're getting a little bit more load. As that barbell comes back to the ground and those chains kind of pile up, that load is removed. And so both banded or chain work would fall into kind of this reactive speed zone. And I think that's the last speed parameter that we need to kind of consider when we're thinking about challenging someone's system. So that's speed for something like the deadlift.

TRAINING THE SPINE UNDER FATIGUE
The other thing that I really want to talk about today is fatigue levels. And there's really two big buckets that that falls into. The first kind of fatigue bucket that you would want to consider is looking at somebody's kind of movement and taking something like the deadlift, which is primarily a sagittal plane movement, a hinging movement. And you wanted to really tax that entire muscular system, those same synergistic muscles that are doing that movement, and you just want to bury them, you're going to give them two or three exercises that are kind of varying the speed, the load, but they're all taxing that same muscle group. And so kind of the metabolic failure that I'm describing in this bucket, is one that's a little bit more energy specific. I mean, I want you thinking about how can I tax out that creatine phosphate system that's going to be the primary one used for the first 30 to 60 seconds of an exercise. And then it kind of switch it over to like Krebs glycolytic. all the way on up to oxidative. And so for leveraging different barbell speeds and loads, you can also again, give them that same stimulus to tax that muscular system. And so you could take something like the deadlift, have them rep some of those out, Then have them go to, again, a hinging pattern with a medicine ball slam. So same muscle groups working, again, different speed. And then last, put them on something like the reverse hyper, where, again, they're going to kind of tax the same muscle groups. They're all different exercises, but you are bringing that muscular system, that energy system, to complete an absolute failure. And so that would kind of be a position-specific failure scenario. The other big failure kind of bucket that we can push our folks into, and really I think we need to push all of our folks into, would be a little bit more of cardiovascular fatigue. And this can be something, again, that's nuanced all the way down to you're doing it with Doris or Betty, where maybe they're pumping some reps out on the new step, doing a reverse Tabata, and then going and lifting the kettlebell off an elevated step, on up to our higher end athletes, where they might be crushing something on the rower for a period of time, jacking their heart rate up, and then kind of transferring to the barbell. In either one of those scenarios, we want to tax the cardiovascular system. And so now I'm talking about fatiguing that, really the heart and the lungs. Can you keep up and continue to lift when you're absolutely gassed cardiovascularly? And so for more of a lifting athlete, this would look like, again, the last kind of swipe on that reel that I posted would be starting with something like the deadlift, And then maybe having them do something like a kettlebell swing, where they're jacking their heart rate up and moving a little bit more quickly, still a familiar hinging movement. But again, with a little bit more speed, a little bit more cardiovascular demand on board, and then having them for a third exercise, pump a bunch of reps out on the rower. So I like jacking the resistance up to like eight to 10, having them do about 30 seconds to 60 seconds, and then cycling those exercises. And really by round three or four, they are going to be absolutely smoked from that cardiovascular demand, those faster movements with the kettlebell, and it's not just going to be a simple deadlifting, hinging routine anymore. And so those would be the final concepts that I think we really need to consider when we're building somebody a robust strengthening program for the spine. You're nuancing these all the way down for some of our lower level folks, and then really challenging some of our higher level folks that might already be deadlifting, squatting, doing some of these movements a couple times a week. Now you got some different lenses to kind of either add or alter the lift, looking at different speeds, isometric, concentric, eccentric, touch and goes, heavier stuff where you're looking at a barbell accelerometer, all the way up to reactive things with a band or chains. That speed also fatiguing a particular muscle group, a specific position, a certain synergy of muscles, or the cardiovascular system. you can hit all of these different parameters and give your folks a nice robust back program to keep with. Again, I think the chances of them having future injury or issues significantly decreases. So just some food for thought. I hope this was helpful. I hope you guys have an awesome Tuesday.

SUMMARY
I just want to touch briefly on a couple courses we have coming up. There's only a couple spots left. May 18th and 19th. I'll be in Casper, Wyoming teaching cervical So if you want to learn how to twist some necks, we'll be doing that on Casper The next cervical course we have on the books is in Kent Washington on June 29th and 30th again You'll be stuck with me for that one for lumbar. We got two coming up here. We got Zach out in Chandler, North Carolina and on May 18th and 19th, and then we got Jordan up in Victory, New York on that same weekend. Those will both be lumbar courses. Again, if you guys are looking to get out to any of those, we go over everything comprehensively, the whole process, and then give you some manual therapy techniques on the weekend. So, hope to see some of you guys at those courses. I hope this information was helpful. Have a great Tuesday. I will see you guys 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.

Apr 22, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses ideas for further treatment for an individual experiencing vaginismus.

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everybody, Alan here. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at sign up to receive a one month free grace period on your new Jane account.

APRIL DOMINICK
Good morning, everyone, and welcome to Pelvic Monday on the PT on Ice Daily Show. My name is April Dominick. I'm here to talk to you today about pain in the vag, a case study. This case study was brought to us by some of our students in our level one pelvic cohort, and they just had some questions about a case on vaginismus and where to go since they were feeling a little bit stuck. So I wanted to hop on here and provide some in-depth guidance on how to continue with what they have already started for their treatment. Particularly, they are interested in how to improve their patient's pelvic floor hypertonicity, as that's where they're feeling a little stuck. So here are some details of the case that the treating therapists have already shared with us. The subject is a 19-year-old female who's diagnosed with vaginismus. Her aggravating factors are history of difficulty and pelvic pain with insertion of a tampon. She more recently was on her menstrual cycle, got a chance to try putting the tampon in. and had another failed attempt. She also has reported pain at her inner thighs after horseback riding, and she is an avid horseback rider. Easing factors so far, the therapist had provided the patient with adductor stretching, strengthening, foam rolling, and that seems to have eased the adductor pain, not necessarily helped with her pelvic floor situation just yet. And from a physical activity standpoint, I don't know much, but again, she is an avid horseback rider. And she also reported history of sexual trauma from a horse camp instructor who is now in jail. And thankfully she is currently working with a trauma therapist as well. In terms of objective findings, again, they found some tightness and pain with adductor palpation. as well as when attempting the internal pelvic floor exam, they were limited by the patient reporting pain. Current treatment, they have done some dilator work that has improved since the start of PT. So a few weeks ago, the dilator itself was shooting out upon insertion, and now the patient is able to maintain a dilator inside the vaginal canal for a few minutes. And if you all are unfamiliar with what a dilator is, it is essentially a phallic-like structure, that can be inserted into the vaginal canal. I like to call it a space holder for the vagina. And there are different variations of it. And some of them have a longer length while others are wider. And so it allows someone to be able to progressively overload the vaginal space or the vaginal canal. And after horseback riding, the general adductor exercises that the therapist provided have helped, again, reduced the patient's adductor discomfort. So their biggest question, again, is how do we address the pelvic floor hypertendency? It doesn't seem to be that we are making progress with this. So initial thoughts. First off, the therapists are doing just wonderfully with the direction of treatment. I love that they zoomed out from that pelvic space and addressed structures that indirectly impact the pelvic floor. And I love that they did attempt an internal exam, but again, didn't find that to be helpful given that the pain was present and the patient needed to stop the exam. I also appreciate that they talked about any previous trauma, as that is extremely important in this case in particular, and that they asked about, hey, are you getting help for this? And yes, the patient is again seeing a trauma therapist. So I'll discuss some of the considerations that I am thinking about, and I wanna talk about some things like working from the outside in, with external manual therapy of the pelvic floor, of the hips, as well as mobility and active strengthening that I would suggest as well, and some thoughts on, hey, what is going on with her nervous system and working together with the trauma therapist. So let's start with the internal external pelvic floor work first. Given that pain was a limiting factor in the internal pelvic floor muscle exam, That's a sign to me that the patient is not currently ready for or would benefit from continued internal exam attempts at this time. As she works with her trauma therapist from the inside out, she can simultaneously work with her physical therapist to treat the outside in. And what do I mean by that? External work on the pelvic floor, that can be simply a visual exam. And the vulva, no palpation, just guiding the individual on how to relax the pelvic floor. This is your pelvic floor. Using mirror feedback or even imagery work, like imagining that she, the patient, is inserting something into the vaginal canal and see if she responds better just from that imagery versus any sort of palpation. And then gentle, moving on towards a gentle external pelvic floor soft tissue mobilization. So techniques like sustained pressure or contract relax on the superficial pelvic floor muscles, like the bulbospongiosis, ischiocavernosis, and near the outer labia, as well as near the perineum. And also tackling the obturator internus, given that it is a hip rotator. So the hip, the obturator internus shares some fascia with the levator ani, and if we can work on the obturator internus externally, then it's very possible that we can just help decrease some of that upregulation in the pelvic floor, no matter where we are tackling the pelvic floor. Another piece is working on hey, can I do some cupping in that posterior pelvic floor region? I've been known to cup that area. And for some of my clients who have just a lot of tension and pain in that pelvic floor region, I will again offload the backside of the pelvic floor. in hopes to also decrease some of that hypertonicity in the anterior side or near that vaginal opening. So I pair the cupping with some child's pose or some quadruped rocking just to get some gentle movement, active movement in as well. And then if there is some progress with those techniques, but then we're running into a roadblock again, and maybe we're still not ready for any sort of internal work, then considering some dry needling plus electrical stimulation, maybe with some neuromodulation to the pelvic floor, and that's gonna directly tap into the cortex, create a nice chemical pump to the pelvic floor, and really help downregulate. Now, if this will work the best, if the patient has really responded well to dry needling in the past and is game to have it done in that region, it can be extremely beneficial. And then after doing all those manual therapy interventions, what are some things that she can do herself? She can do some self palpation externally with diaphragmatic breathing and some pelvic drops or pelvic lengthening to release some of that tension. I want to suggest that she try using her own digit, her own finger, to do some external self palpation. while she gradually moves towards internal insertion of her own digit into the vaginal canal. As this can be often more approachable and less painful for someone who has a history of trauma, for them to do it themselves, rather than inserting something external like a tampon or a dilator, or having someone else do the insertion. This way, if she's using her own finger, then she's remaining in control. Then having the client follow up on self-palpation with the dilator practice. It sounds like this person was already doing some dilator practice. So having her try it in varied positions of comfort, coupled with the diaphragmatic breathing. And then in terms of when someone is ready to trial vaginal insertion, I generally prefer them to be able to insert an object that's the same size or larger to what they're wanting to insert. In this case, having the individual aim for comfortably tolerating a dilator that is the same size or larger than a tampon is a great rule of thumb for test-retest with that tampon insertion. Traditionally, many individuals insert a tampon seated or maybe in a mini squat over the toilet. While this client is building up her confidence in getting those positions and doing this in public, I believe that she can try some more comfortable positions for tampon insertion like semi-reclined, maybe having her legs supported by walls or a pillow in her own home. Again, not traditional, but a great place to start.So attacking the hip from the joint side of things. We can do some manual therapy in the sense of doing some joint mobility. The therapist can do some joint mobilizations. And then that can be followed up by the client getting in some active hip mobility exercises. Gotta love the seated hip 90-90s. or seated banded hip IR and ER, banded hip capsule mobilizations, and I really love the long axis distraction just to get some nice general chemical pumping blood flow to that area to address chemically induced stiffness. Then we have hip mobility via muscle. Given that the adductor's origin is the ischiocubic ramus, I like to say the adductors are the long driveway to the pelvic floor. Dry needling plus e-stem for the adductors to reduce tone and increase blood flow is a beautiful option. Only always follow whatever kind of manual therapy to the adductors with standing banded and loaded lateral lunge sliders, sumo deadlifts or Copenhagen variations. We love the holds for 45 seconds. times five rounds for those Copenhagans, just to really tap into the analgesics from an isometric hold perspective. Also of note, if we're continuing the house analogy, and the adductors are the driveway, I like to think about the abdominals as the chimney. So the abdominals, if they are showing signs of hypertonicity and gripping, then we wanna do some of those same techniques, soft tissue manual therapy, to the abdominals followed by stretching and loading of that area. And then the nervous system, given that the individual has that history of trauma, we have to treat her from a holistic standpoint. Addressing that elevated centrally sensitized nervous system by ramping up the parasympathetic side. So doing vagus nerve stimulation exercises to increase calm, What are those examples of? Having her chew her food at least 10 times. This taps right into the vagus nerve. Humming, gargling, having her do one to three physiologic sighs. And that is two inhales followed by one long exhale. It sounds like this. So making sure that first inhale is longer than the second. or having her create a mantra like, I'm in control of my body right here, right now. Doing any of those vagus nerve stimulation exercises before and during her attempts to insert a finger, a dilator or a tampon in. This is going to really help address that tenacity. And then a time expectation. How long have you been working together? If it's only been a few sessions or if the client has dealt with vaginosis for a long time, rest assured it can take time for that physical side to catch up with the emotional or vice versa. especially given that trauma link and reminding her, hey, progress may not be linear, but here's what you've already improved on and showing her what she's made some progress with in terms of a couple of weeks ago, you weren't even able to have that dilator remain in the vaginal canal. And then I love that she's seeing a trauma therapist. This is so vital in this scenario and asking the patient, hey, can you tell me what you all talk about in your sessions? Or are you okay with me contacting your therapist so that we can do some integrative work? So I can bring in maybe some things that you all are talking about and we can practice that from the physical space. So given I don't have all the details, I'd also be curious of, hey, has she been able to insert a tampon in pain-free previously? And if so, we can lean on those positive instances that she does have the capacity to do so. And then I'd also be curious about some of the previous hip, low back, abdominal surgeries or injuries that she's had. Does she have any associated bowel, bladder? issues, urinary urgency, difficulty completely emptying, as these may be conditions that contribute to that pelvic floor holding tension. And then if she's sexually active, understanding what that means and what that experience is like for her. So hopefully those tips help y'all with the case or if you're someone who has someone like this on your caseload. To summarize, when we're treating someone with vaginismus, we really wanna lean into treating from the outside in, with external pelvic or abdominal or hip manual therapy, whether that's soft tissue, joint mobilization, cupping, dry needling, plus stem, all followed by some active mobility and stretching as well. And know with some of these patients, you may never get to the internal exam, and that is totally okay. The internal pelvic floor exam. Remember, the adductors are the driveway to the pelvic floor. The abdominals are the chimneys, so down-regulating those structures and then eventually loading that is going to be helpful. And then tapping into the nervous system via the vagus nerve just before and during insertion attempts in positions of comfort. Timing can have a huge impact on healing trajectory, and working side-by-side with their mental health or trauma-informed provider to reiterate concepts of the mind and body connection. Okay, so if you all want to learn more about some of those external techniques I was discussing, like the external pelvic floor exam, or if you do want to learn more about the internal exam, our next live courses are Kearney, Missouri, May 18th and 19th, and we have a double hitter of a weekend, June 1st and 2nd, with one course going down in Anchorage, Alaska, and the other in Highland, Michigan. So definitely sign up for those courses, or if you're interested in our online courses, we have two available. Head over to btonice.com and hop in. Thank y'all so much for listening, and I'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.

Apr 19, 2024

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 utilizing hill running as a gait drill for injured runners, explaining the changes in running mechanics between running flat, uphill, and downhill. Megan also explains when and why to recommend uphill or downhill running

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.


MEGAN PEACH
I think both YouTube and Instagram are both live. Miracles. Good morning. Happy Friday. This is your PT on ICE Daily Show, and I'll be your host today. My name is Megan Peach, along with the Institute of Clinical Excellence, bring you this topic today of incorporating hills into your gait retraining toolbox. I am one of the lead faculty for our endurance division here at Institute of Clinical Excellence. and I teach both the live and the online versions of Rehab of the Injured Runner. So I'm super excited about this topic today. Let's get into it. So we have a lot of different tools in our gait retraining toolbox that we might use to keep injured runners running or return injured runners to a running program if they've had to take some time off.

CHANGES IN RUNNING MECHANICS WITH UPHILL RUNNING
One of the tools that we don't often use or that maybe we don't often think about as much of the others like cadence training or forward trunk flexion or maybe quiet running is incorporating hills into their current running program as a gait training tool to keep that injured runner running. And before we talk about specific injuries, I want to talk a little bit about the differences between running mechanics when we're running either uphill or downhill as compared to running over a level surface or a level ground. So when we're running uphill, a couple of things happen in terms of the sagittal plane gait mechanics that are different from running over ground on a level surface. One of those things is that our stride length So the distance from where the foot strikes the ground to a vertical line straight down from the center of mass, that's our stride length, that often will decrease when we are running uphill. And what goes along with that is also an increase in knee flexion at initial contact. So when we're running uphill, our knee flexion tends to be more than when we are running over a level surface. and it tends to be a little bit less in comparison. Also, another change that we typically see is a decrease in the angle of inclination from the foot to the ground when we're running uphill. And so what that means is that, or what that looks like, is that a runner running on a level surface who has a rear foot or a heel strike might look like they have less of a rear foot or a heel strike when they're running uphill. So maybe they look like they have a midfoot strike or they may even have a forefoot strike. It's going to be very, very dependent on the runner and that certainly doesn't happen in every single runner. We don't necessarily see a strike pattern change in every runner when they start to run uphill, but certainly that can happen and it does in many, many runners when we go from running on a level surface to uphill. So that's the third change. And then the other change that we commonly see in that sagittal plane is an increase in forward trunk flexion. So from going from a level surface to running uphill, we will often see that runner shift their trunk forward. And what that does is take a little bit of work off of the knee and transfer it to the hip. And so the glutes end up doing a little bit more work. The quads end up doing a little bit less work when we're running uphill. That has some advantages. but potentially some disadvantages as well, depending on the runner. So then when we talk about running downhill, all of those biomechanics changes that we saw, or that I talked about running uphill, are the opposite when we're running downhill.

CHANGES IN RUNNING MECHANICS WITH DOWNHILL RUNNING
So going from a level surface to running downhill, we often see that stride length increase. And so a runner will go from maybe landing with a little bit of knee flexion to nearly a straight knee at contact when they go from running on a level surface to running downhill. So we also see the knee flexion decrease or the knee extension increase depending on how you want to describe and look at that. What we'll also see is an increase in angle of initial angle of inclination at initial contact at the foot and ankle in relation to the ground. And so somebody who was a midfoot or a heel striker or a rear foot striker running on level surface is just going to shift that impact a little bit more posteriorly toward the heel. And it's going to be relative to how they hit the ground when they are on a level surface. So a midfoot striker may look more like a heel striker, or a rear foot striker may look more like a heel striker, depending on how they started out. Again, not in every single runner, but certainly there is that trend. The other thing we see with running downhill is a change in trunk position. And what we see when they're running downhill is more of an upright trunk posture. And even occasionally, we can see that runner almost lean backwards. And this happens for a couple of reasons. One, they're just trying to maintain their balance. It's a different body position running downhill versus running either uphill or over level ground, and so they're just trying to maintain their balance. And another, they're trying to control their speed. So often when a runner leans forward when they're running downhill, that can almost feel like they're gaining speed and it's a little bit uncontrolled, especially if that runner is more of a novice runner or just not used to running downhill. And so they'll lean back in an effort to just control their position and control their speed when running downhill. that has some obvious disadvantages, as it will increase the load on the knee and the lower extremity and decrease the load on the hip musculature.

UTILIZING UPHILL OR DOWNHILL RUNNING FOR THE INJURED RUNNER
So, in talking about specific injuries and running mechanics in an uphill or downhill, we want to take into consideration where those specific injuries are and what types of tissue we want to offload. So starting with patellofemoral pain, super common running related injury. It's one that a runner can typically continue running through, at least in some capacity, as long as there are some shifts and adjustments in their training program. They may not be able to do the same amount of mileage, but they certainly can, in most cases, continue running. So when we consider offloading the patellofemoral joint, We typically use gait retraining drills like cadence retraining or increasing the step frequency. So we reduce the stride length, increase the knee flexion angle at initial contact. We might also use something like a forward trunk flexion drill to shift that load from the knee more approximately to more of the hip. And those tend to work very, very well for people with patella femoral pain. I personally treat a lot of trail runners and so they're generally not running on a level surface and they're generally running uphill or downhill and that's just the terrain that they're running on. And so often when we're using other drills like cadence or like trunk control, then we're expecting that they're going to run on a level surface. And so if we have a drill like running uphill, they're very, very much appreciative of being able to incorporate their normal terrain into their current running training program while they rehab that injury. And so with runners with patella femoral pain, we will often incorporate running uphill. Now I know it sounds a little bit crazy and runners always give me a little bit of a weird look, but because of the biomechanics that go into running uphill, namely the reduction in stride length, the increase in knee flexion angle at initial contact, and the forward trunk flexion, all take a little bit of that load off of the patellofemoral joint and shift it up the chain, so it shifts to the hip, and they're often able to tolerate running uphill quite well, even in comparison to running over a level surface. It is important that you remind them that they need to walk downhill, and that's really important so that we don't actually increase the load on that patellofemoral joint. Now, when I talk about incorporating uphill running to an injured runners training program, I am not talking about incorporating this giant steep slope that I expect them to run up. I'm talking about a very low grade, like a three percent grade, which is generally what's cited in the literature as something that the authors or the researchers are looking into as does this create biomechanical changes. And even a low grade like 3% is enough to create some of those favorable biomechanic changes that are going to make a difference in that runner's ability to tolerate that running load. And a 3% grade is enough to reduce that patellofemoral joint stress by about 25%, and that's per step. And so when we think about that cumulatively over many, many, potentially thousands of steps, that's a lot of load reduction on a single joint that is going to allow that runner to continue running as they rehab that injured tissue. So moving down the chain and thinking about Achilles tendinopathy, very different injury, obviously, different types of structures, different types of tissue injured. And we think about the biomechanics of hill training. And when we think about biomechanics of running uphill, like I mentioned, we have that reduction in angle of inclination as one hits the ground or as one impacts going uphill. that reduction of angle of inclination or the shift toward landing on a midfoot or a forefoot is going to also result in an increase in load or stress on that posterior lower leg musculature. So the gastroc soleus complex, as well as the Achilles tendon and some of the forefoot structures. And so with an injured runner, with Achilles tendinopathy, they're actually going to accumulate more stress while running uphill than they would running on a level surface or downhill. So much so, in fact, it's about a 25% increase in stress on the Achilles tendon while running uphill as compared to that level ground. And so with a runner with Achilles tendinopathy, we actually want to discourage them from running uphill. We do not want them running uphill. obviously while they're still symptomatic later on in the program. That might be something that we incorporate as they're able to tolerate more and more load, but certainly not while they're still symptomatic. And so when an injured runner with Achilles tendinopathy, we actually want to encourage running downhill because of some of those biomechanical changes, those runners are going to tolerate downhill running much, much better than maybe even overground running. And often in those, Runners with Achilles tendinopathy, they've stopped running for a period of time in an effort to rest the injured tissue and resolve the symptoms, they're not always sure how to get back to running. And so downhill running can be a good start with less load on that injured tissue than overground or level running or uphill running. Certainly we want to incorporate those later on as they tolerate more and more load. Okay, so the last one I want to talk about and It's been 12 minutes already and I haven't talked about bone stress injuries, so it's probably, it's a little unusual, probably a record. I do want to talk about tibial bone stress injuries. And so with bone stress, it's a little different than other types of soft tissue stress because with bone stress, we get stress from a couple of different inputs. One is an external input, meaning the ground reaction forces. Two are the internal inputs, which comes from the muscles that are attached to that specific bone. So in this case of the tibia, the gastroxilia is complex. And both of those external and internal inputs are going to have an effect on the amount of stress that that bone is accumulating. The internal load or the internal stress being much, much more of a contributing factor to bone stress than the external ground reaction forces. Although it does contribute a little, so it still needs to be considered. Okay, so when we run uphill, we know that there is going to be an increased load on that gastrocnemius complex. And so therefore, there's going to be a significantly increased load as well on the tibia because of that internal load from the gastrocnemius complex. When we run downhill, then we see an increase in ground reaction forces, which is also going to increase the load on the tibia. So we can talk about uphill or downhill, but they're both essentially going to increase the load on the tibia specifically. And so while somebody, although they will likely have some time off of running after they've had a diagnosis of a bone stress injury, while they are returning to running, we want them to run on level ground. We do not want them to incorporate any hills up or down early on in their program until we are absolutely sure they are tolerating level ground running without any symptoms or exacerbation of symptoms. And then we can start to incorporate the downhills, which are going to be less problematic and less provocative than the uphills because that internal load with the uphills and the gastroc soleus is going to contribute much more stress and load to that tibial bone than the downhills with the increased ground reaction forces. Okay, so a couple of other things to add. One is that if you are working with novice runners, hills often have to be trained. So they're not intuitive in terms of how we can most efficiently run downhills, uphills a little bit more so, but certainly not downhills. And because of some of those maladaptive mechanics that I talked about with running downhill, specifically like the upright trunk posture and the increase in the stride length or the over striding, those we tend to just do when running downhill if we're not trained how to run downhill. So if it's in your toolbox and you know how to kind of instruct or coach a runner to have better mechanics running downhill, meaning lean into the hill just a little bit. You don't have to have so much forward trunk flexion that it's making you uncomfortable, but lean into it just a little bit, or to maybe just be conscious of not extending the trunk posture or having a very rigid upright trunk posture. And then maintaining the stride length. So trying not to reach out as one goes down can really help to reduce some of that stress on the patella femoral joint, and the lower extremity as well. And so training or coaching a runner to be able to run downhill can also have really positive benefits in their ability to tolerate some of those hills, especially if they either currently are injured or have that running related history, especially if it's something like a patella femoral pain. And then the other thing to mention with using uphill and downhill as gait retraining tools is that The biomechanical changes are not independent of changes in stride frequency or our cadence or changes in speed. And so just like any other gateway training drill that we might use, so cadence for example, it's really, really important that we maintain some of the other variables that go into running. So speed for example if somebody's running on a treadmill and we manipulate their cadence we're really really sure to maintain that speed otherwise we may be changing too much at one time or we may not be getting the desired effect that we want from that gait retraining tool if we are changing more than one variable. So if you are recommending like an uphill run for example try to maintain some of those other variables specifically like stride frequency or cadence and speed. So obviously easier said than done, much easier on a treadmill than it is outdoors like on a trail, but just something to be aware of. Okay, so to recap, running uphill or downhill can be a really effective tool for runners with specific injuries, such as patella femoral pain or Achilles tendinopathy, that we can definitely put into our running gait retraining toolbox. As long as we keep some of those biomechanics in mind, and as long as we understand how uphill or downhill running can shift some of that load from one structure to another, And then also taking into consideration that there are instances when we do want runners to run on a flat surface, for example, in tibial bone stress injuries, when they are returning to run, it's really important to keep them on that flat surface so that they are not inducing excessive stress on that injured or healing tissue.

SUMMARY
All right. So before I let you go today, I do want to mention a couple of upcoming courses. We have, let's see, Rehab of the Injured Runner Online. We are just about to start a new cohort. It is in May, the very beginning of May, so you've got a couple of weeks to sign up, but it's filling up. Sign up now. We have just revamped Rehab of the Injured Runner Online for 2024 and so far it's been really, really fun. We've had a lot of great engagement from current participants and previous participants. in our courses this year. Great questions. It's been really fun so far. So make sure you get into that if that's something you've been meaning to do. We also have Rehab of the Injured Runner live. We have June in Wisconsin and then we have September in Maryland and then Certainly the bike fit course is part of our endurance division and so we have a course this weekend in North Carolina. We've got one in May, mid-May in Minnesota and then up with our friends in Bellingham, Washington in June. All right, so that's it for me today. Hopefully you can add in hill training, uphills and downhills into your toolbox for rehabbing injured runners and just hit the ground running with that and use it right away. That's my goal for you for today. Feel free to ask any questions and hope you have a great Friday. All right, have a great weekend as well.

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.

Apr 18, 2024

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

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses eating disorders & obesity, the relationship between mood & disordered eating, binge eating as the most common form of disordered eating, and the role of the physical therapist in eating disorders.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

ELLEN CSEPE
Good morning everybody and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Ellen Csepe. I'm a teaching assistant with the modern management of the older adult division coming to you live from Littleton, Colorado. I'm an outpatient physical therapist who practices with the same question in mind every day. Why aren't physical therapists more involved in managing one of the most pressing health crises in the world today. Obesity. On today's Leadership Thursday, we're going to discuss eating disorders in those with obesity. To feel complete in our treatment of those with obesity, we have an obligation to understand the link between eating disorders and obesity. This is a very nuanced topic with a lot of viewpoints and a lot of new research, but I want to be respectful of your morning and keep this discussion succinct and have this framework for today. First, we're going to open about how mood disorders and obesity are related. Then we'll talk about the most common eating disorder that affects people with and without obesity. Then we'll talk about our number one job as clinicians to avoid provoking disordered eating and then what we can do pragmatically if we suspect our patient is struggling with an eating disorder. So to open us up, for those of us who have never struggled with an eating disorder or obesity, having an issue with your weight can just seem like a physics equation gone wrong. Too many calories in, not enough calories out equals obesity. But for those who are struggling with their weight, this oversimplified physics equation really overlooks the emotional and mental language that can come with struggling with your weight or your perception of your weight. We see obesity as a complex biopsychosocial chronic disease with this framework in mind that it is anything but simple. And thinking that there's a simple solution and a simple fix can often make this problem worse in treating our patients.

MOOD & OBESITY ARE RELATED
So to start, obesity and mood disorders are related. Obesity and depression frequently occur together and actually there's a bi-directional relationship between mood disorders like depression and obesity. In fact, depression can be a risk factor for obesity and obesity can be a risk factor for depression. This risk and this association is the strongest in women. eating disorders are mental health disorders. The DSM-5 identifies eating disorders as mental illnesses that are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food that significantly impairs physical health or psychosocial functioning. And in fact, eating disorders can be life-threatening and have the highest mortality rate of any mental illness. Eating disorders have their own diagnostic criteria in the DSM-5, and those eating disorders with diagnostic criteria include pica, rumination disorder, ARFID or avoidant restrictive food intake disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. Anecdotally, many clinicians feel apprehensive discussing weight, exercise, and eating habits in part because they're aware that executing these conversations poorly can have adverse impacts on their patients and their mental health. But as clinicians, we have to know the basics of diabetes, cancer, Graves' disease, ALS, MS. And if we feel confident making dietary recommendations to our patients, For things like protein intake, calorie deficits, and reducing added sugar in our diet, we want to at least be aware of the most common eating disorder that will likely impact our patients. So we understand that there's a correlation between mood disorders and obesity.

BINGE EATING AS THE MOST COMMON EATING DISORDER
Now let's talk about the most common eating disorder that we're gonna see in our practice. So binge eating disorder is the most commonly recognized eating disorder among people with and without obesity. So it doesn't matter if you have obesity or not, this is likely going to be the most common eating disorder that a patient will suffer from. So eating disorder, let's understand this a little bit more so that we can really clearly understand what this looks like in our practice. So binge eating disorder is characterized by eating a large amount of food in a short period of time, all while feeling the loss of control during this episode and immense shame and guilt afterwards. So you might be thinking, well, do I have binge eating disorder? I chowed last weekend. There's a difference. Having unhealthy eating habits or chowing or going crazy now and again is not the same thing as an eating disorder. An eating disorder is not a choice. A diet is a choice. You can choose to not be a vegan anymore. You cannot choose to not have an eating disorder. And that's the best way to summarize the differences between diets and eating disorder. But binge eating disorder has some specific characteristics. Eating a large period of food over a short period of time without the feeling of control. Eating faster than normal. Eating until uncomfortably full. Eating large amount of food even when not physically hungry. Eating alone because of embarrassment with how much one is eating. and feeling disgusted with oneself, depressed, or very guilty afterwards. So this is a very common diagnosis that we'll see in the clinic. Other unhealthy weight control behaviors that would be reflective of disordered eating could include vomiting, skipping meals, fasting, laxative or diuretic use, smoking to manage appetite, and consuming stimulants to reduce appetite. So these behaviors aren't the same thing as having an eating disorder, but we should know that these behaviors are rarely successful in managing weight and, more importantly, can lead to depressive symptoms and eating disorders in the future. So we summarized the most common eating disorder that we'll likely see as clinicians. Now let's talk about our number one job.

THE ROLE OF PT: PROVIDE AN ENVIRONMENT FREE OF STIGMA ABOUT WEIGHT
So our number one job as clinicians is to provide an environment for our patients free of weight stigma. For us to be psychologically informed clinicians who want to help those with obesity, We have to be aware of how impactful weight stigma can be on disordered eating. Weight stigma implies that people who struggle with their weight are lazy, less adherent, less motivated, less deserving of empathy, sloppy, mean, have decreased willpower, are unsuccessful, or are otherwise unpleasant. And unfortunately, it's very common among healthcare providers. A recent survey of nurses suggested that 24% of nurses would see people with obesity as repulsive. and that 12% of nurses surveyed didn't want to touch those with obesity. These feelings are not only unhelpful, but they're really hard to hide. If you're repulsed by your patients, it's probably going to show on your face. And actually, a recent 2023 systematic review it'll be in the comments below on this Instagram post, looked at how weight stigma impacted disordered eating. So studies that looked at relationships between disordered eating and internalized weight stigma showed that weight stigma is helpful, unhelpful across the board in managing weight and can actually really commonly provoke disordered eating habits. So the studies reviewed looked at actual experienced weight stigma anticipated weight stigma, so for example, the fear of being judged by others, like if you're going to go out in a bathing suit, having that apprehension that you're going to be judged, and then internalized weight stigma, so the personal belief that you are lazy, unmotivated, have less self-control because of your body habitus. And the systematic review suggested that across the board, experiencing weight stigma made outcomes worse. And in several studies would suggest that experiencing weight stigma from a medical provider immediately caused a binge eating event afterwards. So not only are those weight stigma beliefs that we hold as providers unhelpful, they can make the problem much, much worse and can even cause a binge event for those with binge eating disorder. So I challenge you today to reconsider how you face obesity. If you have biases against those with obesity, I really challenge you to recognize with empathy how hard it is to lose weight and to manage your weight. Recognize that when we lose weight, our bodies fight to get that weight back by changing our hormone levels, our ghrelin levels go up, increasing our hunger, our leptin goes down, decreasing our satiety, and our bodies perpetually try and return to that weight that we lost. It's hard. Our world and our food landscape have changed significantly in the past 50 years. You don't have to grow an Oreo. You could go and buy them from the grocery store, and those are quick, low-nutrient calories that you can access without having to do any physical labor. It is extremely difficult to maintain weight, and those with obesity need our help and support in their journey to manage their health for the long term without judgment or weight stigma from providers. I recognize that obesity is a huge problem that our culture and our entire world face. I know that you likely agree if you're listening to this podcast. Weight issues are hard to manage and where we should start is with empathy and dignity and respect and compassion with those with obesity.

SUMMARY
So we talked about how mood disorders and obesity are related. We talked about the most common eating disorder, binge eating disorder, that affects people with and without obesity. We talked about our number one job as clinicians to make sure that we provide an environment free of weight stigma for our patients. And last, if you suspect that your patient is struggling with an eating disorder like binge eating disorder, we have some options. You can ask, have you ever struggled with an eating disorder? Or do you know if you have an eating disorder? Just as easily as we can acknowledge depression or anxiety on a past medical history form, we can identify eating disorder or disordered eating habits. Within the past 24 hours, a previous patient of mine shared that he had an eating disorder, but is only now getting treatment after years of struggling because nobody asked. So our job as clinicians, if we suspect somebody has an eating disorder, it's totally within our scope to ask. And if they say yes, you can refer them to the National Eating Disorder Association. The link will be below in the comments. Or this is a completely, this is not an ad, but there's an online virtual service called Equip Health that takes major medical insurances and provides mental health therapists, dietician, and medical provider support, as well as mentors who have overcome eating disorders and are there to help your patients. So we have lots of resources. To summarize, mood disorders and obesity are linked and we have to understand that as clinicians. Binge eating disorder is the most common eating disorder that we'll see for those with and without obesity. Our number one job as clinicians is to provide an environment free of weight stigma for our patients. And if you suspect that your patient has an eating disorder, ask and offer pragmatic support with a referral to another dietician or mental health therapist or an online program. Thank you so much guys. I know that we recognize that obesity is a growing problem in our world and you being a part of this podcast and a part of this team really reflects your genuine empathy and caring for those who are struggling. Thank you so much for being here and I hope you have a wonderful rest of your day.

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

 

 

Apr 17, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult division leader Christina Prevett discusses how to incorporate geriatric treatment principles into practice to address pelvic floor concerns with older adults.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on ICE Daily show. My name is Christina Prevett. You saw me on Monday. I am one of your division leads for both the geriatric and the pelvic health division and you guys got stuck with me twice. If you saw the episode on Monday, you can definitely see that my voice is better. So I don't have the same sickness. So hopefully my voice will be a little bit more tolerable for today's podcast. Today we're gonna be talking about how fitness-forward geriatric clinicians do pelvic well. And one of the things that I often will get asked about is, Christina, it seems really weird that you're in both the geriatric space and the pelvic health space speaking to pregnancy and postpartum. How the heck are these two things connected? And they are a lot more similar than you think, especially when it comes to the quality of our care. What I mean by that is that we are not as fitness forward as we need to be in both the geriatric and in the pelvic health spaces. And there is a significant amount of under dosage that happens in both places. And in our older adult course, we talk a lot about this fitness forward mindset and we try and do the ultimate reframe, right? We worry about the cost or risk of loading people and our thoughts are, what is the risk if we don't? And What is the risk if our person gets a little bit weaker or they have an exacerbation of congestive heart failure and now they're five pounds heavier and they were barely getting up from a chair or using their hands when they didn't have that five pounds? We ask, you know, if they have low bone mineral density and we don't give them the resiliency to reactive step when they have a perturbation, what is the risk when they fall of having a fracture versus somebody else? And that reframe is potent, right? Because it eliminates a lot of the fear and it gets us having a sense, or at least it does for me, a sense of urgency with respect to getting individuals moving. When I see individuals in pelvic health, a big part of my clinical practice right now is postmenopausal females. who are struggling with incontinence or other type of pelvic health conditions, and have underlying muscular weakness or muscular reserve issues. And when I step back and I zoom out and I see that the geriatric space, we tend to underdose. In the pelvic health space, we tend to underdose. My goodness, when you slam those two things together, we see that the bias is to keep people on the table doing Kegels, or we don't even offer them pelvic health services because we assume that leaking and incontinence is a part of aging. and it's something that they have to deal with and it's part of being postmenopausal and have had babies 50 years ago and therefore we're not going to address it. Today I want to talk to some of the literature that says that we actually need to prioritize that fitness more. When we look at aging physiology of the reproductive system, we see that as men and women transition through menopause or andropause, right? Menopause blunting of female sex hormones, andro blunting, but not removal of the male sex hormones, AKA testosterone, that we see a rise in pelvic floor dysfunction. For females, there are one in four individuals are struggling with pelvic floor dysfunction that increases with age. For males, significant increases in pelvic floor dysfunction happen because many of our younger or middle-aged men, not all, but the rates of pelvic floor dysfunction are much lower and they start to increase with age, right? So pelvic floor dysfunction is talked about a lot more in the female space because it's more common. It is definitely more common as we get older. And when we are thinking about incontinence, we are thinking about different types, right? We have stress incontinence, that is more of a mechanical issue where inner abdominal pressure in the belly is exceeding the ceiling pressure of our pelvic floor to be able to close our holes, our urethra and our anal sphincter. And if we don't have enough of that capacity to close those sphincters off, then we pee or poop or pass wind when we don't mean to. Urge incontinence is that we get the urge to go to the bathroom and then we don't have the capacity or we have a very sudden behavioral intervention where I have to go to the bathroom and I have to go right now. I get the urge, I can't defer that urge, I have to go right now. That's very largely outside of any pathology in the kidney or the urethra that it's largely we're seeing behavioral issues. The other camp that we need to really speak to in the geriatric space is functional incontinence. So functional incontinence is that individuals are getting the urge to go to the bathroom or when they have to toilet, there is either a functional capacity issue where they physically cannot make it to the bathroom, or there's a cognitive issue where they get the urge, but because of some changes to cognition, They either do not act on that urge or they lack insight to have that toileting behavior. When you are working in acute care, we see a lot of this functional incontinence happen in combination with the burdens on our healthcare system, right? We see that individuals have to go to the bathroom, they're waiting a really long time because of our staff shortages, and then we're giving individuals periwicks or external catheters or internal indwelling catheters to prevent any incontinence issues from happening that are a consequence of them being sick. Okay, so when I think about stress incontinence and functional incontinence with aging, super common, a lot of times this is an issue of muscular reserve. If your body is one rep max living, where the demands of your day are at or exceeding your one rep max, your pelvic floor is a set of muscles that is acting no differently, right? If your entire body is experiencing weakness, then your pelvic floor is experiencing weakness too. And what that means is that yes, we want to be very focused in the pelvic floor. We have excellent evidence for pelvic floor muscle training across the age continuum, including older age. And we have to recognize that by increasing the functional capacity of the system, we are going to improve a person's pelvic floor symptoms, which means that you do not have to be a specialist in pelvic health in order to make a significant contribution to a person's incontinence. And this to me lights my soul on fire because incontinence is one of the leading causes of institutionalization in our older adults. It is one of the main reasons. Urinary incontinence, cognition, mobility disability, right? Those are the top three reasons why individuals can no longer be independent in their home. And when I think about the role of PT and OT, the PT OT dream team and rehab in general, we target two out of three of those issues, right? And every single person can target the urinary incontinence piece. And so the first huge message that I want to have with this podcast is that one, every clinician is a geriatric clinician because we are not going to ignore a group of muscles and just say that this is not our scope and we don't know how to handle it because we know how to work with muscles. Two, if you have a person with frailty or sarcopenia on your caseload, we need to screen for pelvic floor dysfunctions because if we are seeing outputs of weakness in the musculoskeletal system in the person that we are working with, we have a higher likelihood that we are going to see something happen with incontinence. And this is extremely important considering that incontinence is a main reason or a big driver for individuals needing institutionalized care or increased help in the home. decreased likelihood that they can age in place. And then let's talk about how we put this fitness forward pelvic approach in, whether you are a pelvic health clinician or not. Okay, when we look at the evidence of pelvic floor dysfunction in an aging population, there's a couple of things that we see. One is that individuals with higher amounts of sedentary behavior are at increased risk for pelvic floor dysfunction at age match. So when you compare a cohort of individuals at the age of 70 or 75, those that are more sedentary are more likely to have incontinence than those that are not. So by getting individuals moving around more, you are going to reduce their risk for urinary incontinence. That is number one. Number two is that individuals who are physically active have reduced rates of significant pelvic floor dysfunction compared to those that don't. And so individuals over the age of 65 who are more active are less likely to have pelvic floor dysfunction. Speaking to the musculoskeletal reserve component of pelvic floor dysfunction and aging. Number three is that for individuals with pelvic organ prolapse, those that are weaker or more sedentary, have higher amounts of sarcopenia and frailty, are more likely to experience subjective symptoms of prolapse. So subjective symptoms of prolapse are feelings like your bladder is coming out, that you feel like there is a ball in the opening of your vagina, or that there are symptoms of bother as if there is a heaviness or a dragging sensation around your pelvis. And this is one that I wanna kind of focus on. So when it comes to pelvic organ prolapse, the combination of an increase in objective range of motion of the vaginal walls in combination with a subjective complaint of bother is the way that we create the diagnosis for pelvic organ prolapse. Objective range of motion changes to the vagina are a sign of aging, right? So we are going to see an increase in vaginal range of motion. We have wrinkles on our skin. We have wrinkles in our pelvis. That is one of our wrinkles. The subjective signs of bother, though, have a discordance between the amount of range of motion that people see and the subjective reports of symptom thresholds in that person. This is true across the lifespan where some people can have a high amount of range of motion and not experience bother or any symptoms at all can be completely asymptomatic and other individuals can have a little bit of range of motion change and experience a high symptom burden. So that range of motion change is like a disc bulge on an MRI, right? We cannot just hold onto that objective range. We have to do that with subjective complaints. What we are seeing is that those with more weakness have higher rates of bother. And this is where I really want to hit on the fitness forward approach. Because if you are a person who is one rep max living, imagine the strain on your pelvis when you are doing a one rep max lift versus you are doing something that is 10 to 15% effort, right? What are you more likely to do when you're one rep maxing? You're more likely to hold your breath, your inner abdominal pressure in your belly comes out. We see a lot more people who are bearing down or straining when it comes to that activity and that repetitive straining can be a risk factor for subjective complaints of prolapse. So if I have an older adult who is 100 max living, then they are straining with activities of daily living, right? They are straining every time they need to exert themselves around their house, which means that they are more likely to experience some of those subjective complaints of something falling out, right? That is a barrier to us being able to load people. So what the heck do we do about it? First, we acknowledge that that straining can be contributing to how a person is feeling within their body, feeling within their pelvis as they go about their day, okay? That's the first thing. The second thing is that we can acknowledge what our body is supposed to do under strain. A lot of our older adults don't realize that they are pushing down into their pelvis when they are doing strainful tasks. Is that even a word? I don't even know. Straining tasks, I guess, is a better way of saying that, across their day. So the way that I will reduce that strain on their pelvis, if they are experiencing these symptoms, is one, I will get them to acknowledge or understand that the pelvic floor should be contracting, not bearing down on effortful tasks. That might mean that I'm gonna ask them to do a tiny Kegel before they stand up. That means that I may ask them to exhale as they are standing up while we are working on getting them stronger so that we reduce the strain on their system and reduce their bothersome symptoms. And the third thing is that I focus on getting them stronger so that they do not strain their pelvis throughout the day. So if I think about how taxing it is on my body when I'm straining, for a person who has had pelvic floor dysfunction, I have had two vaginal births, I understand what that means, but also a person that has a good musculoskeletal reserve, my older adults are edging into that straining a lot faster. than my individuals without that reduction in deficits. So if you are a person who's working in home health, if you are a person who's working in hospital, if you're a person who's working in long-term care or skilled nursing, they are going to oftentimes be straining down, right? And that's why individuals are farting when they get up from a chair. That is your sign that they are bearing down as they are getting up, which means that they are straining on their pelvis, and that may be a risk factor for their symptoms. add in constipation, which is much more common with our individuals in their 70s and 80s because of a combination of decreased drive for hydration, decreases in gut motility, side effects of their medications, and potentially dietary changes, that constipation that straining, that reduction in musculoskeletal reserve is kind of like this trifecta of risk factors for that pelvic burden. That pelvic burden is a huge barrier to our physical activity, right? 50% of individuals with pelvic floor dysfunction reported as a barrier or a reason to stop being physically active. And so if you are having a person who is resistant, maybe let's ask and really deep dive into why, right? So when we are thinking about our fitness forward geriatric clinicians, where I want to finish off this podcast is know that you are already doing pelvic well. Because if you are getting a person to be less sedentary, get them doing movement snacks throughout the day, if you are encouraging physical activity and exercise in your people, and you are teaching proper movement mechanics, including and avoiding of bearing down, when individuals are doing activities of daily living, you know how to teach the brace, which we get you to do in our MMA live with our plank lab, right? That's the foundations of bracing. You are doing pelvic health well, right? Because we see so many of our older adults are struggling with pelvic floor dysfunction and their musculoskeletal reserve is contributing to that risk. If you are stuck with me for MMA Live, you know I end up on a soapbox about pelvic health because it's so, so important that a deconditioned person is a deconditioned pelvic floor and our older adults do not get the care that they need in conservative management of a muscle group that is absolutely within our wheelhouse. And that is also why if you are in MMA level two, we do an entire week on conservative management for the non-internal pelvic floor physical therapist on pelvic floor dysfunction, because it is a huge part and it is not just do Kegels. It is so much more than that. And everybody who is listening to this can get on board and be positively contributing to some of the improvement of those symptoms. And when I think last kind of point to make with saying that you are all doing pelvic well, is that by adding in the screens, increasing the muscular reserve of the system, and speaking a little bit to straining and breathing, I clear up so much pelvic floor dysfunction almost immediately in my practice. It's like my geriatric PT magic trick, right? If I have a person who is having wind or anal incontinence every time they sit up from a chair because their abs are too weak and they're bearing down and holding their breath every time they sit up from a reclined position, then When I teach them to breathe out as they do that, tell them not to bear down and get their abs a little bit stronger, it clears it up almost every time. And it's embarrassing for people, right? They don't want to engage in certain activities because they're afraid, or they pretend that it doesn't happen because it happens to them so often that they just don't acknowledge it anymore, even if they feel it. Oh my gosh, 20 minutes in. Gosh, sorry, Alan. So if you wanna learn and get the rants on the reproductive system, make sure to jump into MMA Live. We are this weekend up in Hendersonville, Tennessee. Julie's up there in Hendersonville and Dustin is in Aspinwall, Pennsylvania. We are going to have incredible groups. They're looking pretty good. The next courses for MMA, because we have sampler, and we have a long weekend. I am up in Bismarck, North Dakota, the 18th, 19th of May, and Jeff Musgrave is in Richmond, Virginia, same weekend. So you either have the chance this weekend to get into MMOA Live or middle of May is your next opportunities. And if you really want to hear me rant and rave about pelvic floor dysfunction, you guys have made it to the end of this podcast. Our level two is starting middle of May, but today's April, I'm losing track of time. And the level one is our prerequisite for that. We are going all the way to the ICE app for all of our MMA courses, starting our next cohort. We are super excited about that. And let me know if you guys have any other questions, because I love blending the Jerry and pelvic worlds together. Thank you so much, Andrea. All right, have a great day, everyone, and we will talk to you all soon.

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

Apr 16, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Lindsey Hughey reviews the anatomy of the latissimus dorsi muscle, its relevance to overhead movement, and discusses two ways to begin to improve long-term functional mobility. Lindsey also provides a rehabilitation every minute on the minute (rEMOM) program to begin to use for an HEP for patients who need to improve their own lat mobility.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PTonICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane, or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

LINDSEY HUGHEY
PT on Ice daily show. How are you? I am Dr. Lindsay Hughey from our extremity division, here with you today on a clinical Tuesday to share some pearls of how we'll get after our LAT mobility. So I first wanna just briefly unpack the function of the LAT, so a little anatomy review, and then I wanna discuss two ways to really get after mobility access, demo those two ways, and then suggest them in a rehab EMOM sequence for you all, so you can directly use it yourselves, or use it with your patients in the clinic. A lot of our overhead athletes, our weightlifters, our crossfitters, maybe even just our stiff shoulders need more access to lat mobility.

REVIEW OF THE LATS
So let's first just review what is the lat and where is it? Well, the latissimus dorsi is responsible for internal rotation of the arm, arm adduction, arm extension, and it even assists in respiration. in both inhalation and exhalation. It spans quite a big area of our extrinsic superficial back muscles. So we have a vertebral part that goes from our spinous processes and converges into the thoracolumbar fascia, goes all the way down to our iliac crest. There are even connections into that inferior angle of the scapula, and then even 9 through 12 ribs. So it spans quite a bit of area. The reason we review all of those areas is when you're doing your mobility work, you really want to make sure you hit all of those and make sure to challenge them.

TWO WAYS TO ADDRESS LAT MOBILITY
So I'm going to show you how we can do two versions, a way where we fix the arms overhead and move the body away to traction the lats from below. And then I'm going to review how you can fix from below and then move lats from above. What we won't do this morning, though, is just a static hold stretch. So before I review these two with you, I want you to know that purposely these two moves are so effective because in the first we're going to use a hold relax technique. So we're going to actually use isometric contraction, hold, and then lengthen tissue longer. And what we see with our ISOs, as long as you hold it at least six to seven seconds, I'm gonna make you all push to 10, but we see this increase in neural drive and we get those Golgi tendon organs to chill out and make that agonist, the deltoid relax so that we can actually gain more lat access. The second exercise, we're gonna actually go after eccentric training. So the reason we choose eccentrics as we see constant and ongoing research links to improve strength and length and even greater cortical excitability when we train in eccentric fashion versus just like a static hold or even doing concentric work for our lats. So without further ado, let me show you these two exercises. So number one, we're going to fix from above by putting our elbows on a surface. I'm going to show you on a bench here today, but it could be a bar. It could be a foam roller, whatever feels good for your body. It could even be the counter or a wall surface. So we're going to put our elbows in like a goalpost position, and then we're going to fix our arms here. And we're going to lean our hips back, but we're going to actively contract our arms down for a hold of 10 seconds, then relax and push our hips away. So we get this tractional effect from below. So it'll look like this. So elbows down, and we're going to push into the object while we push our head down. And we're going to push down for 10 seconds. and then access greater length. So you'll notice that I push my hips back and away as I gain access to new length, but that key piece is activate for 10 seconds into the surface, pushing down, and then move away. To fully maximize this particular movement, we're also going to tie our breath work, because remember I said function of lats is helpful in inhalation and exhalation, And then we have links directly to those ribs. So we're going to pair our breath with this. So we'll do it one more time, but this time we're going to link that isometric hold with an inhalation. And then on our exhalation, we're going to move away. So it looks like so we're going to go hold for 10 seconds, pushing down and then exhale and push the body away. And then we would do another rep pushing down 10 seconds. Inhale. And then exhale. For those that are just listening to this this morning, I do suggest watching the video so you get the visual. But we would repeat that for at least five to six reps. I'm going to show you how we'll do that in a rehab EMOM. But we really want to get at least a six to seven second hold of that isometric where we're pushing down before we lengthen. The key parts here being tie breathwork with it. And then don't forget to access more length and maintain it. So that next isometric hold where you're pushing down in the hold relax sequence should be in that newer length. The second exercise we are going to review today is eccentric training. So we are going, I'm going to lay in either hook lying position or you can put your legs up to put further tension on the thoracolumbar fascia. My palms are going to face toward the ceiling and I'm going to slowly lower a bar. Right now I just have a PVC pipe with a plate on it and I'm going to slowly lower eccentrically. I want the slowly lower to be three to four seconds and then a hold for three seconds at the bottom. And you'll repeat this with a goal of eight to 20 reps or what in extremity management we would call our rehab dose. Keys being that eccentric slowly lowering on the way down and the hold at the bottom. So we want about three to four seconds in each of those parts. Don't care as much about that concentric raising portion. Appreciate this eccentric could be done with dumbbells as well or kettlebells. I love starting with a PVC pipe and just a five pound change plate for those that are new to lat access. So we have two things that we've reviewed so far. We are going to do Number one, our ISO hold, where we get into a position where our lats are on tension and you push and drive the elbows down for 10 seconds. And then after that 10 seconds of inhalation and pushing down, you'll exhale and lengthen those lats into a new mobility access area. The second one is that eccentric overhead with the either Dow or PVC pipe and weight. Just these two things done.

MAKE MOBILITY EFFICIENT: THE rEMOM
So if you do each of these for a minute and you do three rounds, you have yourself a very efficient six minute rehab EMOM to attack lap mobility access. Nothing gets more bang for the buck when you combine both of these and you'll get relaxation. Start subbing your static hold stretches that either you're doing or that you're doing for your patients and really get the neuromuscular system on board to see change more rapidly. From a frequency perspective, at least two to three days a week is something I would recommend for my patients to get after and even using it as like a precursor before they do some overhead work because we know what will solidify this even more is then to actually load it and do some functional meaningful thing.

SUMMARY
If you want to learn more about how to even test if your patient has lat mobility tightness, if you want to dive a little bit more into dosage and the rationale behind eccentrics and why we don't use static stretches in our course at extremity management, Mark, Cody, and I and our extremity team would love to see you on the road. Um, and literally we have courses all throughout this year, almost every month in May, May 18th, 19th, I'll be in Bellingham, Washington, and our director of marketing say will be with me. So if you want to join us, that is sure to be a blast. And then June 1st and 2nd, we have two offerings, one in Wisconsin and then one in Texas. So check us out on ptlnice.com. if you want to learn more about how we think and treat the lats. Thanks for tuning in with me today. And if you're listening, be sure to watch the video later. Take care, 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 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.

Apr 15, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic division leader Christina Prevett discusses the role of physical therapy in the male fertility space.

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code ICEPT1MO at the time of sign up for a one month free grace period on your new Jane account.

CHRISTINA PREVETT
Hello everybody and welcome to the PT on Ice daily show. My name is Christina Prevett. I am one of our lead faculty in both our pelvic health and our older adult division. I'm going to apologize in advance if I sound a little hoarse. I am not feeling well, but that doesn't mean that we aren't going to be able to have an incredible episode here on the podcast. So today I wanted to dive in a little bit on male fertility. So last podcast episode that I did several weeks ago, I was talking about our role as physical therapists or individuals in the rehab space in fertility. That conversation circled very much around female fertility and around ethical considerations for fertility. We're gonna continue that conversation. We are gonna launch off of that conversation into our male fertility and male fertility related factors. So I feel like when we are talking about individuals who are struggling with fertility related concerns, a lot of our conversation centers around the female pelvis. And that makes a lot of sense because individuals who are struggling with fertility, it's oftentimes, we are hearing about assisted reproductive technologies like IVF and IUI that are largely interventions that are done for females. And so if couples are dealing with infertility, the female is oftentimes doing different interventions to allow for more successful rates of conception or implantation in the uterus based on a variety of factors. What I think is important for us to recognize, though, is that 30 to 50% of couples who are going through infertility have male-related infertility factors. Let me repeat, between 30 and 50% of couples seeking help for fertility-related concerns have a male-related factor in their journey. And I think this is really relevant for us to be starting to have conversations about because so much of our education has focused on the female pelvis and our males really don't know a lot of things that relate to their fertility. So there was a cross-sectional survey that was published asking males of reproductive age about their fertility. 55% of them, 54% could not identify factors that positively influenced male fertility. So we have a role to play sometimes when we are working with individuals. This is probably not an area of practice where individuals are going to be all of the time marketing their services in male fertility, but I think it's important that we talk about the male aspect of infertility as well. When we are talking about male related concerns, we have sexual response concerns and then we have sperm related concerns. When it comes to the sexual response related concern is that in order for conception to happen, an erection has to be able to be developed and maintained in order for that erection to lead to ejaculation in order for sperm to meet the egg. That sexual response needs to happen. If you are struggling with erectile dysfunction, if you are struggling with pain with ejaculation or testicular pain with sexual activity, those are going to be big barriers to a person being able to successfully have penetrative intercourse. We have a huge role to play in helping with erectile dysfunction and with individuals who are experiencing pain. And in our level two course, we go into a lot of these pain syndromes that focus around the male pelvis. And so the first thing is clearing some of those conditions. Secondly is we talk a lot about the sexual response being not just a mechanical property where you want to have sex, you get that sex response, and ejaculation occurs. There are a lot of bio-psychosocial factors that go into a person's sexual desire, their libido, and issues related to their want for that type of intimacy. We have a book called Come As You Are that is focused on the female pelvis and the female sexual response, but we don't have as many of the same type of resources for males who are struggling with the same thing, right? Like if you are really stressed out, if you are not sleeping well, new parents who are like in the thick of postpartum, that doesn't just affect are females, that can affect our males as well. If they are struggling with mood disorders like depression or anxiety, that can have huge side effects on their libido and their desire for sexual activity. If they are on certain medications, it can have influences on their sexual desire. And so having conversations about the biopsychosocial factors of the sexual response are also important. So when we are thinking about the bucket of sexual response for males, our role comes into helping individuals with erectile dysfunction, if that's something that we have cleared that may be in our wheelhouse around hypertonicities or different type of pelvic pain issues that are leading to that response. A lot of erectile dysfunction is a vascular response and individuals with erectile dysfunction are at higher risk for cardiovascular disease. So there's a health promotion component there. And then we're also going to have a lot of education around libido. If it is the physical act of penetrative intercourse that is a stumbling block for a couple who is dealing with infertility. We see this all the time in our female pelvis with those with vestibulodynia or other dyspareunias or pelvic pain syndromes. This can also be true for our male pelvis, which can create a barrier for individuals being able to have sex at the right time. Okay, so that's kind of our male response piece. The second is on the sperm itself. And so when we are thinking about the male sperm meeting in the fallopian tube and being able to successfully have a conception moment that happens, we have to think that there has to be enough sperm and the sperm has to have good motility or movement, which is related to its shape in order for it to make the long road to the fallopian tube. I mentioned in my female fertility podcast that it's interesting with some of our health promotion because female pelvises have all of the eggs that they are going to have in their entire life by the time they are born. They do not develop more eggs. Eggs mature across cycles. That is not true for the male side of the physiology. For females, that means that health promotion is related to their entire lifespan. For males, that is 74 days. So the maturation cycle of the sperm is 74 days. What that means is the acts that you take, the health promotion incidences that you take when you are trying to conceive, what is really important is those 74 days are approximately three months prior to conception. So if you are a couple who is trying to conceive, your health promotion factors for the male in the three months prior to trying to conceive matter, okay? They matter. So when it comes to our sperm volume and motility, what we are seeing is that there is a large influence on motility for reactive oxygen species and low-grade inflammation. And you all are probably thinking, well, that's good news because that means that our health promotion factors are going to be very relevant in male fertility. And you would be correct. OK, so when we're looking at the magnitude of improvement in fertility for those that start taking on more lifestyle related factors, health promoting factors, it is significantly more beneficial for men who are trying to get pregnant or get their partner pregnant than it is for females because females it's the accumulated reactive oxygen species of their entire life up to this point where it's still going to be beneficial but the magnitude is not going to be the same as the 74 day cycle of the male sperm. What that means is that we have several modifiable risk factors that we can be educating on when it comes to our fertility. So heat stress, use of a sauna, is one modifiable factor that seems to degrade sperm quality. Another one is alcohol use. Alcohol use can negatively impact sperm and sperm-related factors, and it should be avoided or minimized for individuals, for the male partner, for the female partner too, but specific to the male when we are trying to conceive. Steroid use and use of testosterone replacement therapy is a big cause of male-related infertility. It is not everybody who is on TRT, but in our male pelvis, right, the exogenous hormones shut down some of our spermogenesis type of physiological pathways and our body or the male body isn't producing sperm because there is an exogenous hormone that is coming in that says we're good. Okay, we're good. So individuals who are on exogenous steroids, so this is kind of our athletes. Pardon me, sorry. They're on TRT. We're seeing a lot of individuals who are topping up their T to be on the higher end of physiological normal. That may be a big contributing factor for them for their infertility. So asking about any supplements or any medical interventions that individuals are doing to top up their testosterone is a big factor. Smoking is another male related factor that can influence fertility. Smoking creates an increase in reactive oxygen species. creates chronic low-grade inflammation, this makes a lot of sense. The other one is obesity. Adipose tissue is low-grade inflammation tissue and can contribute to the burden of low-grade inflammation on the body. So a lot of these like heat stress saunas, alcohol use, TRT, smoking, and obesity are things that we can counsel on. Another very big influencing factor is a person's exercise. So sedentary behavior is linked to lower fertility rates and those who are physically active in the three months leading up to their fertility journey, starting, trying to conceive, have a higher rate of fertility. So the influence here though is a little bit nuanced from what we're seeing in the literature. So individuals who are active going into their conception journey. It doesn't seem for those who are not struggling with infertility to influence how fast a person gets pregnant, but it influences if there is going to be a male factor fertility issue. That makes a lot of sense because it's two people, right? We're going to only be able to optimize the person that we are working with. being physically active, going into your conception is a good thing to do. Especially most of our evidence, you guys are not surprised based on where my research is, like a lot of this is in aerobics, so we're trying to build up some of our resistance training literature. So being physically active, being less sedentary is good. The only flip side of that is for individuals who are really active. Okay, so for our highly, highly active, especially endurance, especially cyclists. Okay, so when we are working with individuals who are very highly active, especially our endurance trained individuals, we are seeing an influence on sperm motility for those who are cycling for more than five hours. And what that is, is the closeness of the testicles to the body when you're on a bike that is putting the seat close to the body, because the heat can influence the sperm and sperm quality. It's also some of the impact, mechanical impacts of the bike seat. We see that there are higher rates of erectile dysfunction and pudendal neuralgia, which can influence sexual response in our high-level cyclists. And we are recognizing that individuals who are in the endurance space, our male endurance athletes, are at risk for RITS, relative energy deficiency in sport. Our female athletes are much more sensitive to underfueling and that low fuel and energy availability and its impact on their physiology, but our males are not immune. And our endurance male athletes, in particular, appear to have a higher incidence of underfueling than we are recognizing. And so Exercise in general is very good for fertility. For those who are on the very high volume side of the spectrum, we may be counseling on type of exercise, fueling, and volume, and clearing for any types of sexual dysfunctions that may influence a person's conception.

SUMMARY
All right, I hope you found that helpful. I found this literature to be so fascinating. When I think about fertility and the male cycle, I just kept thinking, this really feels like a vital sign for health for our males, right? Like when I'm thinking about the sperm quality, reactive oxygen species load, like it almost feels like an HPA1C for health of the entire body. We use HbA1c to get a good idea of blood sugar responses over the last three months. We can get almost like an inflammatory load response for males in the previous 74 days with sperm analysis. Now, we're not going to go and get pupils to have a sperm analysis every couple of months to take a look at their health, but I think it is fascinating to see how sperm-related parameters can really give us some insights into the overall health of the male that we're working with. All right, if you are interested in learning all things about fertility, we dive into fertility management in our level two course across a variety of weeks. So we talk about fertility and influences for fertility. We talk about fertility related conditions that lead to infertility, and we talk about assisted reproductive technologies and the influence of different fitness forward modalities on ART technology. So if you are interested, our next level two, you have had to have taken our level one online course to get into that is in August. I have just been in Texas last weekend. It was so fun. You guys were so great. I'm so thankful for you all. Around learning about all things pelvic this weekend if you were looking to get into our live course Our next course is May 18th 19th in Kearney, Missouri Then I'm gonna be in Highland, Michigan June 1st and 2nd Alexis is gonna be up in Anchorage, Alaska and then June 8th 9th. I have a back-to-back I'm in Mineola, New York. So I'm at Garden City CrossFit close to New York City and I would love to hang out with you guys. We had so much fun at dinner. We were talking all things Pelvic health and we just had a great time. So if you're interested in any of those courses

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.

Apr 12, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete Division Leader Alan Fredendall discusses incidence of knee injury in functional fitness, common types of knee injuries seen in this space, and how to begin to treat knee pain for the fitness athlete.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

 

ALAN FREDENDALL
All right. Good morning, everybody. Good morning, Instagram. Good morning, YouTube. Good morning to those of you on the podcast. Welcome to the PT on ICE Daily Show. I hope your Friday morning is off to a great start. My name is Alan. Happy to be your host today. Currently have the pleasure of serving as the Chief Operating Officer here at ICE and our division leader in the fitness athlete division and practice management divisions. It is Fitness Athlete Friday. We would say that means it's the best darn day of the week. And here on Fitness Athlete Friday, we talk all things for folks who are recreationally active. So those patients and athletes active in CrossFit, functional fitness, running, endurance sports, whatever, that person who is getting up every day and getting in their daily movement, we're here to help you help them. So today we're going to be talking about knee pain in the fitness athlete. And in the context of today, we're going to be talking about specifically those folks who are probably squatting on a regular basis. So CrossFit and functional fitness athletes, folks who are maybe squatting, squatting heavier, higher volume on a more frequent basis than maybe some of our endurance athletes.

INCIDENCE & TYPES OF KNEE INJURIES IN FUNCTIONAL FITNESS
So I want to talk about what types of injuries do we see in the knee in this space, describe a little bit about those injuries, and then discuss the beginning stage of how to begin to treat some of those conditions. So first things first, What do we see with knee pain in the fitness athlete population in general? The great news is over the past decade or so, we have got a lot of great high-quality research out of the CrossFit and functional fitness space about what regions of the body are injured most frequently, and then kind of what conditions follow those injury diagnoses. So we should know that in the fitness athlete, we primarily see shoulder as the most injured region. About 45% of injuries are from the shoulder. Really close behind that is the low back about 35% and then really musculoskeletal injury kind of falls off after shoulder and low back. Specifically today talking about the knee we see about 15% of injuries are related to the knee. Beyond that we have elbow, wrist and hand, ankle and foot, that sort of thing. So primarily shoulder and low back and then a real sprinkle of the knee. With those knee injuries, we're not seeing really major traumatic injuries. It's very rare, probably never in your gym, anecdotally, have you seen somebody fracture their leg, fracture their patella, tear their ACL, get hit by a vehicle, fall off a thing. That usually doesn't happen in the space of the gym. Primarily what we see in the fitness athlete population, folks who are doing a lot of impact, a lot of squatting, is that we see a lot of patellar tendinopathy and we see a lot of what we maybe would describe as a meniscus issue but really something that we could just generalize as medial knee pain. So now breaking down those two major conditions patellar tendinopathy and meniscus or medial knee pain first things first I would tell you if you haven't yet taken our extremity management course with Lindsay Huey, Mark Gallant or Cody Gingrich I would recommend you get to that course as soon as possible. That course is a really great complement to our fitness athlete courses as far as being able to recognize and diagnose and stage a tendinopathy, diagnose an extremity condition, but also treat it and learn a lot of progressions and regressions to treat those injuries. Specifically, they spend a lot of time the entire afternoon on Saturday addressing the knee in a lot of detail. So make sure you're really comfortable with these conditions. if you hear words like patellar tendinopathy or meniscal care and you think, quad sets? I don't know.

PATELLAR TENDINOPATHY & MENISCAL CONDITIONS
So talking about patellar tendinopathy, what do we know in overuse condition? who is that person in the gym that we maybe need to be aware of, or questions in our subjective exam with that person that would let us know this person may be in that bucket. Somebody brand new to squatting, think of somebody in their 40s or 50s, sedentary, maybe their entire life, that's not out of the realm of possibility these days, who is now jumping into CrossFit, jumping into Orange Theory, jumping into F45, being expected to squat at higher volume and higher loads than obviously they ever have in their life. Folks who maybe are not new to this space but are maybe incurring and encountering a higher level of squatting volume than normal may also fall into this bucket. There are also movement patterns that tend to show up in these folks. I like to stage these as two different movement patterns. The first is what I'll call the close enough squat depth pattern, right? That person who is getting to maybe just above or just at parallel. what do we know about that range of motion in the squat we actually know that's when force on the knee is at its highest that above that point at about 45 to 60 degrees or less of knee flexion and then below 90 degrees of knee flexion we know we have a deloading effect at the knee so those folks who are trying to squat to full depth but are in just that close enough bucket are putting a lot of mechanical force on their knee that they could get rid of if they either squatted more shallow, which is not ideal, or ideally squatted a little bit deeper. The second group of movement pattern folks who fall into overloading their knee is that back and down squat pattern person. So that person who does not break at the hips and knees at the same time. So as we instruct the squat, we like to tell people, imagine there's a rope around your hips and your knees and they're pulling in opposite directions at the same time. That means your hips should flex and your knees should flex. And ideally with a relatively vertical torso, you sit down, sit straight down into that squat pattern. The down and back folks tend to initiate their squat with a hinge, and then to get to depth at the last moment, bottom out that squat and drive all of that force into the anterior knee to hit depth. This is kind of how powerlifters tend to squat, especially with a low bar back squat. But folks who just have not grooved out the motor pattern of the squat yet, when they hinge back and then sit down to finish the depth, the knee again is taking up a lot of force that really we could clean up with some coaching and cueing, right? Maybe we could elevate that person's heels, give them a corrective to hold a plate in front of them, but otherwise encourage a more vertical torso and a more sit straight down squat pattern that distributes force equally between the hips, knees and ankles in their squat pattern instead of at the moment of truth, putting all the force in the knee as they try to hit depth. So that's the patellar tendinopathy bucket. What about the meniscus, the medial knee pain bucket? These are folks who are encountering a lot of impact in rotation. So we do see this a lot in the functional fitness space, right? We do running. We might not go run marathons, but we do a lot of workouts with 200, 400, 800 meter runs. We do a lot of box jumping to train triple extension. We do a lot of double unders for model structural cardio work. And we have begun to introduce shuttle runs, at least in the CrossFit space, to be able to run indoors during the winter in a competition environment where maybe we don't have access to run outside or we don't have the treadmills to be able to run inside on a machine. With shuttle runs comes not only the impact of running, but now a turning rotation moment. not too dissimilar from catching a box jump in the bottom of your squat with your double unders or with running in general. Also in this group are folks who might be new to squatting full depth or otherwise increasing their squat volume, right? No different than the patellar tendinopathy bucket that they are now encountering extra volume. So understanding who that person is is really important and that's where knowing that this person is a functional fitness athlete knowing if they are new to this or not, if they're returning after a break, if they've never done something like this in their life. Uncovering all of that in the subjective history is really important because it's going to give you a better idea of where your treatment might take you.

TREATING KNEE PAIN IN THE FITNESS ATHLETE
So let's talk about that treatment. What should be our priorities in treatment? With our functional fitness athletes, we're demanding full range of motion at every joint whenever possible. That means one of our primary goals should be if we find an asymmetry, a lack of range of motion, particularly in knee extension and knee flexion, we need to restore that as soon as possible. Again, I'll point you towards our extremity management course. I'll point you towards our fitness athlete live course to learn techniques to self-mobilize to load to restore that full range of motion. But as we're restoring that full range of motion, respecting the irritability of the patient, we need to begin to strengthen in whatever available range of motion we have. These folks do not need more volume, right? They're coming to you with an overuse, a repetitive use injury already. Giving them a 20-minute AMRAP or a 30-minute AMRAP and having them do hundreds of squats or lunges in the scope of their PT session is just adding insult to injury, especially if we are thinking that this is a patellar tendinopathy case, for example. These folks need strength, they need capacity and resilience in those structures, so that they can continue to not only stay in the gym, but perform in the gym, ideally, beyond the point at which they got injured, right? We don't wanna just return somebody to the exact moment at which they got injured. Ideally, once we clear them fully, hey, you don't need to do your PT exercises anymore, they are a stronger person than when they first began rehab with us. So we need to strengthen that full range of motion of the whole knee. Now PT school has closely associated in our brains that the knee means quadriceps and that's it, right? It's all over the research. It's all over knee extension machines and really, really focused on making sure that we have really, really strong quads, which is not a bad place to start, especially if that person is missing some knee extension, right? Some, some traction banded straight leg raises can do a lot to both begin to restrengthen quadriceps, but also restore knee extension. but we can't just stop at the quadriceps. We need to strengthen the whole knee, right? All four muscle groups of the leg that attach to the knee. So we also need to make sure we're targeting our hip abductors, our hip AD ductors. We need to target, yes, the quadriceps, but we also, especially if we're thinking this is a rotational-based injury, if we are thinking this is medial knee pain, call it meniscus, call it whatever, we really need to focus on the hamstrings because why hamstrings flexed and rotate the knee. They are pulling the knee into medial or lateral rotation in a movement like running. Ideally, hopefully, they're firing pretty much in sync so that we don't have a lot of rotation in our knee. We're primarily going through flexion extension, but our knee does have the capacity to rotate, obviously, and it's primarily driven by our hamstrings pulling the knee into flexion and in rotation. What is the problem with hamstring strengthening? The problem with hamstring strengthening is that in most functional fitness environments, we don't primarily isolate and train the hamstring. We certainly do a lot of deadlifts, we do a lot of kettlebell swings, that sort of thing, but if you think about the range of motion from the knee and the hip in motions like deadlift, kettlebell swing, it is not full range of motion of the hip and or knee, which means we're not strengthening the hamstring through its full range of motion. Yes, you'll feel a little maybe glute, high hamstring burn on high volume deadlifts or kettlebell swings, but you are not getting that deep behind the knee stimulus that you are with things like Nordic curls or even just isolated knee flexion on a knee flexion machine or banded knee flexion or anything like that. So understanding that the hamstrings flex and rotate the knee is really important to kind of finishing the drill on a really comprehensive knee strengthening program. Understanding that biceps femoris is responsible for knee flexion, but also yes, lateral knee rotation, and that semimembranosus and tendinosis are responsible for flexion and medial knee rotation. So particularly with those medial knee pain bucket folks, we wanna get into semimembranosus, semitendinosus, maybe with our hands, with needles, with cups, whatever, try to restore both that flexion and rotary component of the knee, and then get out in the gym and really strengthen those hamstrings on top of, yes, the quadriceps, the hip abductors, and the hip adductors.

TIME UNDER TENSION IS KEY
The key with strengthening the knee, again, is time under tension. The folks you're working with are already doing higher volume, higher repetition, relatively moderate to higher load training for the knee in a Metcon style workout. So adding in more air squats at high volume or light wall balls or thrusters or goblet squats is really just doing the same thing that they're already doing in the gym, which led them to be sitting on your table in the first place. So just giving them more of that isn't necessarily a prescription. When we have students at Health HQ, they're so excited to have people out in the gym moving, folks who are interested in taking care of their health and fitness, and they love to jump up to that whiteboard and write out, Remom 24, Amrap 30. We have to go, wait, stop, stop. That's not appropriate for this patient, right? This patient is already dealing with the consequences of too much volume. We need to back their volume down, especially in physical therapy, and focus on time and attention. So be careful that we're not actually exacerbating or at least prolonging the healing time of that patient's condition because our volume in PT, our volume for our home program is too high. Slow it down, less reps, less sets, more time under tension. Depending on the patient's irritability will let you determine how much tension you can apply both in the clinic, in the gym, and for homework. When someone's really irritable, I'm thinking maybe isometrics, and I'm thinking something like a reverse Tabata. 8 rounds, 10 seconds of work, 20 seconds of rest. There are apps out there. I personally like GymNext. It is a timer. It has a Tabata built in, EMOM, AMRAP for time built in. It can connect to a Bluetooth clock that the company sells, but you can also just use it as a standalone app and play it through a Bluetooth speaker or just through your phone speaker for your patient to hear. So reverse Tabata, eight rounds, 10 seconds of work, 20 seconds of rest, that gets us 80 seconds time under tension. That's a pretty good start, especially if we're doing it isometrically and the patient is really, really, really irritable. Now, as symptoms calm down, as function begins to improve, as tolerance to loading begins to improve, we want to increase that time under tension dose, especially if we're convinced that this is a tendinopathy based condition. So I like to move next to 10 sets of 10 seconds of work. I'll usually do 10 seconds on, 20 to 30 seconds off for 10 sets. That bumps the needle about 20%. That gets me 100 seconds time under tension. Then, when that patient appears ready, we'll probably progress to a Tabata. That's 160 seconds, right? It's the opposite of a reverse Tabata, a full Tabata. 8 rounds, 20 seconds of work. 10 seconds of rest. So the inverse of a reverse that gives us 160 seconds. So now we're close to pushing three minutes time under tension through that structure. At this point, you're probably away from isometric exercise, but if you're not great, keep rocking the isometric exercise for more attention. And then really for me, kind of the hallmark that someone is getting close to the end of their plan of care is when we can do isotonic movement, we can do five sets of five, and we can do some really gnarly tempo right think about a slant board goblet squat right so he was really elevated a lot of focus on tension through that anterior knee and that medial knee structure three seconds down hold the bottom and as deep of a squat as you can show me three seconds and then three seconds standing concentrically out of that squat. That's nine seconds per rep, five reps per set, five sets. That gives us 45 seconds time under tension per set. That gives us 225 seconds across the five sets. That is what the tendinopathy research tells us we need to be hitting as a benchmark for our time under tension. So understanding, depending on that patient's irritability, depending on how long this condition has been going on, that person may not be able to walk into the clinic and do a slant board, heels elevated, goblet squat, five sets of five at 3-3-3-1 tempo. That might be a lot, right? Certainly probably going to make them sore, but it might aggravate their condition. So understand how we can regress and progress, time and retention is needed. And then make sure as well that we're doing that for every structure of the knee. Again, that we're hitting the medial knee, the lateral knee, the anterior knee and the posterior knee, particularly doing things for the hamstrings like Nordic curls, curls on the rower, furniture slide curls, anything to really target the hamstrings as they insert at the knee as they flex and rotate the knee. and not just strengthening mid-range of the hamstrings and mid-range of the quadriceps.

SUMMARY
So knee pain in the fitness athlete. How frequent? About 15% of all injuries, so relatively low compared to all the other injuries that this population encounters. Primarily, folks, patellar tendinopathy, meniscus, medial knee. Why? Overuse, either a sudden spike in volume from a more competitive athlete or a new athlete, or someone who is maybe doing extra stuff outside of the gym, extra running, extra squatting, whatever. Folks to watch squat when they're with you, are they the close enough depth person? Do maybe they need some help in their ankles or hips to hit better depth and take load off the knee? Are they the back and down squat person? Do they primarily squat with a hinge and then bottom out through the knee to hit depth? That is a person that can benefit from sequencing their squat pattern a little bit better, especially if they do have a goal to be a functional fitness athlete. They need to be able to show a relatively vertical torso squat, a high bar back squat, a front squat, a thruster, a clean, that sort of thing. With our treatment, make sure that we're working as soon as possible to restore full range of motion of both extension and flexion. We need full knee flexion to squat. We want full knee extension for impact. We want to strengthen the whole knee, not just the quadriceps. Hit the hip abductors, hit the AD ductors, and particularly full range of motion hamstring work, not just things like deadlifts and kettlebell swings. They're already doing partial range of motion hamstring strengthening in the gym. And then remember, it's not about volume. It's not about coming into PT and doing 500 air squats. They can definitely do that. It's probably going to exacerbate their symptoms. What we're focused on with our strengthening with their home program is time under tension. Start with the reverse Tabata. 10 seconds on, 20 seconds off, eight rounds. 80 seconds time under tension. Move to 10 sets of 10 on, 20 to 30 off. That's 100 seconds. Move through a full Tabata. Now 160 seconds, 8 rounds, 20 on, 10 off. And then the gold standard is can we do 5 sets of 5 of a movement at 3 seconds eccentric, 3 seconds isometric, 3 seconds concentric. Can we get to that 225 second time under tension benchmark? So I hope this was helpful. I'd love to hear questions you all have, throw them here on Instagram, shoot us an email, shoot us a message over on the ice physio app. Some courses coming your way from the fitness athlete real quick before I let you go. Our next cohort of fitness athlete level one online starts April 29th. That course is already almost sold out and it does not start for three more weeks. So if you've been looking to get into that class, that class has sold out every cohort since 2017. This next class will not be the exception, I promise you. So if you've been on the fence, get off the fence. If you've already taken that course, your chance at level two online to work towards your certification in the clinical management fitness athlete begins September 2nd. And then some live courses coming your way. Mitch Babcock will be down in Oklahoma City this weekend, April 13th and 14th, if you want to join him. He'll be back on the road again, May 18th and 19th out in Bozeman, Montana. And in that same weekend, Joe Hanesko will be up in Proctor, Minnesota, which is in the Duluth, Minnesota area. That will also be the weekend of May 18th and 19th. So hope this was helpful. Hope you all have a wonderful Friday. Have a fantastic 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.

Apr 11, 2024

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

In today's episode of the PT on ICE Daily Show, ICE Chief Executive Officer Jeff Moore discusses three fundamentals to working with individuals new to a fitness routine who encounter their first injury: avoid medical imaging, stay in the gym & modify around the injury, and be goal-driven to maintain motivation to continue to create a fitness habit.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the P-10 ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JEFF MOORE
Alright crew, what's up? Welcome back to the P.T. on Ice Daily Show. I am Dr. Jeff Moore, currently serving as the CEO of Ice and always thrilled to be here on a Leadership Thursday, which is always a Gut Check Thursday. So first things first, let's hit the workout. Gut Check Thursday this week is going to be a bit of a partner WOD. So we've got four times, relatively simple. It's going to be 100 deadlifts, 100 power cleans, 100 power snatches. The weight is going to be 225-155 on the deadlifts, 135-105 on the power cleans, and then 95-65 on those power snatches. Essentially, you're going to decrease load with each movement, but obviously increasing complexity, and maybe more importantly, increasing grip fatigue. I'm looking at that workout thinking, boy, that's a lot of pulling on that barbell, but it's in teams of two, so break it up however you want, maybe five, maybe 10 reps on some of those things, and then pass it over to your partner, bang all of that out for time, and then post it so we can see how you did. Tag Ice Physio, hashtag Ice Train. I'm gonna do this at three o'clock with Say over at CrossFit Endure, our marketing director. We're gonna challenge this workout. I will make sure to post my time. so you have something to try and smash later on today or tomorrow whenever you have a chance to get to the workout. So that is Gut Check Thursday. Let's move on to the episode.

THE ROAD TO FITNESS RUNS THROUGH MUSCULOSKELETAL PAIN
We are talking about the fact that their life is in your hands. It sounds a little dramatic. I don't think it is, okay? We're gonna start off with the fact that whether we like it or not, we have to acknowledge it's true and that is the fact that the road to fitness runs through musculoskeletal pain. The road to fitness runs through musculoskeletal pain. We don't have to like that to acknowledge the reality of that. Meaning, if you're gonna take somebody who's relatively sedentary, is not on the path yet, and you're gonna bring them all the way to fitness, right? So through wellness, all the way to fitness, that journey, requires a lot of loading, and a lot of challenging, and a lot of recovering, and a lot of programming, and a lot of strain, and stress, and rebuilding, and remodeling. It is a journey, right, that involves a lot of stress to the organism, right, to be able to get it to adapt, to get to a point where you achieve fitness. You don't get there, first of all, quickly, and second of all, without ever experiencing any kind of symptoms, right? That's a lot of stress to the system. You're going to have some bumps and bruises and strains. I'm not talking about major injuries, but you're going to be working through some stuff, right? How we manage that stuff, especially acutely. And when I say we, I mean the entire team, right? Coaches, trainers, physios, chiros, fitness forward physicians, right? Everybody who these individuals are beginning to trust to guide them along this journey, how we all swoop in and manage the acute response to someone developing symptoms is going to dictate whether or not they stay on the path. And from our perspective, if they stay on the path, is a huge variable in the quality of their life.

MANAGING THE INITIAL RESPONSE TO ACUTE INJURY DICTATES LONG-TERM OUTCOMES
So when I say life is in your hands, what I mean is managing the initial response to someone's acute injury onset dictates probably the longevity, probably the level of thriving, probably the health span. That's why I'm saying life is in your hands because the way you respond to this will dictate those things. And those things really are the quality of this person's life. So let me tell you the three things specifically. that when someone develops symptoms in the gym, that our response kind of hangs in the balance whether or not this person continues along this path that we believe drives so many of the important metrics of the quality of someone's existence. Okay, so if an athlete develops symptoms, right, you're not going to get into a case study of how or why. It happens all the time. Somebody tweaks something, they develop symptoms. Here's the three things.

AVOID MEDICAL IMAGING
Number one, they avoid medical imaging, advanced medical imaging. If we want this person to stay on the path to fitness and they've recently developed symptoms, the number one most important thing is that they avoid advanced medical imaging, okay? We now know the problem, right? That most asymptomatic people have abnormal findings on imaging that can be really scary and knock someone off the path. I am not gonna get in to the myriad of studies here. Nobody reasonably well-read is gonna push back on this podcast and say that isn't true, right? We have now known for well over a decade, you think back to 2012 when the American Journal of Sports Medicine, right, took that cohort of folks, average age of 38. How many had abnormalities in their hips, asymptomatic people? 73%. How many had labral tears? 69%. No hip pain whatsoever, asymptomatic people. You think about that classic Brzezinski article, right? Not article, but systematic review paper. Took a bunch of different publications, bundled them all together, looked at the data, what did we see? Your average asymptomatic person, meaning no low back pain whatsoever, in their 50s. 80% disc degeneration, 60% disc bulges. We now know the average asymptomatic person has all of these findings on their imaging that can be concerning. This is why we focus on tissue health, not tissue shape. What we now all acknowledge is that your connective tissue changes over time in your face, inside your body, your spine, your labrum, right? It changes over time. It doesn't tend to correlate well to symptoms. The problem is if someone just got hurt, If they just started experiencing pain and they're nervous, right? And they're vulnerable and they get that image and they see something that looks kind of scary, it sticks with them. It bumps them off the path. They have a hard time letting it go. They say, well, yeah, I might be able to get healthier, but I saw that cartilage. It was torn. We're not going to fix that unless we go in there and fix that, right? And they get extremely fixated on this. They begin to lose confidence. in the rehab or strength and conditioning process. It really, really sticks. What we know is when that person develops symptoms, we could have sent the other 10 people in that class to get an image and we would have seen the same stuff, but it doesn't matter. We can say that until we're blue in the face. We have said that until we're blue in the face. When the person's injured, when they feel vulnerable, when they're in pain, when they're in that decision-making process and they get that image and they see something that looks scary and maybe somebody in the medical industrialized complex made it sound scary, Those things make it very, very difficult to keep that person on the path. So getting them to avoid that unnecessary image is a massive part of the acute triage process if we want to keep this person moving towards fitness. Now, it always is worth saying, But certainly there are some times when they should get an image. Of course there are. And that is why physios, chiros, physicians, I'm challenging you all to make sure you're available to these gym owners and these coaches that when something does happen, you've got that direct access training and license where you can come in and make that tough call. And it's a tough call on either side. Because if you do send them, we're risking this thought virus we're talking about here. If you don't send them and they needed it, you're possibly putting that person at significant risk. So don't make gym owners make that call. Don't make coaches make that call. This is what you're trained for. Get in there and make that call. And make sure that the gym owners know you're available that day for a quick consult to get that person's mind off of that possibility when that's appropriate, which usually it is, or doing the appropriate triage if it's necessary. Get that part accomplished, okay? Alright, number one, if you want to keep them on the path, avoid advanced medical imaging unless it's absolutely necessary. Have somebody qualified to make that tough call so that you can get over that hurdle quickly and efficiently.

DON'T LEAVE THE GYM; USE THE GYM
Number two, if you don't want them to fall off the path, You've got to convince them they don't need to leave the gym, they need to use the gym. People when injured, when in pain, are going to make a very broad assumption that they shouldn't be in the gym. It's the first thing they're going to say, right? They're going to go to put that membership on hold. Your job on the same day of injury is to help them realize that everything they need is actually in that gym. All the tools to rehab the injury that occurred are right there in that gym. The ability to regress the skill that maybe they were inefficient with is why they wound up straining something. are right in that jam. You can regress everything and build a better foundation so next time you get up to that PR or that new movement, you're more ready for it, you're doing it more efficiently, and you've done the accessory work so that you're not stressing different structures at an unnecessary rate, and now you're having a lot more success with these movements. All of those abilities, whether it's to rehab the area, to work on the skill that you struggled with, to build a better foundation, Those tools only exist in the gym. The number one place you should be after injury is in the gym. So don't let them leave, right? So help them understand that you might not do exactly what you just did, you will in a few months, but everything around here is what we're gonna use to make sure you can if you want to. Helping them realize, whoa, whoa, whoa, whoa, you don't need to be leaving the gym, you're gonna use this place, right? That's a critical part of the acute triage process.


GET OBSESSED WITH GOALS
And finally, number three, Get them obsessed with new goals or at least new angles at the same ones. What I mean by this? is that motivation is fleeting, especially in people that don't have well-formed habits yet, right? Something, some confluence of factors happened in their life where all of a sudden they became someone who goes to the gym, okay? That is a pretty fragile ecosystem early on. We know how tough habit formation is, you're learning new skills. Motivation can be fleeting and fragile. You gotta shift it, don't lose it. shift it, don't lose it. Get inside that person's brain quickly and figure out why they were coming to the gym and show them that they can achieve that while working around the injured area. If that person says, well, I'm here because I've been listening to so many podcasts and it sounds like Cardiorespiratory fitness is a massive predictor of longevity and healthspan and decreasing all-cause mortality. All the things, right? Like, I'm in, but I hurt my knee. So now I can't do the bike and run, etc. So I'm going to call it quits for a bit. You sure are not going to do that. You are going to be on the ski erg, right? Because those things don't involve high or low to those areas, but we can still challenge your cardiorespiratory fitness. We are going to get them obsessed with a different goal, right? If they had a gymnastics goal and right now their shoulders tweaked, we're going to help them realize there's nine other similar goals that don't involve that area that we have a very specific program to move towards. And we're going to get them obsessed with getting that goal. And then we're going to swoop right back around and get on the same path and grab the other one. We're just going to show them. There are so many amazing things that we can do in here. to keep chasing your original goal, add on new goals, work around the injuries, and still achieve everything you set out to do, we understand that motivation is fleeting and fragile. We are going to help them take that motivation they've got right now, and we're going to shift it a little bit. We are not going to let them lose it. And you've got to be convincing in that acute phase, because they're going to make some heavy-handed decisions with all that emotional energy, with pain on board, and you've got to be there to guide that process.

SUMMARY
Team… Whether people choose to chase fitness during their lives is going to be a huge predictor of the quality of their lives. As they chase fitness, they are going to have soreness. They are going to tweak things. We are not going to load the system for years and years and never bump into any of this stuff. How we as a support system come alongside that person in that acute emotional time when they're having pain is going to dictate if they stay on the path. If we can get them to avoid advanced medical imaging when unnecessary, if we can get them to stay in the gym and use it versus leaving it, and if we can take that motivation they have and shift it as opposed to getting rid of it, we can get this person staying on the path. and we can change the entire rest of their lives, their family's lives, everybody they interact with, their life is in your hands. Be a great resource. Think about those three things in that acute management phase. I hope it helps, team. Thanks for being here on Leadership Thursday. As far as courses coming up, We've got a bunch of them. Ice Sampler is coming up at the end of this month in just a couple weeks in Carson City. We're actually going to put a limited amount of tickets on sale for 2025 because we know this event is hard to get into. It sold out in one day last year so we're trying to make tickets available at different times to give folks an opportunity to be a part of the event in 2025. But before then, we've got a bunch of courses. We had 12 last weekend. I think we have another dozen coming up over the next weekend or two before Sampler. So get on PTNICE.com, check those out. A lot of online courses start on April 29th, which is only a few weeks away, and some of them only have a handful of seats. So get over to the website, check it out, have an awesome Thursday, do gut check. We'll see you next week, 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.

 

Apr 10, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer takes listeners through a case study, showcasing how therapists dig deeper into patient goals in order to create meaningful treatment sessions that improve patient function.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JULIE BRAUER
Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division and I'm going to be talking to you all this morning about make it meaningful, load it, dose it. So what is that? Make it meaningful, load it, dose it is the exercise prescription formula that the older division uses. So those of you who have taken our online course or our live course, you have heard this, you have learned about it. So what we're going to do this morning is I'm going to take you through how to apply this formula specifically for the goal of a patient who wants to return to gardening. So we're going to go through a little bit of a case study here. So to dive a little deeper into exactly what's coming up, I'm going to take you through how to dig deeper into the goal of when someone tells you I want to be able to garden on my own. We're going to dig deeper there and talk about why it's important And then I'm going to show you how you can take that goal and break it down into its functional movement parts, because that is going to give you all the exercises that you will be using throughout your plan of care. Using this formula is going to be able to give you all a way to create meaningful, effective, and efficient exercise programs for your patients. So we'll dig into the goal, we'll break it down into its movement parts. Then when I see you all again in a couple weeks, I will have my wireless mic by then and I'm going to go out into my garage and I'm going to show you what some of these exercises look like and give you some scaling options and how we would load it and dose it for intensity.

DIG DEEP INTO GOALS TO FIND THE "WHY"
Okay, so let's start from the beginning. We have to dig deep with every single patient when they give us a goal. We got to dig deep for the details. Why? Two main things. First, we want to know, in particular for this case study, when this patient says, I want to be able to garden, we want to know why. We want to know why gardening is important. What about gardening is this individual most excited about? We want to know the emotional why, because that's going to get us our buy-in. Next, we want to know details down to the nitty-gritty, exactly what this activity looks like. I want to know what this gardening task looks like from start to finish, because once you visualize it, you're going to recreate it. That is going to give you all of the exercises that you're going to ever have to do with this patient throughout your plan of care. It's the easy button. So when I say dig deeper to get to the emotional why, this is what I mean. It sounds something like this. So patient, let's call her Dolores. All right, we'll call her Dolores. Dolores tells you, I want a garden on my own and you're going to say, Dolores, tell me more about that. What about gardening is so important to you? I would love to hear more. When you are asking Dolores about her goal, you are giving her eye contact. This is not the time to open up your laptop and do any typing. You give her your undivided attention for these first few minutes while you are asking her about gardening and why it's important. Dolores, what about gardening brings you joy? What are you most excited about with gardening? This is where you can say, I love gardening. I grew up with a garden. My mom would, we would plant catnip and we would make our cats go crazy. I mean, literally this is true for me. This is what I've told my patients when they've told me they want to get back to a gardening task. Relate to your patient, right? Make that connection. When you do that, you're allowing the patient to give you more of a story behind why it's important. So Dolores is going to tell you something like this is true for a patient I recently had. My granddaughter is getting to an age where she likes to garden with her mom and I want to be able to garden with her as well and I want to be able to go outside and garden with my granddaughter and feel confident doing that. Boom, there's your emotional why. You have to dig deep enough to get to that point. Why? Because superficial goals, if you were to just leave it at, I wanna be able to garden, I wanna get stronger to be able to go outside. If you leave it at that superficial goal point, you lack the emotional connection. And Jeff Moore did a podcast, I cannot remember what it's called, but he says, and it stuck with me, this is probably a year ago, Superficial goals lack emotional connection, and emotional connection is what motivates your patient. Emotional connection is what's going to motivate your patient. So you find that emotional why, now your patient's connected to you, they believe you give a damn, you feel connected to them, you've got that therapeutic alliance, you both are invested and locked in. Okay, Moving on, the next details that you want are the nitty gritty details of what that gardening task looks like. So this is what it sounds like. I will say, Dolores, I want to visualize what this gardening looks like. Can you tell me exactly what it looks like from start to finish, from the very beginning to the end and everything in between? I want to be able to visualize it. as Dolores is walking you through all of the functional demands that she has to be able to do in order to fulfill this goal. I am using my whiteboard and I am writing this down. Now I know this was reversed for you all. I'm going to take a picture of this and put it in the comment on this post, but I am writing down every single thing she says. All right. So I have a whiteboard at the top. I'm going to put her name. Maybe I'll say this is, uh, Dolores, Dolores gets a garden strong, something like that. Those little details can make it much more meaningful to your patient. Little special things that you can add in.

CREATE TREATMENTS THAT PROGRESS PATIENT GOALS
So I have her name at the top and then as she is telling me what she has to do, I write it down. So she will say something like, I need to be able to push the door open on my own to get from inside to outside. So I'm writing that down. And then in parentheses, I'm putting what type of exercise exactly mimics that activity. So if she says, I need to be able to push the door open to go from inside to outside, To me, my fitness forward brain is what does that look like? Oh, a sled push. Awesome. So I write down push door open and then in parentheses I put sled push. Then she tells me, all right, and then I got to walk over grass and I have some stepping stones and I have some gravel. So she told me she has to walk over variable terrain. So then in parentheses, what am I putting down? Okay. So that's stepping on and over obstacles. Then she tells me, then I'm going to have to pick up some stuff and carry it around. So I got to pick up some tools. I got to pick up my mulch. My fitness forward brain goes, okay, what looks exactly like that? Pick up and carry. Well, I know that that's going to be a deadlift and that's going to be a loaded carry. Then Dolores says, then I'm going to have to get down on my knees and do some things on the ground. I'm going to have to get up and off the ground quite a few times. My fitness for brain says, what is that? Well, that's going to be a lot of floor transfer, part practice and full practice. Then she says, I got to pull weeds as well. It's, you know, usually like, Oh, well it's, it's not the best part of the job, but it has to be done. I want my garden to look really nice. I need to be able to pull weeds. So I'm thinking, what does pull weeds look like? My fitness for my fitness for brain says that's going to be quadruped position and I'm going to do some quadruped rowing. Okay. I'm trying to make it look exactly like that functional activity. You're catching on here, right? You're understanding what I'm doing. I am taking everything she's saying and I'm turning it into what the exercise is going to be. That looks exactly like that activity. And then the last thing she says is, and I need to do all of that and I don't want to fall over. So when I hear that, I know that I have to add in some perturbations. So I'm going to be giving her some external perturbations that are going to force her to take that reactive step. So I can train that. So I can train her dynamic balance. So now that I have that entire list, I am going to teach it back to her. I am going to say, Dolores, I was writing down everything you were telling me, all the pieces and parts that are important in order for you to accomplish this goal. Is this correct? And I'm going to go through and I'm going to say, Dolores, what I heard, what you told me is you need to push the door open. You need to walk over grass and gravel. You need to pick up and carry some stuff. You got to get down on your knees. You got to pull some weeds and you want to be able to do all of that without tipping over. Dolores is going to sit back and be like, wow, this person was actually listening to me. You have just improved that therapeutic alliance even more because you have heard her well. So now you have this entire bank of exercises. This is what you're going to pull from. Now that, I mean that was sit one, two, three, four, five, six. Those are six different movements there. That list could be less than six. It could be way more than six. So then you're going to think, okay, well, what's the next step here? I have all of these movements. What do I do with them?

ASSESS,DON'T GUESS THE PATIENT'S ABILITY TO PERFORM FUNCTIONAL TASKS
Next, you want to assess Dolores, how she goes through the motions of these functional movements. So when you are in an outpatient clinic, you got to recreate it in your clinic. If you're in a home health setting, this is easy peasy. You say to Dolores, all right, we're going to go through and I'm going to have you show me exactly what this looks like. All right. Something that I like to do when I, before I do this assessment to watch what this looks like is I will ask Dolores, I will ask my patients, What about all of those movements? Which of those do you feel like you can do really well? What are you really strong at when it comes to all those different pieces and parts that make up gardening? And then I will ask her, which of those movements are you fearful of? Which of those do you feel like that you don't really have the strength to do yet? I want to know her perception of her own abilities. And because as I'm assessing her, I'm looking at a lot, this is going to help me dial in exactly what I should pay attention to. I want to know the things that she's really strong at and see if she is actually strong at those. And I want to know the things that she's fearful of and see if she actually struggles with those pieces and parts. So after I asked her that, I kind of put a little asterisk sign into which of those movements are her strong movements and her weaker movements based on her perception. And then it's assessment time. So again, in the home setting, I am having her do the thing. I am not helping her. It's very similar. If you work in inpatient rehab, you just do the assessment, a FIM care tool. You're not helping them. You're simply watching how they do it. This is not the time. to assist and teach and coach, you are simply watching. In the clinic, this is where you want to set this environment up. You want to mimic and recreate this activity.

BUY FUNCTIONAL EQUIPMENT, NOT BARBELLS
So this may ruffle a few feathers, but as opposed to say you have budget and you have some money to spend at your clinic to buy equipment, I'm going to give you a potentially not popular opinion. Maybe instead of buying that barbell first for your clinic, if you're working with older adults, what if you bought functional activities that older adults actually use and that are not intimidating to them and directly relate to the goals they're trying to achieve? So what if you bought a laundry basket? What if you bought a bag of mulch? What if you bought some gardening tools? What if you brought in a, um, some laundry detergent, some pots, some pans, dog food, things that older adults are lifting and carrying and using at home pretty consistently. I would rather have those things at my disposal to use right away when I introduce loading to an older adult versus rely on jumping straight to the barbell where someone can be incredibly intimidated by that. This is not a or situation. This is an and. However, I have learned over time that I'm going to get more people to buy in if I have those functional activities those functional objects that people use at home that's going to get me more buy-in than saying all right you have to pick up uh and carry tools from um when you go out and garden well let's go do it with this barbell That's a lot harder of a sell. So here's your call to action. Spend that extra clinic money or just take stuff from your home that you don't use. You know, don't throw it away or go to a garage sale or a thrift store, whatever it is, and get this stuff and bring it into your clinic. All right, so you're going to set this all up in the clinic. You're going to assess, you're watching to see her quality. You're watching to see how long it takes her. I mean, this really is becoming an outcome measure for me. this is going to become like a benchmark workout. Okay. So think about it that way. This is, this is much more than an assessment. I'm going to use and recreate this, uh, call it a meaningful obstacle course that looks exactly like her gardening task. And I'm going to run it again and again and again. So I can track her progress and how well she's able to do this activity. So from them, I have recreated, the functional activity. I am assessing how well she does. I'm taking notes. I'm looking at the things she's strong at, the things she's weak at. After we're done, we're sitting down and we're recapping. Are the things that she thought she was strong at and weak at, did that match with how she actually performed? And we have a discussion there. From there, again, I'm looking at this list and now I'm talking to Dolores and I'm saying, Dolores, Based on what we just saw and what you just felt, these are the few activities, and you're looking for three to four here, three to four. These are the three to four activities that we are gonna focus on next session. And what are you gonna do? You are going to create an EMOM or an AMRAP with those few functional activities that you together have determined are the most important and you're going to find a way to load it up, whether that's adding physical load or cognitive load, and you're going to find a way to appropriately dose it so that you know you are at an appropriate intensity to drive adaptation.

SUMMARY
Okay, so that is how we go from taking a goal, digging deep to get to the emotional why, going through breaking down that meaningful goal into its functional movement parts. All right, that is the hardest part. It's the most important part. When I see you on a couple weeks, I will use this same exact case study and I'm going to take all of these exercises and I am going to show you ways to scale this up, scale it down, dose it, add some load, whether that's physical load or cognitive load. The idea here is we want to make our sessions and our AMRAPs, our EMOMs and the workouts harder than what the demand is that she actually has to do to reach that goal. Because if she is able to do her gardening tasks with load on her, with cognitive load on her, adding in intensity, then gardening with her granddaughter is going to feel easy. And that is the goal. All right, guys, that's all I got for you. I will post a screenshot of this list. So if you all have a patient whose goal is to garden at any point the rest of the week, you have a nice list of exercises that would probably be very relatable and meaningful for them. To end things out, I will let you guys know what we have coming up in the Older Adult Division in terms of courses. For the rest of the month, we will be on the road in Washington, Tennessee, and Pennsylvania. And then both of our online courses, Level 1 and Level 2, are starting in the month of May. We would love to see you on the road or online. PTI Nice is where all that lives. If you have any questions, any comments about anything we talked about today, hit me up. Would love to jam on anything with you all. Have a wonderful rest of your Wednesday.

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

Apr 9, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant discusses using isometric exercises for more than just pain relief including newer research emerging that isometric exercise does cause structural adaptation. Mark also discusses key points important for successful dosage of isometric exercise in the clinic.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at sign up to receive a one month free grace period on your new Janex.

MARK GALLANT
All right, what is up PT on Ice crew? We got Instagram, we got YouTube. I'm Dr. Mark Gallant, lead faculty with the Ice Extremity Management Division alongside Lindsey Huey. Cody Gingrich coming at you here on Clinical Tuesday. What I want to talk about this morning is isometrics beyond the pain. So isometrics are obviously a muscle contraction type that have been around since the beginning of time, really. Since humans have existed, we've had to hold things and carry things isometrically. And the popularity of isometric exercises has come up and gone down and come up and gone down as fitness trends and rehab trends always tend to change and the last decade we've been in a period where isometrics have been on the up for the last 10 years and a lot of that has been because of the research of Ebony Rio out of Australia where in 2015 she took a group of volleyball players and figured out that if we hold long hold heavy isometrics we get both cortical pain inhibition and a subjective decrease in pain. Well, that study has been looked at a handful of times over the last nine years since then. And sometimes it shakes out just as ebony Rio found in 2015, 2016. And other times we see that it does not have the same wonderful, incredible pain reducing results that we're all hoping for. And really the reason for this is pain is wildly complex. So if you do the same study that Ebony Rio did with her volleyball players, five sets, 45 seconds, 70% of their one rep max for a two minute rest, and the group of people ate something different for breakfast that day, if they did not get as good of sleep as the other group, if they are incredibly stressed, if their soccer coach yelled at them, a million different things could have possibly happened that are going to impact that person's symptoms overall. So despite pain being multivariable and very complex and maybe not being the 100%, isometrics not being a great, they're still great, not being a 100% reducer of pain every time like we saw in that Ebony Rio study, we've talked about on this podcast.

ISOMETRICS ALLOW FOR THE CONTROL OF MULTIPLE VARIABLES
The reason we're still gonna use them is the isometrics control for so many of the variables that are challenging when someone is injured or early on in their rehab process. It controls, you can control the volume easily, five sets of 45 seconds or four sets of 30 seconds. You can control the position. Is the shoulder flex? Is the shoulder down at neutral? You can control the amplitude of motion. So isometric, there is no amplitude. It is, it's exactly still. You can control the load easily overall. That load's not going to change as they're doing the motion. and you control the speed really well because it's isometric. So there is no speed once that object gets into the position or the joint gets into that position.

ISOMETRICS: TREAT THE DONUT & THE HOLE
Beyond those things, there's more exciting research that has been coming out that gives us even more reason to keep isometrics in our rehab plan, especially when it seems that the tendon and ligament are involved in that person's pathology or the injury. Out of Keith Barr's lab at UC Davis, California, they are now showing that it seems, with isometric, that we can indeed adapt tendon and ligament tissue and lay down new collagen. So classically, we always thought that the catchphrase, treat the donut, not the hole. Treat the donut, not the hole. So what we believed was that you were adapting all the healthy tissues around the degenerative or injured area so that that person can get back to their activities and you're not gonna be as concerned of healing or building back up the degenerative area. And we believed it could, it was possibly, that it was not even possible potentially. And what Keith Barr's lab is now showing, that it does seem that with long hold heavy isometrics, that we can lay down new collagen in these areas potentially. Now this is all new and exciting research, so if it doesn't shake out perfect, we'll adapt with the times. Keith Barr's lab is exciting because what they are able to do that other labs can't is they are able to engineer tendons. So they create a bunch of tendons and ligaments that they can test in all sorts of wild ways because they're literally manufacturing them. Once they get something that's cool or seems beneficial, then they move that same technique or same intervention onto rat or mice studies. Once it looks positive in the rats or mice, then they move it to a human trial. So they're doing this three-tiered system where they're getting a ton of volume from the engineered tendons and trying all sorts of crazy things. Then they move it to rat and mice. And then once they really feel confident, they can move this into human studies. And what they have been showing is through the processes of stress shielding and stress relaxation, that it does seem that we can lay down new collagen and adapt these tendons.

ISOMETRICS & STRESS SHIELDING
What stress shielding is, it is the ability for your healthy, non-injured tissues to take on a majority of the stress to protect the unhealthy or injured area of a tendon or ligament. So it's a wonderful protective mechanism for back when we were foraging for food or hunting or having to outrun predators, that the healthy part of the tissue would take on more of the loads so that you could keep moving to either get food or stay away from them. This is a great process to keep us alive, not a great process for adapting tissues. What we really want instead of that stress shielding is some stress relaxation where the healthy injured or the healthy uninjured part of the tissue starts to relax a little bit so that we get some load or some stress into the injured area. When we get that stress into the injured area of the tissue, it's gonna create a cascading signal to the nervous system that says, hey, we need to lay down new collagen, we need to adapt to be able to remodel this tissue area. The easiest way to explain this is an analogy that Keith Barr commonly gives of two individuals playing tug-of-war together. So you've got two teams of two playing tug-of-war, they're relatively evenly matched. Let's say for this case that it's Mitch Babcock and I. So for those of you who don't know Mitch Babcock, he's an OG instructor for our management of the fitness athlete. Mitch is over six feet tall, over 200 pounds, big strapping muscular guy. I am 5'7", 165 pounds. If Mitch and I are on the same tug-of-war team, early on he is going to carry a majority of that load for the team. He's going to take on most of that stress because he's such a robust human. If the other team is evenly matched, at some point during that tug of war, Mitch is going to either fatigue out or he's going to have to start to relax a little bit to start to conserve his energy. At that point, I am going to have to take on some higher portion of the stress or load. Once I start to take on that higher stress or load, my nervous system is going to start talking, going like, If this is the type of thing we're going to start getting into, we're going to have to adapt. It's the same with our ligaments and tendons. As that healthy area starts to relax or fatigue, then what we're going to see is that the injured or unhealthy areas have to take on a load. And then again, that's going to start that cascade of the nervous system to remodel and adapt those tissues. What we're seeing is that there's a few things that need to be true for this to happen. It has to be long enough duration. So that has to be held long enough, the load, so that it gives the opportunity for the unhealthy, for the healthy tissue, excuse me, and robust area to start to relax a little bit. So long enough load where the healthy areas of tissues begin to relax. It has to be a heavy enough load to create some sort of stimulus. If the person feels like it's easy and they're not having to put out a lot of effort, it's very likely that the healthy portions of the tissue are carrying all the load And it also seems to work best when that tissue is at length. So when those tendons or ligaments are at their most lengthened position, so extended elbow, dorsiflex ankle for the Achilles, bent knee for the patellar tendon, that tends to be where it works out best.

KEYS FOR DOSING ISOMETRICS APPROPRIATELY
Now, there's some keys to this depending on how robust the human in front of you is. The more robust that individual, the longer the heavier and the closer to length that we need to perform those holds. So if the person is healthy, you may need to go beyond a four sets of 30 seconds. So four sets of 30 seconds tends to be this minimum amount of time that has been shown to create this stress relaxation. If you've got that really robust person, if you've got the Mitch Babcock, they may need to hold five sets for 45 seconds. Now there does seem to be a ceiling of about 10 minutes of tendon loading, seems to be this area of diminished return. So if you go beyond 10 minutes, then you need to wait six to eight hours to reload that tendon. Somewhere between four sets in 30 seconds, five sets of 45 seconds, adjusting that depending on how robust that individual it is. It has to be heavy enough again to where that person feels an effort. So if you've got someone who's deconditioned, they have not done as much exercise recently, you can create this stress relaxation with relatively light loads. If you've got the Mitch Babcock that's been lifting weights since he was 12 years old, you're going to have to load that tissue a bit heavier to create that adaptation. It has to be a high effort load. And then the final piece is we see now that tendons and ligaments tend to adapt better from an actual structural standpoint if they're held at length. So again, for the elbow, is it extended? For the Achilles, is it dorsiflexed? For the knee, for the patellar tendon, is the knee flexed? Obviously, if someone is symptomatic, it's going to be more challenging for them to get in these positions. What we do in this case is we get them to the most length that they can tolerate for that four sets of 30 or five sets of 45. And then as time goes on, we progress them to a more lengthened position overall. If you all have been following ice for a while, a couple years ago, Joe Hanksco did a wonderful virtual ice on medial elbow tendinopathy. And one of the key exercises he looked at was wide grip biceps curls to help out those medial elbows. And if we look at this, it's a wonderful exercise for exactly what we're talking about for medial epicondalgia because when you're in that wide grip bicep curl, you are holding that during the max eccentric portion, that elbow is at a ton of length, they're in a relative wrist flexion, it's gonna be a lot of stress to that medial elbow. You can take that same exercise, do it isometrically, four sets, 30 seconds, and it becomes a wonderful thing to adapt the medial elbow, ligaments, tendons, and tissues overall. Last thing that we wanna talk about is anti-inflammatories block stress relaxation. So if that person takes anti-inflammatories early on, everything we discussed the last 10 minutes becomes much more challenging. When there's inflammation in the area of the tendon, it creates a natural stress relaxation where the healthy portions of the tendon are not gonna be able to take as much stress and load, and you're gonna get a little bit more stress and load to the injured or unhealthy area. So if that person takes an anti-inflammatory early on, they're not gonna get that benefit of being able to take less load, less strain, and get some adaptation to the injured area of the tendon. So if folks can, we tell them to use natural processes. Use your cardio to pump inflammation out of the area. Use eating healthier foods that are not going to block the entire inflammatory process. They're just going to decrease some of the inflammation and still allow for that stress relaxation. So overall, if we're trying to adapt tendons, to lay down new collagen, to remodel those tissues, We want it long load, four sets of 30 seconds, five sets of 45 seconds. We want it heavy enough to overcome that stress shielding. So it's a high effort lift and we want it at length of that tissue. So again, if it's the elbow extended, the ankle, dorsiflex, the knee, if it's that patellar tendon bent, whatever the deepest amount of, of length of that tissue that we can, that's where we want to go. Hope this helps. We're gonna come back on here in a few weeks and talk about isometrics for adapting muscle output in the central nervous system. Hope to see you all on the road. Head on over to the ICE app or the ICE website. We have a ton of offerings coming up for extremity management all over the company. My next one, I'll be in Dallas, Texas in June. Hope to see you all there. Message us, comments, love to chat more about this. Hope you all have a great Tuesday.

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.

Apr 8, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses pelvic floor screens such as the PFD-SENTINEL and introduces a new pelvic floor screening resource coming soon to the ICE Physio App!

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

RACHEL MOORE
Good morning, PT on ICE Daily Show. I am getting lunched on YouTube and Instagram and we are good to go. All right, what's up? My name is Dr. Rachel Moore. I am here this morning to talk to you guys about screening for pelvic floor dysfunction especially if you are somebody who is maybe not familiar with the pelvic floor space or this is an entirely new space for you or you're somebody who is like identifying or classifying as a orthopedic PT and you're like I don't know anything about the pelvis. I want to clear things up with you guys and put together or we did put together a resource for you guys that is a pelvic floor screen that you're going to be able to access through the Ice Physio app under the resources section. So you'll be able to get that off of the app, download it, either have it in your intake forms, in your paperwork so that you can use that as people are coming in and kind of have an indicator of if this would be a person who would benefit from a referral for pelvic floor PT. Where this all came from, we've been asked at our courses before for just kind of an easy, quick, general screen. A lot of us use kind of a different option. So there was some people had a couple options that they were using. Other people were using different things. So what we did is we took all of these resources. We compiled them together and we really leaned into the research and what we have out there for pelvic floor screening. So we're going to chat a little bit about what that screen is and how we kind of adapted it or modified it for this really quick, easy, downloadable version that you can pull up and have as an 11 question fast screen for your patients. So This whole screen kind of is based around or adapted from a study that was published in the British Journal of Sports Medicine in December 2022. So the screen is called the PFD Sentinel Screen, S-E-N-T-I-N-E-L. What this was was a Delphi study and they basically polled professionals that are experts in this space. So they had PTs, they had urogynecologists, they had just different healthcare providers, physical medicine and rehab providers that all had either been in this space seeing patients or been in this space researching these topics. And what they did is they polled these providers to kind of come up with a consensus. Because prior to this, there really wasn't a validated published screen in any evidence. that we could really lean into for patients that would benefit from pelvic floor physical therapy. And so they created this screen kind of as a way to have a resource specifically for sports medicine providers, and this was really kind of leaning into sports medicine PTs, like orthopedic PTs, or sports medicine doctors that were already seeing female athletes, and they're kind of range or definition of female athletes was like super broad. So across all ages, across all sports, across all profession levels, whether it was amateur athletes or professional athletes, they came up with this screen based on this Delphi questionnaire, not questionnaire, but survey. And so what they landed on were five main pelvic floor dysfunction symptoms, and then 28 risk factors for pelvic floor dysfunction. So with that, in order to be included on this screen, they had to have over 67% of the consensus of the group. And this went through two rounds. So it was like 43 and 37 were the two rounds of number of professionals. So of those two rounds, 67% or higher had to agree that they felt that these were indicators for potential pelvic floor dysfunction screens. So with this screen, there was this top section of score A, which was five main pelvic floor dysfunction symptoms. So this was things like leaking urine, urinary urgency, leaking gas and stool. And with these five, if they answered yes to any one of these, then they recommend an automatic referral to a pelvic floor specialist. Doesn't necessarily specify PT, but could be a urogynecologist or somebody that specializes in treating the pelvic floor. From there, there was 28 risk factors that they delineated. With these 28 risk factors, they either landed in the categories of score B or score C. If they were score B, that means that they had greater than 14 of these risk factors. These risk factors were pretty broad. I actually really loved the things that they included. So this was things like whether or not somebody's in menopause, if they've been diagnosed with hypermobility or connective tissue disorder, if they have a family history of urinary incontinence or a family history of pelvic organ prolapse, their BMI being under or over a certain range. So they really took a lot into account here under the risk factors. And if they had a score of greater than 14 for those risk factors, then they fell under a score B, and that would be a recommended referral to a pelvic floor PT or pelvic floor specialist. So score A, for sure, send them. Score B, we recommend you get this checked out. And then score C was less than 14. So if they didn't have more than 14 of these risk factors, Then it was just monitor, kind of keep an eye on them and see how they do. And when they made this screen, they made it as a kind of touch point to repeat. So maybe you start this at the beginning of the season, and then as they begin off season, you start or you re-screen this. So this is kind of an easy ongoing screen to see how things are changing as these athletes are evolving potentially, whether they're in off season or in season. Or if, again, we're thinking about just our general population, maybe once a year when they're coming in or once every six months when they're coming in, we're doing this really quick and easy screen to determine if they would benefit from a referral for pelvic floor PT. One thing to kind of note about this is it was specifically created for female athletes. Again, broad term for athletes here, but specifically created for females. So no males were included in this when they were breaking down the rationale for when somebody would benefit for a referral for PT. And so we don't really have a good resource of when our males need to be referred to PT just yet. Maybe that's something that'll be coming out in the research soon. And then also just note that this hasn't been like validated by any further research yet. This is kind of the kickstart point of, Hey, we've got this group of experts that have come together. We don't really have a lot of information in this space. Let's come up with something so that we can then push this out there and see how it flows. So, Love it. It's really awesome. PFT Sentinel is really in-depth. It has a lot of really great risk factors on there. When we were putting together our screen, our thought process was a little bit different. It was a little bit more leaning in towards something quick and easy that, like I said, we can put in our intake forms and just have people check things off. You could really even use this as marketing. So I actually do use a pelvic floor screen on the backside of my flyers. So on the front side, I have all of my business information. I've got a QR code for people to book a session pretty easily. And then on the back is the pelvic floor screen printed on it. So as people are setting these out, it's got our business logo on the top, set it on a counter at the chiropractor's office or at the gym or whatever, and they can pick up the screen and read through it. and it says at the top if you say yes to one of these following questions, you might benefit from Pelvic Floor PT. So, great option for marketing, great option just to have as part of your intake form in your paperwork. If you are not a Pelvic Floor PT and you're not really sure who you should be sending to Pelvic Floor PT, it's also a really great resource to have on hand. So, diving into our specific screen, what we really focused in on were what we felt were kind of the heavy hitters for recommendations for pelvic floor PT, and then maybe some of the things that doesn't necessarily jump out at somebody that's not in this space. So, some of the more obvious ones would be like experienced urinary leakage, urinary urgency or frequency, issues with remaining continent or holding in gas or stool, sensations or feelings of heaviness or seeing something bulging at vaginal opening and then really leaning into the pain side pain or discomfort and we really kept this grog because we've seen pelvic floor dysfunction show up as hip pain, we've seen it show up as low back pain, we've seen it show up as groin pain, and so we really wanted to kind of catch a broad range here, especially if you are the orthopedic PT who's maybe been seeing somebody for their hip and you're doing all the right things and you're like, I'm crushing this, but they're just not 100% better, maybe that would be the time to kick them over to a pelvic floor PT if you're not doing pelvic floor. and see if there's some contribution from the pelvic floor to that issue. Childbirth, whether it is a vaginal or a cesarean delivery, both of these situations we feel weren't a referral to pelvic floor PT, just to really kind of recalibrate and get things on the same page again. Being in menopause or perimenopause, A, from the education standpoint, there is so much education that we can provide to this population. but also just kind of staying ahead of any problems or symptoms that may arise as they're progressing into this low estrogen state. And then having a history of relative energy deficiency in sport. And this is something where we might need to lean into our providers to do some education. If somebody doesn't know what that is, really knowing if somebody's had irregular cycles, if they have these chronic injuries, or one week you're seeing them for their knee, the next month it's for their shoulder, the next month it's for their back, these signs of these chronic kind of nagging injuries would be a thing to hone in on that maybe they're potentially in this relative energy deficiency in sport state. We've got a lot of really great information out there, lots of podcast episodes about reds that we've done as the pelvic division. So if you're unsure about that, definitely go to YouTube and type that in the search bar and pull that up so you can learn a little bit more about that topic and really be able to screen that a little bit better. But again, we came up with this resource. I hope you guys love it. I hope it's helpful. We've been asked for it at our pelvic courses. I've been asked for it at our other courses that I've attended just as a participant. OrthoPTs that are like, I'm not really sure what I'm supposed to do. Can you please come up with a resource that we know how to screen? So we're really excited about this resource. It's going to be on the ICE app. So keep an eye out. In the app, we'll also blast it out on the pelvic newsletter. So if you're not signed up for the pelvic newsletter, go ahead and get signed up for that. And same thing with hump day hustling as well. Sign up for that. That way you know exactly when it gets posted, exactly when it goes live, and when you can download it to have it as part of your screens.

SUMMARY
If you are somebody who wants to be in the pelvic floor space but maybe isn't in the pelvic floor space yet or you want to learn more about pelvic floor pt then jump into one of our courses We've got so many live courses coming up. Christina and I are actually teaching in Spring, Texas this weekend at my home gym. I'm so excited. We still have openings there if you want to come hang with us. But lots of offerings for our live course coming up, as well as our L1 coming up again. And then our L2 is sold out for this upcoming cohort, but we do still have spots open. in our fall cohort so head to the website figure out where you can jump into a pelvic course if you're interested in learning more about pelvic floor pt and how to treat these women If you're not really sure how to treat these women or who should be referred out, head to the resources link. You're going to see this resource posted in just a bit. And then we are excited for you guys to have it out there. Use it for marketing if you are a pelvic PT and let us know how it goes. Thanks for joining in. I appreciate it. I hope you guys have a great day.

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

Apr 5, 2024

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete Division Leader Jason Lunden discusses three factors to consider when transitioning from biking indoors on a trainer back to riding outdoors: equipment, road/weather conditions, and controlling training volume on the road.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

JASON LUNDEN
Good morning. Happy Friday, everyone. Welcome to another edition of PT on Ice. My name is Jason Lunden. I am the lead for our endurance athlete division, which entails rehab of endurance athletes, including our professional bike fitting course and both our online and live versions of the rehabilitation of the injured runner. So today I am going to be talking about a very timely topic, transitioning back onto the road after training all winter indoors for especially those of us in the northern climates. And here in Montana, we are definitely seeing our transition back to spring and everyone's getting back out onto the road. after being on the trainer for the past four to six months. So I just wanted to give some tips for either yourself or your clients on how to make that transition as smoothly as possible and not interrupt their training cycle. So we're going to cover three things, equipment, conditions, and then the actual mechanics and transitioning of back on the bike in terms of volume.

EQUIPMENT
So first thing being equipment. Obviously, when you're on a trainer, you're not really all that concerned about, you know, are your brakes working? Is your headset working, et cetera? Do you have like your kit already with a spare tube and… Spare tube and… Pump etc. So first and foremost Making sure that you're checking that your headset is indeed tight. So that is going to be the top bolt where the handlebars go into the steer tube and Way to check that tightness is depressing the front brake and rocking the back the bike back and forth and you shouldn't feel any clunking at all. If you do feel clunking you need to tighten the headset. Things can get loose over time so it's an important thing to do. So loosening the two screws on the sides and then tightening the top down and then tightening the screws on the sides back too. And then also making sure brake wear and everything are okay as well. Because typically in the spring, you're going to be encountering wetter conditions. So it's really important that your brakes are working and to avoid any catastrophic, traumatic injuries. And then probably lastly is just making sure that you do have the supplies with you if you do break down. Again, typically at the end of the season, when transitioning back indoors, We always think that we're going to get those new CO2 cartridges, replace the used ones that are in our pack that we used already, as well as making sure that that spare tube is still working and adequate. So making sure that you're kind of restocking your kit or at least reassessing your kit for while you're out on the road, as well as making sure you got those tire level levers with that too.

ROAD CONDITIONS
Number two is conditions. Uh, obviously biking outdoors, there are a lot more environmental conditions and biking indoors. Uh, and that's really important to, to take account of. So again, in the spring, we're typically going to be dealing with some wetter weather, uh, some cooler temperatures, uh, especially for us, uh, working folks, uh, working athletes. We're going to be having to try to fit our rides in around our work schedule. So typically in the early morning. um, or after work where temperatures are already going to be cooling down. And so making sure that you, you are, you or your patient are dressing and layering appropriately. Uh, as if you're, if you are riding in cold weather, um, it can get cold really quickly because of the wind resistance and all of that. Um, and your muscles can get cold, which, uh, you know, anecdotally, I think a lot of us think, well, you know, we're more likely to actually strain or have injuries in the cold with not being warmed up and there's actually some very limited evidence on that but there is some evidence on that in looking at exercises in different temperatures and the incidence or likelihood of increasing the incidence of tendon strain or muscle strain. And anecdotally, this is the time of the season when I really the only time I see cyclists coming in with quadriceps tendinopathy or tendinitis, more acute. And I think there is a correlation with the colder weather and just not muscles being warmed up as well as maybe not quite being acclimated to the volume that they want to do. in the style of riding that they want to do. So just tucking that in the back of your head and just making sure that you're prepared for that.

CONTROLLING ROAD VOLUME
And then lastly, looking at how you're going to approach your volume in your training with transitioning outdoors. Training indoors is really efficient, especially you know, more recently with our direct drive trainers that can add resistance and simulate hills, et cetera. But we're still very, it's very easy and more comfortable to have your hands up on the flats of the bars and not all the way out on the hoods or in the drops. And I think a lot of us have the tendency to ride in that position of comfort. Either if you're watching the virtual screen of racing on Zwift, or you're watching a show, just being in more comfort even with putting that effort out. So realizing that your body may not be adapted to being in the drops or being on the hoods for a long time, as well as the increased instability of being on the road where you're having to balance more. So not maybe necessarily having the core stability strength for that as well. So ideally before transitioning into back onto the road for the month prior, making sure you are getting time in the drops on the hoods, making sure you're getting time where you're getting efforts standing up on the bike, and then doing an assessment of your core and spinal extensor strength to make sure you can sustain those positions. And then even with that, when you're transitioning back onto the road with your training, Have those first rides be just shake out rides, totally, um, just going out for, for fun rides, not really, uh, equating that into your training and keeping the volume on the lower side. One to make sure your equipment's working, uh, to, you know, the, the conditions are going to be more variable. And then three, just to, to be able to have a smoother transition back onto the road because of the. wide variety in terrain, conditions with the wind, and again, that instability and maybe being in slightly different positions and having slightly different mechanics while you're out on the road. And then after a week or two of that, well, two weeks of that, then diving back into your training plan with that. So while you're doing those shakeout rides, continuing your actual training indoors. It's easy to get excited when it's nice out. I've certainly been a culprit of it, too, where, you know, we're just stacking rides back-to-back days when it's nice out, especially here in Montana, in the mountains, where the weather can be changing rapidly, and we're getting to really try to take advantage of those nice days and getting in as much as we can. set ourselves up for success and pumping the brakes a little bit and just having those rides be enjoyable a little bit a little bit lower volume before really getting after it back to our training to prevent injury. So just some practical advice for you on again transitioning from the trainer back onto the road things to consider Double checking your equipment, making sure that's functioning well, especially the headset and the brakes, and that your emergency kit is dialed. Two, preparing for the weather, mainly in terms of layering so that those muscles, you don't get too cold, perhaps increasing the likelihood of a strain or a tendinopathy. And then three, just going easy with that volume back out onto the road and having those first few rides just be shakeout rides just for fun not really training rides.

SUMMARY
So hopefully that's that's helpful for you and you are getting back outside onto the road or if you've been in the south you've been on the road all along and you know If you're interested in treating endurance athletes, please join us for one of our offerings. We're really starting to ramp up here with professional bike fit certification. Matt Keister and I will be in Asheville, North Carolina, April 19th and 20th. We still have some spots for that. This should be a great time. It's the only time that we have both lead faculty at the same course for the year. And then I'll be in Minneapolis in the middle of May. Matt will be in Denver in June. For Rehab of the Injured Runner Live, we only have two offerings so far for 2024 until Megan Peach gets back from Austria later in the fall. Uh, first offering will be in Milwaukee the first weekend in June that is filling up. So, uh, if you have an inkling to, to, to join us there, uh, sign up sooner than later. And then second offering will be in Maryland in September. Uh, we're getting some signups there too. So hope to see you at a course. And then next, um, online cohort for rehabilitation of the injured runner is May 7th. Uh, everyone have a great weekend. Get outside, do something fun, get out on your bike if you can, or get out running. See ya.

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

Apr 4, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty Jordan Berry discusses five different ways to work on correcting lateral shifts in patients demonstrating low back pain with radiculopathy, including standing, sidelying, and prone variations.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

JORDAN BERRY
All right, what is up? PT on Ice Daily Show. This is Dr. Jordan Berry, lead faculty for cervical management and lumbar spine management, as well as our T and D content over all the spine division. I've got Jenna here with me today from the fitness athlete division, and we're talking lateral shifts again. So a few weeks back, we talked about the lateral shift and how we have to be able to pick that up in order to oftentimes move forward with the planned care. So when someone comes in that has really severe back and back related leg symptoms, oftentimes the lateral shift is the number one thing that you have to be able to pick up. and clear up, because if you don't, you're not oftentimes going to be able to work into this agile plane and start resolving those symptoms. So a few weeks back, we talked about the main ways from an objective and a subjective standpoint that we could pick up on the lateral shift. Today, we're going to change gears and talk about actually correcting it. So a few ways during our treatments that we can correct the lateral shift. Now, by far, the most common is the standing variation. or we're shifting the person that we'll talk about in just a second. But oftentimes the irritability is too high to allow for that. So we can't use that variation. We have to go to something in a non-weight-bearing position. So we'll talk about a few ways based on irritability that we can regress the standing lateral shift correction to be able to match that person's irritability and move forward during the plan of care, okay?

CORRECTING THE LATERAL SHIFT IN STANDING
So I'll have Jenna stand for just a second. and we'll demo as if she has symptoms on let's say the left side. Okay, so oftentimes we turn the camera just a bit here. If we have symptoms on the left side, almost always, 90 plus percent of the time, the shift is gonna be away from the side of symptoms. So we're gonna assume today that the shift is away from the side of symptoms. And Jenna would then, if she has symptoms on the left side here, right, would be shifted away from those symptoms. So for the standing variation, I would be standing on the opposite side of symptoms. So I would be in a staggered stance here, right? She's going to have arms either across like this or at least up away from her hip so that I can get around her hip. And I'm going to have my head on the backside of her shoulder blade with my arms wrapped around the very top of the hip. And so we're right here. And then I'm going to shift over and load towards this side of symptoms, right? So she's avoiding that side. And I'm wrapped around shifting towards the side of symptoms, okay? So we covered that technique in a lot of detail during our lumbar spine management weekend course, so we're not gonna spend a lot of time on the standing variation right now. But what I do wanna do is show you a few non-weight-bearing variations, because if you go to test that out, and the irritability's high, and that person either starts to peripheralize or pain increases, we have to have a variation in a non-weight-bearing position that is a little bit less vigorous that we're gonna start from.

CORRECTING THE LATERAL SHIFT: SIDELYING
Okay, so immediately if that's not working, my first regression here is in the sideline position. So now we're going to have Ginego on the table here. And I'm actually, I'm going to change sides for the video, but it'll be easier to see here. So Jenna is lying on her side, and we're going to say that the side that's up on the table, in this case, the right side, is the side of symptoms. And so for their side-lying technique, we're going to do a side-lying lateral glide. Again, during our lumbar spine management weekend course, we cover this in depth and we typically refer to it as a way to improve range of motion and mobility, just generally speaking in the stiff back. But it's a great technique for a lateral glide or a lateral shift correction as well. And so the way that we set up is I'm facing the bottom corner of the table and I have my contact hand that weaves through Jenna's arm here. and right around my hypothenar eminence rests along the paraspinal right here that's on the top. So I'm just hooking my hand in, facing the bottom corner of the table, and I just drop my weight down here. So again, we're saying that the top leg here is the side of symptoms, and we are gliding down towards the table or away from the symptoms if you want to think of it like that. And oftentimes that, because we're not in the weight-bearing position that we were in standing, the patient will be able to tolerate that much better.

CORRECTING THE LATERAL SHIFT: PRONE
Now, what if they can't tolerate the side-lying version or they're peripheralizing or not seeing the changes that you would expect? Well, we could then go to a prone variation. And so appreciate for that last technique, right? I was standing above the side of symptoms and we were gliding away from the symptoms. So we're doing the exact same thing in this prone position now. I'm going to bring the camera slightly closer here. And the same idea here in the prone position. So we're going to say that the side that I'm standing on right now, right, the side towards me or closest to me is the side of symptoms. In this case, it would be Jenna's right side. So instead of having my hand fully on dropping down into the lateral glide, I'm still going to glide laterally or away from the symptoms here. But I've got my thumb pads here together. and they're on the side of the spinous process that the symptoms are on. So again, for those listening and for those watching, just to make sure we're on the same page, if we have right-sided symptoms, the pads of my thumbs are on the side of the spinous process on the right side. And I am just gently gliding away. This is the exact same thing as the sideline lateral glide. It's just a less aggressive version. So again, my thumbs are together like this on the side of the spinous process where the symptoms are and I'm gliding away. And oftentimes just that very, very gentle, soft mobilization is enough to start to get some centralization. Okay, but what if we can't tolerate that, right? What if, for example, the actual spinous process or the area in the low back is too sensitive to actually be able to put contact or pressure on the spinous process? So then we could do the exact same thing, only now we're contacting the torso and the hip. So our contact hands are above and below the lumbar spine. So with the exact same setup that we had, again, the side of symptoms or the right side, the side that's closest to me, I'm going to have one hand on the right glute, right to the glute on the side of symptoms. And then I'm going to have my other hand on the torso on the opposite side. and I'm pushing the glute away and pulling with the torso towards me. So again, it's the exact same thing that we're doing the previous two techniques in the lateral glide. We're just not contacting the actual lumbar spine now. So we push away with the glute and pull towards with the torso here. Push away at the glute and pull towards on the torso. And now we can do the exact same mobilization in the lumbar spine without actually having to contact the lumbar spine.

CORRECTING THE LATERAL SHIFT: BELTED MOBILIZATION
OK, I've got one more. So this is my my go to if someone cannot tolerate any of those other variations. It's very, very rare that someone would not be able to tolerate one of the ones that we just went over. But I want you to have a technique in your arsenal where if the person really isn't tolerating anything at all, where you're going right at that area where they're having to cross that leg over on the table that's painful. I want to give you a version that is completely passive on the patient's end where we're actually going to use a belt around the person to lift the hips. So for the setup here, the painful side now is actually down. So this is the opposite of that first version that we showed. So we move the camera so we can see here. Jenna's painful side would be down towards the table. And what I'm going to do is take a belt here, mobilization belt, you could use a gait belt, and I'm going to wrap it underneath Jenna's hips. So we're going to weave this through. And I'm just making a loop with the belt. And so what I can do now is actually get on the table. I'm going to be up above the person and I can lift Jenna's hips up while she's completely passive and does nothing. And what that's doing is the exact same thing as what we were doing with the lateral glide, right? When the painful side was up and we were gliding down. Well, now the painful side's down and we're the ones that are pulling up. So I would be on the table above pulling on the belt. here. And Jenna can stay completely relaxed. She doesn't have to do anything at all. And I can do a lateral glide with the painful side down. Again, very rare that I would ever have to go to that technique, but it does happen and it's nice to have that in your arsenal.

SUMMARY
So those are five ways, five of my most used ways to correct a lateral shift in the clinic. The one that we're probably all familiar with, again, is the standing variation. That's the one that you see in most courses. That's the one that you see in most textbooks. And it's a great technique when it works, right? It's a great technique when the irritability allows for that weight bearing position to be used. But plenty of times in the clinic, the person's not going to tolerate a weight bearing or a loaded shift correction. So we have to go to a non loaded or non weight bearing position. I love the lateral glide that we started with. You can also go prone and do that really small, gentle lateral glide with the pads of your thumbs on the side of the spinous process. We could also go above and below the area if it's too hot to actually get your hands in there and contact it. You could go one hand on the glute, one hand on the torso, push and pull to do the exact same loading to the lumbar spine. Or you could go painful side down, belt around, lift the hips up. All right. Well, those are five variations. Hopefully that helps you out in the clinic with managing some of these folks with back and back related leg symptoms. If you're going to be at a cervical spine or lumbar spine management course in the future, we will see you there. Have a great day in the clinic. Thank you, 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.

Apr 3, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave as he discusses three key steps to keeping older adults moving while injured: symptoms, guardrails, and modifications.

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

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

EPISODE TRANSCRIPTION


INTRODUCTION
Hey everybody, Alan here, Chief Operating Officer at ICE. Thanks for listening to the PT on ICE Daily Show. Before we jump into today's episode, let's give a big shout out to our show sponsor, Jane. in online clinic management software and EMR. The Jane team understands that getting started with new software can be overwhelming, but they want you to know that you're not alone. To ensure the onboarding process goes smoothly, Jane offers free data imports, personalized calls to set up your account, and unlimited phone, email, and chat support. With a transparent monthly subscription, you'll never be locked into a contract with Jane. If you're interested in learning more about Jane or you want to book a personalized demo, head on over to jane.app.switch. And if you do decide to make the switch, don't forget to use our code ICEPT1MO at sign up to receive a one month free grace period on your new Jane account.

JEFF MUSGRAVE
Welcome to the PT on Ice Daily Show. My name is Dr. Jeff Musgrave, Doctor of Physical Therapy. It is Wednesday, so it is all things geriatrics. Happy to be here with you for a PT on Ice Daily Show brought to you by the Institute of Clinical Excellence. So, team, I had a really interesting scenario. One of the things that I do is I'm an owner and a coach in Stronger Life and it's fitness for people 55 and up. We had a member who had missed a couple weeks trying to go through the diagnostic process for some reactive arthritis. And actually, still, that's just a working diagnosis. About four weeks now, currently, since diagnosis. But after a couple weeks, she reached out and was like, hey, I really want to get back in the gym. It's good for me physically. It's good for me mentally. This is a member that's been with us for about four years, very dedicated to her fitness, showing up, doing what she can. Each day has gotten really strong and didn't want to lose her fitness. So here she is in the medical system advocating for herself Which is sad that during this process, you know this this PT first Idea that we're trying this mission that we'd like to see come to fruition if we're not there yet. Okay, so she's had her blood work, she's had x-rays, all these things are done, she's getting no intervention, no formal PT, and she's begging, can I go back to the gym? And we're like, absolutely. Now, are her providers and her medical team on board with this? Not quite, but that's okay, because we're going to take good care of her. So, oftentimes we find ourselves on the other end of this scenario, right, where we are trying to figure out If we've got someone we're treating for some type of injury, an older adult, and they are going to group fitness, how can we set them up for success?

3 STEPS TO CONTINUING TO MOVE WHILE INJURED: SYMPTOMS, GUARDRAILS, AND MODIFICATIONS
Particularly, we know when we're working with older adults, it's all about this game of building reserve and maintaining resiliency. We know we want our older adults to be as strong as possible. We want to put as much distance between minimal ability to function on a daily level and their fitness. We want to build as much margin, build as much reserve as possible, so when illness or injury comes knocking, because we know it's going to happen eventually, right? We want them to be able to fight back. I want to outline a few things that we do at Stronger Life that I think are just a good guideline if you're a treating physician and you want your patient to be able to go into group fitness. A lot of these things you're probably already doing, but just thinking through this lens, we know that the game is vital. We've got to keep people moving. We're trying to get people as fit as possible and keep them that way as long as possible. So I'm going to say, by and large, we believe keeping people moving is paramount. That is what we have to do. We have got to get and keep people moving despite their injuries. With our formal physical or occupational therapy interventions and or in the gym, fitness, Most of the time we can keep them moving if we can set them up for success. So I've got three steps that I think will be very beneficial. The same thing that I used for this Stronger Life member, and that is symptoms, guardrails, modifications. Symptoms, guardrails, modifications.

SYMPTOMS
I'm going to set the stage just a little bit more for this patient. So when we're thinking about this specific scenario, it was reactive arthritis in the knee as a working diagnosis. This member had been nearly non-weight bearing to partial weight bearing limited range of motion, painful loading of the knee. So focused on the knee here. And at this point, two weeks of symptoms, no better. We wanted to dig into her symptoms. So she gave us a heads up she was gonna be coming in, which is nice, we don't always get that on the fitness side of things, but you're gonna have that information as a treating clinician. So things we want to know, obviously just like during the diagnostic process, if we're thinking about what do we need to know about their symptoms going into some type of movement practice or group fitness, or maybe group fitness are already engaged in. We wanna know their ags. We wanna know what's making these symptoms worse. Is it the range of motion? Is it the pain? Is it the volume, the number of repetitions? Is it power-based movements that are exacerbating their symptoms? And this is all information you're gonna know about your patient that you're treating already. So we wanna know that. and set those baselines. So if you're treating the patient, you probably already know the symptoms. Step one, check. We know for this specific case scenario, it was painful range of motion past about 30 degrees. 30 degrees of knee flexion is about all we could get. Weight bearing Sometimes not exacerbating symptoms, sometimes it was. So the member was walking in on a cane and was very leery of weight bearing. So the things I knew about this member coming in is they've had chronic knee pain for a long time. Their baseline, she's telling me, is a five out of 10. It was a nine out of 10. She was in the ER on pain medication. Two weeks later, she's weight-bearing, ass-tolerated, on a cane, about 30 degrees of knee flexion. Loading the joint through range is painful, okay? So that's kind of the information I knew coming in. Dug in just a little bit right before class.

GUARDRAILS
And then we need to set some guardrails. So now that we know the ags, we also want to know the irritability. How irritable are these symptoms? If we flare this up, is she going to go into non-weight-bearing status? And is this going to affect her activities of daily living the rest of the day? or is she going to have a little increase and then as she rests symptoms are going to come back down. It wasn't, her symptoms in this scenario were not like once they're spurred on she's dealing with these for days. So I put her in the low irritability category. Symptoms had been severe but they have been stable. So I wasn't really too worried about her Causing any symptoms in class but wanted to have some some options to take her out of weight-bearing make sure we're limiting her range of motion because we had identified those were the things that were exacerbating her symptoms, so That was the symptom baseline irritability, I would say low and then some guardrails and So for her, we let her push into the discomfort and set some guardrails. Hey, if your pain gets five out of 10s your baseline, if you hit a seven out of 10 or above, we need to make some changes. You need to pull me over, we'll cut the range of motion, or we can reduce weight bearing.

MODIFICATIONS
And then the last thing that we need to do is we need to give her some modifications. So we knew it was range of motion, and weight-bearing positions. So those are the two things we're looking at first. So I'm going to give you the exact workout we did and then we'll walk through symptoms, guardrails, modifications, and how we went through this. So the workout was a station-based workout where it started with weighted step ups. Okay, you can see how that could be a problem. Then we had sumo deadlift high pulls, which were weight bearing. We had some time on the rower. We had a three position balance movement. So it was dynamic balance with a water tube. And the last thing was spending some time on the ski. Heard different movements with her to work on modification. So she was weight-bearing with the cane, she was not able to do much more than a few steps, so we knew adding weight wasn't going to work. So we got to the weighted step-ups, I had her try it just with a couple inches, cut the range of motion, cut the load, still uncomfortable. I took her over for a wall sit, wall sit didn't work either. Okay, so cut the range of motion, cut the load, still too painful. So what did I end up doing? I ended up replacing the movement. And this is the last thing we want to do, right? We want to stick to the body group to get the desired stimulus from I had misjudged a little bit. She was a little more irritable than I thought, couldn't tolerate a static position to work the lower extremities, couldn't handle the reduced range of motion or the reduced load. So instead of replacing it, she ended up doing a seated Russian twist, okay, working on some core work, taking her knees completely out of weight bearing for that movement. Next movement, we got sumo deadlift high pull. Since I knew she couldn't tolerate much load plus, like body weight plus resistance, I went ahead and put her on a box to do a sumo deadlift. So she's still, she's in a seated position, has a dumbbell in each hand. She's driving from her feet, giving us this nice high pull motion. So she's still working her legs, her hips, her core. We're able to maintain the stimulus on that one, which was great. She was able to tolerate that. The next movement was the rower. So on the rower, I knew that her range of motion, she had about 30 degrees. That's all we could work with. Rower, pretty friendly place for people, especially with reactive knee arthritis. So she can control the range of motion and it's limited resistance, right? We've taken gravity out of the picture here. So what I did is I had her put her feet on the floor of the rower and just drive through her feet and cut the range of motion. And she was able to tolerate that really well and actually saw progress during this workout from the beginning of the workout to the end of the workout with her getting more and more range of motion. She actually said that time on the rower made her knee feel really good. So that was good. So we modified the rower. Then we've got this dynamic balance movement where you're starting on one leg, quick step, and then standing on the other. So there's a dynamic component, there's a power piece, there's a single leg support piece, and we know weight bearing on both legs is okay. Single leg is kind of out of the picture. So we had her work on some weight shifting, holding a little bit of load and she was okay with that, which kind of surprised me. And actually as the workout went on, she ended up doing a little bit of single leg support and weight shifting until she was on one leg and then the other. So that was a replacement. So that dynamic power-based movement ended up being more like weight shifting side to side. I gave her the option to close her eyes to make it a little more challenging and the surface she was on was dynamic. So that was the modification there. When it came to the ski, knowing how much weight bearing was in there, she's walking from station to station, I had her do the ski from a seated position. So arms length away, the setup is still very similar for the ski, reaching up nice and tall, pulling to the hips. So she's still getting a cardiovascular stimulus, she's still working overhead pulling, so we're able to maintain the stimulus. So that is the process that I went through, looking at her reactive knee arthritis, trying to figure out what she could tolerate, cutting the range of motion, cutting weight bearing, but she got a great workout. Her fitness is better because of it. She's worked really hard to maintain and build that reserve and resiliency, and we're able to go through and give her a great modification, something that's meaningful and helpful, trying to stick with maintaining the stimulus as much as possible, what direction, what muscle groups, and then last case scenario on modification, sometimes we just have to replace it. What's something valuable you can do, even if it's not the same muscle group, not the same position? So oftentimes when I'm, I gave you kind of the scenario I did this with for this patient in particular, knowing weight bearing and range of motion was limited and producing symptoms. But when you're thinking about just in general, oftentimes cutting the range of motion, cutting the load, those two can help. If those don't help, you can still maintain the stimulus from going from a dynamic, to a static position. So say it was push-ups, for example, are painful, can we do a static plank? Tristatic, so cut the range of motion, cut the load, take them a little bit more out of the weight bearing position, and then tristatic. If you can't do a static with reduced range of motion, reduced load, then it's time to start thinking about replacing that with another upper extremity movement. But if you're in a scenario where you've got to make a decision quickly, or you're trying to arm your patient to make these modifications in a group class, just have them see if there's anything else they can modify going in. So the reality is this patient is still in the diagnostic process. There has not been any solid diagnosis for her, no clear prognosis, still getting no intervention. She's been coming to group classes for two weeks. Her pain is better. Symptoms are reduced. Range of motion is improved. She's walking without the cane all while awaiting her one-on-one intervention and a diagnosis. So during this time she's been able to improve her fitness, improve her range of motion, improve her weight-bearing tolerance, and the other benefit that she brought up, which we've not discussed yet, is just the mental and emotional piece. we have to remember for older adults, maybe they're seeing us for a pain or a problem, if we can keep them moving in the group setting, we can equip them with the guardrails, we know what causes their symptoms, we know what we need to modify, because we're already working around them, we just need to give them modifications they can use once they get into the group fitness environment. And she's getting better, even though she's had no formal intervention yet, which I love. But the other piece is the social isolation piece. For our patients, a lot of our older adults are socially isolated. That changes our health outcomes, team. Friends save lives. And keeping our older adults connected with their social networks is crucial to treat the whole patient. And she said mentally and physically, she has felt a lot better. And if you've done any studies, looked at any of the studies for chronic pain, We know that keeping people moving and some of these mental emotional factors can be huge in the experience of pain. The things we want to do to set our older adults up for success, to keep them moving in the group environment as much as possible, to maintain that reserve, to maintain those social connections, is we've got to know their symptoms. We've got to know their ags. We've got to know what makes their symptoms worse, their symptom irritability. After we know their symptoms, it's guardrails. If this, then that. If your symptoms get to, in this scenario, was a seven out of 10, then we need to cut the range of motion, cut the load, or we need to take you out of weight bearing. And then the last piece is to be set with those modifications just like we outlined. We knew for this client, the range of motion, the load was the issue. So those are the things that we changed. And if those two things don't work, then we completely replace it. But the more we can get and keep people moving, The more we can help them maintain their fitness and their social connections, ultimately, the better their outcomes are gonna be in our clinic. So, I hope that was helpful. Real life scenario, patients getting better, no formal PT, symptoms, guardrails, modifications. Team, I hope that was helpful. I would love to hear your thoughts on that. If you have any other strategies you like to use to modify around symptoms, in particular to equip your patients for the group training environment, I would love to hear about those.

SUMMARY
If you are interested in coming to check out us for more mmoa content we have got our mmoa level one eight week online course level one is happening may 15th if you've already had level one you're looking for level two it's going to be may 16th We've got our live course is gonna be in Raleigh, North Carolina, Urbana, Illinois. We're gonna be in Burlington, New Jersey, and we're gonna be, I'm gonna be in New Orleans, Louisiana this weekend. Team, the live courses are a lot of blast. If you've not been to one, you should come check us out. The weekend after, if you're on the West Coast, I'll be in Bellingham, Washington. Would love to see y'all in the live course. If you get a chance, love to hear your thoughts on this topic, on this case study, keeping people moving in group fitness despite their injuries and symptoms. Have a great day team. We'll 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.

Apr 2, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division Leader Zac Morgan discusses the gap between social media and actual clinical practice, seeking real mentorship from real clinicians treating in the clinic instead of social media influencers, and the importance of having a healthy sense of humility regarding manual therapy treatments. 

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, Alan here, Chief Operating Officer here at ICE. Before we get into today's episode, I'd like to introduce our sponsor, Jane, a clinic management software and EMR with a human touch. Whether you're switching your software or going paperless for the first time ever, the Jane team knows that the onboarding process can feel a little overwhelming. That's why with Jane, you don't just get software, you get a whole team. Including in every Jane subscription is their new award-winning customer support available by phone, email, or chat whenever you need it, even on Saturdays. You can also book a free account setup consultation to review your account and ensure that you feel confident about going live with your switch. And if you'd like some extra advice along the way, you can tap into a lovely community of practitioners, clinic owners, and front desk staff through Jane's community Facebook group. If you're interested in making the switch to Jane, head on over to jane.app.switch to book a one-on-one demo with a member of Jane's support team. Don't forget to mention code IcePT1MO at the time of sign up for a one month free grace period on your new Jane account.

ZAC MORGAN
Good morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty here with the cervical and lumbar spine management, teaching both of those courses on the weekends. And if you have not had those courses, both of them involve a decent amount of manual therapy. So we enjoy kind of teaching manual therapy, doing manual therapy on one another those weekends and kind of reframing how you might frame that manual therapy intervention with your clients. in the hopes of maybe creating a little less dependence on manual therapy and instead a lot of independence in our patients and kind of pushing them towards a more fitness-forward lifestyle. For those of you that have been to the courses, you know that's a big deal to us here at ICE and we love doing that. And this morning's podcast is titled Manual Therapy Misconceptions because I think this is definitely an area in the manual therapy world, physical therapy specifically, where I see a lot of disconnect between what happens in the clinic and then what happens on social media. So I want to start out by talking about over the last several years of spending a lot of time on the weekend, you know, teaching manual therapy techniques, fielding questions in those settings, as well as spending a lot of time in the clinic treating a lot of clients with acute back pain, with acute neck pain, with persistent back pain, with persistent neck pain. I see a lot of misconceptions and at our clinic we spend a lot of time training younger clinicians and bringing through students and then also on the weekends working with a lot of seasoned clinicians And I just see that social media has had an influence on our profession's willingness to use manual therapy and our understanding of everything. And so I think that's what today's podcast is about, is sort of how that has been influenced and maybe just reframing some of our thoughts around it.

THE GAP BETWEEN SOCIAL MEDIA & REAL CLINICAL PRACTICE
There's one thing that's for sure. If you spend a lot of time on social media and specifically follow a lot of the conversation that happens in our profession, you'll see a huge gap between what a lot of people say out there on social media and what actually clients want and what drives people to seek out physical therapy. So there's a huge gap there. And that's where I want to kind of start is with the social media conundrum. Obviously, social media platforms have become such a popular way for us to get new clients, for us to educate the public, and for us to educate one another within the profession. But there is a conundrum here. And the conundrum is that all of the platforms, really regardless of which one you spend time on, they are built specifically for the reason to drive engagement. The goal of those apps is to keep you on them for longer. That's why they exist. So within that, the content that typically keeps people's eyes on it for longer is generally framed more contrarian or more negative, that tends to drive engagement more frequently. So if you post something negative or if you point out something negative, often you will see a lot more engagement, a lot more comments, a lot more likes, a lot more just overall view of that content. And I think that this can cause a lot of issues in clinicians and has caused a lot of issues and I've seen it firsthand and that's a huge issue in our profession. So I kind of want to talk a little bit about those issues specifically and then what we might do to sort of reconcile them.

SOCIAL MEDIA DRIVES CLINICAL CONFUSION
So the biggest issues that I see and this is really regardless of whether it's a younger clinician or somebody who's a little bit more of a seasoned veteran What we see is when people spend a lot of time kind of intaking some of that negative information from social media, it drives a lot of clinical confusion. People are confused about what they should do with their patients. It drives ethical challenges. Some of these posts call into question how ethical manual therapy is, and it makes people feel like maybe it's a little unethical for us to be doing hands-on care. And they definitely often drive further away from expert opinion. So when I say expert opinion, I mean things like our clinical practice guidelines. So you think about what that is, like how those are formed, and it's really the foremost experts in our profession getting together, synthesizing all the data that exists, synthesizing clinical experience as well, and then making evidence-based recommendations. To get a clinical practice guideline published, it requires a lot of work, a lot of experts to communicate with one another and develop expert opinion. And here's what we think. This is a grade of A, this is a grade of B, and so on. To get a social media post out requires nothing other than an internet connection and a device that can do it. sometimes we're reading these opinions from non-experts and those non-experts could wind up being very loud and have a large platform and that doesn't always equate to someone that actually spends a lot of time in the clinic. So I think this is where some of that confusion can come into our practice, whether again, whether you're a younger clinician or someone that's more seasoned, it's kind of who we're choosing to listen to because of who's the loudest on social media and that being where we get most of our information.

"MANUAL THERAPY DOESN'T WORK"
So the narrative specifically, the misconception specifically that I'm addressing in today's episode is this manual therapy doesn't work narrative. So a lot of people have that feeling that manual therapy doesn't work and there are certainly studies that have challenged the efficacy of manual therapy and you see those studies get talked about a lot on social media again because they're negative and they drive engagement. But that narrative is one that I have heard often be challenged either on the weekend or in the clinic where people are just confused about whether or not manual therapy works. And that's a huge disconnect between clinicians that you talk to that do treat a lot of these issues. Those clinicians typically feel strongly that it does work and again our experts If you look in the clinical practice guidelines for back pain, for instance, you're going to see that really regardless of the presentation, there's some expert opinion that we should use manual therapy, that it should be used almost regardless of acuity or stage. Manual therapy might be something that should be included in back pain. And that's not just profession-specific. A lot of clinical practice guidelines make those suggestions, but ours certainly do. The updated ones from 2021 from Stephen George and colleagues make a lot of recommendations surrounding manual therapy. So I think that disconnect is driving a lot of clinical confusion for us. The reason this podcast kind of came up in my head, the topic, really came to me when I was looking through the recent JOSPT and there was a systematic review from, forgive me if I butcher the name here, but I think it's Ruzick et al, and this was just a couple of weeks ago that this one was published. You might have seen it in Hump Day Hustling, our newsletter. But essentially, it was a systematic review. It was done over at Bellin College. So the DSC program and the fellowship there at Bellin went in and they did a systematic review, kind of analyzing the literature, looking at manual therapy for low back pain. The question they were trying to answer was, are the methods in these manual therapy studies, the way they're described, are they repeatable? So in other words, if you read these studies, and you're an independent researcher outside of the group that just did that study, could you read through that and then actually replicate the findings? And the way they were looking at that is, are the methods described well enough for us to replicate the interventions? The answer was no. There was poor reporting in manual therapy intervention studies, and that limits the reproducibility of those findings. This is a big issue because one of the major tenets of science is that it needs to be replicable. You need to be able to check your work. If you're not able to do that, I would call into question whether or not it actually is science. At the end of the day, science has to be described well enough that an independent researcher could then come in and replicate the interventions to see if they can replicate the findings. If you then get a lot of data pointing in one direction, we start to say, you know what, I think there's some merit here. But if the methods aren't described well enough that we could even replicate them, you have to call into question whether or not that's actually science. And I guess my point here is a lot of these conclusions that are drawn on social media posts are of an independent study where maybe the methods aren't even described well enough to where you could apply them to the clinical cases you're seeing. And so we're drawing a huge conclusion that manual therapy doesn't work Meanwhile, the studies aren't even replicable. I think this is a massive issue. There's a huge disconnect there. And so I don't just want to point out the issue, I also want to talk to you briefly about what we might could do going forward, given that the studies don't guide us that well, given that they're not super replicable, and given that we can't draw those big conclusions off of non-replicable studies. And so let's address those problems.

CLEAR UP CLINICAL CONFUSION WITH ACTUAL MENTORSHIP
I think that the confusion here can be sured up by seeking mentorship. expert opinion and just time around expert practitioners. So what you will find often when you're actually seeing those people treat in the clinic, when you're working alongside of those people, is they're not confused about whether or not manual therapy works. They often have some type of a framework that they're bringing forward to the patient and they feel confident that they can often help patients because of their skill set. So I think we, as a profession, need to lean more on the empirical side of the scenario, given that our data is a bit confounded by lack of replicability. So what I mean by empirical is things you can witness, things you can see. The test-retest model, actually spending time around clinicians that utilize that and frame it positively for patients. That's what I think we should be seeking out as our evidence-based practice right now, because I think a lot of our actual evidence is challenging. That is the short-term solution. In the short-term, I would suggest if you're a younger clinician or a seasoned clinician who has some disconnects surrounding manual therapy, seek out mentors that have an understanding of manual therapy, who see a lot of back pain, who have busy schedules, busy caseloads full of patients with back pain looking to get better and see how they handle those scenarios. I think that is a much better route than seeing social media posts and drawing a huge conclusion from those posts. Meanwhile, the evidence that they're analyzing isn't that great.

RESEARCH METHODS MUST IMPROVE
The second thing would be a more long-term solution, and this is more speaking to the research going forward. We have to improve the methodology. That's what that systematic review from JOSPT That's what they suggested, and I couldn't agree more. In the future, our methodology has to improve. We have to get better at describing our techniques so that we can, over time, whittle down what is the most effective. But the problem is, that doesn't help you today. When you go see that patient that comes to see you with five days of low back pain, and they're really looking to feel better quickly, and they're starting to lose a lot of functional capacity because they're not doing much, because their back hurts so much, and you're confused about whether or not you should use manual therapy, long-term improvement of methods won't help you. You need to fix the short-term problem and get some understanding by spending time around clinicians that are used to seeing that and that can help you move that patient forward. And again, our practice guidelines are pretty clear here. they make a lot of suggestions surrounding utilizing manual therapy. And most of my colleagues that also treat a lot of back pain, that's basically my whole caseload is back pain and neck pain, occasionally shoulders, hips, knees, but a ton of back pain and neck pain. and I utilize a lot of manual therapy. And I don't feel bad about that. I feel like framed in the right way, it's so helpful to help that person reduce their concern and improve their activity. I agree that there are some ways you could frame it that might challenge someone's belief system in their body, but just don't do that. Just frame it correctly. And so that's my call to action. Seek credible mentors, contribute by pushing our profession forward with the use of these techniques that patients are going to seek out and they're going to get regardless of whether they see you or someone else. So let's be good at it so that they do seek us and then reframe the methods in future studies so that that way we can actually get good scientific data moving forward and understand what works and what doesn't.

SUMMARY
Team, in summary, I think a lot of clinical confusion comes down to a mismatch of understanding the quality of the information you're receiving. Social media has made it very easy to get your opinion out there, and often there will be opinions coming from folks who may or may not even be experts, who may or may not even be treating in that region, and challenging your belief system on whether or not an intervention works. And I see that confusion manifest as confused young clinicians who have a challenging time deciding whether or not they should utilize manual therapy. Spoken from someone who treats a lot of those problems and who has spent a lot of time around experts who also treat those problems, I've been very lucky to get a lot of time on board with experts. there's not that much confusion on the other side of the coin. So I think that mismatch of where you're getting the information from is huge. So my call to action is let's improve our manual therapy skill set. If that's what you're looking to do and this message is resonating with you at all, I'm going to tell you about a handful of upcoming courses because this is huge for us at ICE. This is why we don't hire people who aren't clinicians. It's really important to us that at ICE, when we bring forward a message to you, you're getting that message from people who actually are in the treatment room. They're behind the walls. actually trying to eradicate these problems over time.

UPCOMING COURSES
If you're looking for that in the cervical spine, May 18th and 19th, Casper, Wyoming, that one's filling up fast. So if you're in that area and you need a spot there, Casper, Wyoming only has a few seats left, make sure you jump into that. At the end of June, the 29th and 30th, will be in Kent, Washington. And then in July, the 13th and 14th, Charlotte, North Carolina. So a handful of options there for neck. If you're looking for low back, this weekend we've got two course offerings. If you want a last minute ticket, you can certainly jump into one of those. Carson City, Nevada, and then right here where I'm at in Hendersonville, Tennessee. Still seats left in both of those. And then next weekend, April 13th and 14th, near Boston in Braintree, oh I'm sorry, yeah, in Minnesota. I think I've got that down wrong. I think it's Braintree, Massachusetts and that's actually over in the Boston area. So if you're looking for either one of those and you're liking these narratives for reframing manual therapy, jump in with us. We're excited to bring forward some different ways of framing manual therapy. Thanks, that's all I've got for you team. We'd love to hear some interaction here in the comments throughout the day. Keep an eye on the thread.

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.

Apr 1, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jessica Gingerich discusses the kipping pull-up as well as modifications to maintain kipping for pregnant athletes & reintroducing kipping sooner for postpartum athletes.

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

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

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

EPISODE TRANSCRIPTION

INTRO
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.switch. And if you decide to make the switch, don't forget to use the code ICEPT1MO at signup to receive a one-month free grace period on your new Jane account.

JESSICA GINGERICH
Good morning! Sorry for the late start. Welcome to the PT on Ice Daily Show. My name is Dr. Jessica Gingrich, and I am on faculty with the Pelvic Division here at ICE. My goal for today is going to be expanding on my last podcast that was about gymnastics during pregnancy, and really during the postpartum phase as well. So just a quick review of what defines gymnastics. It is a broad term that encompasses many movements and is utilized in many different sports like gymnastics, cheerleading, yoga, trampoline, and also CrossFit. So today I'm going to expand on the kipping pull-up rather than just a strict pull-up.

WHAT IS KIPPING?
Kipping is the act of using momentum to help drive certain movements. So we will see this on the rig, on the rings, and even during some handstand movements. So during pull-ups on the rig or the rings, kipping is using your lats and your core to drive into a hollow position, so that looks like a C, and then pulling into an arch position, which would be the opposite range of motion. This taxes the core through active muscle contraction, as well as putting the anterior core on a stretch. We often see coning and doming during the hollow or arch position as it stresses the anterior core during both movements. We see this during pregnancy and postpartum, but we also see this in other populations as well. Now, this is often communicated as something that is bad or dangerous, especially in the pregnant and postpartum women. And just remember, we want to help redefine that language as more of preparedness versus dangerous. Is your client prepared from a musculoskeletal standpoint to perform said movement. This is a less aggressive way of communicating. And remember, we don't want to induce fear around movement ever, but especially in this already vulnerable population of people.

WHY IS CONING & DOMING WITH KIPPING SEENAS DANGEROUS?
Now, let's unpack why coning and doming is seen as dangerous. So this was based on what we didn't know. a recommendation that came about because we didn't have research, so we erred on the side of caution, especially in the pregnant and postpartum world. We now know that coning is going to happen, and this is because of a mismanagement of pressure in that core canister. Mismanagement of pressure does not only happen in pregnancy and postpartum. It happens in all populations. We see coning and doming, and we use those words interchangeably by the way, in all populations like men, babies, and nulliparous women. That is just someone who has not given birth. Now, with this mismanagement of pressure, there are ways to optimize core recruitment to decrease objective coning or doming and increase co-contraction of the obliques, transverse abdominis, and rectus abdominis. However, you will see that many of your clients don't really care. They don't really take our advice on how to optimize their core. So will they hurt themselves? The short answer is no, they're not going to hurt themselves. Depending on overall core strength and preparedness of a particular task, they may be more susceptible to injury, but we're not scared of injury, right? We know how to rehab injury. What we don't want is to create fear around movement. So how do we negate this?

ELIMINATE FEAR AROUND KIPPING
So first and foremost, we eliminate fear. So, this can be difficult as mom, grandma, a random dude at the gym, friends, and really most commonly what we are starting to see now with Instagram is the fitness influencer that doesn't know the research. Telling your client that they shouldn't do certain movements. We train their core before, during, and after pregnancy. This includes more than just dead bugs, bird dogs, supine TA contractions, et cetera. Furthermore, we show them modifications in the gym to keep them on the rig and closely mimicking the stimulus of the workout when it comes to kipping pull-ups. The biggest point to make is your client maintains points of performance. This could be during any core movement, but specifically, kipping pull-ups is going to be, are they able to maintain the hollow position? If they are able to maintain that, then we let them go. Do your kipping pull-ups, whether you're coning or you're not. So the points of performance are going to be scapular depression and opposed to your pelvic tilt or that hollow position. This can be maintained. Can this be maintained throughout the pole? If they cannot maintain that, A, they're not going to hurt themselves if they continue. However, if you are educating around core optimizing strategies, then we modify. Modifications can look like feet supported kipping pull-ups, so that could be on the ground with a rack chin or with a box. Single foot supported kipping pull-ups, same thing, most of the time is done on a box so that other leg can hang off the box. Or they can further regress to feet supported strict pull-ups, known as the rack chin. There is always an option to decrease reps or rounds while we are choosing to modify that mimics the stimulus as well. When we choose a foot supported option, we are maintaining the kipping movement throughout a period of time rather than eliminating it. So we are saying, try this to maintain your pulling strength rather than eliminating it completely. This way they have more time or I guess less time between when they come off the rig during pregnancy and get back to it in that postpartum time. So to recap, change your language in the clinic, deal hope not fear. Bring attention to social media and how really we can't trust everything that we see and this may be showing your clients who to unfollow or who to mute in real time in the clinic. You should do the same thing for yourself and also report misinformation. So just like your client is going to be influenced by things that they see, so will you. The human body is resilient, and it does not stop being resilient once they become pregnant. Help your clients understand that. They will move with less fear, and they will come to you if they're unsure, or if they're having pain or symptoms. And so therefore, you're gonna be keeping them in the gym. And we want that, right? We want them to come to someone who is gonna encourage exercise throughout the lifespan, and that includes pregnancy and postpartum. Use modifications as necessary or if your client wants to. Remember that it may not be, they may want to use a modification because they feel better doing it. That's okay as well. Train their core in all positions and all ranges and prepare them for what life is. Prepare them for beyond what life is going to throw at them. Now, as always, we're gonna end with some courses. So if you head over to PTOnIce.com to check out our upcoming courses. In our live course, we dive into pull-ups, we dive into rig work and gymnastics. So if this is something that you wanna better your skills at, head over to PTOnIce.com to sign up. I hope you guys enjoy the rest of your week and I will 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.

1