The #PTonICE Daily Show

Now displaying: May, 2024

May 31, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the principle of Specific Adaptations to Imposed Demands (SAID), the principle of Somewhat Humdrum Adaptations to Rehab Treatment (SHART), and how to help patients & athletes reach & meet specific goals.

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 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 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, PT on ICE Daily Show. Happy Friday morning. I hope your day is off to a great start. Welcome to the PT on ICE Daily Show. It is Fitness Athlete Friday. I'm your host, Alan. I currently have the pleasure of serving as our Chief Operating Officer here at Ice and the Division Leader in our Fitness Athlete Division. We're here on Friday, Fitness Athlete Fridays. We talk all things CrossFit, Functional Fitness, Endurance Athletes. If you have a patient or client who is active on a regular basis, Fridays are for you. We have an exciting announcement next week you'll see on our social media. An entire week, thanks to dry needling faculty member Paul Killoren, an entire week dedicated to the deltoid. So you'll see the podcast next week, all the episodes will be about the deltoid, and you'll see all of our social media posts next week focused on educating you, everything related to the deltoid muscle. If you've taken our upper body dry needling course with Paul, you know that he has quite the obsession with the deltoid muscle. So we're really excited to see just how much shoulder content we can give you all next week. So tune in beginning June 3rd for an entire week of deltoid themed content. Today, the topic for Fitness Athlete Friday, what are we talking about? The SAID principle, specific adaptations to impose demands. You may have heard of this principle at some point in your life. You probably heard a very generalized definition of this term that maybe did not really help you understand what it is or how it could possibly apply. to exercise or to clinical practice.

WHAT IS THE SAID PRINCIPLE?
So the SAID principle, really, again, very basic definition that training a particular movement pattern, training a particular skill, training a particular time domain or energy system will result in the most efficient adaptation to that imposed stimulus that imposed demand on the body. And when we uncover, when we unpack the definition of the said principle a little bit more, we talk about actually the two ways that we see changes from this. The first being structural, that we see muscle size and shape takes place, and the other being neuro or neuromuscular, that we get a more efficient recruitment of muscle fibers, that we're able to recruit more fibers, larger fibers, recruit them in a more efficient sequence, so on and so forth. So that's the said principle in a nutshell. Today we're gonna talk about why it matters, give you a practical example from the gym, give you a practical example from the clinic and kind of wrap up why maybe we need to reconsider this. Maybe if we did learn this back in high school or undergrad or grad school or maybe all of them, maybe why we need to consider this more often in our practice, whether we're working with patients in the clinic or athletes out in the gym or a more active setting. So when we interact with folks in the clinic, whether they're patients for physical therapy, whether they're athletes coming to us maybe even for performance help, they don't necessarily need help with a physical therapy related issue. They come in and they may complain about a plateau about not making progress with their physical therapy about not making progress with their performance in the gym in their running plan or whatever. And if we take the time to unpack, and if we take the time to assess a couple things, what we usually find with these folks is they seem to be at a plateau, but it's really because they're not doing things specific enough to create the adaptation that they're wanting from the stimulus that they're giving themselves. Their rehab exercises, their exercises in the gym, their strength training, their endurance training, whatever that might be.

WHY DOES THE SAID PRINCIPLE MATTER?
And so why does the said principle matter? Training similar things may result in some carryover, but people I think fail to understand that it won't result in the most efficient, time-wise, in the most efficient carryover to develop a specific skill, a specific movement pattern, a specific progress towards a goal. So we often say, hey, well, doing a bunch of strict pull-ups make you better at strict pull-ups. Yes, of course. Will doing a bunch of strict pull-ups make you better at free climbing El Capitan? Well, there's gonna be some carryover, right? But probably the best thing to do to get really better at free climbing is to do free climbing. And arguably, we would say and not or. The best thing to do would be to practice the thing you want to get better at and then do accessory stuff like strength training to further enhance your way onto goals. We see this a lot. In the gym and CrossFit, folks always complain about not being great at running. We do run in CrossFit, but often lower volume, shorter distances than someone who would consider themselves a runner would consider running. And so when folks want to improve their 5k time, or they want to run a 10k or a half marathon, or maybe even become a marathon runner, They often say, I'm not getting better at running. And when we ask, okay, how often are you running? And they say, oh, well, I hate running. Running bothers my shins. So every time there's running, I just row or bike. Again, is there going to be carryover from rowing or biking or doing some other cardiovascular modality to running? Yes, of course, but not as specific, not as great as if you did running training to improve your goal of getting better at running. There are certain things that happen when you run more, You get an improved running economy. You get more efficient in that movement pattern because you're spending time in that movement pattern. And yes. We can get cardiovascular adaptations from rowing or biking, but it's just not gonna translate 100% to that specific thing. So that is why the said principle matters.

PRACTICAL EXAMPLE: "GRACE"
When we look at our practical example in the gym, we just had a benchmark workout last week at our gym called Grace. You may have heard of this CrossFit benchmark workout. 30 clean and jerks for time at a standard barbell weight of 135.95. And talking to members that day, people asking, hey, like, what is the world record on this? Do you know? I do know it's it's 59 seconds, right? With some people completing it, CrossFit Games athletes under 90 seconds. And so the conversation began, okay, If this takes me eight minutes, and it takes them 90 seconds, what is the difference between them and me? And I think a really lazy answer when people want to improve their performance when they want to break through a plateau, whether that's in the clinic, whether that's in the gym is well, they're just in better shape than you, right? That's a very lazy answer. When we break down why is that person better at doing that workout than you, we can start to unpack some characteristics, some specific characteristics of why their performance is higher than yours. We look at somebody like Matt Frazier, five time CrossFit Games champion, a minute 18 clean and jerk, grace time 30 clean and jerks for time, which is faster than a clean and jerk every two seconds. So moving fast, moving unbroken for 30 clean and jerks, what do we know about that athlete? Again, the lazy answer would be, well, he's been doing CrossFit a long time and he's just in better shape than you. Yes, but why? And the why matters, the specifics matter because that can turn into a training program for a person who wants to maybe cut 15 or 30 seconds off their grace time. or cut time off their 5K, or get better at strict pull-ups, or rock climbing, or whatever, right? When we look at Matt Frazier, why is he better at that workout? A long history of Olympic weightlifting, very familiar with a movement like the clean and jerk, very efficient in the clean and jerk, very strong, not only in the clean and jerk, but the movements that support the clean and jerk, the front squat and the strict press, an athlete who can strict press above his body weight, an athlete who front squats several times his body weight, and an athlete who has a 425 pound clean and jerk, right? So when we look at 135 pound barbell compared to a 425 pound clean and jerk, a 500 pound front squat, a 250 pound strict press, we say, okay, this is a very strong individual and specifically related to things like the SAID principle, he is very well trained in this specific movement pattern. It makes sense that because this is an incredibly light barbell for him, but he can hang on to it for 30 reps, move it touch and go unbroken, and get that workout done in 90 seconds that might take you five minutes. Why? You don't have as strong of a clean and jerk. You don't have as strong of a strict press. You don't have as strong of a front squat. You aren't as efficient at cycling that barbell because you have not been doing CrossFit as well. And in specific, we also look at time domain, right? He is getting a workout done while he is still in the anaerobic glycolysis time domain. He still has a lot of high power output. versus when you transition, when it starts to take you more to two to three minutes, we know your power output goes down. We know you're transitioning into your aerobic energy system. He's getting it done because he's more efficient at it before he runs out of gas. And so, how do we take that and translate that to a training program for that athlete? Well, of course, we need to work on your front squat. We need to work on your strict press so that your clean and jerk gets stronger. We also need to train your clean and jerk so you get more efficient at clean and jerks. We need to train your clean and jerk where you do touch and go reps at a light to moderate weight so you get efficient in the endurance of the clean and jerk, not just the strength. And we need to train a very fast, explosive time domain for you, right? That is a great athlete where we might say, hey, every minute on the minute, I want you to do five clean and jerks, seven clean and jerks, 10 clean and jerks, progress it and make them work in the time domain in the movement they want to get better at, right? This is what endurance athletes do all day long. They progress their volume, they progress their time domain, and they get very specific in what they're doing, right running, biking, swimming, maybe all three of those, maybe just one of those, but spending a lot of time in the movement pattern you want to get better at spending a lot of time in the time domain you want to get better at.

THE SAID PRINCIPLE IN THE CLINIC
Switching gears, we see this happen in the clinic as well. Just like somebody is plateaued maybe on a workout like Grace, we have patients who are maybe plateaued in their plan of care. And if we're not careful, if we're not specific, if we're not assessing in the clinic, if we're not using our clinical reasoning, we can develop a very high quality loading program, a very high quality accessory program for the wrong area, for the wrong athlete, for the wrong time domain. I call this the specific humdrum adaptation to rehab treatment or the sharp principle, right? A very boring adaptation that serves no purpose, because that person in rehab was forced to do what we told them to do. And maybe we weren't giving them specific enough of a treatment. So without proper assessment, we may not know what people need to work on. And so we're often surprised and curious and maybe upset when Gladys comes in and she hasn't improved her 30 seconds sit to stand. She is still only getting four reps done in 30 seconds. She's been here for six weeks and we look back at her treatment plan and most of her treatments consist of coming into PT and riding the new step at zone one heart rate for 30 minutes or most of her session. We should not be surprised when we reflect back on the said principle that Gladys is making no meaningful improvement, right? She is struggling with a high power, short time domain demand, a 30 second sit to stand, and her treatment almost entirely consists of relatively low intensity, long duration endurance activity. Again, specifics matter. What we have our patients do, they will adapt to. If we give them the wrong stuff, or maybe just not as effective stuff to do, we should not be surprised when we do not see them make a lot of meaningful progress. We can see the same thing with patients who are symptomatic. Why are we surprised when Mark comes to the clinic, he's made no progress on his lateral elbow pain, and all we're giving him in PT is high volume, low load, banded, or lightly resisted exercises. We know that's a tendinopathy, we know it needs load, specifically it needs time under tension, and it needs progressive loading. Giving that person a high volume, low load dose is likely what caused that condition in the first place, so we should not be surprised that that person is not making any meaningful progress. So getting specific, adopting the said principle matters. Avoid the sharp principle. We can make people pretty averagely better at stuff they don't need to get better at or don't want to get better at if we're not careful with our rehab treatment. I truly believe we have a lot to offer patients and clients from both a rehab and performance perspective, but only if we take time to assess where is this person weak in their game? What is the most important thing or the maybe most important two or three things they need to work on? That's what our rehab plan, maybe that's what our accessory program for the training they're already doing should look like. Keep it specific, especially if that person needs or wants a specific result. We can be very good at giving a lot of general treatment that gives a lot of general improvements, but if it's not helping that person meet their specific goals, then it's not as effective as it could be.

SUMMARY
So remember, what is the said principle? Specific adaptations to impose demands, train in the time domain, exercise in the time domain they want to get better at, you want them to get better at, train the movement patterns they need to get better at, and you'll be surprised at how quickly somebody makes progress. Avoid the sharp principle. Avoid just giving a general exercise prescription. We see this a lot in students who are so happy to walk in and write down a 30-minute AMRAP on the board or 24-minute REMOM and sometimes we have to stop them. We appreciate the enthusiasm, but we have to let them know, hey, you're just giving that person a bunch of general stuff that may not translate to them getting specifically better at the stuff they need or want to get better at to meet their goals. We have a lot to offer, but we have to make sure that we're assessing, reassessing, and we're being specific. So I hope this was helpful. If you want to learn more from us in the fitness athlete division, we'd love to have you. A couple chances coming up in the month of June. Zach Long will be down in Raleigh, North Carolina, the weekend of June 8th and 9th. And then we have our Fitness Athlete Live Summit here in Fenton, Michigan. That's the weekend of June 22nd and 23rd. We'll have all of our lead faculty, all of our teaching assistants here. That's gonna be a really fun weekend. Online, our next cohort of fitness athlete level one online starts July 29th. That course always sells out. And then our next cohort of fitness athlete level two online begins September 2nd. So, I hope this was helpful. Remember, keep it specific. Assess, reassess, keep it specific. Have a great Friday, have a great weekend. Bye everybody.

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

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Episode 1739 - Loading the lateral shift 0

May 30, 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 three different variations to load the lateral shift: side plank variations, RNT side bends, and unilateral carries.

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

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

EPISODE TRANSCRIPTION

JORDAN BERRY
All right, what is up PT on Ice Daily Show? This is Dr. Jordan Berry, Lead Faculty for Cervical Management and Lumbar Spine Management. And today we are continuing our theme of the lateral shift. So we've had a few episodes over the last few weeks. For the first episode, we were chatting about how do you actually recognize the lateral shift? Like from a subjective, from an objective standpoint, how do you pick up a lateral shift in the clinic so you're not gonna miss it? Second, we went over what are our lateral shift correction variations. Besides the standard one, then standing, what are some other ways that we could correct the lateral shift based on the patient irritability? Today, we're talking about loading the lateral shift. So this is something that comes up in courses quite often for our lumbar management courses when we're talking about the lateral shift and we have some different ways to reduce symptoms and to correct the shift or reduce the person's pain, decrease the irritability, but then what do you follow that with? Like in the session, right? We're not oftentimes just doing 40 or 45 minutes of a shift correction. We want to try to apply load to the person's system as well. And if we can start to load that person, the shift correction is going to quote-unquote stick more or be more effective during the session, between sessions. As long as the irritability allows for us to start to apply some load, we want to be able to. So we're going to go over three exercises that we commonly use in the clinic to start to load the lateral shift. So I've got Jenna again with me. Jenna is part of our fitness athlete division. She's going to be demoing some of the exercises while I'm talking through it. So let's get the camera set so we can see the ground a little bit better right here. Okay, perfect.

SIDE PLANK VARIATIONS
The first way that we're going to talk about that we load for the lateral shift is a side plank variation. So I want you to think about really just loading unilaterally. Whether it be the midline, core, whether it be the lateral hip, we're just trying to load that side to get the person to load that part of the spine. So for example, let's say Jenna had left-sided symptoms. Left-sided symptoms. So we said in a previous episode, almost always the lateral shift is going to be away from the side of symptoms. So, it might be slightly backwards depending on what platform that you're watching with the camera, but we are shifting away from the side of symptoms. So again, we're saying this side here, and if you're listening on the podcast on whatever platform that you're on, be sure to hop on either Instagram or YouTube and watch this episode as well so you can see the exercises in real time. Okay, so the first exercise. So we're going to say again that left side is painful and we are shifted towards the right. So we are going to do a side plank variation in order to load in to the painful side. So we're going to start with our standard side plank variation. The painful side is going to be down. So again, the side towards the floor would be the symptomatic side. And you can appreciate as Jenna comes up and squeezes the glute, squeezes the midline here, she is loading this bottom side that is towards the floor. Now, we could of course go through our same variations with the side plank that we would if we were loading the lateral hip to increase or decrease the difficulty, right? We could have the feet together, we could have knees together, we could also have that top leg floating that makes the bottom side work even harder. How would we regress that? if the person can't tolerate that full version. So Jenna, you can come up here. We would go to an elevated surface. So you could use a bench or you could use a box or you could use a table. But what Jenna is going to do is mimic the exact same position. only now she's at an angle, right? So she's not fully on the ground and we've taken out some of the load. So now it's likely only about half of her body weight that she's having to hold up. And again, the painful side is still down. You can appreciate if this is the painful side and we went here, that's basically the way that Jenna would be shifted. But when she contracts, that is the same thing as a shift correction. Only now we're applying load. instead of regressing it, how would we progress it? We could just add some resistance to the side plank. So we've got a band right here around the rig here. And what you would do, I'm gonna lift this up, Jenna would do the exact same side plank, only she's got this resistance band right around the hip. Much more challenging. When she comes up, she has to press into the resistance band and now she's getting way more load and working way harder to correct that shift or load that shift after we have done the lateral shift correction. You can come out of that, Jenna. So that's number one, a side plank variation. There's a million different ways. You just have to respect the irritability.

RNT SIDE BENDS
Number two is essentially an RNT side bend. So RNT meaning reactive neuromuscular training. So we're going to take a band and put it around Jenna's torso. And the band is just essentially pulling her in the direction that we don't want to go so that she has to fight against it and go in the opposite direction. So we're going to take this band, Jenna's going to wrap it around, and then bring your arm over top. Perfect. So we've got the band here, okay? So we are saying again that the left side, side here, is the symptomatic side. So if we had a lateral shift, she would be going this way. Well now, in order to stand in midline and keep herself centered, she now has to push in to that resistance band. So again, the band is pulling her more in the direction that we don't want her to go, right? There would be more in the direction of going away from the symptoms. So the more that resistance band or the more resistance the band has and the heavier, thicker that band is, the more she's going to have to fight against it to self-correct into that position. essentially a standing version of the side plank that we just demonstrated. Okay, so that's number two.

UNILATERAL CARRY
Number three is going to be a unilateral carry. Unilateral carry. So you could use dumbbell, you can use kettlebell. We typically will load it with a kettlebell. But again, just to stick with the same theme, saying the left side would be the symptomatic side. So Jenna would almost always be shifted away towards the right. we are going to put the weight on the right side. So we are putting the weight on the side opposite of symptoms so that she has to fight against the weight and correct back to midline. So again, the weight is pulling her in the direction that she's already going, avoiding the symptoms. And the heavier the weight is, she's going to have to work that much harder to pull herself back to midline. So you could start with just the static hold with the kettlebell. We could also add in a march to make it more challenging. And she's just lifting one foot at a time, going nice and slow and again, trying to just make sure that her midline is really engaged and active and holding her in this neutral position, fighting against the direction that she would typically be going to avoid the side of symptoms.

SUMMARY
So those are our three variations. We've got the side plank, very similar to how we would typically load the lateral hip. We've got progressions and regressions, just based on the patient irritability, find something that they can tolerate that does not increase symptoms. We also have that RNT, that banded side bend, where the band is pulling more in the direction that we don't want the person to go, so they have to fight against it. And the exact same thing with the unilateral carry. Whatever side the symptoms are on, the weight is on the opposite side, so they have to self-correct and pull themselves back towards midline. Three ways that you can start to load a lateral shift in the clinic. So again, we've got three parts now in this series that we're doing on the lateral shift. Part one, how to actually recognize it in the clinic. Part two, what are the lateral shifts? And three, how do we actually start to load the lateral shift? All right, that's all I've got. Have a great day in the clinic. And we have a few lumbar management courses coming up this month. We've got Anchorage, Alaska, and we've got Paoli, Pennsylvania. So check out PTOnIce.com for tickets. All the other dates coming up. Have a great day in the clinic.

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

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Episode 1738 - Urinary incontinence in the older male 0

May 29, 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 the management of urinary incontinence in the older male, implications for function, and quality of life.

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everyone, 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 our geriatric division and today I am hoping to talk a little bit about urinary incontinence in the older male. A lot of times we focus a lot of our conversations around pelvic health on the female side of the sex spectrum. But today I really want to talk about males. We talk a lot in MMOA, especially in our Level 2 course where we do an entire segment on pelvic health for the older adult. around how every clinician is a pelvic floor clinician. And the reason why we say that is because if you're interacting with hip and low back pain, then you're interacting with the pelvic floor as part of our core canister. And urinary incontinence is a leading cause of institutionalization and a very big reason why some people may not want to engage in the dosage of exercise that they need in order for them to gain the independence that they're hoping to gain. And so we really want to make sure that we are at least doing our due diligence in screening. When we are working with individuals, we wanna know if there's any urinary incontinence on board. And then we wanna talk about what is going on with respect to the male aging pelvis and how that interacts with signs and symptoms like urinary incontinence. So the biggest, biggest, getting bigger area of the male pelvis where there's a lot of conversations around its impact with age is the prostate. So we do know that there is an enlarging of the prostate that occurs with age. And the main roles of the prostate is to create seminal fluid and help with propulsion of ejaculation of that seminal fluid when mixed with the sperm when achieving orgasm. And what we recognize is that as individuals age, there is a growing of the prostate, an enlargement of the prostate that occurs. that is called benign prostatic hyperplasia. Now this is non-cancerous. This is not a malignancy. This is a part of aging physiology in the pelvis. And what we recognize is that there's also a lot of discrepancies of if this is something that we need to worry about or not. So enlargement of the prostate happens in almost every human with a penis. And it can be associated with lower urinary tract symptoms. In the literature, sometimes it's called BPE, benign prostatic enlargement. If it is associated with symptoms, that is not always consistently done, but there is screening that can happen. And then that enlargement, if it does have cancerous tissues in it, now we're thinking prostate cancer and individuals are going for screens for malignancy in the prostate, and then leading to potentially intervention, including radiation and, or radical prostatectomy. And I've done podcast episodes on radical prostatectomy before. When we're thinking about lower urinary tract symptoms, that can include stress urinary incontinence. And oftentimes in males, because of the length of the urethra, the level of incontinence is significantly less than in the female pelvis. So only about 5% of individuals over the age of 65 have incontinence. And usually it is as a consequence of conditions like radical prostatectomy. So it can be radical prostatectomy. Individuals can have pelvic fracture trauma. Some neurodegenerative conditions can also have a urinary condition associated with it. And so usually there's a precipitating event, not always, but most of the time there is some sort of precipitating event that has happened around the pelvis that has led to urinary incontinence. For example, when you have a radical prostatectomy, the prostate is removed. That includes the areas around the external anal sphincter. The urethra is then pulled up to reconnect to the bladder, which can disrupt the pelvic floor, the deep pelvic floor muscles that are responsible for kinking that hose of the urethra in order for a stress urinary incontinence not to occur. And so it makes sense why there's a disruption to that longer urethra can lead to things like stress urinary incontinence. When you have an older adult with stress urinary incontinence, I know it doesn't sound that, that surgery doesn't sound that great, but it is minimally invasive and people do respond pretty well to it, but we have podcast episodes on the, the surgical art of radical frost detective and what we can expect postoperatively. So when we're working with individuals, urinary incontinence is something that we may be managing and we have a big role to play in helping with post-operative or the new development of urinary incontinence. And so when we're thinking about management, we have kind of our conservative buckets, and then we have surgical management. If you are a person who's had a radical prostatectomy, the natural physiology is that many symptoms resolve within a year. So usually we are not doing any follow-up, or your urologist is not doing any follow-up surgical intervention around the pelvis until a year post-operatively with individuals post-radical prostatectomy. But we do have conservative methods that we can use in the shorter term, and hopefully to try and avoid a subsequent surgical management. And so those buckets are pelvic floor muscle training, penile clamps, and surgical intervention. And so the first and go-to knee-jerk reaction is always going to be conservative management, especially if initiated pre-operatively or pre-event, where individuals who are males get an awareness of the pelvic floor system. Because incontinence and pelvic floor issues in the male pelvis are not as common, many times education around the pelvic floor is not as widespread, individuals are not having these conversations as frequently, and then recognizing how to contract and relax the pelvic floor muscles can be something, especially if there is a training effect that we are doing with appropriate dosing, can help with mild to moderate urinary incontinence post pelvic event in the older male. When we are thinking about pelvic floor muscle training, we are trying to cue the pelvis either to stop the flow of urine, or to try and shorten the base of the penis. Those are the two cues that have been shown in research to have the highest EMG activation of the pelvic floor when trying to teach the pelvic floor contraction in an older male, and trying to get a strengthening effect with appropriate dosage. And there's some protocols in the post-radical prostatectomy world that tries to accumulate 20, 30, 40 reps. It's a bit variable, but we wanna make sure that we are getting a training effect based on where individual's baseline status is. initiating pelvic floor muscle training, seeking a pelvic floor physical therapist, or if you're okay with palpating externally, you can go kind of medial to the sits bones and see if there's a contraction of those pelvic floor muscles in the male. If you are a non-internal pelvic floor physical therapist, then you can work on some of that coordination and contraction in individuals who this is a barrier for them going out into the house. So that's kind of our first option. Our second option is a penile clamp. And so if you're aware, in the female pelvic space, we have a device called a pessary, which is inserted intravaginally, and basically what it does is it kinks off the urethra mechanically in order to help reduce symptoms of pelvic floor prolapse, or pelvic organ prolapse, rather, or urinary incontinence. We see this a lot as a conservative management in order to avoid pelvic surgery, We have a similar type of compression device for the male, but obviously there is not an intravaginal hole for our male anatomy and therefore it is placed externally. So what a pelvic clamp is, is It is attached to the mid shaft in a flaccid penis and it has a little bump on the bottom of the device. So there's a compression and on that bottom ridge, it essentially applies the same type of compression as the pessary to the bottom of the male penis in order to avoid incontinence issues. And what we see is that it can significantly reduce the number of pads or reduce the pad test, which is urine coming into a pad in a certain amount of time by weight. and the amount of subjective reports of incontinence. When we are thinking about penile clamps, comfort is going to be one of the biggest concerns where, you know, individuals, I think the last study that I was looking at was like about half of individuals reported that it wasn't really that comfy to be wearing the clamp on the shaft of their penis. It may be because of, you know, making sure that we have proper education or finding the right fit of the clamp, but something for us to be thinking about or, you know, having conversations about with the individual where we may be suggesting this conservative management strategy. And then the second thing that is a really important part for us to be considering is vascular health. We know that a lot of issues around the pelvis, including benign prostatic hyperplasia and erectile dysfunction, have a big vascular health component, aka we're screaming from the rooftops about health promotion, including around the penis. It's just super important for us to consider if individuals have poor perfusion, that even with a small amount of compression, we have to think about vascular health and skin integrity concerns. So trying to figure out who this might be the best individual to be using this type of thing with. Individuals who may really like this option are those who are very adamantly against having surgery or those who are not a candidate for surgery. So here's that double edged sword, right? Where a lot of individuals with high amounts of vascular concerns are going to be individuals who cannot undergo another surgery. They may be the ones that we are thinking about, you know, using this clamp, but we're going to make sure that we take a lot of breaks from wearing it. There was a study that was done out of Japan that was showing that individuals were able to wear it for two to three hours with a 15 minute break. and there was no adverse events to using it. Other studies have talked about doing an hour on, hour off, or using it when trying to do activities around the house. So you're kind of using it for a specific goal or task in standing to try and prevent some of that UI issue from happening. So that's bucket two. So we have our pelvic floor muscle training, We have our conservative penile clamp, and then we have our surgical interventions. And so for the two interventions for our males, we have a urethral sling, which is done through the trans or obturator foramen. And it is essentially a meshing tape that helps to apply resistance to the urethra with or without additional compression, depending on the technique that we are leveraging. in order to help keep the sphincters closed when we want them to be closed. These are indicated for mild to moderate types of urinary incontinence and not usually indicated for more severe cases. When we have individuals with more severe cases, individuals are using an artificial sphincter. So what this is, is it is a device that comes in and essentially creates a clamp with a balloon, or a cuff with a balloon rather, over the urethral opening, not the urethral opening, mid urethra, and your urine starts to accumulate in your bladder. Person's body is going to get the cue that they have to go to the bathroom, and when they go to the bathroom, they release a button in the scrotum that's placed in the scrotum, and it deflates the balloon, allowing the urethra to unkink and for urine to be able to pass through. And then the mechanism goes on a timer. So either it's between 90 seconds and three minutes, depending on the device, and that allows the urethra to be open for that amount of time. And then after that time has elapsed, the cuff closes. Yeah, it's really incredible. Like the technology is really intense. So when you're thinking about who might be indicated for using this artificial sphincter, dexterity and cognition are two big issues in an older male population where we may be thinking about, you know, are they gonna be able to get to the release mechanism on the scrotum? Are they cognitively gonna be able to do the procedure in order for the cuff to deflate? In more severe cases, this is indicated. And there is a fairly severe revision rate. So 20 to 30% will require some sort of mechanical revision, whether the device is kinked, whether there's clogs or hoses, like there is a higher chance of that happening because it's a more, it's a mechanical device, like there are moving parts. And so those parts can break down versus in a sling where you're essentially tacking up that resistance against the urethra. It's something that's a little bit more, doesn't have the same amount of moving parts. So there's a very high success rate for both of these surgeries. Infection rates and things like that tend to be fairly low and it can help to improve sexual function and be able to help individuals achieve better quality of life and physical function and is a good option for individuals who have exhausted their conservative management and have not seen the improvement that they wish to see. So if you are working with these individuals, usually the post-operative instructions are to avoid heavy lifting for six weeks. and then can start returning to moving around. It's not very smooth where individuals can get back to what? That is a conversation for another day. But overall, management can be quite good. So I hope you found that helpful around the way that this is kind of managed from a medical perspective. We can be very helpful in the conservative management piece where it can come along individuals in the post-operative piece or perioperative moment. And it's a thing that we see when we're working with our older adults, right? That we see it in geriatrics. So hopefully that was helpful and kind of fills in some knowledge gaps for you if this is not an area that you practice in all the time. All right. If you want to get all of that information in our UI section, that is in our MMOA level two. So you have to have taken MMOA level one in order to get access to our special populations because we build on a lot of questions. Thank you so much. That's so sweet of you. And we build that into level two. If you are looking to take MMOA live, we are still on the road all summer. It is nice weather, but we are visiting all over the United States. We are in Scottsdale, Arizona, June 1st and 2nd. Spring, Texas, 8th and 9th. We are getting toasty in those places. Let me tell you, I'm not doing those courses. Those are all dusted and jammed. June 22nd, 23rd, we are in Charlotte, North Carolina. And July 13th, 14th, we are in Virginia Beach. So if you are around and you want to take out live content in the summer, we got you covered. Other than that, please have a wonderful week. I hope you all are enjoying your post Memorial Day week and we will see you all next time. Bye.

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

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Episode 1737 - Building the perfect HEP 0

May 28, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division lead faculty Cody Gingerich discusses tips to build the perfect HEP: time availability, equipment availability, and dosage.

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

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

EPISODE TRANSCRIPTION

CODY GINGERIC
All right, good morning, PT on ICE Daily Show. My name is Cody Gingerich. I'm one of the lead faculty with the extremity management division, and I'm coming on here today to talk about building out the perfect HEP. Okay, so there's several factors revolving around building out what is considered the perfect HEP. Now, perfect means best ability for our patients to complete the HEP that we want them to, okay? And so what I'm going to go through is all the different factors that you need to consider, including what you are deciding you're doing, but also the patient's expectations and what they have the ability to accomplish when you are trying to say, all right, these are the HEPs. These are the exercises that I want you to do at home. What factors do you need to consider to build out the HEP that is going to give you the most compliance? Cause ultimately you can build out the perfect HEP as far as these are the exact exercises that I want them doing. These are going to be what I consider the perfect exercises for what I found. But if the patient doesn't do them, that HEP is no longer perfect because they can't get it done and they're not going to progress the way that you want them to. Okay.

HOW MUCH TIME DOES YOUR PATIENT HAVE?
So starting off the, the number one thing that you have to figure out is what time does your patient have? Okay. I know a lot of times when you know, you're going through your, if it's an initial examination, you're trying to figure out the first HEP, you're, you could have multiple different exercises available to you. Um, so let's say, you know, it's a shoulder issue and you're wanting to give them three, four, maybe five exercises that immediately you're like, Oh, okay. This would be good. That would be good. This also would be good. But if it takes 20 minutes for your patient to do and they have five, they're not going to say, oh, well, I'll just do a couple of them and get, they'll do none. Okay. So the first thing that you have to figure out with the patient is what time available do you have to, do you think to get these things done? Some people will say, whatever you tell me I'm going to do. And those people are great, right? You know, they're going to do it. Whatever you think is best. That's great. There are other people that said, you know, they've got kids, they've got to take care of family members. They've got jobs that are stressful. They've got all kinds of things. Maybe they're traveling a ton. And so they're like, you know, honestly, I may have five minutes at the end of the day to be able to get something done. Or they say, I can get to the gym five to 10 minutes early to get things done. Or, you know, I can get to the gym, I'm like running in like two minutes late every time, I'm barely, you know, either for class or it's like right at the end of the day. And they're like, well, yeah, but I could end class and stay 10 minutes extra. Um, and so that's where you then have to start figuring out, all right, well, if I choose two things in each and I give them a rep scheme that can get accomplished what I want and still get them in and out and under 10 minutes. Now, all of a sudden we have something that they feel confident that they can get done. Okay, what I would consider then 1A and 1B is like time is 1A, but 1B or maybe flip-flop those two things would be, you know, what are you trying to accomplish as far as your exercises in general?

DOSING
So in extremity management, we talk about dosing a lot, and that's one of the primary factors as far as when you're treating people out is dosage, and it matters. And there's a strength dose, and there's a rehab dose, and there's a power dose. And you need to make sure the HEP is equally as dialed into that as what you're doing with them in clinic. So up front, you need to think, am I trying to get this tissue legitimately stronger? in which case you are building them out their HEP for probably closer to that five by five right at about 80 percent of their one rep max or around that like three sets of six to eight somewhere like that where it is heavy load being lifted on whatever tissue you're trying to accomplish And in that moment, they may not need to do that multiple times a day, maybe not even every day. So if your brain is saying, well, this tissue needs to get stronger and I'm going to dose this out as a strength dose, then you could say, hey, you know, I might ask you to do this. It might take you more like 15 to 20 minutes, but can we do this three times a week? We want to really hit this hard. We want to make sure your tissues are going to significant fatigue. but then we're going to give you at least a full day of recovery in between. Those tissues also need to be able to recovery, repair, and then come back stronger. So then you have a day in between. Now I'm only asking you to do this three days a week. Could you do that for me? If you're thinking more of that rehab dose, you're wanting more blood perfusion to those tissues. Maybe now you give your one exercise that you think is going to be best, but they're highly irritable, and you need to get just as much blood pumping to that system as possible. Maybe you give them something that takes one minute, but you ask them to do that four, five, six times throughout the day. Because we need a lot of touch points on that tissue often throughout the day, as opposed to saying, I need you to do a lot X amount of time for this specific thing. But if you're saying I need blood pumping, they're sitting at a desk for eight hours a day, but they then have. 20 or 15 minutes where they do something to their shoulder, it's probably not going to bump them forward as fast as possible. But if you say, Hey, 30 seconds to a minute of this, I just, anytime you think about it, like set an hour timer, can you do one minute every hour or every two hours? A lot of times that becomes, um, more manageable for people to do. And then even if they, you know, you're like, Hey, could you do the six to eight times in a day? They say, yes, maybe though that gets accomplished three to four times and you're still doing okay. Okay. Those are kind of your one A, one B. What time do they have and really what are you trying to accomplish with their tasks that you're giving them?

EQUIPMENT AVAILABILITY
Okay. The third thing is what equipment do they have available to them and how willing are they to potentially go and get equipment? So that means before you start doing anything, you need to ask, do they have bands? Do they have weights? What kind of things do they have at their house? What access do they have to anything at a gym? Different gyms have different equipment, right? Do they have kettlebells? Do they have dumbbells? Do they have small looped bands? Do they have big pull-up type of bands? You can manufacture exercises from almost anything and your goal There is no one perfect exercise. There is the exercise that's going to get the person doing what you want them to, to the tissue that you think is most involved, and then you build that exercise for that person, right? So, let's say they have absolutely nothing at their house, but they go to the gym five or six days a week. That first visit is not the time where you say, you know what, I need you to go by XYZ. Nope. You say, great, your HEP is only going to be done at the gym. I need you to do this every time you step in the gym for five minutes, whether that's before or whether that's after you can make that choice, but you need to build out the HEP so that they can get that accomplished as simply and easily as possible when they go to the gym. That's the only way that they're going to get it done. Alternative, if they have nothing at their house, at our clinic a really good option is have either bands for sale or an Amazon link or something. The best one is bands for sale right there and then. Or if you can find them in bulk somewhere and can just hand those out, if they're like a dollar a piece, maybe eat that cost and give them out. But that's a really good way to say, okay, well I need you to do, you know, some band pull aparts or some 90 90 raises or something. And you have one of those like booty bands that you can hand them. And now all of a sudden they have something to accomplish at home. So that's where you need to get a little bit creative up front and maybe at home they've got like a two pound dumbbell or a five pound dumbbell or they've got one band, right? That is again where you start navigating that whole question of what exercise can I build based on the equipment that they have available to them. Potentially then after you have built a little bit of rapport or if that person in front of you is like, Hey, I'm going to do anything you want. You just tell me what to go and I'll go get it. That's when you can start shooting off Amazon links. Be like, Hey, go to play it again. I need you to get a 10 pound dumbbell. I need you to get a kettlebell. I need you to get this band. There are those people, but those questions have to be asked before you say, here's what I want you to do for your HEP.

SUMMARY
You first have to ask how much time do you think you have in a day? Your own brain has to be saying, what's my goal for these HEP exercises? Is it strength dose? Is it more rehab dose and blood perfusion? Then you say, okay, well, what do you have at your house? Do you have anything, any type of equipment that can be built on weights or whatever? Or is everything that you do at the gym cool? What is your gym routine look like? Do you get there super early in the morning? Do you get there in the evening? Do you have more time before? Do you have more time afterwards? Right? All of those questions have to be asked. Ideally, before you start thinking, I need them to do this exercise, this exercise, and this exercise. Now on that first visit, you might pitch optimal a little bit more heavily and say, Hey, this is really what I would like to do. And like for you to do, even based on those equations, Then they come in and say, Hey, you know, I don't think I was, I wasn't really able to get those things accomplished as much as you told me. After the first visit, if they're not able to do that, that first time is on you because then you have to say, okay, well what can I do to make your life easier? I have other options that we can do. There are more things, more different ways that we can make this HEP more accessible to you. If you don't answer that or ask that question, then the reason they're not doing their HEP still falls in your hands, not on theirs. If they say, you know, this is really easy. I should be able to get this done. And they take responsibility for it. Great. But until that happens, I would still say that you need to figure out how can you still make it easier? pitch optimal, then we negotiate acceptable. And you can still have that conversation and say, look, this isn't exactly how I would like it to be, but I think we can get the job done if this is really all you can commit to. Okay. So in that sense, now they know that like, Hey, this probably my, you know, my shoulder pain isn't going to go away quite as quickly as Cody probably hoped because I'm not able to do exactly what he was thinking. But if I still do something, it's still going to bump forward. And as long as they're okay with that, you have to set those clear expectations. But overall, that's how we are building out a really nice HEP that people are going to also be compliant with. Bring them into that. Use your creative mind as far as exercises are concerned, because really it's not the exercise that matters, it's the dosage. You need to know what tissue that you're hitting, and you need to know what dosage that you are trying to use to try to make those tissues happier. If they need to be stronger, we could potentially pull back the actual number of times per week that they do it. Give them an opportunity to recover. If it's more blood perfusion and a rehab dose, maybe make that incredibly short where they can do that one time for 30 seconds to a minute. You give them one exercise and say, hey, you're hammering this over the next week. You're pumping as much blood to that. When you come back in next week, then we're gonna adjust and do something different. But overall, you then need to know what equipment do they have, what do they have access to, what are they willing to go and get? Can you provide them with something that will help them get that accomplished? Whether that is selling something in store or in house, whether that's handing them something that costs a dollar to $2, something like that, that again, lets them be more compliant with what you're hoping for. Okay, so those are three things building out a perfect HEP. The perfect HEP, shocker, is not the exercise that is the best one. It is the exercise that they're gonna get done, that you have dosed out perfectly, that is going to be compliant, and you know what dosage and tissue that you're hitting. Okay. That's all I got for today's PT on ice. If you want to catch extremity on the road, we've got two courses happening this coming week, one down in Texas, one up in, um, Wisconsin. And then in a couple of weeks from that, we've got one happening out in Utah. So hit one of those up sometime in the next couple of weeks, we're all over the country 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 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.

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Episode 1736 - Murph for the pregnant & postpartum athlete 0

May 28, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore discusses the CrossFit hero workout "Murph", including modifications & considerations for pregnant & 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

RACHEL MOORE
My name is Dr. Rachel Moore. I am here this morning on Memorial Day to chat with you guys about the MRF workout and reflections for the MRF workout as a prenatal or maybe postpartum athlete. So whether you yourself have been that athlete and been prenatal or postpartum while doing MRF, or maybe the population of patients that you see is this prenatal space. I want to dive in to some reflections on that today. So first of all, we're going to kick it off. If you are not familiar with the CrossFit space, you're not in the CrossFit space. What is the Murph workout? So Murph is a workout. It's called a hero workout. it's done typically on or around a memorial day so whether memorial day weekend or memorial day itself it is a hero workout which is a named workout in the crossfit space for somebody that has given the ultimate sacrifice and paid their life for whatever the reason so michael murphy Um is who this workout is honoring he was a navy seal and he died in the line of duty So the workout itself is a one mile run 100 push-ups or sorry 100 pull-ups 200 push-ups 300 air squats and then you cap it all off with a mile run and the rx version of this workout is wearing a weight vest 20 pounds for guys 14 pounds for ladies If you have never done this workout, it's a long one. Most people kind of fluctuate like earlier times or fast times or sub one hour, but a lot of people tend to hover around that one hour a little bit more mark if they're doing a quote unquote full Murph. We also can do a half Murph, which is where we take that workout. and cut that volume in half. So the Murph itself is one of those workouts that is a really powerful symbol within the CrossFit community. Typically, most gyms are getting together, whether it's on that Saturday or on that Monday. It's a large community event. It's a really exciting thing to be a part of and a really exciting thing to come together. A lot of people really look forward to this workout every year. not only for the reason of what it represents and the fact that we're paying honor and tribute to people that have given that ultimate sacrifice of their lives so all of us have the freedoms that we have. but also because it is a pretty big test of fitness. And depending on what season of life we're in, sometimes those tests of fitness can be hard. Whether it is physically hard or emotionally hard, regardless, it can be tough. And in one of the largest seasons where we see that is in the perinatal space. So when somebody is pregnant or when somebody is maybe newly postpartum, and they're trying to figure out how to tackle Merv. it can be tough to set aside that athlete brain. It can be really hard to turn that off, especially if you're somebody that's done Murph maybe in the past, and you want to know where you shake out. Or if you're brand new to CrossFit, maybe you started doing CrossFit, found out you were pregnant shortly after, and you're seeing everybody in your gym get super excited about testing their fitness and seeing where they're at, seeing how they compare, maybe doing it for the first time, and knowing that you can't do it the way that you would quote unquote like to. So let's unpack that a little bit. For one, we at Ice really preach that we don't modify unless we need to modify. Just because we're pregnant, quote-unquote, is not a reason to modify MRF. If you're somebody that this workout is in your wheelhouse, maybe you are doing pull-ups and have been doing pull-ups in the gym. maybe push-ups are not bothersome to you, you're early enough on in pregnancy that your bum's not getting in the way, you feel good doing all those push-up volume, air squats feel great, running hasn't gotten to a point where it's bothersome at all, then there's no reason to modify the workout. We don't modify the workout because of pregnancy. We may be able to tweak it slightly, so maybe you partition instead of doing all of the reps in a row to save some of your core fatigue, So instead of doing 100, 200, 300, you do 5, 10, 15, and just give yourself some breaks in between. But if none of those movements are problematic for you and the volume isn't problematic for you, then it's okay to just do the workout, maybe a little bit slower than you otherwise would have, but it's okay to send it. If you're somebody who has issues with one of those movements, whether it is the pull-ups. You don't have that midline strength and stamina anymore and you're seeing a lot of that coning repeatedly over time and it's something that's bothersome to you or maybe the push-up volume is way too high for you or squatting below parallel triggers some pain. It's also okay to modify the workout. Modifying a Murph is not a sign of shame. Doing the Murph in and of itself is huge. modifying the MRF, whether that is because of pregnancy, whether that is in the postpartum season, or whether it's because of an injury, or you're a new CrossFitter, it's okay to modify when we have a reason to modify. It's still exciting to show up. It's still exciting to be a part of your community and do that workout. I have done this workout myself. This was my sixth MRF this year and I did it as a new postpartum. So it was three months postpartum and I was a newer crossfitter. I've done it as a, I think 18 week pregnant crossfitter. I've done it as a year-ish postpartum crossfitter, and then I've done it Rx twice. And in each of those seasons, the challenges were different. When I was a pregnant athlete, I wanted so badly to send it. I wanted to do a full MRF. I wanted to do the entire volume. But my body didn't feel great with that. And so that year, my husband and I ended up splitting the MRF. So we ran the mile together. It was a little bit slower than I otherwise would have ran. and we did you go, I go rounds and we took turns so that I had some built-in rest breaks because for me at that stage in my pregnancy, my heart rate was skyrocketing and I was having a really hard time managing that much volume with that high of a heart rate for that long a period of time. That was a challenging year for me. It has nothing to do with the physical side. Honestly, when we finished our MRF that we split, I was just like, okay, like that was fine, I guess. I'm excited I was here. But physically, it didn't feel like that much of a challenge. But that was the most mentally challenging year. On the flip side, the very first time I did MRF, I did a similar thing. I split a Murph, quote unquote, with a friend. We did you go, I go rounds. I was a newer CrossFitter and I was postpartum. So I scaled the pull-ups for ring rows. I did push-ups for my knees and I did air squats, but I did it all with a vest because I wanted to know if I could. So half a Murph shared with somebody, quote unquote, with a weight vest on, so reduced volume and scaled movements. And I have never felt so powerful than when I finished that workout at three months postpartum. It was awesome. So those are two very different seasons, two very different iterations of the workout from the standpoint of RX movements versus scaled movements, weight vest versus non-weight vest. And the outcome was different. One, I felt physically strong, mentally strong, felt super empowered. And one, honestly, was a really hard mental load for me because I wanted to do what all of my friends were doing in the gym and I wanted to be able to push myself. that athlete brain is tough to turn off. So if you are one of these patients, or one of these people that is doing MRF this year, or has done MRF by this point at 9.20 on a Monday Memorial Day morning, and you struggled with that, it's okay. If you have patients coming in in the future, and they're talking to you about, I wanna do MRF this year, but I just don't really know what to do, it's okay to tell them to modify. It's also okay if they wanna send it. At the end of the day, we're not modifying just for the sake of modifying. We had a gal in our gym last year who was in her 30th week of pregnancy. She's a former CrossFit Games athlete. She crushed it. She swapped out the pull-ups for ring rows, but otherwise did everything else RX and did fantastic and felt fantastic for her body. that challenge and that load was appropriate. We've also had people like myself who at 18 weeks pregnant decide that I need to modify. I'm not going to do a full Merv and I'm going to scale the movements. All of these options are okay. The beautiful thing about this workout is there are so many ways to modify it. There are so many ways to modify the movements themselves. There are so many ways to break up the volume. There are so many ways to cut the volume down. And at the end of the day, showing up and being a part of the community is what is really key this weekend. Being there, paying that tribute, showing that respect, and getting to be a part of your community is huge. If you're somebody that's been in this season and wants to chat more, shoot me a message. I would love to talk with you more. This is a topic that I'm super passionate about because I've been there. I've been in those shoes. And sometimes, you know, we just need to commiserate together about how hard something was.

SUMMARY
If you are looking to join any of our pelvic courses, we have got, we're about halfway through our L1 and our L2 cohorts. So we've got another L1 cohort kicking off. Our next L2 cohort is not until the fall. If you're interested in that, hop into it because it's going to fill out. Catch us on the road this summer. We've got a lot of opportunities to get to the live course where you can sit for that cert test and become ice pelvic certified. I hope you guys have a great rest of your day. If you did MRF today or at any point this weekend, make sure you take care of yourselves. Hydrate get your electrolytes in make sure you're getting protein in take care of your bodies And I know I'm feeling a little bit sore from my Saturday Murph So just know that in the next couple days you may be feeling some type of way, but it's temporary and it'll pass See you guys around

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Episode 1735 - Salty science 0

May 24, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete division leader Alan Fredendall discusses the science and practical application behind hydration & recovery drinks.

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
Good morning, PT on ICE Daily Show. Happy Friday morning, I hope your day is off to a great start. My name is Alan, I have the pleasure of serving as our Chief Operating Officer here at ICE and the Division Leader here in our Fitness Athlete Division. It is Fitness Athlete Friday, it is the best darn day of the week. Today we're gonna be talking about salty science. No, we're not gonna be talking about how upset Drake fans are by how badly they're getting beaten by Kendrick Lamar's diss drops. We are talking about the new era of salt-based hydration and what that means and how that compares to previous eras of things you might be more familiar with. Gatorade, Powerade, those sorts of things. So today we're going to talk about the origin of hydration in recovery drinks. We're going to talk about the pros and cons of what we might call the first generation of those recovery drinks. And then we will move in and talk about the new era of sodium-based drinks that may or may not have any sugar included in them.

THE HISTORY OF RECOVERY DRINKS
So recovery drinks really started as we know it a long time ago back in the 1960s, actually 1962 at the University of Florida. Researchers created a recovery drink for the Florida Gators. You now know that is Gatorade, A-D-E. Back then it was spelled Gator dash A-I-D like a band-aid, Gatorade. And this formula was rather simple. It was water, sodium, and some lemon juice. And when we look at the macronutrient breakdown of the original formula of Gatorade, if you're old enough, you may, even if you were a kid in the 80s or maybe even 90s, you remember it used to come in that glass bottle and it really had nothing in it. It had 50 calories total, it had 14 grams of carbohydrates, it had some sodium, and that was essentially it. And that was a 20 ounce bottle, 20 ounce serving. So a little bit of sugar, a little bit of sodium, and that was it. A lot of credit went to Gatorade in the 60s and 70s when the Florida Gators went on to win and many other collegiate and professional teams went on to win sporting events, they maybe sarcastically credited Gatorade with their success, and at that point Gatorade took off into orbit. That is very different from the Gatorade of today. The current formula of Gatorade is significantly different. It has a lot more calories, as you may be aware, that is primarily sugar. So for the same serving, a 20 ounce serving, a 20 ounce now plastic bottle that you might find in the store or the gas station, 160 calories, so over three times as much. caloric density, way more carbohydrates, three times the carbs, 42 grams of sugar, which is a lot. More sodium now, giving credit, 10 times more sodium, 300 milligrams of sodium, but also a lot more potassium, 90 milligrams of potassium. What's changed from the 60s to today? Pepsi bought Gatorade, Pepsi sells Gatorade, You may know Pepsi owning a lot of the snack brands and soda drinks that we are very familiar with. So it's not really surprising when you find out that Gatorade is now owned by Pepsi that it's just kind of pumped full of sugar and it's essentially turned into a soda drink.

THE CRITICISM OF SUGAR-BASED RECOVERY
So that being said, what is the main criticism of Gatorade? as it relates to its functionality as a recovery drink or not. The first thing to consider is just looking at it from a molecular level, it's sugar water. The primary ingredient is sugar. It's a bunch of calories. Yes, it has a little bit of sodium. Yes, it has a little bit of potassium. But it is primarily sugar water. Now, we may think, okay, we know we sweat, we know we burn calories when we work out, surely we can put that sugar to good use. But it's really important to know that the majority of people drinking these drinks are perhaps not exercising at all. They might be sitting at a computer desk and or they may not be exercising to the level that they are losing that much sweat and that much glycogen from their system. Certainly somebody running, cycling, doing a long endurance activity, 90 minutes, 120 minutes, longer, running a marathon, ultramarathon, triathlon, Ironman, that sort of thing, that person does need to consume glycogen to keep their aerobic energy system running. But those folks just recreationally active, going to CrossFit for an hour, going to run a couple miles, working out in an air-conditioned gym where they may not be sweating at all, don't really need that amount of caloric replenishment and sugar during their workout to keep their workout intensity high. Go way back to episode 1552 of the PTA Nice Daily Show if you want to learn a little bit more about fueling during exercise, we talk about how the human body has about 400 grams of glycogen stored inside of it, inside of our muscles, and about another 100 grams in our liver. So we have the ability to go 90 to 120 minutes before we dig deep enough into those reserves that we need to consider drinking glycogen, drinking glucose to sustain our energy system. And again, the argument and the largest criticism, especially in the past 10 to 15 years or so of Gatorade and similar drinks Is it simply too much sugar? Some really good papers here. Zimmerman colleagues way back from 2012, sports drinks, not just sodas, drive up weights in teens, looking at 11,000 kids aged nine to 15 and finding that kids gained two pounds for every two years in which they drank a can of soda per day. So if they drink a can of soda per day for two years, they would have gained two pounds per year. If they drank two cans, they would have gained four pounds, three cans, six pounds, and so on. And so we say, yeah, Alan, we know that. We know soda is bad. But what is really, really, really interesting about this study is they also looked at sports drinks. They looked at things like Gatorade and Powerade. And this is kind of shocking that they found the same level of consumption, one bottle of a sports drink, two bottles of a sports drink, et cetera, following that same scheme for every one bottle consumed per day. kids gained three and a half pounds per year, two bottles per day, seven pounds, three bottles per day, so on and so forth, 10 and a half, 14, all the way up. And so, recognizing that these drinks actually contain as much or more sugar per ounce of basically table sugar than a can of soda, a can of Coca-Cola or Pepsi or something like that. I love the conclusion from this paper, sports drinks fly under the radar, The danger is that they're sold as part of a healthy and active lifestyle, and it's just part of something you do being active. Most kids are not getting the two hours of high-intensity exercise needed every day to justify refueling with a sports drink. And so, finding that because they have so much more sugar per serving, and that it is so much more acceptable to drink a Gatorade versus to drink a Mountain Dew or something like that. Shout out to Brian Melrose, the Mountain Dew King. that these kind of fly under the radar, and there might be kids that drink these every day in their lunch. They might drink one for lunch and one after school, after playing outside, and it's not surprising that we're racking our brains to figure out why we have a childhood obesity and type 2 diabetes epidemic when it's right in front of our face. Gatorade just simply has too much sugar for the folks who are drinking it on a regular basis. Now, if you're out there, you're running marathons, triathlons, Ironmans, whatever, you're working out for hours at a time, you're working in the heat, you're sweating a lot, ignore me. But for most of our patients, for most of our athletes, we need to understand why that criticism of Gatorade is there and that it's pretty cemented that it is simply too much sugar for the small bit of electrolytes that you might get out of Gatorade. And so that's maybe what we call the first generation of recovery drinks.

THE ERA OF SODIUM-BASED RECOVERY
The new generation you may have heard of a product called LMNT Element. There are a lot of similar brands now. A sodium based recovery drink that has no sugar. This high sodium drink, which also faces criticism of, isn't salt bad? Doesn't that give us high blood pressure? But really finding that these drinks are entirely different on a molecular level from something like Gatorade or Powerade. That again, they have no sugar. They have 10 times more sodium, a thousand milligrams, one gram of sodium. They have a little bit more potassium, usually around 200 to 250 grams. And they also come with some magnesium. What is the scientific argument for drinking something like Element or similar compared to something like Gatorade or similar? Understanding that individuals that are active and exercising may not be using muscle glycogen to the point where they need to drink sugar during or immediately after their workout, but also recognizing they are sweating, which means they are losing especially salt from their system, and that if we replenish that salt, people will probably feel better without feeling the need to go and drink 50 grams of liquid table sugar during or after their workout. A really good article, Sharif and Sawaka, 2011, the Journal of Sports Science, finding that folks can lose up to seven grams of sodium out of their body through sweat per day. If they're active with exercise, if they're maybe somebody outside working, whether that's for a job or just active in the garden for a couple hours on weekend days, that sort of thing. And so we are losing a lot of sodium. And there's kind of a catch-22 here of active individuals don't tend to eat a lot of processed food. And so active folks are not naturally taking in a lot of sodium yet, because they are active, they are losing a lot of sodium at the same time. They're sweating in the gym, they're sweating out running, biking, whatever. Maybe they're sweating outside at work or in the garden or doing lawn work or whatever, and they're simply not replenishing it unless they happen to be somebody that really salts a lot of their food to taste at home. which again may not be the case. So this argument for high sodium, isn't sodium dangerous? Not if you're losing seven grams. Replenishing with just one gram is really just trying to bring you back to balance. We're not as concerned that somebody drinking a sodium based recovery drink is going to run into issues with maybe their blood pressure or any sort of cardiac issues because they're not drinking seven grams at a time. But again, also they're losing it by being active. Why does this matter? What is the science behind a sodium based drink? It's the sodium potassium pump. Way back in like sixth grade biology, you probably remember the pictures of the cell. It looked like a little half sandwich with some ridges in it or something and little circles were moving around. We probably learned about it again in exercise physiology in undergrad and maybe you heard about it again in PT school, but the sodium potassium pump in the membranes of your cells does a lot of work. It is responsible for a lot of body functions. It powers muscular contraction. It transports glucose into your cells to power those contractions, power that cellular activity. It regulates neuronal activity, the actual firing of our nervous system, our synapses. It regulates our body temperature, and overall it maintains our physical performance. of a workout where you sweat a lot, it was really hot, you felt terrible, low energy, you may have even felt cold even though you knew you were really hot, your sodium potassium pump was running out of the sodium needed to power itself. Three molecules of sodium come in, two molecules of potassium come out. So that is the rationale behind a high dose of sodium compared to a relatively smaller dose of potassium. maintaining that sodium potassium pump. And the end goal is, without consuming a lot of sugar that you probably don't need, we can help sustain your current activity or the activity you're about to do, or feel better and recover from the activity you've already done by drinking one of these sodium-based energy drinks.

PRACTICAL APPLICATION FOR PATIENTS AND ATHLETES
Now, the history of Gatorade, the history of sugar-based recovery, element in similar, the new era of sodium-based recovery, what is the practical application at the end of the day for our patients, for our athletes? For those folks who are not already active in exercise program, which is statistically 90% of the human race, they don't really need to be drinking Gatorade. They probably should never be drinking Gatorade because they're not expending enough calories, they're not burning enough glycogen to really justify housing 50 grams of liquid table sugar. That being said, even folks who are active, if they are not active for 90 to 120 minutes of higher intensity exercise, they probably also don't need that much Gatorade. Certainly if you go out for a run for an hour on a warm day or maybe 90 minutes, You might want to cut that Gatorade with some water and dilute it down. That can be beneficial to maintain your energy levels, maintain your hydration, but you don't necessarily need to take two full bottles of Gatorade out on your run and house 500 calories and 50 grams of table sugar. I'm sorry, 100 grams of table sugar while you're out on that run. Now what about our athletes who are training really hard folks who might be in the gym for a couple hours, folks who are long endurance athletes, I would argue those folks probably already have their fueling plan dialed in for what they're going to be drinking, what they're going to be eating. So just leave those folks alone. They probably already know what they want. They probably already know what they like, and they probably already know what their body can handle as far as digestive system issues. So if it's not broke, don't fix it, right? Leave those people be. However, you can give the recommendation of if you're not already drinking something sodium-based, you might want to consider that. Why? Because if they are using things like Gatorade or Powerade, whether it's the pre-liquid version already sold in the store, or whether it's the mix, that stuff just simply does not have a lot of sodium or potassium anyways. Again, it's primarily sugar. So recommending to those folks, even if they feel like they have their fueling plan dialed in, of hey you might want to consider a packet of element or something similar before your long run or your long bike or whatever or maybe during maybe after whatever and just see how you feel feel if you feel that you're able to perform better you're able to recover better maybe both And then what about our regular folks? Our folks who we maybe say, you don't really need Gatorade or Powerade, but we can feel very optimistic and very comfortable recommending something like Element to them, even if they're only going to the gym an hour a day, even if they're only going to run a couple miles or bike a couple miles or something like that. Why? There's no sugar in it, right? It's just sodium. We know they're going to sweat it out anyways. And so really it's about their body maintaining balance and they're not going to be worried about extra weight gain or anything like that from drinking more calories than they're expending. So in general, these new sodium-based recovery drinks can be a really safe recommendation for folks to improve their hydration, improve potentially their performance, and also improve how they feel and how they recover after. So that is salty science for this Fitness Athlete Friday.

SUMMARY
If you want to learn more from us out on the road, we have a couple chances coming up for a Fitness Athlete Live course this summer. Zach Long, aka The Barbell Physio, will be down in Raleigh, North Carolina. That will be the weekend of June 8th and 9th. You can join all of the faculty all of the teaching assistants from the Fitness Athlete Division, June 22nd and 23rd. That'll be right here at CrossFit Fenton, here in Fenton, Michigan. That's gonna be a fantastic weekend. If you've been looking to take Fitness Athlete Live, that's the one you wanna be at. Online, if you wanna learn from us online, our next Fitness Athlete Level 1 course starts on July 29th. That course sells out every cohort. That course sells out every cohort. Don't be that person emailing us the Tuesday after asking to get in. It won't be possible. And our next cohort of Fitness Athlete Level 2 Online begins after Labor Day. That will be September 2nd. You must have taken Fitness Athlete Level 1 to get into Fitness Athlete Level 2 Online. Just like Level 1, that class always sells out every cohort as well. So I hope this was helpful. I hope this is a great resource for yourself, for your own exercise, but also a great resource for you, your patients, and your athletes. Have a great Friday. Have a wonderful Memorial Day weekend. See you next time. Bye, everybody.

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Episode 1734 - Top 3 things to consider when changing positions 0

May 23, 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 three things to consider when changing positions: transparency, pay, and communication.

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
Good morning, PT on ICE Daily Show. Happy Thursday morning. We hope your day is off to a great start. My name is Alan. I have the pleasure of serving as our Chief Operating Officer here at Ice and a faculty member in our Fitness, Athlete, and Practice Management Divisions. Today is Thursday, Leadership Thursday. We talk all things small business management, practice, ownership, and management. But more importantly, it is also Gut Check Thursday. This week's Gut Check Thursday, coming up on Memorial Day weekend, we have Murph, the infamous hero workout performed by CrossFitters and functional fitness enthusiasts across the planet. This is a very long, grindy, aerobic bodyweight workout. If you've done this workout before, I don't really need to tell you anything about it. a one mile run, 100 pull-ups, 200 push-ups, 300 air squats, and then finish with another mile run. You can't manipulate the order of the mile runs at all. You can change and partition or not partition the pull-ups, push-ups, and air squats in the middle any way you want. As long as you get 100 pull-ups done, 200 push-ups done, and 300 air squats done, you are good to go with that work that you get done in the gym. Typical times are going to be 40 to 60 minutes and obviously a little bit slower if you wear that 20 pound or 14 pound vest. A lot of different ways to approach this workout. We have a lot of scaling options over on the Gut Check Thursday post on our Instagram account. But there are numerous ways to modify and scale this to get a really good workout in on Memorial Day before you head off to hopefully celebrate some barbecues, some beers, that sort of thing. Today, Leadership Thursday, what are we talking about? We are talking about things to look for if you are considering changing your job position. So we're gonna talk about transparency, we're gonna talk about pay, and we're gonna talk about communications and leadership presence.

JOB CHANGES ARE NORMAL
Before we talk about the three things we think you should look for, the first thing I want to say is to understand, and we can have a lot of reservations about this, we can get in our head a lot about this, it is completely normal to change your job, and even to change your job on a regular basis. Bureau of Labor Statistics. It's a government agency that posts a bunch of data about really a wide variety of topics related to working and the workforce. They have data that shows the average person will change their job 12.4 times between the age of 18 in 54. So the average person is changing their job maybe as frequently as every year or maybe every two to three years. So I think that's really important to understand that it's normal to move on for whatever reason that you feel like it's normal to move on. Often we can encounter a lot of shame, a lot of pushback of I can't believe you're going to leave, who's going to treat all of these patients, so on and so forth. But we need to recognize That is not your problem and that it is normal to want to move on again for whatever reason you feel like you need to move on. A different schedule, more flexibility, less work, more work, more pay, different location, whatever. It is normal to change your job positions. About 30% of all Americans change their job each and every year. And then why do we look at that? All the reasons that we think about in the profession of physical therapy are the same across other industries. 80% of people leave a position because they feel like they are burned out. 70% feel like work is overtaking every aspect of their life. They're losing that balance between work and personal life. and then about 50% leave because they believe they are overworked or underpaid or both. And certainly, in the profession of physical therapy, we can relate to that.

GET IT IN WRITING
Before we talk about transparency, pay, and communication, the other thing I'll say is that as we get into these topics, it is in your best interest, and I cannot reinforce this enough, that whatever you discuss, whatever is told to you in words, should go into writing, and any unwillingness about specific details of your job tasks, of productivity, of pay, of time off, of other benefits, so on and so forth, anything related to the fine details of this position you might be considering should go into writing. And unwillingness or hesitancy or any sort of mystery about that should be immediately a beige flag, I would say a red flag in your mind that already you're thinking, why would I accept this position if it is not willing to be put into a contract? that I will be promised these things in writing, that I am being promised verbally. So, that's always front of mind, that if it's not in writing, it's probably not going to happen, and you'll just find yourself likely, eventually, in the near future, thinking about changing job positions again.

TRANSPARENCY IS KEY
So getting into our first point, the most important thing I believe related to perceiving a job position to be a good fit is transparency. That in the profession of physical therapy, in the field of physical therapy, whether it is being a frontline staff clinician treating patients, whether it is being in a management or ownership position, there is no secret to what we are doing. There is no mystery formula. secret technology, government secret for national security that we can't talk about, that transparency rules the day, especially in a profession like ours. A healthcare profession, a medical profession, a graduate level, doctorate level profession. Transparency should be there in all things. How are people paid? What are they paid? We should not go home every night and wonder if someone is making more or less money than us for whatever reason because I am a female and they are a male or vice versa. We should have very clear cut transparent lines of how does pay work and where does the strategy and where does the logic for that come from? How does productivity and time off and benefits Again, all the stuff that you would care about and all the stuff that you would want to see in writing, where is that at? It should be there. It should not be hidden. It should not be something that is not told to you. We live in a day and age. It's 2024. We know how much we are charging. We know how much we're receiving. We know how much we're getting paid. It should not be a big mystery. Any reluctance there, any hesitancy to share? First of all, regarding what the clinic gets paid in 2024 is illegal. As of 2021, we have to have our rates published on our website or somewhere posted publicly that patients considering care with us can find it, right? That's the no surprises act of 2021. So we should at least have an understanding of how the clinic and what the clinic is making for revenue and understand how our pay is calculated, how our productivity and everything that kind of follows downstream from that. So there's no secret that we have to hold on to. Certainly if you work at NASA or something, I could see that being a little bit secretive is important, but in the field of physical therapy, that just does not make sense. You should, again, never go home and have to fester about this stuff. Am I being underpaid for whatever reason? Am I being asked to do more work for whatever reason? All of that goes out the door when you work in a really transparent workplace.

PAY MATTERS
The second point is pay. High quality leaders, and I will take this to my grave, high quality leaders recognize that pay is very important when you want high quality folks to join you at your business and help you grow your business. No one is happy when it is National Physical Therapy Month and you work in a hospital or some other big group clinic and instead of a bonus or an extra day off, what comes through the door? Some old, stale, gross, soaking wet Jimmy John's sandwiches, right? That really just makes everybody upset. You don't feel like you were awarded. You don't feel like you were valued. Pay is one of those things that is just Part of going to work, whether you're going to work for somebody else or somebody else is coming to work for you. Several high quality papers exist now. We've talked about several here on the podcast. The most notable one is Killingsworth and colleagues back from 2023. establishing an objective database link between pay and satisfaction. Job satisfaction, life happiness. We know that human beings fall into buckets. Not everybody is motivated by money, but most people are at least somewhat motivated by money. That paper is really profound to me knowing that there is about 33% of the population who does not really seem to care about money beyond having their basic needs met. That being said, the majority of the population, therefore, is motivated by not just enough money to have food and a place to sleep, but having enough money to start a family, buy a house, retire, all the other stuff that we do with our money. So we know there's a middle portion of the population that sees a linear increase in happiness up to and beyond $100,000 a year of household income. And there's also another a third of the population, another 33%, that sees an exponential change in the relationship between their pay and their satisfaction up to and beyond $100,000 a year. We've said it here a thousand times, we won't beat the horse too much here today, but pay matters, and in specific, if you're not getting a raise every year, you are taking a pay cut. So pay should be one of those things that's included in transparency, and it should be a big factor, and it should not be a thing that is a mystery when you're looking for a new position. You're not quite sure how it works. And again, everything related to pay should be put into writing. We talked to a lot of people who are presented a salary or an hourly or a per visit or whatever pay scale that then find out later, Oh, by the way, that's based on X productivity. And because you did not hit X productivity, you are now being paid Y instead of Z. We see this often related to a percentage of arrival, that if only 90% of your patients showed up this week, you only receive 90% of that promised salary, for example. So be really careful, ask a lot of questions about pay, and make sure that stuff goes into writing, because if it's not in writing, again, it's probably not going to actually happen when you accept that position and you begin working.

COMMUNICATION IS CRUCIAL
And the final thing here is communication and presence of leadership. I think communication is really important. I think we can over communicate. We can have a lot of meetings that are maybe seen as wasting time. But I also think a lot of workplaces, a lot of communication between owners or managers and staff clinicians does not happen often enough. There is no inclusion of the other people that work at the facility of hiring somebody else. Is that person not only a good fit for the clinic, but is that person a good fit with everybody else who works at the clinic? And so having open communication, having the ability for folks to ask questions, Again, not necessarily over communication, just to communicate, but making sure that when decisions are made, as much as possible, everybody else who works at that clinic should at least know what's going on. Maybe it's not relevant for them to have a say in, you know, that you switch toilet paper brands or something like that, but at least the option to have that open line of communication should be included. And with that comes the presence of leadership. I truly believe that to run a very successful business and to have a staff that works really well together, the people in charge should probably be there on a somewhat regular basis. Very often we hear that clinic owners are living in the Caribbean or across the country at their second house. They haven't been seen for weeks or months, and they're primarily just collecting their ownership distribution from the business at that point. It's really difficult to feel connected to the business side of your job when you are not even sure who is in charge and what they're doing. We see this in our bigger clinic groups across the country, that the people that own the company are not even physical therapists. They've never been a physical therapist. They've never treated a patient in their life. an investment banker or a stockbroker or some sort of real estate mogul. And the physical therapy business is just numbers on a spreadsheet to them. It's just profit and loss. And it can be naturally very difficult to feel connected to that position, to feel like you're doing meaningful work, and to also feel like you're being rewarded for that meaningful work when there's not that communication and there's not that presence of leadership going on.

SUMMARY
So, what are three things that you can very quickly use to screen in and out a good position? Making sure that everything that is talked about is put into writing. Focusing on transparency of understanding why and how the business is run and what those decisions and how those decisions are arrived at. Knowing that pay is very, very important. We need to recognize both that from the ownership and management side of the equation as well as those of you seeking a new position. It would be, Not a great optimal decision to change positions for a lateral promotion or even a decrease in pay unless it meant living in your dream geography or something like that. And then the final point, communication is important. Having open lines of communication with ownership, with leadership, both ways. Having a say in important decisions or at least being able to voice your thoughts on the matter. and having active presence of your leadership and ownership in the actual business. When is the last time the clinic director or the clinic owner has maybe even been in the same state that their clinic is in? Those are all important things to consider. So we hope this was helpful. We hope you have a wonderful Thursday. Have a fantastic Memorial Day weekend. Have fun with MRF. If you're looking for more business practice ownership information, if you're looking to start your own practice, whether it's insurance based, cash based, you're not sure based, check out Brick by Brick, our practice management course. The next cohort starts July 2nd. Have a great Thursday. Have a great weekend. Bye everybody.

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Episode 1733 - A framework for balance 0

May 22, 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 a framework to begin to better assess balance & tailor focused interventions for patients, including assessing risk factors, understanding inputs that affect balance, and how to measure outputs from balance.

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.

EPISODE TRANSCRIPTION

DUSTIN JONES
Good morning, folks. You are listening to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the lead faculty within the older adult division, and we are going to be talking about a framework for balance, about how we can think about balance from the assessment side of things. over to the intervention side as well. I feel like this area is very kind of misunderstood in the rehabilitation realm and it's often handled very poorly from what I've seen and I'm definitely guilty of this as well. Let's kind of play out the typical scenario when we're talking about trying to assess and improve people's balance, right? We have someone if you're an outpatient they likely came to you for you know some type of painful issue right back pain shoulder pain whatever and then you realize oh this person you know reports that they feel unsteady or that you may notice it yourself or you may have gotten a referral that said they've had a fall and we need to look at balance then we do our assessment and typically what we're doing is throwing some type of of you know quote-unquote balance outcome measure that we learned in school, probably something like the Berg, you know, balance test, where we take them through that test and we see a score and we say, oh my gosh, all right, you are at risk of a fall. I saw some deficits in some of these activities and man, all right, I'm gonna give you my balance program, right? So you've got your balance exercises. There's probably, you know, some tandem stance in there, semi-tandem, maybe one-legged stance if you're feeling funky, right? you're maybe doing some obstacle courses, maybe tossing a ball back and forth, you may be having to stand on an Airex foam pad, right? We kind of got this kind of generic balance program that does challenge people's balance capacities, but what we often see is that that generalized program is not specific to the deficits that that person provides. Balance, I would say out of any other facet of performance is probably one of the most complicated, because there's so many different variables that can influence someone's balance ability, and we need to identify those and then address those specifically, as opposed to giving these kind of generalized balance exercises, quote-unquote balance program, crossing our fingers and hoping that they actually make a significant difference in these people's lives. All right, so let's talk about a framework for assessment that's ultimately gonna lead to intervention. I think one of the big takeaways for many of us when we start to really look at people's balance abilities is we have to zoom out and look beyond their performance on outcome measures. We focus solely on that, and we miss the boat on some very, very important factors and variables that are contributing to that poor performance in the outcome measure that we see. All right, so think of this in three steps from the assessment side. You want to look at risk factors, you want to look at inputs, and then you want to look at outputs. If you go through those steps, you're going to get some very, very valuable information. I'm going to go through each of those three.

RISK FACTORS FOR FALLING
All right, so risk factors. We can put risk factors that are going to influence people's balance ability or increase their risk of falling in kind of two buckets is how we typically think about this. Intrinsic and then extrinsic risk factors. These are areas that some of y'all may be thinking about, talking to them, asking questions, maybe getting a good idea, but a lot of folks may be completely ignoring some of these things, right? So like intrinsic risk factors could be their medical history, right? Permanent medical diagnoses that are gonna have an influence on balance. Type 2 diabetes, if they have peripheral neuropathy, they don't have that somatosensory input, they're going to have issues. Think Parkinson's disease. If they have Parkinson's disease, they probably have some issues with initiation of movement, maybe reactive, postural control is a little impaired, that's going to influence their balance. We need to have a good idea of their medical history. We need to have a good idea of their current medications. Think of the last time you did medication reconciliation. There are a lot of medications that can actually impair balance, balance capacity, reactive, speed, that can ultimately increase the risk of falling. These medications are in their own category called falls risk increasing drugs. Other things that we can think about is there their vision, their foot health, their footwear, for example. There's a whole host of these different intrinsic variables that are a lot, right? There's a lot of things to work through. but they will give you valuable information that is contributing to their impaired performance on some of the outcome measures that you're seeing. There's a lot, a lot of intrinsic risk factors. What I'm going to point you to that's going to be a really helpful resource is the CDC's study, S-T-E-A-D-I. This is going to give you a framework to be able to work through some of these contributing variables, particularly the intrinsic risk factors, that can negatively impact balance. And it'll give you a really good framework to be able to address those. Then we have our extrinsic risk factors. This could be assistive device use, the fitting of the assistive device, which we often see it's not properly fitted, whether it's a cane walker, so on and so forth. What's the home look like? Do they have that pesky rug that they end up tripping over? almost every day, right? Can we do something about that? Probably not, but you can go ahead and try. We can think about lighting in certain areas, particularly at night. Let's say if they have nocturia and they have to go use the bathroom at night, we need a well-lit area to reduce their risk of having a fall, improve their balance capacity in that particular situation. So CDC study is going to be very, very helpful for you to work through some of these risk factors, intrinsic and extrinsic, all right? So I would start there. So that's risk factors. Get a good idea of that. Check.

INPUTS THAT AFFECT BALANCE
Next is going to be inputs. This is where we're looking at those afferent signals, those three main systems that are giving us really helpful information that allow us to execute and maintain our balance. That's that somatosensory system, the visual system, and then the vestibular system. There's some different ways we can check this. From the somatosensory side, we could look at their proprioception, their joint position sense. We can do this starting distally, maybe at the big toe, and get a good idea if they're able to tell where their big toe is in space. that's going to be really helpful because that's going to carry over to their proprioception when they're on their feet navigating a complex environment, for example. Do they have protective sensation? This could be monofilament testing where we're seeing if they're able to be able to feel that little pinprick that seems Weinstein monofilament. If you're working with someone that has blood sugar issues, type 2 diabetes is on their chart, This is something you definitely want to check because that's going to influence that input, that information that they're getting that's going to negatively influence their output that we're seeing with that outcome measure and there's some things that we can do about that. Then we look at their visual system. How's their visual acuity? How's their depth perception? How are their visual fields? We need to have a good idea of the health of their visual system because we may want to make a referral to get it reassessed if it's been over 10, 15 years since they've updated that prescription in terms of their eyeglasses, or we may need to teach compensatory strategies to overcome some of their depth perception issues or their visual field loss that they have. You could throw all kinds of generic balance exercise at these people, but if they have visual deficits, you need to have visual specific interventions that are addressing that visual deficit. And oftentimes it may be compensation, right? So we need to address those inputs. And then the vestibular system. This is where we can do a vestibular screening. We can look at their smooth pursuits, for example, which is more kind of in the visual realm, but it's very closely tied to that vestibular system. Smooth pursuits, vestibulocular reflex, or that VOR. How is the health of that VOR? Is it intact? Are they able to cancel that VOR and be able to move their head and eyes at the same time without an onset of symptoms? And then we can do different positional testing as well. If we can do a vestibular screen, that is gonna be very helpful to identify, hey, this is more of a vestibular issue than anything. You doing your tandem stance, tossing a balloon back and forth, probably ain't gonna do much for that, right? So it's gonna influence our interventions.

OUTPUTS FROM BALANCE
So we take those risk factors, we take the information from the inputs, and then we do the outputs, which is our outcome measures that we typically think about. Many folks will do a Berg balance test, That. is not the perfect test for everyone, right? There's a lot of issues with the Berg Balance Score. It doesn't really address a lot of different variables of balance in terms of balance performance. What we really like to recommend for folks is looking at something like the Mini Best Test. It is more of a well-rounded test. It looks at people's ability to anticipate maybe a destabilizing event, maybe their ability to react to a perturbation in terms of their reactive postural control. How do they handle different scenarios where we've limited vision or limited that somatosensory input or kind of muddy the water in terms of the vestibular input? How do those people respond in that situation? How they do in a dynamic gait scenario where they have to do different tasks or they have to do, they have to emulate but then also add on a cognitive dual task. That mini best test is going to reveal a whole host of different common scenarios that these folks are going to be struggling with that we can work into our intervention plan. For someone that may be more in a seated position most of the time, we can do the FIS, the function and sitting test, which is as well-rounded as the mini best test that will give you a good idea of their performance in a seated position. And so we take those risk factors, we take those inputs, and we take those outputs in our assessment. And then what we find, we have a individualized, tailored program to that person. And so for some people, the first thing you may do is call their physician or pharmacist to have their medications looked because they're on a couple of FRIDS or false risk increasing drugs that we need to take a look and make sure that they're still appropriate and they're still necessary because we know that they have a negative influence on people's balance ability. You may realize that, man, this person is very visually dependent, that as soon as we close our eyes and we're asking more of the vestibular system and the somatosensory system, their balance really starts to crumble. Then we know, all right, we need to maybe restrict their vision in some of these balance training activities to really strengthen up these other systems, to be able to compensate in the event that we don't have that visual input, make these people more resilient. And you may notice, maybe in the mini best tests, where man, when we do that cognitive dual task, timed up and go, that's a part of the dynamic gate portion of the mini best test, Betty's performance really, really crashes. but she did fine on everything else. Well, what do we need to do? We need to do some balance-based activities where we are going to add on a cognitive dual task. There's so many things out in the real world that demand that, we can practice that in our sessions. And so you go through those risk factors, you go through those inputs, you go through those outputs, and you're gonna get a very tailored program that's going to address that person's specific deficits to overcome them and make a significant improvement in their balance ability. Right? How we typically do it where we're just giving our general balance program to people not really knowing what the true deficits are. It's like throwing darts blindfolded. You're just crossing your fingers, praying to God that you're going to hit that bullseye. Take the blindfold off, assess that person, understand their deficits through that framework, and then you'll be throwing those darts, hitting bullseyes every single time. All right. I will drop some links in to the comments. You can shoot me a direct message as well, and I can give you those links. The big ones are going to be the CDC study. It's going to give you that framework to particularly look at the risk factors. That's what that one's really helpful for. and then I'll link to that mini best test and then the FIST, the function and sitting test as well. So you all have some resources as a result of today's episode. All right, hit me up with any questions. Let me know your thoughts, any other things that you'd add to the conversation around balance. I think we can really level up here.

SUMMARY
If you want to learn more about balance, if you want to practice some of these interventions of how we can take that information and really put it into a tailored program, I want to recommend our live course, MMOA Live, where we give a bunch of intervention ideas related to this framework. We've got a bunch of courses coming up. I'll just mention the ones coming up in June. We're going to be in Scottsdale, Arizona, June 1st and 2nd, in Spring, Texas, June 8th and 9th, and then we'll be in Charlotte, North Carolina, June 22nd, 23rd. We also hit on this in depth in our MMOA level 2 course where we take a step deeper into the topic of balance. Alright, well I'm gonna get off here. We got our first MMOA level 1 call for this cohort coming up in about 15 minutes. I hope you all have a lovely rest of your Wednesday and I'll talk to you soon.

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

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Episode 1732 - Upper trap focus 0

May 21, 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 assessing, treating, and loading the upper traps when suspecting their involvement in neck or headache symptoms.

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

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.

ZAC MORGAN
All right, good morning, PT on Ice Daily Show. I'm Dr. Zac Morgan, lead faculty in the spine division, teaching both cervical and lumbar spine management. And this morning I wanted to bring you all a technique Tuesday, looking at the upper trap, thinking more in that cervical management arena. So I think we all really appreciate that a lot of our patients with neck pain have some upper trap dysfunction. That's a very common muscle to have issues with, whether you're dealing with mechanical neck pain, Maybe you're dealing with cervicogenic headache patients, patients with TMD, temporal mandibular joint dysfunction. We see it a lot in our patients who have an irritated nerve root, something like a radiculopathy. They'll often hold some tension in that upper trap to kind of slacken their brachial plexus over time. Lastly, folks who are just really stressed out, which I think we all can kind of appreciate. That's most of our clientele. Most Americans carry around a ton of stress. I think all of these pathologies really lend themselves to quite a bit of tension in the upper trap. I wanted to talk this morning a little bit about actually like soft tissue assessment and kind of how to progress your vigor throughout that assessment to replicate those symptoms. But then I also wanted to just bleed that straight into treatment because they look quite similar and show you all some things that I find that are very useful for both identifying the symptoms and then eventually eradicating these symptoms doing some soft tissue work. So let's move to the table and we'll talk a little bit about the actual hands-on assessment of the upper trap and some key points to not miss. So we'll go ahead and shift gears over here. I do think having a little bit of soft tissue cream can be helpful when you're assessing the upper traps. So I like the company Deep Prep because Deep Prep is still, you can still get a grip on the muscle, but you get a little bit less friction, which is nice. There are plenty of soft tissue creams on the market. This is just the one that I typically will use. So I'm just going to kind of coat that whole region of the upper trap all the way up into the cervical spine with some lotion just to get it to where I can feel all of those fibers without getting too much grip on the person's skin. So, starting out from an assessment standpoint, the big piece that I don't want you to miss is the anterior side of the upper trap. So, I think a lot of times we feel these things with the person in prone, and we miss that anterior side of the upper trap, and I always like to think of it like a wave that's crashing over the shoulder, and we wanna feel that anterior side, or where the wave's almost curling. And so really, all the way down at the clavicle, I like to find the AC joint, and then start to just gently stress that lateral upper trap. And typically for palpation of the upper trap, I'm going with a grip like this. Kind of a lumbrical grip and avoiding DIP flexion. DIP flexion is what gets really uncomfortable, really pinpoint for the person. So I'm almost trying to sandwich that upper trap like this with my hand. So I'm going to feel that distal anterior upper trap and basically just make a couple of quick passes. I'm going to feel my way up through the anterior side of the upper trap. A couple of passes through there. I'm going to feel it as it connects to the neck right there where it's starting to dive into the actual cervical spine. And then of course the last place is up at the nuchal line where it's proximal insertion is. So you want to feel through all of that just with some really gentle strokes to start. you might pick up that the patient's a little heightened as you're feeling through this and that might be plenty of palpation to kind of elicit the symptoms but if the symptoms are a little less irritable and you want to kind of up the vigor of what you're doing here What I would suggest first is to just hold some tension in the upper trap and then push it straight down towards the table. So you won't be able to see my hand move down towards the table much because it's just bearing in the pillow. But essentially what I'm going to do is find each third of that upper trap, so the clavicular the AC joint attachment, like right there at the end of the clavicle, the middle of the trap, and then up towards the neck. I'm gonna find a tense spot, hold pressure, and drag it straight down towards the table, like this. So I would call that like pinning and then depressing. And then same thing in the middle of the trap, pin and depress. And then same thing up here at the neck, pin and depress. You'll often find that when you drive that trap down towards the table, that tension creates some of those cervicogenic headache symptoms, maybe even just their plain neck pain you might replicate like this. But if you really want to stress it even a little bit more, what I would encourage for the assessment is going to be pinning it, depressing it, then stretching it. So it's a pin and stretch, but we want to make sure we get that depression in as well. So I'm going to hold the bottom of my client's head like this. And so this part of my hand is going to be on one side of their head. Their head's going to lay across my forearm. That way I can add all of the motion that I want through my arm really easily. So I'm just going to gently slide my hand under their head, swung all the way through. Now I had easy control of her head and neck and I can come in, pinch, depress and stretch. move to the middle of the trap. Pinch, depress, and stretch. Team this technique for assessing the upper trap is the most common way that I'll wind up eliciting a lot of those soft tissue symptoms for the person. It's because it's pretty vigorous. As you pull that tension into the trap and then pull the proximal insertion away from the muscle, that often gets a lot of tension through that big muscle and the person will feel their symptoms. So make sure as you're assessing, pay special attention to the anterior side of the trap build your vigor slowly, start out with just gentle palpation throughout the muscle belly. If that gets the job done, no need to get more vigorous, but if you haven't found those symptoms and you're suspicious of the upper trap, then add a little bit more pinching and depression. If you want to get more vigorous still, pinch, depress, and move the head. Now from a treatment standpoint, thinking about soft tissue techniques that we can do, basically what I will typically do is take the depression out, but still do the pin and stretch. If you really want to get vigorous, you can of course add the depression back, but for most people you won't need that depression to get them a really big stretch and get their soft tissue a bit looser. So for that, it's the same thing that I just showed you from an assessment standpoint. But I'm going to do a lot more passes. And I typically think about the trap, the upper trap in those thirds. So there's like the lateral third, the middle third, and then the medial third. And I probably am going to do 10, 15 reps at each one. So I'm going to hold, side bend 10 times. Hold the middle, side bend 10 times. Hold the proximal, the part closest to the neck, side bend 10 times. Go back through, do the exact same thing with rotation. Go back through, do the exact same thing with flexion. And then the most vigorous or last one that I would do would be like that flexion quadrant where you're getting flexion rotation and side bending all at the same time. Those can look like this. So again, I'm gonna have that same exact grip of their head like this. I'm gonna find whatever that spot is and then just side bend. And it doesn't take much side bending for you to feel a lot of tension between your thumb and like index middle finger where you've got that kind of pincer grip. you will feel quite a bit of tension as you side bend, and I'm just going to loosen that up. Encourage the person to just breathe normally. This can be pretty intense. When I want to look at rotation, same thing. A little less tension and rotation than side bending, so often not quite as big a deal, but can just work rotation right here with the neck, holding just tension through this part of my hand. Last thing that's useful is flexion. Definitely more tension here in flexion. You're going to get a lot of stretch across those anterior fibers. This will often feel a little bit symptomatic for the person as well, but they'll often tell you how it feels like it needs to happen. It's kind of a hurts so good type of thing. And then last thing would be flexion quadrant. So moving into this diagonal. So I'm here and there. That'll be your most vigorous. So I'm thinking about moving her nose towards her armpit each time. That'll be definitely the most vigorous of all of these. So team, all of that is some nice ways to sort of assess and treat the upper trap. A lot of our neck pain clients would benefit from that. A decent amount of them are carrying tension already, whether they even have neck pain or not. Our clients are commonly complaining of tension there. They'll feel tense when you check their range of motion exam. This may not be the first thing you go to throughout their plan of care. There may be some other things that you do to address the local tissue. But throughout a lot of my clients with neck pains plan of care, I'm gonna do that deep dive into the upper trap, feel all the fibers, figure out where it really is the most tense, and then address that with a bunch of reps of soft tissue work. This works great and I think you'll find that it bumps people's symptoms down pretty well. The other thing is people love it. People generally love to feel thoroughly assessed, soft tissue and all, and it's rare that someone doesn't feel some tension here, so often patients just like for you to go ahead and take that nice broad overview of the upper trap. So make sure, whether it's a cervicogenic headache, mechanical neck pain, radiculopathy, you name it, there's a lot of patterns of neck pain that show up. Assess the upper trap. You will often find that you're able to bump those asterisks forward even better when you do so. And so I would really encourage you to make that a part of your practice.

SUMMARY
If you're looking for an upcoming spine course, if you're looking for cervical specifically, we've got a few coming up. So June 29th and 30th, Kent, Washington. So make sure you check us out there on the west coast. July 13th and 14th, Charlotte, North Carolina. So back over on the east coast. And then July 20th and 21st, Oviedo, Florida. So down south, right next to Orlando. If you're looking for lumbar management, June 8th and 9th in Anchorage, Alaska. So if you're out there in Alaska, join me for lumbar. June 22nd and 23rd in Paoli, Pennsylvania. And then July 13th and 14th in Amarillo, Texas. So several good course offerings upcoming. We'd love to see you out there on the road where we cover full head-to-toe management in spine conditions. Thanks everyone. I will catch you on the next one.

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Episode 1731 - Advocating for birth control 0

May 20, 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 benefits of birth control and when we should be thinking more positively about these medications and methods

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.

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey 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.

CHRISTINA PREVETT
Hello, everyone, and welcome to the PT on Ice Daily Show. My name is Christina Prevett. I am one of the lead faculty in our pelvic divisions. And I am coming to you from a hotel room. I'm about to get back after teaching MMOA Live here this weekend. So you got my hotel version of today's podcast. Today we're going to be talking about advocating for birth control. And so this might be a bit of a hot take hot topic, because in the allied health or birth provider space, there has been a lot of anti birth control messaging. And so I want to kind of play devil's advocate a little bit. and speak to some of the potential pros of birth control, and then really try and loop this into why it is so important, especially as healthcare providers, that we become more nuanced in our approach, right? It is so easy with social media for us to be thinking in 30 to 60 second snippets. But one of the reasons why I love the podcast is that we're able to kind of dive into nuance a little bit more. So firstly, the development of the oral contraceptive pill was one of the big revolutionary medical marvels that allowed women to have reproductive choice in a lot of ways, right? The idea behind oral contraceptives was that females could have some, you know, obviously when they're having intercourse, but like they were able to prevent unwanted pregnancies and that gave them some sense of control in a lot of ways. So the development of oral contraceptives outside of barrier methods was truly such an amazing medical advancement that paved the way for a lot in reproductive healthcare. With the use of exogenous hormones, what we have also seen with the use of oral contraceptives is that it has been used in the management of different gynecological conditions. So here's where we get to messaging numero uno. When people take birth control, they aren't actually balancing their hormones. Something is doing it for them and it is a band-aid and it's making all your sex hormones go down. This is the messaging. So we shouldn't be giving people birth control because it's not fixing the problem. So let's talk about an argument where that works, and let's talk about an argument where it doesn't. Okay, so in our pelvic division, we talk a lot about relative energy deficiency in sport. This is for individuals with primary or secondary amenorrhea, where because they are not fueling their body appropriately, their body goes into battery saver mode, which means that they are not doing any bodily processes that require excesses of energy out like energy out because they don't have enough energy coming in, which can include pregnancy. And so we suppress the HPT access to prevent ourselves from ovulating because right now we're not taking in enough fuel for our body to function. We're definitely not taking in enough fuel to support a pregnancy. In those circumstances where individuals are not getting their period because of under fueling, sometimes birth control can be recommended and The argument can be made that. we're not getting at the root cause for the hormonal imbalance, because you need to have that fuel to the root cause, and we should see a hormonal re-regulation, and reds from the literature that we have right now is reversible, right? So that makes sense, right? If individuals are highly active, they're in low energy availability, and they're not screening for root causes of issues with hormone status, and we give birth control as a knee-jerk reaction without doing the proper investigations, I can see where that argument of it's exogenously balancing your hormones would work. But here's where it doesn't. Okay, here's where it doesn't. So birth control is also used as a frontline treatment for a lot of fertility-impacting conditions or gynecological conditions, such as PCOS, endometriosis, and fibroids, right? PCOS, is a androgen excess and it is a chronic disease. It is a chronic disease. It is a chronic disease that has no cure. So there is no cure to be able to balance your hormones naturally with PCOS. Does health promotion potentially help with becoming more regular with your menstrual cycle? Does it help with bringing you to a more regular cycle where you may be more ovulatory with PCOS? Yes. Are you going to change to a, within normal levels, your androgen access? Probably not. So guess what? The birth control pill is being used to bring androgen load down, right? And that is how we treat chronic diseases, right? I don't give a person, oh, I'm not, I'm not a physician, but physicians don't give a person a blood pressure med and we get mad at the physician for giving them a blood pressure med because they're treating the symptom of the high blood pressure, but they're not getting to the root cause of the issue, which is cardiovascular disease, right? These medications are given specifically to manage the symptoms. which is the exact same logic that we are seeing with individuals with gynecological conditions. We are not giving oral contraceptives in order to balance their hormones because they are chronic diseases, right? Outside of excision for endometriosis and fibroids, where we may see a reduction in symptoms, that is not a guarantee. And the only known cure for true 100% cure for endometriosis and fibroids is a hysterectomy. So if we have individuals with a high amount of symptom burden, heck yes, we are going to treat the symptoms, right? And so we can use oral contraceptives to treat those symptoms, right? If I wanted to pull this into our physiotherapy logic, that would be like saying, well, this person has a disc bulge on MRI. If we can't fix the disc bulge and get it back in that spinal alignment, then all of our interventions for pain don't matter because we're not fixing the root cause, right? So, but, PT we say you are not your image like we're not just going to treat you mechanically we're gonna treat how you're feeling within your own body and yet we flip that in our health care providers spaces when we talk about birth control and we make women with heavy menstrual bleeding with heavy periods with individuals who are suffering from fatigue and lethargy because they have anemia we have cyclical pain that could be treated with oral contraceptives and we make them feel bad that they're using it or make them feel fear that they shouldn't be using this because they should be able to balance their hormones regularly and so inadvertently in an attempt to help we're kind of gaslighting them, right? And, and I, I mean this in a very, like, I want to have a fruitful conversation about this because I have seen this messaging over and over and over again. And when individuals have gynecological conditions, birth control can be a management strategy. Should it be a knee-jerk reaction for everybody without the need for further investigation or evaluation? No. Are individuals oftentimes dismissed with birth control because they're not actively trying to get pregnant? Yes. Do some people not tolerate certain types of oral contraceptives or different types of birth control methods? Absolutely. But it is a trial of treatment that has some evidence to back it up. and it can be helpful in some circumstances with some individuals. So having this knee-jerk reaction and saying, well, it's not getting to the root cause or it's not balancing our hormones in the background of a chronic disease with no cure, we are missing the mark on our messaging. And so many of our clients come to us as pelvic PTs and they trust our opinions. And we are trying to lock shields with physicians, not battle with swords. And we need to be mindful of that, that by being very dismissive or not getting to the nuanced approach to contraceptive care or using birth control methods, we are not doing ourselves any favors and we're not helping our clients by not getting into the nuance of it. So the first argument that we see a lot is you aren't balancing your hormones, like it's doing something for you. It's taking your HPG access and bringing it down to nothing, right? That's not always the case and not always the method of oral contraceptives. It can blunt the HPG access, but it doesn't make it go down to zero. And then the secondary piece that individuals have fear on when thinking about oral contraceptives is future fertility. So, There was a cross-sectional study that said that almost 70% of females surveyed were worried about long-term fertility because of oral contraceptive use. We do not have evidence. We actually have multiple systematic reviews and meta-analyses that actually demonstrate that there are no changes in fertility upon cessation of long-term birth control utilization. All right, let me repeat. We do not have evidence that being on birth control negatively impacts future fertility. It does not. What we see is that using hormonal, non-hormonal IUDs, oral contraceptives and patches, the rates of live pregnancy or positive pregnancy rate for contraceptive versus non-contraceptive users in age-matched cohorts appears to be the same. where we can kind of get into this bias, this selection bias, is based on the reason for individuals going on birth control. So if you were a person who went on oral contraceptives in order to prevent pregnancy, but you did not have any fertility related concerns, and that wasn't a factor in your prescription, once you stop taking oral contraceptives, maybe after a couple months things will kind of re-regulate, you should have no future impacts on your fertility. Where you can have downstream fertility related issues is based on the reason for being on those oral contraceptives. So if you are on oral contraceptives for heavy bleeding or cyclical related pain, or hirsutism or clinical androgenism as a consequence of PCOS, we know that PCOS, endometriosis and fibroids can negatively impact your fertility and increase your chance of infertility. So in those situations, because we were treating the symptoms of your condition, we do not have the capacity outside of excision and endometriosis and fibroids to cure these conditions, that downstream fertility consequence is still going to be present upon removing your birth control method or upon removing oral contraceptive use. So it is not the pill itself, it is some of the reasons why you were on the pill that can negatively impact future fertility. And so I have now been talking for about 11 or 12 minutes on the nuance of birth control. The final thing that I will say is it is hysterical to me that the clinicians who are absolutely adamant against birth control for reproductive age individuals, are big advocates for using topical estrogens and hormone replacement therapies, menopausal hormone therapies, for individuals going through the menopausal window, because they are treating the symptoms of menopause, right? We are not trying to fix a person's hormones. We aren't gaslighting them and saying, oh, well, you know, this is your natural aging consequences, so you're just gonna deal with your menopausal symptoms. No, we're at the forefront advocating for topical estrogens and the use of exogenous hormones to be able to help individuals at the end of their reproductive window. So then why are we telling individuals with chronic diseases like PCOS that we can't or shouldn't use, that we should be fearful of using oral contraceptives in their reproductive window when they do not want to be pregnant? Right, and we know that it is a chronic disease that has no cure, and we make them feel bad for treating the symptoms with these exogenous hormones. So we just need to be so careful in our profession about how we are catching onto these trends. I always talk about the fact that I am scrunchy, not crunchy. I am a huge advocate in holistic care. And I think that holistic care can come alongside Western medicine in an evidence-informed way. All of my research is in health promotion, which means that I am in the science-based crunchy. So we just need to be mindful about not having this knee-jerk reaction and saying that birth control is bad. That is the messaging that I'm seeing. And that is absolutely not true. In the messaging, the logic in the messaging is flawed. When we're thinking about gynecological conditions, many of them are chronic conditions that do not have 100% curative rate. PCOS is a chronic disease with no cure. Endometriosis and fibroids can have excision, but the only thing that's going to guarantee that you are not gonna have another growth is a hysterectomy, which is not obviously a viable option for individuals who wanna get pregnant. And therefore, using oral contraceptives for managing signs and symptoms of those conditions is a evidence-informed utilization or medication that people can do. That does not mean that it is for everybody. That does not mean that people can self-select. It's okay for them to self-select away from it. We just wanna make sure that they're getting the right information about what it is and what it isn't. Birth control does not impact your future fertility. We now have multiple systematic reviews and meta-analyses that pending normal reproductive status, normal fertility rates, that we have no infertility-related conditions that there is no difference in conception rates once getting off birth control. And then we are huge advocates for the use of supplemental hormones through menopausal hormone therapy at the end of a person's reproductive window. All right, that was my rant for the day. I hope you guys found that helpful. I really just wanna get into the nuance of this, right? Like we wanna make sure that we are being mindful of our messaging and we are not, inadvertently shaming people or making them fearful or Gaslighting them and saying you don't need birth control you can use all these natural methods When we don't have the same effectiveness data in some of those health promotion technology or health promotion interventions

SUMMARY
All right You probably wonder why we're deep diving into this. This is because of level two, right? We have a huge role, right? We are doing level two right now for our pelvic course, and we are trying to do fitness-forward pelvic PT in a variety of different conditions. Fertility, baseline fertility, infertility-related conditions, and our role coming alongside those who are going through assisted reproductive technologies is in our curriculum. So we are in the weeds of that research and talking about the ways that we can be involved in rehab. And then if you guys are interested in seeing us live, we have two courses going June 1st and June 2nd. I am in Highland, Michigan, and Alexis is up in Alaska with Heather. And then June 8th and 9th, I'm in Mineola, New York. I'm near New York City at Garden City CrossFit. So if you are hoping to jump into a pelvic live course, I hope that I can see you at the beginning of June. Otherwise, have a really wonderful week, everybody. Hopefully I won't be so nasally and sick the next time I'm on the podcast. One can only hope. And have a really wonderful week.

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Episode 1730 - 1 degree away 0

May 17, 2024

Dr. Matt Koester // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Matt Koester discusses the difference that one degree can make when performing adjusts to a cyclist's bike fit.

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.

MATT KOESTER
Okay, we are live on Instagram and live on Facebook. Good morning, everybody. Welcome to another episode of the PT on Ice daily show. I am your host today, Dr. Matthew Keister. I am an elite faculty in the endurance athlete division with a specialty in bike fitting. So today I definitely am excited to step in and have a conversation about one of my favorite aspects of bike fitting. And that is the really nitty gritty small details that we love and we talk about every course and we get really into the weeds on. But I think sometimes to the outsider can be a little confusing. Before I step into that realm, though, I do want to take a second and highlight a few upcoming courses. This weekend, Jason London, my co-faculty, is going to be in Minnetonka, Minnesota. That course is pretty darn full. If there was any spots left to grab, it's probably the last second to do it, and they might not even be available. The next course we've got is in Bellingham, Washington. That is June 1st and 2nd. That course is sold out, and we're currently building out a wait list. We're also working on setting up a second course offering for that in the fall right now, but there's more details to come on that. And then we have another course set up. Next one coming in is July 27th and 28th in Parker, Colorado. That is going to be an awesome course. Just an easy place to get to in Denver. Always good to ride around there and get some time outside in the mountains. So super stoked for that one as well. That's it. That's it for the upcoming courses right now that I wanted to talk through.

THE DIFFERENCE OF ONE DEGREE WITH BIKE FITTING
Let's get into the title of today. I called it one degree away and I think When we think about like one degree, first of all, the margin of error for that with our measurements is often really, really hard to overcome. It can be incredibly hard to take a look at somebody and say, I'm going to make a one degree change on this and think that that's going to be clinically significant or meaningful to their pain or their experience. It gets a little bit different when we talk about bike fitting, though. When we talk about bike fitting, we're often using a little bit more precise measurements. We're using laser levels. We're using digital electronic levels, things that give us really specific data. And then when we think about the other part of bike fitting, when we make that adjustment to whatever componentry it is on the bike, and I'm going to talk through two specific cases in a moment, but whether it's the pedals or it's the seat, when we go to make adjustments there, that adjustment, while small at the instrument, one, two degrees, has upstream effects or downstream effects that are pretty pronounced when you extrapolate that one degree as it gets further and further away from the axis in which you made the change. So I think sometimes that's the missing piece when we try to have conversations about making a one degree change or a two degree change to something really small. So I mentioned we're gonna go through two different cases and I think the first one is the one that is oftentimes the trickiest when we're actually at the course. We spend a ton of time in the course talking about the art of trying to improve somebody's pedal stroke so that their legs are driving more up and down like pistons and less with dynamic changes or aberrant motions that are in the frontal plane. So knee valgus or going more into abduction. We try to kind of eliminate those things because any power that isn't going straight down the pedals is wasted. So one of the ways that we typically will make a change to get somebody into a better position or consistently riding in a better position is we'll add shims to their shoes. The shim is like, I mean, think about it the way like you would shim anything. It's a, it's a little wedge. It's thicker on one side than it is on the other. And it goes right underneath the shoe or sometimes inside the shoe. We can put that on the medial aspect of the foot. If we want to push that knee out a little bit into more abduction and stop a little, stop some of that abduction or potentially dynamic valgus. We can also, for the individual who rides with their knees pushed out a little bit, We may have to solve other things around the hip and the low back, but for that individual, we can also shim laterally and drive the knee in some to create some stability and drive them into the more neutral up and down position. Every single time that we break out one of these wedges though, they seem like, how could that thing make the change? It is one degree or it's one and a half degrees. And I think that's where things get lost a little bit. It's not the one degree made at the foot that makes the impact. It's what that one degree does when you extrapolate that 12, 18 inches up through somebody's shin bone. When you take it up through all that to the knee, we see some changes. And I grabbed this old-fashioned measuring tool. I had to pull it out of the dirt to get it here. But if we have our goniometer, we have it set up, and I make at the bottom, from a perfect 180, if I make a one degree change and I push that thing over. Down here, that is almost a non-measurable, hard to even see that change happen. But when we get up here towards the top, it's pretty crazy how that one degree change, just in this amount of space, moved us out probably four to five millimeters. Or for those who like freedom units, that's more in the quarter inch range. Many people's tibias are not this length. They'll think even further, take that out even more. All of a sudden now that person whose knee was riding like a half inch or a little bit more outside of what we'd want in a neutral position, as one degree change down here might have a dramatic shift at the knee. So it's really cool when you actually see it. And every time we put it, we put one underneath the client's shoe as fit as ourselves. I think we're constantly amazed. that we put that thing in and we're like, well, we'll see how this goes. And then it's amazing how much different it is and the patient can feel it too. They'll be like, yeah, that feels really good. My foot feels really supported. And you're like, okay, that one degree really did it, did it great. Another really key case for this, there's been research done by Andy Pruitt, who's kind of the godfather of bike fitting. He's done a ton of the leg work for the style of fitting that we do nowadays. When he was early on in his career and he started to really put a lot of content out for this and put a lot of effort and research behind it, he got partnered with Specialized. They're one of the largest bike brands in the country and they wanted him to help create what they considered their body geometry line. The body geometry line was essentially a best attempt to create the best contact points on the bike possible. So that's the cleats, or the feet, so the shoes, the seat, and the handlebars, or like the grips. So they put a ton of effort into their shoes. What they found after just time and time again testing folks, they found that everybody benefited from some level of a medial shim in the shoe. So they were like, over and over and over again, if everybody's benefiting from this and we're getting less adduction and a more piston-like vertical motion, why don't we just build this into the shoes? At this point, they actually do. Specialized, with all of their shoes, the Torch is one of their most, like their flagship and most consistently sold shoes, is baked in with a three degree medial shim to take up some of that flexibility in the foot so that the power we're putting down isn't lost in these aberrant motions, it's more direct into the pedal and it's nice and sturdy. So, that's one of the main changes that came out of the research from Andy Pruitt and Specialized. And I think it just kind of goes to that point of, we know how impactful a degree can be. The person who's dealing with knee pain that is definitely coming from these constant, shifty, aberrant motions, we start to clean that up. We start to get a cleaner picture of what's going on. That all starts with a one degree change. Now, I think the interesting one and the more pronounced version of this is actually at the seat, though. So we're not talking about now adding components or putting new things onto somebody's bike. We are talking about just making an adjustment to tip or tilt the seat. If we bring the nose down, which is a pretty common change for a lot of riders, it makes pretty pronounced changes in low back pain as well as some of the perineal pressures. So you can imagine that if this was the front of my seat and it's tipped up, there's going to create a lot of excess pressure in the perineum. This is a great conversation for any of our pelvic physical therapists to step into because the ramifications of sustained pressure in those areas is definitely in their ballpark and certainly outside of mine, especially if I make the changes and it doesn't quite get what I want. However, when we bring that seat down to try and fix those problems, we want it level or potentially slightly nose down. It's usually like one to two degrees. The reason we want that one to two degrees nose down is because what it allows the person to do is achieve a more relative anterior tilt. They're able to get out of this posteriorly locked lumbar flexion and roll a little bit forward and get into a little bit more favorable position to take stress off the low back when they're riding. This is a space where you go to make your adjustment and you put a electronic level on their seat with a nice level platform on top, and you might make a tiny little adjustment, one degree down. And in that moment, the client is sitting there going like, why did I come in here for this? That was the tiniest little adjustment I've ever seen. And then they hop back on and it's incredible how much better they feel. And the reason for that is the same thing that I already explained at the knee. When we're talking about a one degree change at the axis where you make the change, it has a lot of ramifications upstream. So I'm gonna use my Sangoniometer example. If I look at a one degree change, so let's just say I wanted to get somebody's shoulders more upright, get their back out of some flexion. I make a one degree change nose down. At this point, I've got my quarter inch, maybe a little bit more at this point. Think about somebody's torso being almost double this. and then consider the fact that we might have made a two degree change. I've already got a half inch here. By the time I get to the shoulders, I've probably got a full inch or more change. And that's just a rough estimate, assuming that the person's body was a super rigid straight line. Think about the fact that we have this chain link of vertebrae going up. If you can reduce stress up each one as it goes, you actually can get even more range of motion out of that. So it's pretty profound when you take somebody from a locked out lumbar spine position make a one degree change to something that's sitting right underneath their pelvis. It allows their pelvis to get into a one degree better position, but what it does up the chain is pretty incredible. You'll have somebody immediately go, Oh, that feels so much better. Like I don't feel that pressure underneath my butt anymore. That was really giving me numbness. Oh, I already don't feel that tension on my back. I don't, I feel like I can like get myself upright a little bit. I can get myself into a more neutral position and neutral coming in air quotes there. Cause it's a little bit different. Um, like we're not actually in lumbar spine neutral, but they get closer to it. And that can be the thing, getting out of that fully locked out position, getting into a slightly more neutral position is something that happens with a one degree change. So when we're talking to these folks and we're talking about the adjustments we want to make, it can almost sound really unexciting when we do our wrap up. We're saying, hey Sally, when you came in today, we made some adjustments to the bike. The first one we did is on your shoes, we actually added a shim to them. I put a one degree shim in there. And then when we went to the seat and we made our adjustments, we made a one degree change nose down and we actually slid it forward two millimeters. Those things don't sound really exciting when you say them out loud, but when you start to put together what those things are doing throughout the chain, throughout the whole body, bike fitting ends up becoming one of these things where we can make a very minute change now and have immediate, immediate reductions in pain, immediate improvements in performance, immediate changes in posture and positions and access to those positions. So getting into the nitty gritty, getting into the details, knowing that if you're going to make a one degree change or a two degree change, that it's going to have even bigger effects, talks even more to how important it is that we're accurate with those changes. If you are really, really interested in learning about making those changes, how to keep them accurate, how to make sure that we're not Throwing something else out of whack while we make one adjustment, I highly suggest you join us on the road. The BikeFit course is probably one of the most unorthodox courses in all of ice. It is the most niched down, it's just a bunch of people who love riding bikes and love tooling on bikes. And it's also folks who have absolutely no experience turning wrenches. People who come in who's first time using a torque wrench is in the course and we love that. It's a beautiful thing to have in the clinic and this is one of the main reasons why. It's those tiny adjustments that give us access to positions that we never would have had access to otherwise or would not have been able to fix even if we'd spent a ton of time in rehab when we could have just made the one degree change. Thanks y'all. Appreciate ya.

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Episode 1729 - Obesity & sleep apnea 0

May 16, 2024

Dr. Ellen Csepe // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Older Adult division teaching assistant Ellen Csepe discusses which patients are prone to sleep apnea, how to identify signs & symptoms, and when to know to refer & who to refer to

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, check out our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.

EPISODE TRANSCRIPTION

ELLEN CSEPE
Good morning everybody and welcome to the PT on ICE daily show brought to you by the Institute of Clinical Excellence. My name is Dr. Ellen Csepe. I'm an outpatient physical therapist. I'm also a teaching assistant with the modern management of the older adults division. I'm coming to you live from Littleton, Colorado today, repping my Denver Nuggets playoff shirt. And today, my goal has been for several months now to make sure that physical therapists are here to support the growing patient population with obesity. I really want to make sure that physical therapists are involved in this conversation to meet their needs because this population is growing rapidly and the healthcare world needs all hands on deck to help support this patient population. Today, for today's Leadership Thursday, We're going to be talking about obesity and sleep apnea. So in a lot of our course conversations, we talk about the importance of sleep hygiene. We talk about how important sleep is to mitigate the risk of injury, to help with healing, to decrease pain. But I think it's a really missed opportunity if we don't talk about how obesity can cause sleep apnea and sleep disorders. And I think we should feel compelled as physical therapists to know those risk factors and also kind of be the first responders for our patient population to make sure we pass the baton to the right clinician to help them with a potentially life-threatening problem. So what you can expect today, we're going to talk about how sleep apnea and obesity are related, but not mutually exclusive. Then we'll talk a little bit more about what the symptoms of sleep apnea are in both adults and children. Next, we'll talk about our screening tools that we can use in the clinic to look for sleep apnea. And last, we'll talk about where to pass the baton to make sure that we refer patients to the right discipline to help manage this issue and what treatment might look like with them.

THE RELATIONSHIP BETWEEN OBESITY & SLEEP APNEA
So first, obesity and sleep apnea are very closely related. Sleep apnea incidence has increased significantly in the past several decades, largely because of the increase in obesity rates in our country. Sleep apnea is basically a loss of breathing or difficulty breathing at night, which can be life threatening. Obesity is a disease and how we look at it. And that disease is kind of twofold. First, we look at obesity as an adiposopathy disease, which basically means sick fat disease. What that implies is that excess adipose tissue basically sends excessive chemical messengers throughout our bodies, which puts us at risk for diseases like cancer, heart disease. diabetes, also hypertension, all of those are chemically mediated from excess adipose tissue in our bodies. Then we also look at obesity as a fat mass disease. And what I mean by that is that excess adipose tissue puts physical pressure on our joint structures, like our joints, increasing risk factors for arthritis, But the way that sleep apnea is a disease is because excess adipose tissue in our bodies puts pressure on our chest, our throats, and even excess adipose tissue in our tongue can make breathing very difficult at night. I'd like to bring up this point that obesity isn't the only risk factor for sleep apnea. And as we're learning more about sleep apnea, there are lots of different things that can cause sleep apnea, from centrally mediated sleep apnea with risks of medications, to actual physical changes in our jaw and our throat structure which makes breathing difficult at night. So people with obesity aren't the only ones that can have sleep apnea and the rates are increasing for several different reasons. I'd like to bring up that those with a lot of muscle mass in their thorax or breast implants can also have obstructive sleep apnea, increasing that difficulty because of the physical pressure to breathe. So here's some annoying things about sleep apnea. It makes managing obesity way harder because we know how important sleep is for our overall health. But having disordered sleeping patterns or difficulty sleeping or literally stopping breathing while you sleep makes your risk of cancer, heart attack, having all of those increased risk factors because of poor sleep makes this even more difficult to manage. Additionally, when we're in a decreased sleep kind of pattern. And when we're sleep-deprived, our food choices kind of gear towards higher nutrient or higher calorie density foods. So if we're not sleeping well because we're struggling with obesity, we automatically go to higher calorie food choices because our brains are in a sleep-deprived state. And that's what we think we need. So sleep apnea makes managing obesity and the risk factors for lots of the sequelae of that disease significantly more difficult to manage. And in fact, people die from sleep apnea. I know this is really kind of hard to understand, but 38,000 people in the United States die annually because of unmanaged sleep apnea. That's about as how many people die in car accidents in the United States. That's a big number. And I feel like it's part of our job to see that risk and to know what the signs and symptoms are. So we know that people with obesity are more likely to have sleep apnea, but it's not the only risk factor. We know that a lot of other patient populations can have sleep apnea as well.

SIGNS & SYMPTOMS OF SLEEP APNEA
Next, let's talk about some of the signs and symptoms that we'll see in those with sleep apnea. So as adults, we'll hear a lot of Okay, they're snoring really loudly, louder than they would talk. You can hear them on the other side of the door, so snoring. Patients with sleep apnea often express daytime sleepiness, fatigue, difficulty concentrating, depression, anxiety, because they're in a sleep-deprived state constantly. They cannot breathe. Additionally, they'll likely have hypertension, walking headaches. they'll likely be more likely to get sick in their daily routine. So those adults with sleep apnea are more likely to be tired, snore, have apneic events that are observed by other people. Like, dude, you stopped breathing for an entire minute when I was sleeping next to you the other day. So being mindful of what that looks like as an adult is really important, but sleep apnea and sleep disorders are affecting children more. As we kind of go into the weeds, we know that sleep apnea is related to our jaw shape and our upper airway shape, both of which are influenced by our food choices. And with foods becoming softer and softer throughout the past millennia, We don't have to develop why jaws and our airway and our tongue and our palate all change because of that. If you've read the book, Jaws or Breath by James Nestor, it kind of talks about, okay, our jaw size is very closely related to our risk of sleep apnea and breathing disorders. So in children, sleep apnea can look similar. You know, stopping breathing, snoring, mouth breathing at nighttime, more likely to have allergies and throat infections. Bedwetting is another really common side effect of having sleep disorders as a child. Additionally, ADHD and inattention are very closely related to sleep disorders. In an adult and neurological conditions, pediatric neurological conditions, we always like to know how well they're sleeping because we know how impactful sleep is for our overall health and our brain specifically. So, okay, we talked about what symptoms patients might come to if they have sleep apnea.

SCREENING TOOLS FOR SLEEP APNEA
Next, let's talk about some screening tools that we as clinicians can look out to see, okay, is this patient struggling with sleep apnea? How can we get them to the right place? The questionnaire that I often use in the clinic is the STOP BANG questionnaire. So, STOP BANG looks at sleepiness. So, we like to see, okay, are we having snoring at nighttime or apneic events? So, STOP looks at, the letters are kind of mixed up. But looking at daytime or nighttime snoring, we like to look at hypertension because adults with sleep apnea are likely to have hypertension. We look at daytime sleepiness. If they're having a lot of daytime sleepiness, that could be an indicator for sleep apnea. And then the BANG stands for BMI, so if they have a BMI over 35, that's problematic. The O stands, or I'm sorry, BANG, B-A, looks at age. If they're over 50, that puts them at a likelihood of having sleep apnea. N is for neck circumference. So if your neck is bigger than 17 inches, that's problematic and puts you at an increased likelihood of having sleep apnea. And then G stands for gender. Males are far more likely to have sleep apnea than females. So that's a really great screening tool. I'll put a link in the comments on Instagram so that you can use it in the clinic if it's helpful. A few other clinical features that we can look at in our patients is looking at the tongue. If their tongue is having a lot of scalloped edges or wavy edges, that could be a risk factor for sleep apnea. If they have venous pooling under their eyes, so a lot of purple dark bags under their eyes, could be indicating that they're not getting quality sleep. And then the MalinPati score, so if you have your patient open their mouth as wide as they can and stick out their tongue, you want to be able to see their uvula and their soft palate. You want to be able to see a lot of structures at the back of their throat. I'll link this score as well, but if you can't see their soft palate, their uvula, and can only see their hard palate because their tongue is in the way, that is a really strong predictor with excellent specificity that that person is likely to have obstructive sleep apnea. So those clinical tools are very helpful for us as physical therapists to be able to pick up on these problems. So next, let's kind of talk about who we would pass the baton to. If we were thinking, okay, yeah, this person is having episodes of sleep apnea, they're snoring really loudly, they're having a lot of daytime sleepiness, they're high blood pressure. We've got problems here. Their tongue is really impeding their airway flow. They even have that weird scalloping on their tongue.

REFERRING PATIENTS WITH SLEEP APNEA
What do I do next? So of course you could refer the patient to their primary care doctor. That's an easy pass there. Additionally, I have found dentists to be hugely helpful. I'd like to give a shout out to my favorite referral source, or place to refer, Dr. Pat Prendergast. He helped me kind of prepare this podcast this morning and wish me luck. But we talk a lot together about how to manage patient sleep apnea without using things like CPAP machines or oxygen at nighttime. And dentists are taking kind of the charge here and looking at airway disorders and breathing problems at night because this is such a huge problem in our communities and in our world. So dentists are another great referral source or another great place to refer patients to if you're concerned that they have sleep apnea. And then obviously pulmonologists, ENTs would be appropriate disciplines for patients to see if they had structural problems or pulmonary problems that could contribute to their sleep apnea diagnosis. So treatment can look different from person to person. So Depending on the findings, we might suggest that a patient lose weight to manage some of their obstructive sleep apnea. That is a really exciting new thing that we're finding, that managing weight can be hugely helpful in minimizing the risk of sleep apnea. New medications like the GLP-1 agonists, Ozempic, Wegovy, those have been helpful in managing sleep apnea, and bariatric surgery is helpful in managing sleep apnea too. So understanding that those weight loss efforts will likely impact somebody's sleep is huge to recognize. Additionally, we have options from jaw devices or oral appliances likely created by a knowledgeable dentist like Dr. Pat. Mandibular advancement devices kind of pull your jaw forward to open your airway more. You could have a retainer or different options that they would fabricate to kind of improve your tongue positioning. Additionally, there are other techniques like vivos, which is actually here in Highlands Ranch, Colorado, to basically spread out your palate and change the shape of your upper airway and your jaw to make it so that your airway is more open and allow breathing. Additional interventions, there are CPAP machines and other machines like it which basically force air into your airway, into your nose and your mouth. Some attach only at your nose, some attach throughout your nose and mouth. Those, as physical therapists, we like to know if those are changing or new because they can put excess pressure on the suboccipitals. change pressure there. But we really want to encourage our patients to use those because they can be life-saving and if that's what their primary care doctor recommended, we don't want to ignore that recommendation. Additionally, there are surgeries that can be performed to get more airway through that upper airway and even newer technologies, newer interventions like the Inspire which basically has a battery pack, monitors your pulse oximeter, looking at your oxygenation in your blood, and has an electrical stimulation to your tongue that if you were having an apneic event it would stick your tongue out and get it out of the way so that you could breathe. I've had several patients have the Inspire procedure and been really happy with that intervention.

SUMMARY
So we talked about a lot today. We recognize that patients with obesity are far more likely to have sleep apnea, but not everybody with obesity will have sleep apnea, and not everybody with sleep apnea will have obesity, and it's a growing problem in our culture, in our world, and with our patient population, and we need to care. So we recognize that obesity and sleep apnea are related, but not mutually exclusive. We talked about some of the symptoms of sleep apnea in both adults and children. We talked about the screening tool, the stopping screening tool, and looking at that Malin-Potti score. looking at the tongue and other clinical features like bags under the eyes, that venous pooling, those are the things that we want to look at in our patient populations. And then we talked about who's the right person to take it from here, knowing that dentists are underrated and how they could be helpful in managing this if they're aware of sleep dysfunction and how to treat it. So we recognize that there are a lot of different interventions and those will likely impact our patients in some way, whether or not that's going to impact their jaw positioning and potentially need treatment for their jaw or their upper neck, their suboccipitals. So thank you guys so much for joining me this morning. I hope that this information is helpful in managing this growing crisis that we see in our patient population. Have a great rest of your morning and go Nuggets.

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Episode 1728 - How Italy creates successful agers 0

May 15, 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 environmental factors influence all aspects of the aging experience, including movement, nutrition, and social interaction.

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.

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.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.

CHRISTINA PREVETT
Hello everyone and welcome to the PT on Ice daily show. My name is Christina Previtt. I am one of our lead faculty for our geriatric division. I am also one of our leads in our pelvic division, but today we are going to talk about all things older adults. So I have been away for the last two weeks because my family and I took, my husband and I took a vacation to Italy. And it was the first time I've ever been in Europe. It was an incredible, incredible trip for a lot of different ways. But of course it got my Jerry brain working and reflecting on differences in culture and the way that we interact with older adults and how I saw older adults who were moving around their environment in Italy. And so, I just kind of wanted to go on today and talk a little bit about some of those differences. If you have followed the MMOA podcast, you know that Ellen and I and some of our MMOA team did a grouping of episodes around the blue zones. So the blue zones are areas around the world that have a above average number of individuals who live to 100. And it's been a big area of research and trying to figure out like the secret sauce of being able to live to a hundred. And one of them was actually in Italy. So it was in Sardinia and that was, that's not where I was. Um, I was in Rome and Maori, but a lot of the concepts and themes that they were talking about in the, that mini series and in the book on the blue zones, it made a lot of sense and it just made me highlight or see a lot of the differences in our North American culture than what we're seeing over in Europe. And Going into Rome was the craziest experience. It's so busy. It is almost impossible to drive. And then going into Maiori, which was in the southern part of Italy, we were in a very small town, not one of the bigger touristy towns along the Amalfi Coast. And it was being in Maori that I really saw some of, or I was more able to really look at how individuals are aging in different areas, in different countries, and made me think a lot about our aging experience in North America. So the biggest thing that I saw in our culture, and these are things that we cannot control, and I'm going to kind of bring this back to our course content, is It is very difficult. The environment at which a lot of the cities in Europe being so old are developed. are very walkable. They're very walkable and it almost is not disincentivized, but it's almost a net negative to have a vehicle. In Rome, for sure, it would be terrifying to drive around Rome. But even in Maiori, like a lot of the areas were very condensed in terms of the groceries and where you would grab most of your main amenities for the week. And it allowed for individuals to walk a lot of their tasks. And not only was that environment one where walking was really the main source of transportation, the environment at which you were walking was not a straight plane. This was a big area, like it was obviously had a coastal, like mountainous coastal plain. And so there was a lot of steps. And so one day my husband and I, we went on a lemon hike or a pathway of the lemons, which I became obsessed with, but it was literally a straight shot up. It was, I think we did like 17 flights of stairs to get to the pathway. for this hike and there were houses that were littered across the side and so I saw a person they were in probably their early 70s and they had groceries in each of their hands and they were gradually working their way up these steps. And a lot of the times, we know some of our recommendations for our older adults is to walk more. When you're walking around this town, you are going up and down hills. And there is an intensity to that. My heart rate was not low. And when you're adding in groceries in your hands and there isn't a handrail, it forces you almost to maintain a certain amount of physical activity in order to maintain your independence. And so the first thing that I was really, it really struck me about being in an Italian city was how the environment really was conducive to movement. And it wasn't low intensity movement. It was actually quite high intensity movement just because of the way that the city was built. And it made me reflect a lot on our thoughts of just walk more, right? Like there's a lot of debate about is walking intense enough for us to be able to incur either some physical activity benefit or to be able to maintain physical activity as we get older. And when I compare and contrast the way that cities are designed in North America that has so much more space and does not have the same historical architecture that's trying to be maintained, we don't have walkable cities in a lot of ways, right? If I think about the current city that I live in, it is very, very spread out. And it is almost impossible outside of the downtown center for you to be able to walk and have yourself walk to get groceries or pick things up. It is always the knee-jerk reaction that you get into your car and go places. And when you are walking, at least where I am, I'm not in like a beautiful area like Colorado that's all hills and mountains. It's pretty straight plain. And so When that happens, a lot of the blue zones are in areas where physical activity is forced into your day-to-day interactions. If you want to go see your friend, you have to walk up the hill to their house. If you want to get groceries, then you need to go down four flights of steps to get to the market. That is not the same. And so when we think about our industrialized cities, And the way that technology and car transportation has really changed the way that we build out different cities, what we recognize is that when our environment does not create opportunities for physical activity, that is when purposeful movement needs to be scheduled in a person's day. And I think this is a really interesting concept, right? Because the blue zones were in a lot of these areas where the environment was conducive to intense exercise, at least in a moderate intensity zone because of the way that the cities were developed. That is not true in a lot of the areas where we are practicing. And so this This dichotomy between just walk more can work, but the intensity oftentimes isn't there because of the way the environment is set up. And when that environment isn't set up to encourage physical activity throughout our day, we can very easily get into the slippery slope of sedentary behavior. And when that occurs, we have to make purposeful movement a priority in our day. And this is not just for our older adults, this is for everybody. But this is where gyms come in, right? This is where purposeful exercise programs now are coming front of mind and are becoming a really important aspect of our culture. Because so many of us now, or the people that we are working with, our older adults that we are working with, are not in gyms. those environments anymore, like that is not the way that our environments are set up. And so we have to be mindful of that when we're thinking about our interventions. So the difference in the environment and how easy it was to walk with intensity when we were in Italy was so, so different than what we see in our very typical North American cities, where you have to get into your car. That was probably one of the biggest things, is just looking around the environment and seeing just the stark differences. One of the things that I also really enjoyed watching, especially when I was in a small town in Italy, was the way that slow-paced, naturally occurring, intergenerational conversation happened. When I was walking down a street with my husband, I would look around and people would walk and they would see people in the city square and there were moms with their little kids and they were talking to older members of the community. And again, the environment made it so that this intergenerational conversation happened as a natural consequence of a person's day. And instead of rushing by each other, and maybe giving a head nod of acknowledgement if we weren't head down in our phone, people stopped and interacted. Now, I'm not saying that everybody in Europe is in this area, but definitely the area that I was in, which is very closely structured to the way that Sardinia is, I saw these interactions happen every day where you are walking down the street and they had a place to go, but they weren't so rushed that the thought of a five minute conversation was something that they could not handle, or they weren't ready for, or they weren't rushing from one place to the other. And then these social interactions occurred where you could just see this transfer of knowledge that was happening from older generations to younger generations. And there was just this sight of respect and reverence of these communications that was just so lovely to see. Again, I'm not saying the North American culture does not have that front of mind, but we live in a place where I don't know many people who stay in the very close proximity bubble of their family, right? Like I talk to clinicians every single weekend where I say, where are you from? And they say, oh, well, I'm living in North Carolina now, but my family, of, yeah, my family is in Michigan, or it's not abnormal for people to be very far away from their family or their loved ones. And the culture is so busy that even calling loved ones weekly can be something that has to take a lot of conscious effort because it's so easy to get into the rhythm and fast pace of the week that, and this is speaking to myself as well, that those stop and pause conversations with someone on the street. They're not as commonplace and especially across generations where you're seeing a mom with their little baby stop in a group of older Italian men who are playing a board game outside in the community square and you're seeing that interaction happen in such a beautiful way. And so seeing some of that intergenerational communication because of the way that the environment was set up was just so lovely to see and made me think a lot about how we have this loneliness epidemic in North America. And it is really from the fact that we are so spread out, we are so far apart, that it makes it really difficult for those interactions to happen very naturally. And it creates this spot where, you know, my grandmother had 10 children. My mom was one of 10. We don't see that size of family as often anymore. And there would be times where my mom would visit for 45 minutes, but that was the only interaction that my grandmother had throughout the day. And her kids would call, and this is not like a negative on them. It is very much the fact that, you know, the way that our culture is set up now is that those interactions don't happen very genuinely or very easily. And they take a lot of effort and there's a lot of things on our time. And so that, again, that environmental piece is like this big umbrella where the environment was set up that allowed for physical activity, but it also allowed for social interaction. And so subsequently with those two things, it being very easy, those barriers were almost stripped away for movement and for interaction. What I noticed was that the pace and stress of life was very different. So we went from Maori, we went back on a plane or on a train rather to the Rome terminal, which is a crazy busy terminal. And on the last day of our trip, we ended up going back around rush hour. So we took a six o'clock train from Salerno and we went to Rome. So we ended in Rome around 7.30, which is peak prime time. And if anyone has been in a train station or taken public transportation, I used to go into Toronto and Union Station is a very big hub. Toronto is a very big center for commuting. So the GO train is very busy. And if you are in Union Station around rush hour, It is true chaos. People are trying to get on the train, but they're still on the clock, so they're on their phones. There is a rush to get a seat. It is stressful. You find out 10 minutes before, which is similar to the Rome Terminal, about where you are going, and it is a rush. It is so busy, and there is this stressful environment that is in the air, and people get so used to it because they do this every single day. Their commutes are really long. I was kind of expecting to see that in Rome, right? Like Rome is a very big central hub for Italy. It essentially mimics what we see in Toronto or other big city centers. But even though people were dressed and heading to work, that stressful environment wasn't there. People were walking casually to their job. They were not racing. They were not running. And it made me think about the underlying stress that our culture and our community is under. and how this translates into our aging experience. Like what is our nervous system primed for when we are in a very high stress state all of the time? And then we retire after being in that high stress state for 40 years and go into retirement, right? There is a well-known statistic that there is an increased incidence of health events in the year following retirement. And there's a lot of conversations around, you know, purpose and drive and changes in status. But maybe part of that is that you're changing your sympathetic drive so drastically that your body is having a hard time adjusting and it can show underlying issues. The stress piece on our culture in North America, even in the busiest centers of Rome, like the chaos of the Colosseum or around the Basilica, it was not there. Like that feeling of underlying stress and tension for having a group of people who are all very hastened and rushed to get into a lot of different places, despite Rome being crazy busy with tourists, like they were telling us about the millions of people that come into Rome every year for tourist related activities. And it was wild to me to see how much of a difference, even with that amount of tourist attraction, even with that bustle and busyness, that that underlying stress was not there from even people who are local to Rome, who are working in Rome. And so I think about how that presence of stress for us in middle age, what does that do on the system or on the resiliency of the system with age? And so Again, the change in the environment really was opening up my eyes to a lot of the things that we see in our fast-paced cultures and made me reflect a lot on how that changes a person's aging experience. And when you are forced to do movement and you retain a certain amount of physical capacity, and that allows you to engage in life, that allows you to live at a pace that is amenable for your mental health, and you're surrounded by, honestly, so much beauty, it just makes me think about how Italy can so easily create successful agers. And I'm not saying that North America can't and that the US and Canada can't, but it definitely takes more effort, I think, in North America. I think we need to think a lot more about the way that we are aging and the way that we are interacting with our environment, with our people, and make a conscious effort to engage in physical activity, engage in purposeful interactions, engage in a pace of life that works for us and our family. And that is just so ingrained and it is so easy to do in Italy because of some of the cultural considerations that are there when we are working or we are seeing individuals interact. Now, of course, I am the outsider looking in, I am an aging researcher who just finds this super fascinating, but I want to know what your guys' thoughts are. If you've visited Europe, especially if you've been in a small town in a European country Do you see those differences? How can we think about the way that the environment in a lot of European countries and cultures is set up to make successful aging a little bit easier? How can we create that with our people? How can we create that type of environment that makes successful aging easier, that makes successful aging for us easier? Because that environmental switch it just takes away a lot of the work of it. Like there was no processed food in the markets. If you wanted to get processed food, you would really have to look hard for it. And that was in Rome too, right? There wasn't a ton of candy, like there was pastries and things like that, but you were making it when you were in Maiori. And it just, it made some of those health promoting decisions easier to make and more intuitive. So it made me think a lot about that. I have had an incredible time, but seeing some of the older adults in Italy was definitely one of the highlights for me and seeing just the way that they interacted. All right, if you are aiming to get into one of our MMOA live courses, we have two courses going up this weekend. So I'm going to be in Bismarck, North Dakota with Trissa. We are also in Richmond, Virginia this weekend. June 8th and 9th, we have a smaller course in Spring, Texas. So if you're looking for a lot of one-on-one time and attention from the instructor, that is Jeff Musgraves going to be out there in Spring. So really encourage you to jump into our live course. Today is the last day to sign up for MMOA level one. So if you are hoping to get into our online course, that is your last opportunity is going to be today. We get started this week on the circle platform on our ice physio app. I'm super excited for that and all of the newness of the app. If you have any questions or comments, I want to hear about your European aging experiences. Let me know. Otherwise, have a really wonderful week, everyone. And I'm going to get off here before Alan kicks me off.

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.

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Episode 1727 - The paradox of the fitness-forward clinician 0

May 15, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division division leader Mark Gallant

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

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.

MARK GALLANT
We're live on YouTube, we're live on Instagram. This is the PT on ICE Daily Show. I am Dr. Mark Gallant coming at you here on Clinical Tuesday. What I wanna talk about today is the paradox of being a fitness-forward clinician. So when the Institute of Clinical Excellence first started back in 2012, so 12 years ago now, the physical therapy landscape was quite different at that time. As a profession, in orthopedics or outpatient orthopedics, what we really tended to focus on was very local tissue intervention. So we would have specific tests to indicate a local tissue or a region, and then we would apply either an exercise or a manual therapy stimulus to that very specific local tissue. And that was pretty prevalent in general throughout the profession. The other thing that was true in the physical therapy profession at that time was most of our referrals, or most of how we got patients, was through physician referrals. So either through a hospital system, an orthopedic surgeon. We were not getting nearly as many direct access folks. There were performance physical therapists, but there were far fewer folks doing that. And so because all of our folks were, most all of our folks were coming from the medical community, what we tended to see was people who were not as fit overall. So people who had a lot of medical comorbidities, they were metabolically unwell, just not as robust of a population. And that makes for a very interesting combination where you have people who are generally not very fit overall and you're going after very specific local tissues. Those things don't tend to work well together because If the overall human, the overall organism is unhealthy, it becomes very challenging to treat local and specific things. If cortisol's high, if inflammatory chemicals are high, if the nervous system is having to allocate resources to keeping basic organ function alive, to keep this person going, it is not going to be allocating resources to fix specific tissues. And on top of that, what we see, What we now know from pain science and general fitness is a lot of the reason these local tissues were getting sensations of pain or not feeling well was because the overall organism wasn't doing well. So when the company started in 2012, Jeff Moore, our CEO, who a lot of you have heard on this podcast, he started to notice this and some of the other early faculty and we've got to get better as a profession. in helping the overall human, getting general exercise better, nutrition, sleep hygiene, stress management, all these things to make the overall human a bit more fit and robust so that we can then potentially go after more of these local tissues. And then in 2016 when the fitness athlete division came on board, when modern management of the older adult came on board, Then we really started getting a lot better at making these folks fitter, getting their metabolic health in check. And what we learned from those two divisions is The CrossFit model of intensity is really the shortcut to metabolic wellness. So the more intense that person can exercise at, we're gonna see more of a direct correlation to their general overall fitness. And what we learned from the CrossFit model and fitness athlete and modern management of the older adult is the definition of intensity is work divided by time. the more work you can do in a given time domain, we're gonna see a lot of correlation to general fitness overall. And that could look like a wide variety of things. So if someone's really into CrossFit and they improve their FRAN time, so 21, 15, nine of pull-ups and thrusters, we're gonna see oftentimes a direct correlation to their blood markers, their overall metabolic fitness. on the same side of someone's more deconditioned, if you get them on the new step and you say, I want you to do as many steps as you can in five minutes, and then we see a 20% improvement in that over the course of a month or two, we're also gonna see a correlation to metabolic wellness. And that's really what this company was about, is showing folks and getting the profession on board where we've got to get these folks more metabolically well and get that intensity up. Now as someone gets metabolically well, if we go the next spot on the pyramid above intensity, you're going to find work. So just if we take the time domain out of it, how much load can that person move? How many reps can they do? What distance can they go without time as a domain? So we're taking that intensity out of it. That could become the constraint. someone who gets really into CrossFit and they're like, hey, I'm getting a lot fitter, I'm metabolically more well, I'm unable to do FRAN because I don't have the pull-up capacity. Okay, well let's take the time domain out of it and let's build your pull-up strength, let's build your pull-up endurance. Now what that person might find at the tip of that pyramid is, ooh, the reason I'm not able to do these pull-ups is because I have some legitimate constraints at my shoulder. The range of motion in my shoulder is not good. The rotational capacity of that shoulder is not good. And now we can work on some more of those local tissue things. Always keeping in mind that the base of that pyramid is that intensity and that metabolic wellness. And everything is a means to an ends to get back to that general overall fitness. And so that's what ice has been about for a long time now. Intensity, metabolic wellness at the bottom of that pyramid, get these folks feeling better, and then if they need to focus on some local work capacity, they need to get their deadlift better, their press better, their pull-up better, we'll work on that. And then if there is a local tissue constraint, then we'll take care of that. And what we often found is once these people get metabolically a little bit better, all of a sudden their joints are moving better, they're feeling better, and you don't have to look as far up the pyramid, that intensity and that metabolic wellness resolves a lot of things.

THE PARADOX OF THE FITNESS-FORWARD CLINICIAN
Now the paradox of the fitness forward clinician is now that you folks, all of you who are listening are out in your communities and you're known as the fitness forward clinician in your community, what you're starting to see is way fitter people are coming into your clinic because they know you know how to coach. They know that you know how to program fitness. They know that you believe in fitness yourself and so they identify themselves with you. They're like, oh man, April is like me. She is really fit. She likes to do this stuff. I'm going to go see her because she's not going to tell me to stop doing CrossFit or to stop rock climbing or that it's ridiculous that I want to start running again at 76 years old. She's going to help me build up and make a plan from there. So when you start seeing these fitter folks, the interesting thing is they don't need you to train that intensity. They already know how to do a lot of work over a given time domain. They are already very metabolically fit. When Kelly Benfie, who's in our fitness athlete division, comes to see me in clinic, Kelly is one of the fittest humans on the planet, like literally one of the top 200 to 300 fittest humans on planet Earth. Kelly does not need me to coach her how to get faster at her FRAN or how to do any given of the classic CrossFit workouts faster. What Kelly likely needs to see me for is that because of the high volume of gymnastics and Olympic lifting she's doing, her shoulder gets a bit irritable. She needs me to do some dry needling, some myofascial decompression to calm that shoulder down and build up some of the rotational capacity and capacity of the lats for her to tolerate those overhead positions. She now needs me to do the 2012 thing. She needs me to focus deeply on those local tissues because the overall organism is so fit and doing well. And now we can deeply turn our attention to making those specific joints, those specific regions as optimal as possible, which will then allow Kelly to keep doing her fitness at a very high intensity level. So either one of these folks can come into your clinic and anywhere on the spectrum between the two of them, What it's up to us is to be really good at both things.

PHYSICAL THERAPISTS MUST BE GOOD AT LOCAL AND GLOBAL INTERVENTIONS
We need to do the modern fitness forward physical therapy thing where we can coach gymnastics movements, we can coach the deadlift, we can program fitness to build intensity, we can track fitness to help people build intensity and metabolic wellness over a given period of time. What we also need to be really good at is the old school physical therapy thing, so that when really fit people do come into your clinic, you know how to treat the local shoulder. You know where you want to put your needles and what settings you want on your E-stem. You know where you want to put your myofascial decompression. You know how to specifically load that shoulder at various positions, at various amplitudes of motion, under different loads and at different speeds. It is up to us to treat all of these people and to recognize which one of them is coming into your clinic and give them the best optimal program for that N equals one patient overall. Hope this helped overall. Again, paradox of being the fitness forward clinician, that bottom of the pyramid, intensity with work next and then local tissue. Now, because you're the fitness forward clinician in your area, oftentimes that pyramid will be flipped where your focus is gonna be on working on the local tissues for that folks, so that they can keep their intensity. Comment in the comments, we'd love to chat more about this. If you wanna catch extremity management on the road, Lindsey is gonna be out in Bellingham, Washington this weekend, so definitely go hang out at Onward Bellingham and catch her out there. I'll be in Dallas, Texas, or Hazlet, Texas, right outside of Dallas, June 1st and 2nd. I would love to see you all out there. Hope you have a great Tuesday. See you on the road soon.

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Episode 1726 - Cut to the core: LBP in the OR 0

May 13, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares a case of an OBGYN client with lumbar radiculopathy and the unique approach to core training that increased the client’s tolerance to sustained positions with less pain in the OR.

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.

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

EPISODE TRANSCRIPTION

APRIL DOMINICK
Good morning, PT on Ice Daily Show. My name is Dr. April Dominick and I am here with the Ice Pelvic Division to talk to you about a current client case I have on cutting to the core, a case of the low back pain in the OR. So today I'll talk to you about a doctor with lumbar radiculopathy. radiculopathy that I've been treating, and the unique approach we took to core training that increased her tolerance to sustained positions in the OR and reduced her pain. a bit about my client. She is a cheerful female obstetrician in her early 30s who lives a very healthy, active lifestyle. She is strong. She loves to ski, hike, lift. She also lifts really heavy, which we love. And she came to me with a myriad of complaints of TMJ pain, headaches, cervical thoracic pain, and reports about 80 to 90% improvement with those issues. And then for the purposes of this podcast, we will just focus on her hip and low back pain. So she described it as aching, stabbing, and she, that was for the low back pain, as well as her right-sided hip pain. It was a six out of 10 at worst and three out of 10 at best. that intermittently worsens. And her pain originally started after she had to sit for a prolonged period of time in order to study for her boards for residency, something that we all are very familiar with. And she sought PT care with me about six months after when the pain had been steadily worsening. And then the final straw was she had 10 consecutive days of pain in her hip and back after a really long shift in the OR. So things that made it worse, exacerbating factors, prolonged sitting, prolonged standing, so any sort of prolonged positioning, sometimes heavy lifting days at the gym, especially leg day, and work days. And then easing factors, stretching, changing positions, supportive shoe wear at work, or sometimes exercise would help it, So after her subjective and objective exams, signs and symptoms pointed towards lumbar radiculopathy, coupled with some right hip labral pathology, and she had moderate irritability. So I took her through the typical lumbar radiculopathy and intraarticular hip treatment, including manual therapy like manipulation, dry needling plus stem, I dialed in some back and hip strengthening and mobility. And then she also responded really well to a little EMOM that I gave her for when she had acute severe flare-ups in between our sessions, which included some cardiovascular bike intervelling to address her chronic inflammatory state, nerve glides, and isometrics. So after a few sessions, she made really awesome improvement in, she had improved in neurodynamics testing. Her weekly frequency went from having pain daily to every couple of days, which was great. And then her intensity and duration of those pain cycles also reduced. Love it. And then her progress stalled, and she continued to have some low-level symptoms that would flare. And the culprits seemed to be work. Particularly, we narrowed it down to her labor and delivery shifts, where she had to hold sustained positions, as opposed to when she was working in the clinic and she was getting up and down from her stool or moving between patients' rooms.

THE HIP & PELVIS SHARE MUSCLES
So it wasn't until we unpacked two key pearls that we began to make another difference. So during initial eval, she had, when I asked her, she had denied any bladder, bowel, or sexual dysfunction. And given that I was able to reproduce her pains, why she came in, with specific exam of the lumbar spine and her right hip capsule and surrounding musculature, Pelvic floor dysfunction wasn't high on my hypothesis list, but given our roadblock in progress, I decided to go ahead and screen the pelvic floor externally. And when I palpated her obturator internus externally, and then we did some further testing internally, it reproduced her lingering secondary hip pain on the right lower extremity. So she had like a major hip pain. And then we found out she had, um, another hip pain that she hadn't really noticed as much, um, because of the other pains had kind of been so overpowering. So, um, she also had some difficulty, um, from the pelvic floor side of things and in relaxing, she had some hypertonicity throughout and then, um, some coordination issues. So we treated the pelvic floor, did manual therapy, dry needling to the obturator internus, along with some circuits with her low back and hip. And that seems to have really helped her quite a bit as well. So that was the first thing that helped us in this stalled progress was lesson number one, don't forget that there are bits and pieces of the hips that share a wall with the pelvic floor. and that the OI lives in that pelvic bowl and it's a direct connector over to the hip via the greater trochanter that it inserts on and it influences hip stability, hip rotation, and that was one of our key pieces in helping her get some more improvement.

ADDRESSING JOB-SPECIFIC DEMANDS
The Second piece that really helped move the needle and address those lingering back and hip symptoms was getting more specific about her job demands and environment. So specifically when she is working in the OR, our operating room, if we can't change her job duties, like she has to deliver babies, that is her job, what can we affect? Can we set her environment up for success, specifically as it relates to VOR. So in the clinic, we set up her operating room using what we could, and we went through things like, what is the table width and the height? We positioned her tools. I asked her where her coworkers stand in relation to her. We talked about the amount and direction that she's leaning over the OR table. She ended up describing a really common position that she ends up in, which is a right side bend and rotation. And that is, if you remember, her hip pain is on the right side. So that was really helpful. And then we also looked at the percent of or we kind of labeled it in an RPE way of the isometric pull during retraction of the abdominal tissue for her C-sections. So I basically had her try out different percentages of pulling and and she kind of landed on, okay, this is about how much I have to pull when I am either using my own strength to do that retraction, or if I'm using tools to do that retraction. So we then, after I got her table set up in my brain, I also asked about detailed information of the surgeries itself. So of the C-sections in particular, about how, With the C-section itself, how is time split up? You have to do a lot of retraction. That seems like the thing that she's doing in a sustained position. When does that happen? And come to find out for her, it happens in two-thirds of the time that she's in the C-section. So there's like a first retraction and then there's some other things and then there's a second retraction. So that was helpful to know that there were some breaks, so to speak. And, um, then we, uh, we talked about her, uh, average time it takes to have her symptoms come on during the C-section. And, um, she has to do multiple C-sections a day, uh, intermixed with some vaginal deliveries. So we, we talked about, is it within the C-section if it's a particularly long one for some reason, about when does your symptoms come on or after about how many. So all of that was really helpful information. And then we, we did some treatment. So we brainstormed strategies that she could use in the OR. Can she Use the retractor tool instead of her actual hands or her own strength to help reduce some of that burden on her body. And then can she use tools like a step stool to increase her height or get closer to the table, redistribute her weight, use the step stool to put one leg up on top, or even the bottom of the table sometimes has that. And then an anti-fatigue mat or supportive shoe wear. And then I asked her if she would be able to sneak in some lumbar extensions or side bending just in the OR when she's not actively assisting with the retractions just to give her body a break from that sustained position. And then increasing reliance on the other staff on her residence to give her a break prior to her reaching that symptom threshold of more than five or six out of 10. So that was super helpful for what she could do in the OR. And then we talked about what she could do before her surgeries. And this is where the core piece comes in. So she sometimes is able to return back to her office or back to the floor between her C-sections and vaginal deliveries for her shift. which led us to creating a quick core rehab EMOM, every minute on the minute, that focuses on multi-planar core strengthening and endurance for those long duration positions. It's that duration piece that seemed to really exacerbate her symptoms. So the core remom we came up with includes neutral and extended trunk work, side bending and rotation of the trunk. And we threw in some isometrics as well as mobilizations just to help with both the pain from an analgesic effect with the isometrics and then some mobilization given that she is just in that sustained position for so long. So for the core remom, I gave her basically three to four categories that she could choose one exercise for to do for a minute. And she could do anywhere from a three to four minute remom all the way up to 12 to 16 minutes, depending on what time she had. So for the core remom, in the neutral slash extension category, she could do a reverse plank for a 45 second hold. And then we talked about having a tote bag filled with a bunch of the medical textbooks that are just collecting dust in her office, two tote bags actually, and that was going to be her load for some of these exercises. So she could put the tote bag on top of her for that reverse plank to add load. We also did a side plank plus a top leg raise hold. She could use her loop band that she brought if she wanted. And a loaded windmill. So that was the, sorry, the loaded windmill is actually in the side bending category. So for the neutral extension, she had the reverse plank for about 45 seconds. as well as prone press-ups. And we found out that the prone press-ups tended to make her feel better from the discogenic symptoms she would have after the surgery itself. From a side bending category, so next category side bending, we had her do standing heavy farmer's carry with a band on her feet. So she'd have to work her hip flexors during that time and anterior core. and obliques. And then she had the side plank with the leg raise and then the loaded windmill. And then from the rotation category, we had her pick, or actually we just had her do a banded doorway. She could either do diagonal chopping, so that P and F pattern, or lifting. And that was really helpful because it really mimicked the retraction kind of pull that she had to do. And so I had her do it in different positions, tall kneeling, all upright, tall kneeling, half lunging, and then standing. And I had her match the percentage of pull or the RPE that we talked about, I had her either match it or go a little bit higher that she has to use her own body weight or the retractor tools in surgery. So we could kind of get her used to practicing that pull with good breathing mechanics and then also good awareness of her core. And then a bonus, was some hip and back mobility, like banded long axis distraction, quadruped rocks, or thread the needle. So that's a bonus if she wanted as well. So all that, she only needed a long band, a loop band, and then her tote bags filled with the medicine textbooks. And with that, She's been able to incorporate that into, um, before some of her C-sections or at least before the first couple, as well as, um, in between. And she has had some really awesome results in terms of reducing her low back pain, hip pain, and being able to tolerate standing in the OR and working on these individuals as much as she could. Um, so love that. And it was really cool to be able to, brainstorm and put ourselves in her actual environmental situation as best as best that we could to figure out what it was that she was doing with her body and how we could use her core to better support her so that her hips and low back didn't have to do all the work as well.

SUMMARY
So Our pearls from today don't underestimate the power of a 30 second external pelvic floor objective screen, even in the absence of bowel, bladder, sexual dysfunction, when there's hip involvement on the table. Even me as a pelvic floor PT, I missed that in this particular case, she did have a lot of other things going on, but it was interesting to find just a little bit of that secondary hip pain that we hadn't uncovered initially. And then taking that deeper dive into understanding the nuts and bolts of someone's job duties and environment to paint a clearer picture. And then with this case in particular, OI-focused obturator internist-focused treatment, as well as brainstorming strategies to alter the environment during the case itself, as well as priming the anterior core and hip with that focused multi-planar remom, helped her diminish some of her lingering hip and back symptoms. And we were able to raise the threshold that she could tolerate in terms of the number of C-sections that she could complete. So, success all around. If y'all want to dive deeper into the latest research on the core as it relates to pelvic health and some examples of actually some of these remoms that you can practice with early core management or advanced core management, then join us live. You can grab a seat on PTOnIce.com. Our next courses are in Kearney, Missouri this coming weekend, May 18th and 19th, and a double header June 1st and 2nd will be in Anchorage, Alaska and Highland, Michigan. Everyone have a wonderful week and I hope that helped you out with some of your cases.

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Episode 1725 - Earning more as a PT 0

May 10, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Zach Long discusses how to earn more as a PT working with fitness athletes, including learning to understand how much you're currently generating & earning, as well as ways to increase your take-home pay.

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

EPISODE TRANSCRIPTION

ZACH LONG
Good morning, everybody. Welcome to the PT on Ice Daily Show, the May 10th episode, Fitness Athlete Friday, always the best day of the week here on the podcast. Excited to chat to you all today about a couple of different strategies for us to earn more money as physical therapists. We all know how much money that the average student is coming out with in terms of Debt when they graduate and that's we're constantly as a profession complaining about these declining reimbursement rates while it's becoming more Expensive to become a physical therapist But I think we're missing the boat on a lot of different things that could actually help us generate more money Whether we are a business owner or an employee. So I want to hit a couple strategies for that For you all today Before we jump into that topic, I do have to mention one thing that we have coming up inside the Fitness Athlete Division. That is June 22nd and 23rd in Fenton, Michigan. We are hosting our first Fitness Athlete Summit. So we're going to have the entire team there. All of our instructors are going to be together for one course. That one is going to be an absolute blast. Check that one out at PTOnIce.com. Alright, so we're going to talk about a couple things specific to the fitness athlete in terms of earning more income. But before we get to those specific things, I want to talk a little bit more big picture on some things that I think are incredibly valuable for us to research and know and think about if our goal is to earn a little bit more income here.

UNDERSTANDING WHAT YOU'RE GENERATING
And so the first, whether you're an owner or an employee, and this is going to be more particular to employees, most owners hopefully already know this, is we need to be educated on how much money that we are generating for our clinic. Or if you're an owner, you need to know how much money is each one of your employees generating for you. But I really so frequently don't see employees understanding this. And so one thing that I did throughout my career when I was working for different people, now I own my own businesses. But even when I was an employee, I was always diving in these numbers because I wanted to understand what I was doing for the company that I worked for. So, you know, depending on what software your clinic uses for billing and things like that, that might just be a couple of clicks to be able to see how much money you've generated over this entire year. Or you might have to do a little bit of math yourself. I've been in situations where that number was readily available. I've been in situations where that number was really hard to find. But in general, if it's hard to find, then you just have to figure out what your average reimbursement if you're in network is per visit and multiply that by how many visits you see per year. And you're going to get a decent idea of how much overall money that you're generating for the clinic. And then what you wanna do is you wanna take that number and compare it to your income. How much of that money that you're bringing in are you taking home? And I don't, you're gonna find a lot of variation in that number in terms of what you're taking home versus what you're generating. I will say that the number that I've heard thrown out repeatedly is the 30 to 40% number. At Onward, we're at a network, Onward Physical Therapy. So we believe that that number should be 50%. or maybe even a little bit more than that, depending on a number of different factors. But 30 to 40% is the number that I've seen thrown around the most. I'm always really shocked at how often when I'm traveling and teaching and talking to different physical therapists, at how often some of them are in a model where they're seeing four patients at once. And if we do four times $75 times, you know, however many patients per week, that is times, however many weeks per year you work, I've run into a number of physical therapists that are out there generating 500, $600,000 a year for their clinic. while making about $80,000. We'll make it like 20% of that number, which is just insane. And you have to be educated on this so that when you go in for your next contract negotiation, you kind of have an understanding of where you sit here. Now, again, that number is going to slide back and forth quite a bit. And I think one of the things that that would slide back and forth considerably on is if you were taking a salary, a set in stone salary versus you having a deal in place where you take some sort of percentage of revenue or you're paid per visit or something along those lines. And that tends to scare a lot of physical therapists that tend to want that set in stone salary. But I'll say like, if you really want to have the ability to make more money, then I think a lot of times we need to do a better job of just betting on ourselves and being willing to say, yeah, I'm happy to take a percent of my revenue. I know that up front that might be a little bit harder as I'm building my caseload. But on the back end, I could potentially make more money as long as I'm doing a great job providing clinical outcomes to people so that more and more people want to come see me. That is a great way to make more money as a physical therapist. The first time I went from a set salary to that, it obviously took me a little bit of a while to build my caseload up. but it resulted in me making $30,000 more per year. Once I got past that first year of rebuilding my schedule, that helped me pay off my student loans dramatically faster because I was willing to bet on myself and take a percent of my collections rather than a fixed set in stone salary. And I'll also say, if you're an employee, there are a lot of owners that love that idea as well, because they're not going to have a fixed expense. They're going to have somebody that's in this eat what you kill model. And they know that that's going to keep you hungry. That's going to keep you working a little bit harder, things like that. So it can oftentimes be a very big win-win for all parties there. And, you know, if you're an owner, one of my favorite parts about being a business owner is being able to pay my employees really, really well. And so I love to see when they're really dialing in on their clinical skills or doing a great job marketing and selling, and then they're getting rewarded for their hard work. And I wanna pay them so much money as a reward for that hard work that they never want to leave my clinic because of the finances of it. I want them to stay with me forever because they know that I'm gonna do the best job I possibly can of taking care of them financially. So think about betting on yourself and taking a percent revenue instead of a flat salary. With that one other tactic that you should consider is are there things in your contract? It that you don't need So let me give you an example of this a few years ago I was working for a clinic and I was making 40 of my collections from that company That resulted in me again making a big jump from my previous salary, but they also offered a couple other things They had a health insurance plan that they offered and they also gave me 15 sick days Valued at 150 dollars per day. So I don't remember the exact math on that. But when I ran the numbers here I recognize that number one I could use like a religious medical sharings insurance option instead of their insurance option And that would cost me less money and get rid of the fixed expense for the business And I also recognize that this was earlier in my career before I was married I wasn't taking that much vacation time and I wasn't taking any sick days. So I'd get to the end of the year and I'd have all these sick days at $150 per day. And I recognized that, goodness gracious, I could take those five sick days, but I generate more money when I'm in the clinic than $150. So I'd rather work. This was when I was trying to really aggressively pay off my student loans. And so I actually did the math on this in terms of the insurance versus the sick days. And if my My percent collections went from 40 percent to 41.5 percent That was like my break-even point there So I went to my boss and I said look you've got these fixed expenses of sick days And my insurance and I don't need either one of those So what if instead of that we just change my percent collections to 43 percent? My boss was thrilled. He was happy to get rid of a fixed expense And so just by doing those numbers and thinking through what I valued and didn't value as much I was able to come up with a strategy that made me several more thousand dollars per year probably resulted in about Probably results in about two and a half to three thousand extra dollars per year, which is wonderful So negotiate those things away that you don't need And then another thing that I think is really important for us to do when we just talk big picture numbers here is to set your goal income, then backtrack to the amount of money you need per hour. And this is one that's really important for both employees and owners. But like if you're an owner of a business and you're trying to decide how much to charge for different services, especially the ones that we're going to talk about here in a minute, what I like to think of is what's my goal salary for that year? Divide that by 2,000 hours and that needs to be the net income that I make per hour. So let's say just for simple math, you want to make $100,000 per year divided by 2,000, that's $50 per hour that you need to be taking home. And so that means that you then have to factor in your admin time, marketing time, your expenses, et cetera, et cetera. But that gives you a really good idea of where to start from your pricing standpoint. And you got to have that in mind if you really want to grow financially a little bit. Final big generic thing before we get into a few fitness athlete specific tactics is that I think overall, we need to worry dramatically less about the alphabet soup behind our name. Our patients don't really care that you have the ABC and the XYZ certification, et cetera, et cetera. What people are looking for now more than ever, especially as people are more and more educated, there's more information available online. They are looking for specialists in the areas that they are having issues with. If they're having hip pain, they want to see the best hip physical therapist in the area. If they're struggling with running, they want to see the best running physical therapist out there. If their shoulders hurt with snatch, they want to see a physical therapist that understands the needs of the fitness athlete. So worry less about the alphabet soup and more about building an undeniable skill set with your target demographic that you can then market to and have basically a guaranteed nonstop, um, influx of patients into your door. That's why ICE is really working on revamping our course logistics here. We're really pushing people towards our certification, such as our fitness athlete certification or older adult certification. We just want you to start to become known as the go-to person in your region for X or Y. That way you can really market that and leverage that in growing your business.

CHARGING FOR ADDITIONAL SERVICES
That then brings us to our fitness athlete division. And some of the specific things that I think that we teach in our courses, that we think that a lot more physical therapists should be marketing and selling to add additional revenue into their clinics money, or maybe some of these things become a side hustle that you do. So I'm gonna throw just a couple of different ideas out at you. Number one, mobility programming. Especially in the fitness athlete space where we're doing some really complex movements that take our muscles and joints through more range of motion than we see in almost any other sport. So take somebody that's working out trying to improve their strength at a global jump. Maybe they're doing lat pulldowns. Well, that pulldown usually take your shoulder to about 160, maybe 170 degrees of flexion. If you join CrossFit and you're doing kipping pull-ups, bar muscle-ups, etc, your shoulder is being taken to absolute enrage. If you don't have 180 degrees of shoulder flexion, you're going to be in really poor positions. You're not going to perform as well. It's going to often lead to some little aches and tweaks. So writing mobility programming is something that so many CrossFit athletes are looking for. And if you have that skillset, you should be marketing that to them. It doesn't take a ton of time. You could do really quick, you know, once a month, 30 minute follow-up sessions and you write them, you know, three or four days a week. Here's your 10 minutes of mobility work that you should be doing before or after or on your off days in relationship to your workout. So think about mobility programming. Alongside of that is accessory programming. Like say somebody comes and sees you for, for back pain. You analyze their squat and they've got a good morning squat pattern. You recognize that they need a little bit more quad emphasis, a little bit more quad strength and hypertrophy to help improve that movement pattern a little bit and reduce those aches long term. write them some accessory program. So that could be like two or three days a week. You're writing them, you know, 10 to 15 minutes of work to do after class. It could be that maybe they're dropping one day a week across it and they're doing really specific work on the areas that they are held back in a little bit. Because I think a lot of times we forget, you know, CrossFit's broad general fitness. So if somebody comes into CrossFit from an endurance athlete background, they're going to have a big hole in their game, like their strength is going to be behind their aerobic capacity. So maybe they need more strength bias in their programming and maybe one day a week you program that for them. Maybe somebody comes from a powerlifting background, they need the opposite. And so you start programming them some accessory Zone to work to really build that aerobic base There's a lot of stuff that we could do in the accessory programming standpoint, too And I honestly I don't see a whole lot of CrossFit gyms doing this right now So most of the time you won't be stepping on your local CrossFit gyms toes by doing this because they just simply usually don't have the time to handle extra programming. I also have a friend that does full programming. So like when he discharges his patients, he offers them fitness programming on the back end of that. So he works for a standard clinic and he's adding, last time I checked in with him, $20,000 extra per year that's straight to him. His company doesn't mind him doing this at all. Straight to him an extra $20,000 a year, just programming for people that he's already discharged. So a lot of these things don't even require that much more work, that much more marketing, and simply just offering this to your existing customer base as a little bit of add-on. In terms of like the specific like fitness athlete, you know, crossfit or powerlifter, limit weightlifters, I think one other thing that we should really look at is regular maintenance work. And physical therapists always get really up in arms when we talk about maintenance work, but I think we need to recognize something about this. So many individuals out there are actively seeking out regular maintenance work. They see a chiropractor once a month to get adjusted. They see a massage therapist once a month. They talk to a personal trainer and they're paying for accessory programming online, something like that. Why not offer doing all of that in one spot? Like why would you not say, okay, Jimmy, I know we took care of your low back pain, that upper back still stiff, your pain's gone, but we need to get that upper back unlocked a little bit. So why don't we follow up once a month for the next few months, I'm gonna write you some accessory mobility work to do. But once a month, we're going to crack your upper back. We're going to spend some time doing some mobilizations there. We'll do some soft tissue work, et cetera, et cetera, et cetera. We can put all of that together in one package for them rather than them having to go out to multiple different places. And it's a win-win there. We're still providing valuable services that's helping out their performance, that's potentially preventing future injuries and issues from happening while simultaneously growing our business. So I think we dropped the ball quite a bit on maintenance work and we Need to be a little bit more open to that in certain situations when we're providing value to people still. And then finally, I want to mention a couple of things from the more endurance side of the fitness athlete division here, and that's things like bike fits. So we have a bike fit course at ICE. We also have a running evaluation course, but both of those are things that people are more than willing to pay cash for because they understand how much it's going to help them perform to their absolute best and reduce, you know, a little bit of those aches and pains that they get with those sports that do have a decent injury rate there. And then with that population too, we should also be thinking about programming for both. We all know that runners aren't doing enough from a strength training perspective. And so often they have a running coach that they're hiring that's programming their running. And usually when I look at the strength work that the running coaches program for them, it's air squats, unloaded lunges, glute bridges, things like that, that we all know are not heavy and intense enough to drive adaptive changes in that population that needs the heavier loading. So why do we not offer that? Can we not really quickly write twice a week, a 30 to 45 minute program to get those individuals a little bit stronger and help stay ahead of issues that they have going on? So I hope that gives you a lot of different ideas that you can do and market to your business. The question that I always get asked when we talk about different ideas like that is then how do I know what to charge for that? And that goes back to setting your goal income. So you set your goal income, how much money that means you need to generate per hour. And then you look at all of these different extra services and you say, how long would it take for me to do this? So let's say bike fit, for example, let's say a bike fit takes you 90 minutes. It also takes you on average, about 30 minutes of marketing to get every new person in the door. So we're saying it's two hours for every bike fit. Two times the amount of money you need to generate per hour plus your expenses results in you understanding exactly what you need to charge for these services. So I hope that really helps y'all understand a few different things. And as always, we look forward to seeing you on the road at Fitness Athlete Courses in your area. Have a great one, everybody.

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Episode 1724 - Poise 0

May 9, 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 concept of poise, poise gone wrong, and poise gone right.

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

EPISODE TRANSCRIPTION

ALAN FREDENDALL
All right, good morning, PT on ICE Daily Show. Happy Thursday morning, hope your day is off to a great start. My name is Alan, I'm happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at Ice, and the lead faculty in our fitness, athlete, and practice management divisions. Leadership Thursday, we talk all things business ownership, practice management. Leadership Thursday also means it is Gut Check Thursday. So this week's Gut Check Thursday, we have a partner workout. We're working our way with a partner through five rounds, 20 or 15 calories on that rower. Ideally, that's together, side by side, two different rowers. Coming off the rower, moving through 15 synchro toes-to-bar, and then finishing with a little you-go, I-go, working our way through 10 total sandbag cleans. I do one, you do one, until we've done 10. and then resting a minute after each round. That's gonna feel a little bit like anaerobic intervals, a little bit like maybe doing 400 meter repeats on the old cardiovascular system. Our goal there is two to three minutes per round, a minute per rest, get done with all of that work right around the 20 minute mark. I tested that yesterday in the garage, was able to hang with about 230 to 245 per round. My toes to bar are not the best, but a really nice workout, very simple, very easy to warm up. So that is Gut Check Thursday. Speaking of working out, May is Mental Health Awareness Month. We're happy to be partnered with Forging Youth Resilience. You may have seen at the Ice Sampler a couple weeks ago, we did the Ignite workout, a fundraising workout designed to support FIRE and support Mental Health Awareness Month. So all throughout the month of May, you still have time to donate to our campaign, which is for Forging Youth Resilience. We're trying to raise $10,000 to help some of those kids go to camp this summer in July up outside of Boulder, Colorado. So you can find more information about that on our link tree on Instagram. Find all about Forging Youth Resilience. Find all about the Ignite Workout and our fundraising campaign for FIRE.

EMOTION CAN SPREAD LIKE A DISEASE
Today we're talking about the concept of poise, the definition of poise, of staying in balance or staying in equilibrium. And in the context of today, we're really talking about staying balanced, staying composed, representing poise as it relates both to leadership within the clinic, you and your colleagues and your teammates, but also poise in front of our patients. So the idea of this topic came upon me actually several years ago. Two years ago in June, I had the pleasure of watching Dustin Jones and Jeff Musgrave teach Older Adult Live. down in Kingman, Arizona, and then we took a trip up to the Grand Canyon to do a rim-to-rim hike. So if you have never heard about that, you've never done it, rim-to-rim is half of the hardest thing you can do there, the other being rim-to-rim-to-rim. So starting at the top of the Grand Canyon, hiking down to the base of the Colorado River, and then hiking back up. Some individuals hiking south rim to north rim and then coming back. So many, many miles of hiking, very rough terrain, And this time of the year, spring, summer, very, very, very hot. So stepping off around 4 a.m., hiking down to the Colorado River. If you don't know anything about the Grand Canyon, it's really mentally defeating. It can be because as you come down in elevation, the heat actually goes up, which is not something our bodies are used to happening. So as you get closer to the river, it actually gets very, very hot, sometimes approaching 120 degrees. And then at the hottest point of the hike, at the hottest part of the day, you turn around and hike back up the Grand Canyon. So very, very tough, both physically and mentally. And as Jeff and Dustin and I were making our way back up the Bright Angel Trail, very wide trail, very exposed trail, sandy, not a lot of shade, very hot, very dry. And again, you're already halfway through the hike, so you are already pretty fatigued. And overall, I think it's fair to say that coming back up to the rim to finish the hike, most people are just trying to finish. They're looking forward to being done. And along the Bright Angel Trail, as you come back up, what you encounter along the trail are these things called rest houses. These are just little brick houses for shade that have a well pump nearby so that you can top your water off. And so, Jeff and Dustin and I, coming back up from the base of the river, making our way back out of the canyon, about halfway up, passed by one of these rest houses, decided to stop, take a break, top off our water. And we walked in this rest house, It was packed full every every inch of space had somebody sitting and hiding in the shade. And as we looked around, we realized a lot of these people probably had no business doing that hike. If you've never done the Grand Canyon hike, what you experience when you start the hike is signs everywhere. telling you, asking you, begging you not to do that hike, warning you that usually somebody dies every day hiking the Grand Canyon. It's very tough. It's very hot. And so as we're sitting in this rest house, we were sitting among some folks who maybe should not have been out on that trail. who were in a really tough spot physically and mentally. And unfortunately, on that hike, you're not really in a position where you can give much help to people. You certainly could not throw somebody on your back and carry them out. You're really not in a place where you could afford to give somebody any of your water or your food. Those folks, unfortunately, are just gonna have to wait until the sun goes down, until their body has recovered enough to hike back out of the canyon. And so my first experience with poise and with negative emotions was in that rest house, watching all those people really, really suffering and the three of us kind of sitting down, not as deep in our tank as some of those folks. But really, the longer we sat there, the more we realized kind of how quiet, how defeated those people were, and how that negative emotion, those feelings of maybe hopelessness, of extreme physical and mental fatigue, were actually starting to get into us. The longer we sat there, the longer we rested, the more we kind of let the whole vibe bring us down, even though when we walked into that rest house, we were definitely not in the same mood. And I'll never forget Dustin standing up and saying, okay, let's go. We have to get out of here. It smells like death in here. And what he was saying was, hey, we're actually not as bad off as these people, but if we sit among them for too long, we will convince ourselves that we are. So let's get going. Let's keep making our way Kback out of the canyon. We don't need to sit and rest here and feel bad about ourselves and how tired we are and how much we just want to be done. we can't let those negative emotions affect us. So, realizing that our poise, our balance, our equilibrium, our confidence can rub off on other people near us, and especially the larger group of people that is around, the more people feel a certain way, we can almost palpate those emotions, right? We've all felt that at a concert, or maybe you felt that at church during worship or something, you can feel kind of positive and negative emotions start to infect you almost like a disease. And so recognizing that is a concept that can happen and that we ourselves are in charge of not only how we pick up on other people's poise, but how we demonstrate our poise to someone else.

KEEP YOUR POISE: GRIPES GO UP THE CHAIN OF COMMAND
And so my second point today is learning a little bit about leadership in the military, going to non-commissioned officer academy, and really learning a foundational leadership concept that when you are frustrated, when you are upset, when you have suggestions, when you don't like the way things are going, your suggestions, your feedback, your complaints, your gripes, call them whatever you want. should always move up the chain of command, they should never move down the chain of command. And very similar to the Grand Canyon story, the idea behind that in the military is poise, is confidence, of we don't want to mislead people, we don't want to lie to them about the current situation, but at the same time, complaining to people beneath us about how tough our job is, or how bad things are going, especially if they think things are going well, and otherwise putting a damper on the situation again, can really bring in those negative emotions, can really start to fester, and really start to spread and infect almost like a disease. That if we're not careful, that if we complain too much about our business, about our clinic, about our patient caseload, about financials, about taxes, about any of the different things that we can have suggestions to improve, that we can have wishes that they were better, that we can have complaints about why they're not better. All of those things When we voice those things, especially to people in leadership positions beneath us, we need to recognize that we're just fostering that environment of negative emotion. And my final point is, why does this really matter? Even if you don't consider yourself in a leadership position, even if you're not in a leadership position in your business, in your clinic, you are in a leadership position with your patients. And just like complaining downstream can really have a lot of negative effects on a whole organization, having that same mindset individually with a patient about your business, about your clinic, about how busy you are, all of those things are concepts, are thoughts, are emotions that our patients are very easily able to pick up on.

POISE WITH PATIENTS
So my third point is, your poise matters probably the most with the patient in front of you. I truly believe it's our job to make that person feel welcome, to make them feel like their concerns are valid, and that we do have a way to help them, and probably most importantly, our poise is that we are excited about helping them. Not every patient that walks in is a high-level athlete and it's really fun to help them improve their snatch or their clean and jerk or something like that. Some folks come in and we know those patients. They are very deconditioned. Their therapy protocol can look very low-level to us, but it is our poise. It is how much We make it seem exciting to do things like sets of sit-to-stands, and one-pound dumbbell bent-over rows, and really partial range of motion burpees, and that we clap it up the first time that person's able to transfer on and off a bike for the first time, for an example. and that our poise, our balance, is always, if not neutral, erring on the side of positive. And when we really step back and question what are the benefits to having negative poise, to letting this person know how busy we are, how many patients we have on our schedule, how far away we think they are from the finish line, that really does not do anything to meaningfully move that person closer to their goals. If anything, it might keep them or slow them down from their goals if they pick up on the idea that they are not doing well, that their function is not great, that they are maybe making slower progress than we'd like to see. If they're able to perceive that, then we know those emotions can spread and those emotions can become reality. So being very careful with our own poise, making sure that when we have complaints about what's going on in the clinic, what's going on with our schedule, whatever is happening in our life, that those complaints go up the chain of command, that our patients don't hear them, that folks who work with us in leadership positions beneath or to the side of us don't hear about them, that those gripes, those complaints, those suggestions, those feedback things go up the chain of command so that the poise of the organization at least again stays neutral, ideally trending towards positive. Knowing the effect that those negative emotions can have. Despair, bad mood can really spread like wildfire if we're not careful to control it. And so recognizing when you show up for that patient your poise really, really matters. How steady you seem, how confident you seem, even how confident you seem and maybe not knowing something plays a big role into your poise. Hey, you know what? I don't know the answer to that question at all, but I'm going to look into that and as soon as I find out the answer or I find out somebody who maybe has the answer, I'm going to put you into contact with that person. So just trust me, that even if I don't know, it's okay that I don't know, and I'm going to help you find a solution. Just that poise, that level of confidence that we display, can go a really long way in patient buy-in. That if they leave the clinic and they feel like, man, my therapist knows what's going on, they know what I need to work on, they're happy, they're excited, they're stoked, they're measuring my progress, they're letting me know how I'm doing towards working towards my goals, and that overall it feels like a really positive environment, It's no surprise that those patients tend to show up for more therapy, they tend to do better in their plan of care, and even when their plan of care is done, they tend to be the folks that recommend new patients for us. And so, in those cases, having a really strong, confident, positive poise rewards everybody.

SUMMARY
So think about that the next time you're getting ready to stand up from your desk, you're getting ready to start your day, you're getting ready to restart your day after lunch break or something like that. Check your poise. Are you excited to work with this patient? Are you gonna clap it up that they do that one pound strict press, that they get eight cals done in a minute on the rower? No matter how low level it seems, no matter how basic it seems to you, maybe compared to your normal clientele, check your poise. I promise, the more you work on this, The more folks will have fun, the more you will have fun, and not surprising, you'll find yourself having more patients wanting to see you, then you have time on your schedule as well. So poise, think about it a little bit. That's it for today. I hope you have a fantastic Thursday. Happy Mother's Day to all those moms out there. Mother's Day, if you didn't know, is coming up Sunday. Still time to go get a gift if this is brand new to you. And then we're happy to restart live courses after a little bit break next weekend. So check out ptinice.com for all the live courses coming your way throughout the summer and into the fall. Have a great Thursday. Have a great weekend. Bye everybody.

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Episode 1723 - Build your own older adult fitness class 0

May 8, 2024

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

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the brand new "Build your own older adult fitness class" starter kit now available on 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.

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 slash 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 Jane account.

JEFF MUSGRAVE
Welcome to the PT on Ice daily show. My name is Dr. Jeff Musgrave, doctor of physical therapy, proudly serving the older adult division. And today is Wednesday. Wednesday means it is all things geriatrics. So it is Jerry on ice. I am super excited to be sharing with you today. some of the hard lessons learned and I think some helpful steps for building your own older adult group fitness class. So, getting more and more questions about this stuff, my business partner and I, Dr. Dustin Jones, who also is faculty in the older adult division, have built a community for people 55 plus and we have learned a lot of hard lessons along the way. I'd love to share those learnings with you and then also pitch a couple free resources that are coming your way that you can get when you download the PT on Ice app. So all that being said, super excited to share this with you, but we would be completely remiss if we just blew past and got to the nuts and bolts of building the program and not touch just a little bit on, oh, we've got some people on that are interested in doing the same thing. I love this. super remiss not to just share why we would want to do this. And the reality is, our older adults' lives are being destroyed from a lack of resiliency, that lack of reserve, that lack of extra physical strength. And it comes in many names, right? We like to call it one rep max living. We talk about limited reserve, limited resiliency. But they come in diagnoses like sarcopenia, right, dynopenia. We've got potentiopenia, that loss of power, loss of strength. We've got type 2 diabetes. We've got heart failure, cardiovascular disease, heart attacks. I know I'm preaching to the choir here, team, but it's just so sad to see the long-term outcomes and how that changes the trajectory of someone's life when we know that most of it's preventable. If we could get someone to high intensity, they've got a safe place to exercise where they can get the options that they need, then we could make these things go away. We have the solution. It's not like we're waiting on scientists to bring us a solution. We're not waiting on research here. The research is very clear that most of this is completely avoidable. Completely avoidable. So team, if this has got you pumped up, if you're curious about what it would look like to build this, I've got some simple steps and some considerations and then I'll share with you about a couple free resources we've put together for you. So the first step I feel like… We've got to be very clear about who we want to serve. You've got to know who is your best customer. Sometimes people will reference these as avatars or personas. Who is that person that you are best suited to treat? Who do you want to treat? The reality is, unless you're in a very rural community, a small community, you need to get very specific about who you want to serve. You need to know where they eat. You need to know what kind of car they drive. You need to know where in town they live. You've got to figure out where that geographical area in your community is you want to serve. You've got to know how to serve a very specific customer well. Let's be honest, the person that is maybe coming off of outpatient caseload, who is just barely above independent, community dwelling, older adult, Their interest in fitness and what is going to draw them in versus what's going to push them away is going to look very different than someone who has been a lifelong athlete, a master's athlete that's coming into your clinic because they've got an achy knee or an achy shoulder or something like that. I mean, those customers are going to be interested in a different intensity. They're going to have interest in different equipment, and we need to know how to speak that language. We need to know how to identify that very specific customer we want to serve, and then we've got to create an environment that is irresistible to them. It's got to be equipment they can use. It sounds like such a simple thing, but it's all fun and games in your older adult group fitness class until you try to get someone on a bike and you realize they physically can't get onto an assault bike or they physically can't use a rower anymore. What are you going to do with them during that class? Do you have a plan? But that is a completely different customer that's more like that person that just came off outpatient caseload versus someone like that Masters athlete where they're going to be able to use all the equipment that the general population in a CrossFit gym is going to be able to use. But you've got to be very specific about who you're going to serve because I truly believe you cannot serve everyone well. You've got to be very specific. You've got to niche down as much as possible. If you're in a small rural area, you may have to widen your lens just a little bit more, but be very specific. So the who is the first part. You've got to know who you want to serve. The second part of who is with whom. So the with whom is, are you going to do this alone or are you going to find a partner and partner with somebody? I'm very excited to say that I've got a wonderful partner. Dustin Jones is gonna be really upset that I said this, but I trust the guy with my life, okay? I don't have to worry about the decisions he's gonna make for our business. He is a very strong, has great character, he's dedicated to excellence, and he's gonna challenge me. He's gonna push me. outside of my comfort zone based on the mission that we're serving and the people that we're serving. And that is crucial. A great way to summarize that goal, and depending on the project you're trying to put together here for your older adult group fitness class, you may be able to do it solo and that may be fun. But I'm gonna give you some advice via Jeff Moore, via an African proverb, and that is, if you wanna go fast, go alone. If you want to go far, go together. And we found this true because we launched right before the pandemic. And I think if we hadn't had each other's support, there may not have been a stronger life. And man, what a huge missed opportunity that would have been to the people that we get to serve. So that's the first part. Who and with whom is what you've got to figure out. The second piece is you've got to know, you've got to start figuring out what model you're going to use to serve in this older adult fitness. You've got to figure out your space. You've got to figure out your equipment. So if we're thinking about different models that are out there, you could, um, Start like we started in a CrossFit gym, maybe in off hours. You want to make sure it's a place that's supportive. We were lucky that we were at CrossFit Maximus in Lexington, Kentucky, and they were all about having us in there during the hours they weren't using class. The equipment's there, the space is there. Team, these business owners, they're paying the rent. They're paying utilities through this whole time, but they're not getting any income during that time. Usually what you're going to find in those gaps, mid-morning and early afternoon, are you're going to find open gimmers who are paying the maximum price, but they're using maximum equipment, maximum space. And if they could get someone that was going to generate exponentially more income during that time, they'll probably take a shot with you on that. So that's one way you could do it. You could also choose to do a virtual model, where maybe you're using Zoom or you're using Google Meet, and it doesn't really matter where your customer lives, as long as your customer's tech savvy, right? They could be all over the world. So you're probably gonna have to build some type of following. You're gonna have to get your name out there. But a virtual model frees you up from having to have a brick and mortar space. It can free you up from the geographical barriers of not being able to get to your customer or your customer get to you. A lot of studies say people are only willing to drive 10 to 15 minutes for their group fitness classes. So if you take wherever you're targeting to put your spot, and you kind of draw a circle, that's how you can start looking for real estate in that market as well. You need to figure out, are you going to do only group fitness? Are you going to do personal training and offer one-on-one sessions? Will those be in person? Will those be online? You can mix and match these things as they meet your needs and the person you're trying to serve. Is that a good method to serve your ideal customer? So something that's probably gonna ruffle some feathers is equipment. So this discussion about equipment and space. So the thing we've got to get focused on is being focused on results and serving that customer well. Every piece of equipment that you find will not necessarily serve your customer well. Can they physically get on it? Can they use the piece of equipment? or not. You've got to figure out weight limits for things. Are you going to serve customers? Are you going to serve larger bodied athletes and patients that just came off caseload? Kind of like the C2 bike. I think the post can only hold like 200 or 210 pounds and it's tiny. If you're a larger bodied athlete, that is super uncomfortable. and you're probably going to break the equipment. Can you think about what's going to happen to your business early on if one of your larger bodied athletes breaks the equipment in class? How embarrassing that's going to be for you, for them? That story, unfortunately, is going to be shared very quickly and probably very widely. So you've got to figure that out about equipment, but also how much space does that equipment take up? How many people can use it? And is it gonna be an attractor or a detractor to your target avatar? Now, if you're working with more of a master's athlete population, they've been in the weight room before, they're maybe not gonna be upset about seeing dumbbells and barbells and all these different pieces of equipment in the environment that seems a little bit harsher, a little more, well, most of us would consider pretty badass, right? But you've gotta consider in a group environment, if you're trying to onboard people, that are terrified of a barbell. They've never seen it. Say you don't have training bars. Man, this one hit us really hard. We didn't have enough training bars when we launched. We had several members that couldn't even get the empty barbell out of the holder and move it to their spot. We're trying to build autonomy. We're trying to build their confidence and their strength. They can't even move the frigging piece of equipment around. Like, how upsetting would that be? You're terrified. You go to your first group fitness class and not only can you not use a piece of equipment, you can't even pick the thing up. It was, man, lots of hard lessons learned there. But we want to figure out with our model and our space and our equipment, how are we going to use these things? Does everyone need everything all the time? Do you need, if you're going to do a class of 15, do you have to have 15 rowers? Do you have to have 15 Ski Ergs. Do you need 15 GHDs? I love GHDs. They're fun. I use them all the time. But they're not the best to serve our avatar at Stronger Life. You will not find GHDs lining the walls in Stronger Life. Most of our members would not be able to use that piece of equipment. And it wouldn't give them the most bang for their buck on their time. So you've got to figure out, like, how accessible is your equipment? How much of it do you need? programming for stronger life, and the reality is you can program these problems in, or you can program these problems out. I mean, if you do a, if anyone is in the CrossFit space and done, shoot, Filthy 50, man, you gotta have a box, you've gotta have barbell, you've gotta have jump rope, you've gotta have rig, you've gotta have all these things. Like, the amount of equipment and space you need is incredible to run that class, if you're thinking about building out your own space or leasing your own space. But think about a workout like Fight Gone Bad, where you're rotating through stations. You need a fraction of the equipment, you need the fraction of the space, and if anyone's done any of those five gun bad workouts, you can get a tremendous workout that way. And I'm not saying that's the only format, but that is one example of where you can program in lots of expense, lots of overhead cost to make it really hard to open your space that's gonna push you into a much larger footprint than you need, and then you're gonna have hanging over your head a big lease a large utility cost, insurance, just the whole thing. And the more equipment you have, the more you've got to buy and the more space that takes up. So this takes me to a term when we're trying to consider all these things and figuring out if we can build a profitable business, we've got to consider things like operational capacity. So operational capacity is when you're looking at your space and you're trying to figure out, okay, I've got, say, 3,000 square feet and I've got this many square feet of bathrooms. I've got this much square footage in the lobby. I've got this much square footage for equipment storage. How much of the space that you're going to be leasing or using can actually produce income? You've got to figure that out. You've got to know how much revenue you can produce in your space, how you're planning to program with your customer. Because if you don't know how much income you can produce, like maximum capacity, then I mean, we've kind of turned this into like a volunteer job, right? And there's nothing wrong with that if you want to volunteer and do this for free. But if you want to build a healthy business, you've got to figure out your operational capacity. And this was first, I learned from Stu Brower's podcast, WTF Gym Talks. Now, if you don't like four-letter words, you may not get through his podcast episodes, but some very savvy business learnings there. WTF Gym Talks, Stu Brower. Brilliant guy. He's actually got a short episode on that that is really helpful and very eye-opening. I actually go through an example of looking at different operational capacities on the free resource on the ICE Physio page I'll tell you about at the end. So, that leads me directly into profitability. The reality is, team, if your business fails, you can't help anyone. So do your math up front. Figure this stuff out. Who am I going to serve? What kind of equipment am I going to use? What do I have the capacity? How many people can I serve? You've also got to figure out your pricing. You've got to be reasonable to the market, but also value what you can offer as a physical therapist or a physical therapist assistant or a fitness pro that has gone through older adult training to know what in the world is going on. What we need here is we've got to figure out where that intersection goes. When are we going to become profitable? Based on the number of people I can serve, how much I can charge reasonably, how soon I think I can fill this out, when can I expect to not be losing money but making money? And we've got on the PTI and ICE free resources, you can get access through the ICE Physio app. We're sharing with you a break-even spreadsheet where you can put in all your costs, what your pricing is, how many people you're expecting to serve. to figure out how many weeks until you have a break even point, when you're not losing money, but you're actually, you're floating. And the reality is this idea of reserve and resiliency dovetails very beautifully. with a business. If you've got high financial reserve, you're making way more money than you're spending, then your business is profitable. If your business is profitable, then you can invest in more equipment. You can invest in more advertising. You may be able to bring on a second person to help you or another coach that you can train. Those things are beautiful to be able to consider and to be able to share this dream and this vision with someone else. We like to call it building a bigger table, dreaming big. I would argue to say, once you have some level of success, you should be thinking about how you can share these opportunities with other people around you who are also passionate. But you've got to figure out the break-even point, and that can also help you figure out what profitability can you expect at a certain price point at a certain membership level. So once again, that's on the Ice Physio app under free resources. you can get access to that.

SUMMARY
So what we've actually got, I've got a lecture that's a little bit over 20 minutes long, going through these items in detail with some more examples of what your operational capacity would look like, what your profitability would look like, based on two different models, more of kind of the extremes like, master's CrossFit class that everyone needs a barbell everyone needs a rower and then an example of more like a cycling studio where it's like you've got a very small footprint you can really pack the house so you can kind of just see compare and contrast. I'm not saying either one is right or wrong it's just you need to be informed before you make decisions and move forward. You've got to know who you're going to serve and with whom. Are you going to do it solo or are you going to partner up? You've got to know your model space and equipment, a.k.a. the operational capacity of your business, if it's going to survive. You've got to figure out how long until you become profitable, how your equipment, how your programming feeds into whether you're going to be profitable or not. and make decisions as needed. You need to know your break-even point. That's going to give you your financial runway. How long can I operate and keep this dream alive financially until I've got to make money? And you can't do that with rose-colored lenses, team. You've got to take a hard look at the numbers and repeat these steps as many times as possible until you've got something that's really going to work. So team, that's it. All of that is wrapped up in more detail with a free lecture and that spreadsheet to figure out your profitability. That is the free starter kit on the Ice Physio app with the free lecture. Should be very helpful. So please check that out. Reach out to us. We'd love to hear your thoughts or questions. I wasn't able to keep up with the comments. I probably didn't answer any of your questions live on the call. I love that you ask questions, but please ask them in the comments and I will get back to you. If you have questions about this stuff, I love this. This is my passion, getting to live my dream. Love this. Check out the free resources. Ask your questions in the comments. If you're looking to see us from MMOA out on the road, we've got a few seats left in Level 1. That's going to get started on the 15th of May, so grab those seats. Level 2 already sold out this cohort. You're going to have to wait until October if you're trying to get into L2. Don't let that happen if you're looking for L1. Live on the road, we're going to be in North Dakota and Richmond, Virginia in the middle of May and then Scottsdale, Arizona early June. Team, I hope this was helpful. I hope this got your wheels turning. Check out those free resources and we'll see you next time.

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

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Episode 1722 - Dry needling travel guide 0

May 7, 2024

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

In today's episode of the PT on ICE Daily Show, Dry Needling division lead Paul Killoren describes his ideal setup to travel with all the supplies & equipment needed to perform dry needling on at least 2 individuals.

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

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

EPISODE TRANSCRIPTION

PAUL KILLOREN
And good morning, Instagram. Paul Killoren here going live broadcasting worldwide PT on Ice daily show. If we haven't met before, I am the current division lead for dry needling division. And today I want to tackle a big FAQ, one of the top frequently asked questions. It comes up almost every course. It comes up during holiday season and travel season. And really any time that someone says, here is a box of needles and you're flying anywhere. So we're talking travel guide for dry needling. And to give you some background on myself, I had a brick and mortar clinic cash pay for almost 5 years, many years ago. Since that clinic closed, I have more or less been mobile, and mobile really means getting on airplanes to treat pro athletes. And that brings up a lot of questions. So whether you are truly traveling with needles, we'll talk TSA, baggage, all of that stuff, or you're just more of a mobile setup and you're looking for some solutions that maybe aren't your typical, like you don't have a cabinet, you don't have places, brick and mortar in a clinic. So we're gonna talk the travel guide to dry needling today. And first of all, I get zero kickback, zero financial incentive, but what I'm wearing here is actually the Go Rucksack, the GR1. I've actually traveled with this heavily teaching for a long time, almost nine years, and this thing has held up. So it gets my stamp of approval. It is an expensive bag, but for me, it has been more than valuable, and this is traveling consistently across the country. So this bag is, is just your standard backpack. And if you are traveling, let's say getting on a plane to see a, uh, an athlete, or if you're traveling for vacation to see family members, that bag is large enough that I have my laptop, all my normal personal travel carry on stuff. Um, but that is where I put a lot of my non needling supplies. So, I mean, if you're doing cupping or scraping or taping, any of your other things, that GoRuck gives me plenty of space to stick stuff in. But today, this is the pack that I think most people have questions about and will talk about the most. So this is my travel kit for dry needling. You can see the logo there, Instagram, YouTube. Medpack is the name of this company. Again, I have no financial incentives. Honestly, I've been wanting to carry their stuff for a long time, and I dry needle, but it's been just a tough distribution setup. But I do give this my endorsement, and the pack I'll show you today is actually the one I've had the longest, it's the smallest, and actually the least expensive. meaning if you go to Medpack site there are lots of different options and really they're kind of EMT or athletic trainer quality bags meaning they are durable, they do have nice sturdy locks and straps and holding longer straps I guess for carrying but they are high quality and they are medical grade bags. This bag specifically is their 300 series bag. It's their cheapest one. It's less than 100 bucks right now. And honestly, I like this better than some of the larger bags that I've used. And I'll show you everything this can fit in a moment. The larger bag has enough, it has more space, it has enough space really for more needles, but for two of the ES-160 e-stim units, which is nice. Larger means it doesn't always fit as easily in the overhead bins of some of the regional jets that I've been on or underneath the seat. And if anything makes me more uncomfortable and nervous on a plane, it's watching Bob try and cram his carry-on bag right next to my med pack that has two ES-160s. You know, you picture them spinning it around, cramming it in, doesn't fit, doesn't fit. There's been a few times where I'm just like, it's made me nervous enough that I prefer to travel with the smaller bag because it fits better, at the very least, underneath the seat in front of me. So this is the Medpack bag. Again, no financial affiliation by me. This is the one I've liked the best. The 300 series is less than 100 bucks. So let me walk you through it. And I've got Instagram here, YouTube over here. Try to give you the best angle. So again, what I like about this is it has sturdy straps. And you see big pocket one side, other side, these outer pockets. One is where I have my new gloves. So it's full of gloves that are unused, will be used. And the other side is my garbage. So during a treatment session, I travel to an athlete's home, I have gloves, I have swabs, I have all the needle debris. I'm sticking all of that in my garbage pocket during the session. I mean, really, I'm not trying to leave any waste or trash, even those tiny little shims, at a patient's home. So I'm constantly sticking that in here. Those are the two outer pockets. If we unclip here. First of all, I just have your standard cord pouch, I guess. Nothing fancy to this, but this is where I keep all of my lead wires for the ES160. And I will say that it's worth having extra of everything when you travel. That's batteries, that's lead wires, that's almost have a second everything, because what you wouldn't want to do is travel to a client and not have a functioning unit for whatever reason. So here are my lead wires, including a few extra and some extra batteries for my e-stim unit. If we take that out, another clip here you can see, here you go, inside of the purse. I'll try not to dump it out entirely, but what you see is that there are little compartments for almost everything. This middle one is actually customizable, meaning there's Velcro that I can make this smaller or larger. So I made it perfectly sized to actually have a pretty secure hold on a quart-sized sharps container. And then there's my needle, the main needle compartment. So I have 105-75s, and if you want a pro tip, I mean I'm biased, I use iDryNeedle, Needles, which means they have a shim tab. I really like having max packs for being in a patient's home Again, if the goal is not to leave any of the shims or any garbage much less clutter with the multi pack I like having those and then let's see if I can tilt this up even further two front pockets have my swabs so my skin prep swabs and You saw there a little gel electrode. If you know, you know that it's kind of nice to have one of these with the metal button. You can put it on a patient's skin, clip up an alligator clip to that metal button and then to a needle. So it's nice to have a few of those handy. And then in this front pocket is just more needles, smaller individual size needles. So needles, sharps, kind of cleanliness, skin swab stuff, more needles. And in the back, this is really why I like this bag specifically, is almost a perfect size compartment for the ES-160. So there is my 6-channel e-stim unit, slides right in back. Behind there you see that there's a little pocket or another compartment where I have the e-stim 2, so a smaller e-stim unit back there. There's a larger pocket where you can fit more supplies there if you need. That's where I used to keep my extra batteries, but then I kind of got the cord carrier. And then up top you have a zipped pocket, I guess. And I guess since real early on, like the first year that I started needling, Someone terrified me into carrying a hemostat just in case a needle would ever fracture. So that's what's in there right now. I've never used it, never had to use it, but a zipped pouch for whatever you'd like to put up there. So again, that is the Medpack 300 series bag that I travel with. Again, there are larger ones. If you're not getting on a plane, there are roller bags and backpack bags like there are MedPak makes a nice, again, more durable, more resilient, and almost healthcare grade pack, kind of EMT, ATC bag quality. So that's me getting on a plane. I have my GORUCK, I have my Carry-On. So let's talk plane travel specifically, because again, this commonly comes up. First of all, whether you've heard or not, you are allowed to carry on needles. They can be in a closed box. They can be in their loose sleeves. They can be in a sharps container. You are allowed to have needles. I know that from experience and also from Delta Airlines policy. So again, that bag I just showed you, I'm going through TSA pre-check goes through there. I will admit that 50% of the time it gets kicked to the side. So you're sitting there waiting for your bag. The person is going to ask, like, whose bag is this? Is there anything sharp or that's going to poke me? And that's when I say, yep, it's full of needles. Ha ha. And they don't believe me until they open it up. But once they do, there's been no issue. They basically say, like, oh, are you a health care provider? Are you an acupuncturist? And you say, I'm a physical therapist. It might be worth carrying or having a copy of your license should there be more questions, but me doing this for several years, there's never been more questions. They basically nod along. Honestly, why my kit gets kicked to the side half the time is either a hand sanitizer that I carry with me or a cleaning, like a table cleaning bottle, basically a fluid that's more than three ounces. They actually let you keep both of those after they test them. So even if your hand sanitizer or your cleaner is larger than three ounces, they will run a little swab test on it. Typically they give it back. I'm not sure if that's because we are health care providers or because there's some exclusion for sanitizer, but that is why it gets kicked to the side or it does look a little suspicious to have all sorts of wires and batteries under x-ray so half the time they don't even realize or care or know that your bag is full of needles they see eight nine volt batteries or eight c batteries with a bunch of wires and that looks kind of suspicious. So every once in a while, you'll get questions on what is that unit? And I say electrotherapy device, electro stim device, therapeutic device, whatever answer you want to say, but that is why half the time when I'm carrying through that pack, it gets kicked to the side. But honestly, never had any issues from there. Again, I travel pretty frequently. So those are the common frequently asked questions. I already gave you the pro tip that if you are traveling two clients on a plane or even driving, you should have extra everything. And that's needles, batteries, lead wires. Learning over the years only from one or two failures, but it is pretty embarrassing to show up and not have extra batteries. You're basically asking your patients if they have batteries. So just have extra batteries, have extra lead wires. Unfortunately, if you do travel or you are mobile for your treatments, It puts a little more wear and tear on your stuff. As far as stem units go, I actually haven't had any issues durability wise with the ES160. Aside from the wires, I've replaced a couple over the years. The E-stem 2 is one of the smaller, cheaper units that holds up really well. The Pointer XL and the E-stem, sorry, the ITO ES130, the 3-channel unit, do not hold up as well. So as far as the plastic inputs on the ES-130 or the wires, if you're looking for more durable units that really don't wear as quickly with travel, I like the eStim 2 and 3 and the ES-130. But that's what I got for you supply-wise. Again, no issue with TSA or otherwise with needles or sharps containers or e-stim. Really, I'd just be prepared for maybe one or two follow-up questions, but there's never been an issue. Other things that are worth having if you're just more of a mobile setup or if you are getting on a plane, I would always have extra consent forms or maybe a one pager for what is dry needling. You'd be amazed if you are mobile how it's not even a word of mouth referral. You're traveling to see one person or a mobile session with one person and they have a friend or a family member that just happens to be there during your session. Whether it was planned or unplanned, they just want to watch it, ask you all the questions while you're working with Gladys in her living room. So I would just have some reading material for that person First of all, to avoid distractions from them, but also to answer their questions, potentially gain a new client. Otherwise, consent forms, same thing. You find the opportunity to potentially do a trial treatment. I would always have extra consent forms with you, or just have an electronic version that's easy to pull up. I still do the paper. I have extra ones with me. I do scan it with a PDF scanner and can send it to the patient right away. But otherwise, I do the old school consent forms. But that is what I have for traveling with needles. Once this episode drops on Instagram, I'll drop some links for the bags. If you have any questions on travel, I think I hit the big ones. I think one other question that comes up, um, less so for the more formal like mobile or travel client, but more frequently with I'm at home at Christmas with uncle or grandma. Um, some other questions that come up are, is there kind of a less formal way to dispose of sharp needle or dispose of sharps? Um, and the answer is yes. And even depending on the state you live in, some states would say this is entirely legal, which is you should just put them in a water bottle with a cap that you can twist, and then dispose of it in recycling. Maybe put duct tape over the top of it. But maybe if you're at home on the holidays, you have a few needles in your bag, whether you are going to do gloved clean needle technique on family, that's up to you, like whether you have those sorts of supplies, but I would certainly dispose of the needles semi-properly, which might just be a water bottle and some tape.

SUMMARY
All right, team. So that's what I hope that answers some of the main questions you have. I know summer means you're going to be traveling a little more. Um, we're coming right off of sampler and honestly, the number of folks that came up to me and ask questions about treating athletes or, or travel treatments or mobile treatments were high. I think it's just becoming a model that even healthcare consumers are more intrigued by, you know, having the option of us driving to them, even if we charge them a premium. So when it comes to needling, there are some pretty nice setups. Again, I like this bag. If you want to know some of my failed or my less desired travel tips, I kind of went through the plastic tote phase that had a snap-on cover. I tried kind of, I guess, a makeup kit or a taco box. Nothing really seemed to fit quite as well as what I just showed you, which is the Medpack bag. But there are other options out there. So if you have questions on travel tips for needling, drop them once this goes live. Again, I'm Paul Cloran. I'm the division lead for dry needling. If you're trying to catch a course with us on the road, May we actually only have two courses and they're both the weekend of the 18th and 19th. Ellie will be in Virginia Beach. I'll be out here in Seattle. And really throughout the summer, we have some big courses, but we have a lot, we have fewer courses throughout the summer. We just know that you all are out there being active, friends, family, a vacation. We want our faculty to kind of decompress a little bit, but if you're trying to find courses throughout the summer, they are there. If you want more options or you're looking for something more convenient, check out our summer, but also our fall options for needling. All right team, thanks for tuning in. Drop any questions you have on traveling with needles. Signing off.

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.

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Episode 1721 - Most bang for your buck: pelvic edition 0

May 6, 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 two different presentations of pelvic floor patients who may present to the clinic.

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.

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.

JESSICA GINGERICH
Good morning, PT on ICE Daily Show. I hope everyone had a great weekend. It is Monday, so that means that you are live with the pelvic division. My name is Dr. Jessica Gingrich, and today we are going to talk about the most bang for your buck pelvic floor addition. So I'm going to present today two separate presentations. So I don't want to talk about necessarily a case study or two separate case studies, just different presentations that you may see in the clinic. if you are a newer pelvic floor clinician, you may feel stuck. You may feel, oh, I haven't seen this or haven't seen this many combinations of things. Where do I start? And so, that's what I want to talk about today. So, the first thing or the first patient we have is going to be the person that has pain. That could be back pain, that could be hip pain, SI joint pain, tailbone pain, pain with penetration, and that may be during intercourse, during a vaginal exam, whether that is a speculum or digital exam. They may even have a history of this with tampon use. Even bedroom toys can be an issue. They may also say that they have issues with bowel movements. They have difficulty emptying or they do have a bowel movement, but when they're done, they don't feel quite empty. From the urinary standpoint, they may feel like they pee all the time, so they have frequency. Or when they get the urge to pee, they really have to go, so more like urgency. And then this also may present with or without urinary incontinence. On the flip side of that, we have the weaker pelvic floor. And so this is someone that comes in and maybe when you're talking to them about their activity level, Well, I haven't worked out all that much or I like to walk. I don't really lift weights. I haven't done it in years. And they may also present with leakage. They may even have heaviness in their vagina or dragging sensation. All of these presentations may come with, um, babies or, or no babies, right? Back to our first presentation, that person also may have that type A personality, where they like structure, and they feel like they have to work out all the time. I wanna kinda go off on a little bit of a tangent about that personality. We tend to say that, oh, well, they have that type A personality, and that's not a bad thing, right? If we didn't have that personality, what would our world look like? What we wanna do is we want to help that person Um, lean in to how they can best just function, right? And so when it comes to working out for a type a person, it may be a lot of education, right? You don't need to work out seven days a week, but this is what it can look like. Here's what programming looks like to really maximize things. There's a great book that I'm currently reading. It's called A Guide to Losing Control or Type A, I'll have to post it in here. I can't remember the title of it. But it's a really great book around just the structured Type A personality and how to really lean into that and help that person just feel better and function better, really optimizing recovery, stuff like that. So I'll drop that in the comments here when I'm done. So what I wanna talk about is where can we start with both of these presentations if we don't know where to go? So with that weaker person, they need to be loaded, right? They need to get stronger. So that's the first and foremost. But maybe they're not ready for that. So what we're gonna talk about, there's a thousand different ways to do this, but we're gonna talk about relaxing, okay? This is not the, well, you need to just relax your pelvic floor. You need to just relax. No, it's more about knowing how to relax. So, the first thing that I want to talk about, and I know this is everywhere, but is the squatty potty or getting your feet elevated to some capacity. What this does from a mechanical reason, and I love talking about this in the clinic, is give them the reason why they're doing it. Don't just say, hey, when you go to the bathroom, elevate your feet. Okay, see you later. Tell them why. So what this does is it decreases that anorectal angle. So when that angle decreases, now we're not having to fight against natural angles in our rectum to help keep us continent. The other thing that it does is it allows that puborectalis muscle to relax, to just unkink the base of the rectum. So two biomechanical reasons as to why we are suggesting that they get their feet up. Now you may be asking yourself, why are we talking about a squatty potty to relax the pelvic floor? Cause that's maybe one or two times in a day, depending on the patient in front of you. So that is going to allow the pelvic floor to just work optimally, right? You're getting the pelvic floor. When the pelvic floor needs to be off, you are helping that to be off rather than sitting and without your feet elevated and your pelvic floor might be on a little bit, or if you're bearing down, maybe your pelvic floor reflexively kicks on. And so that's just optimizing your pelvic floor on day-to-day functions. that need to happen, right? Now, I will say that some people don't feel great with having their feet elevated, and that's okay. Also, the angle of which their hips are is different per person. Also, I feel like you guys can hear my dogs barking. They're making their PT on Ice daily show debut. Sorry about that. The second one is a diaphragmatic breath. And we hear this one all the time too. Well, let's just teach our patients how to diaphragmatically breathe. Yes, that's a really important thing, really for anyone, but we need to teach this well, right? We can't just say, here's how you breathe. Okay, go do it. We need to have them focus on what they are trying to feel. And so when we are diaphragmatically breathing, when we inhale, our pelvic floor should descend. Have them focus on that. Where does your pelvic floor go when you inhale? Focus on that movement. And also just… and have them do this in different positions. You know, they may be on all fours doing it. They may be in a deep squat. They may be sitting on the floor. And this is likely going to be a static thing that we're doing. So, having them be still really focusing on it. Don't watch Netflix and do this as you're starting to learn. Now, different cues that I like to use around where your pelvic floor is, it looks different for everyone. So, does your pelvic floor descend? Some people, they're like, yeah, it does. They kind of understand that they are aware enough about that. Sometimes people aren't, and so you have to give them one structure to focus on. One of my favorites, and I know you guys have heard me say this a thousand times, is feeling your butthole open. We know where that is most of the time, right? When we have to go to the bathroom and we are not by a toilet, we know where that muscle is because we squeeze it. That's certainly not everyone, but it's a good place to start, okay? Now, the third thing is incorporating that diaphragmatic breath that we talked about after a workout or even before intimacy. And that can be a really powerful thing if someone is having pain with insertion, painful orgasms, painful arousal. And that could work for people who own a vagina and for people who own a penis. So give those three things a shot. But remember, we always want the end of that plan of care to look like that person lifting weights. They also may be doing Kegels, right? They may need to have that base strength of where, or I say strength, Kegels can increase strength for someone, but it's probably going to be short-lived, right? Because A, it's really kind of body weight, and B, we don't function just under body weight, we function under load. And so, ending with your plan of care of teaching this person basic barbell movements, dumbbell movements, Kettlebell movements, maybe that's where they're starting and encouraging them to lift weights. This looks different per generation, right? We may have to convince some people that this is a really good thing. And then other times we may not need to, right? People are going to be a little more into it. So, go out and try these three things. We've got the Squatty Potty, we've got Diaphragmatic Breathing, and we've got Diaphragmatic Breathing following a workout or before intimacy. Give those a shot and let me know how they go. I will see you in a couple of Mondays.

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Episode 1720 - Advancing grip strength 0

May 3, 2024

Dr. Joe Hanisko // #FitnessAthleteFriday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty Joe Hanisko tackles the difference between grip endurance & maximal grip strength. Joe also provides several programming examples to help clinicians know what to program, who to program it for, and when to program it.

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

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 slash 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 Jane.

JOE HANISK
Good morning crew. This is Dr. Joe and it's going to One of the lead faculty of the fitness athlete division here at ICE. Coming off a great weekend last weekend out in Carson City, Nevada at the Sampler. It was fantastic to see 150 or more PTs from the ICE community there. Great times, great learning, and looking forward to next year as well, which I think is sold out. So if you are interested in going, hop on and grab a waitlist ticket. Pay attention. Jeff will be throwing out some dates for hopping on that waitlist as well. So today, though, team, my plan is to cover… One second, I got a camera issue here. My plan is to cover advanced grip strength. So about a year or so ago I did a podcast on grip strength and it predominantly focused on what I would say is the nuances of grip strength using more of accessory training to build a grip strength within a fitness athlete or just an individual specifically who was looking to build grip strength. But the more I've sat back and thought about it, The more I've independently tried to train my own grip strength, which I find to be one of my weaknesses in the sport of CrossFit, I really believe that there's two versions of grip strength, strength that we need to focus on, depending on what our athlete or our person is looking for to develop there. Basically, what I'm going to get at today is specificity of advanced grip strength. And what we're breaking this down to essentially is two categories. Either someone is looking to build grip strength from more of an endurance perspective, and in the world of CrossFit, I would say that would be like in the gymnastics world. we're often really taxed on endurance grip strength. That is, while we are on the bar doing things like pull-ups, toast the bar, or possibly on the rings doing more than likely ring muscle-ups of some kind. That is typically what we're going to hear athletes complain is one of their breaking points is that they just couldn't hang on or that their grip strength was weakening and therefore when we know through a lot of research now that when the grip goes so do a lot of the other power producing muscles because the energy transfer is just not as clean and clear there. So when I think about endurance grip strength, we're thinking about gymnastics grip strength training. So that's one silo. The second silo is going to be more in our weightlifting world of CrossFit, moving maximum loads. But I think that the thing that we haven't really thought about as much is that when we move max loads, we're not doing it for long durations. The bar is in our hands for only a few seconds or fraction of a second from the time that the bar leaves the floor until the weight lifting movement, the clean or the snatch, for example, is complete. In other movements like the deadlift, we have strategies like a mixed grip that seems to not be a limiting factor for most once they've figured it out, meaning that many people can deadlift their maximum capability with a mixed grip on the bar and their posterior chair and their legs their back are not though are the limiting factor I should say that their grip strength is not the limiting factor so we have a resolution to that in the deadlift but when it comes to the clean and the snatch which require hopefully a hook grip position oftentimes people's grip strength can be a limiter they may not realize it but often again similar to the gymnastics world when the grip goes our power and our connection to the bar is dampened and when we're looking to create speed through that mid zone through that second pull of the olympic lifts Often people lose that torque, that grab on the bar, and they lose power production, and the lift may eventually be failed because of that. So certainly it's not the only thing to consider with weightlifting, but when we're talking about grip strength, we're going to look at max grip strength on the barbell as a separate training thought process than we would look at max grip on a gymnastics movement, which tends to be more endurance based.

GRIP ENDURANCE
Let's talk about endurance first. When I think of endurance-based grip training movements, the one that jumps to me right off the bat is just long-duration bar holds, dead hang or active hang holds on the bar or on the ring. That would be the most obvious one because it's the most specific to the gymnastics positions and that we are moving on the bars or on the rings. You could add in some dynamic challenges like hip swings or beat swings while doing long duration grip and hold. We could add weight or loaded holds active and dead hang holds from the bar and maybe you would even consider things like farmer's carries in this group where you're sustaining a grip on an object for long durations but often the load tends to be relatively moderate compared to our maximum effort, meaning that if you're hanging from a bar for a minute, that clearly wasn't, it may have been a max effort for that one minute, but it wasn't a max effort overall in total grip, like max grip strength there. So those are some of the ideas of how we might choose certain movements, but they're certainly going to look more like the movement itself, meaning the gymnastics movement as the basis. I wanted to give an example in each of these categories as like a programming idea that we could use so that it kind of comes into play. So lately what I've been playing around with on my grip strength training for endurance in the gymnastics world is mechanical drop sets basically, or even just loaded dropsets I guess would be the better word here because we're not changing the movement as much, but a drop set. Meaning that we're going to start with something that is significantly more challenging. and then we're going to try to maintain work output throughout the following sets but we're manipulating a variable in this case it'll be load so that even though we're fatiguing we're able to maintain high work output over the span so A drop set of active hangs for me lately has looked like this. I have determined what my maximum effort of around 60 to 70 seconds of a hang is loaded, and I picked that one minute mark for a couple reasons. I feel like it's an easy trackable number that we can repeat over and over again. It is a long enough time in the bar where very rarely are we going to see an athlete maintain more than a minute on any type of gymnastics movement that would be kind of at the peak. So I chose that 60 to 70 second mark and I've over time I've tested what my max ability to hang in that one minute mark is with adding load onto my body. So let's say in this situation that I can do a 45 pound plate hang for 60 seconds. That would be set number one. I would then give myself about a minute of rest following that 45 pound hang. I'll let the grip recover, but not too long. We're thinking endurance here. We want to repeat this again and I'm hopping back on the bar, but this time I'm dropping by, we'll say maybe 10 to 15 pounds. So we go from 45 to maybe a 30 pound a dumbbell or a kettlebell that we're now hanging from. Repeat that one minute. There's the drop set that we dropped load, but we're still doing one minute of output here. Rest 45 to 60 seconds. Then maybe we go to a 20 or 25 pound weight. And ultimately I've been doing anywhere between four to five sets. So if I start at 45 pounds, my very last set over those four or five sets is going to be just my body weight and I'm trying to hang. My goal is 60 seconds. But often what I'm doing here now is just providing a opportunity for me to really test my max grip hold on the bar or on the rings at body weight after hyperloading it in the three to four sets prior to that. So this is an example of grip strengthening for the endurance training of gymnastics, but you could do a whole lot of other things. But again, as a summary for the endurance grip strength, we're looking at moderately challenging loads, for longer durations, simulating ultimately the experience of having to hang on to the rings or the bar for long periods of time. We could consider dynamic movements as well, like kipping to challenge the grip or load. Those would be my two best suggestions. And if you're really, you know, in a bind, we could consider things like farmer's walks or carries as well too.

MAXIMAL GRIP STRENGTH
So now this has to directly, sort of oppose the next scenario in which we talked about silo number two being grip strength training on a barbell we're looking to move maximum weight the literally the the absolute max of load that we can hang on to and move effectively and then how we change our ability to have a stronger grip during those movements and So for me personally, I mentioned this briefly before, I believe and I feel myself that often if my grip is going, it's not that I physically couldn't necessarily hang on to the bar, it was that it was starting to break my ability to hang on to the bar effectively and energy was leaking out of my hands and therefore as I was trying to create speed on a clean or snatch, once I got past the knees more than likely in that second pull, into triple extension through the following third pull movement that I wasn't able to create enough energy through the bar to keep it accelerating upward at the appropriate speed or height and I was failing to get my arms up and under it. So I've been working on training grip strength on the barbell in really heavy positions on the bar and not only incorporating load but also considering speed because i think speed will challenge the grip as you start to move upwards and everything in the world is trying to push that bar back down towards the floor that has a unique dynamic that needs to be offset by incredible grip strength so here in the olympic lifting world i like to treat this more like strength training max strength training. If I were trying to improve a one rep max back squat, bench press, whatever, I want to kind of treat grip strength training in this scenario very similar. So this could be movements like Simply put, maybe even if you're warming up your deadlift, we start working on deadlifting with a regular grip, not even a hook grip, just a regular hand over hand grip, which is often going to be the most limiting, but this is a great opportunity that as you're working from 135 to 225 to 275 and maybe into that 300 pound range as you're warming yourself up for your heavy loaded deadlifts that you're just doing a regular grip. That is one option of training grip strength on the barbell. You're only getting those three or four seconds of each movement. If you're doing multiple reps in a row, you may have to re-grip the bar and you'll also realize how quickly that fatigue in the grip comes into play with that. But it's certainly an option that we could think about building grip strength on the barbell during our deadlift and our deadlift warmups. If you are a trained deadlifter, you will probably run into the scenario that eventually Your body could move more, but your hands can't hang on to it. And that's usually when we go to a hook grip, a mixed grip, or possibly straps. But more recently, the way I've been going after this is doing rack pulls or heavy barbell holds with rack pulls. So in a rack pull, I can set the barbell height to be starting at around the knee level, which is right after that transition zone of the Olympic lifts. And what I'm often looking to do here is pick a load that I can regular grip that i can move with some sort of speed and intent and i'm moving through that second pull position quickly but just from the rack so grabbing the bar really gripping it standing up with good technique good form and pulling into that essentially hip crease position that power position taking the bar right back to the rack letting go and then repeating it is a short burst a short intentional burst of grip strength that I'm looking to train at loads that are often similar to the amount of weight or even slightly heavier, we'll say 90 to 110% of what I could clean or snatch. You could do this in a wide grip or more on your clean grip, either one would be fine. But essentially what we're doing is doing short bursts at high loads. So if we're thinking about building out like a working set for somebody, I've lately been doing anywhere between six or seven, upwards of maybe 10 sets, depending on how I'm feeling, of just sometimes one to two or three reps in a set. So let's say I have 300 pounds on a bar in that rack position. I grab the bar, squeeze it like hell, pull to power position, set the bar back down, and depending on how that load is feeling, I'd either re-grip and repeat for rep number two, or possibly three, or maybe I'm just doing eight to 10 sets of singles at my max effort. It's unique in that it won't be overly taxing from a stamina standpoint, but it certainly will start to train the grip from a speed, power production, and we'll just call it an integrity position, where it really has to commit to doing what you're wanting it to do, which is hang onto that bar as it's moving fast through your transition zone. So that's an example of a working set that I would do, six to 10 sets, one to maybe two or three reps total at anywhere between 90 to 100, 110% of your Olympic lifting capabilities to start to build confidence and strength in that second pull, or possibly off the floor if that's where you feel like you're weakest, but the second pull seems to be where that speed change is occurring, which will challenge the grip the most. The third phase of grip strengthening, I guess, would be back to my original podcast that I'd done a while ago now, which I think a lot of us are becoming more familiar with, which is just accessory grip strength training. And this is the things like, you know, doing forearm work, doing plate pinches, doing spherical or dumbbell head holds, where you're grabbing on the top of a dumbbell, training our grip in different positions, narrow to fat grip. There's so many different ways we can go after that. But if we're only focusing on the unique, accessory grip strength training, I think we're missing the ability to be more specific and whether that specific need is in endurance, long duration, moderate holds, or if it's in more of a strength world where it's maximum loads, quick, fast bursts, I think we need to be thinking about what our athlete is looking for, what we're looking for as individuals and starting to train within that bubble. So hopefully that was helpful guys. It's been certainly helpful for me to train this way. I've been really putting some time into it. I'm hoping to see some changes because I've worked on a lot of grip work for years on and off and I felt like, you know, pound for pound, my grip was okay, but it was starting to inhibit my ability to move barbells faster. So I've been putting a lot more of my energy into this max barbell grip and hold position. Um, Good luck with it. It's challenging. I think you'll learn from giving it a go. And it certainly fits that mold of specificity, which is always important in our strength training world.

SUMMARY
So last thing before signing off, CMFA live courses coming up here in May. I think Mitch is out in Bozeman, Montana. I'll be in the Duluth, Minnesota area here in the next few weeks. So if you're looking to get a course last minute and you're out in Montana or you're in Minnesota, Michigan, Midwest area, that Duluth course would be awesome. It's a cool town. We're already filling up out there. And then in Fenton in June, the third weekend of June, we are doing a fitness athlete summit, which we are pumped about. It is going to be myself. It'll be Mitch Babcock, Zach Long, Kelly Benfield will be there, Guillermo will be there, Jenna will be there, Tucker, all of our lead faculty and TA are gonna be there. We're gonna try to implement more fitness, but you'll have tons and tons of opportunity to learn from some of the best in the business, so I would absolutely get onto that course. It is filling up super fast, people are excited about it. Mitch's Gym, CrossFit Fitness is an amazing place to be. It'll be a great time, so if you're looking for anything this summer to get into, I would say don't miss your opportunity there. Have a great weekend, we'll talk to you later.

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Episode 1719 - Dry needling for recovery 0

May 2, 2024

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

In today's episode of the PT on ICE Daily Show, Dry Needling lead faculty Ellison Melrose discusses using dry needling for recovery, including e-stim parameters using the ES-160 unit.

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

EPISODE TRANSCRIPTION

ELLISON MELROSE
Welcome to the PT on Ice daily show. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am here to talk to you guys today about recovery, so dry needling for recovery. We are coming off of Ice Sampler Weekend, and we had two pretty intense workouts this weekend, and we're feeling it, I think. So we are pretty sore in the quads, so what I wanted to demonstrate today was a recovery method for primarily the quads. We're gonna go over recovery mechanisms, how to choose the muscles when you're thinking about setting up a recovery circuit, and the e-stim parameters that you want for dry kneeling for recovery. So there are three main mechanisms of action when we're thinking about recovery.
The first is pumping, so hemodynamics. We're getting big muscles to pump. There are some muscles that are better pumps and better sponges, so they do a better job at the fluid dynamics. The second mechanism is washing out cellular debris from in that intracellular space. So thinking a little bit more microscopic than just vasohemodynamics or moving fluid. We're thinking cellularly. So we know that active recovery and facilitated recovery can do both of those things. What's nice about dry needling when we're thinking about recovery is that we're not putting any mechanical stress on the tissues, loading like we would with active recovery. Third, we have an autonomic nervous system response.

DRY NEEDLING FOR HEMODYNAMICS
So one thing that they saw throughout the research is that dry, or e-stim, facilitated recovery with e-stim, there is a longer base of dilation effect after we removed the e-stem from the tissue. And so what they postulated from that is that we have an autonomic nervous system response, so we have increased vasodilation, which is just going to improve our body's natural ability to pump fluid. When we're thinking about choosing muscles, again, as I mentioned earlier, there are some muscles that have better capacity to pump, but also absorb fluid and that is based off what we call O2 flux capacity. We're not going to dive super deep into that today, but pretty much what it means is that there's increased capillary density in those tissues and so they act as better sponges and better pumps. When we look at the lower quarter, there are two main muscles that are going to be pretty good or have higher O2 flux capacity. One is the medial gastroc and the other is the quadriceps.

CHOOSING THE RIGHT MUSCLES FOR RECOVERY
Another way to think about what muscles to choose are thinking about following the venous system. So again, we're trying to improve hemodynamics. So we want to follow the venous and lymphatic system to encourage that fluid to work its way back up towards the heart. And so thinking about a lot of the bigger venous structures, the lymphatic tissues run immediately. So when I'm thinking about setting up an entire lower quarter circuit. Sometimes, depending again on why I'm choosing these, we may be doing medial gastroc, medial quad, adductor magnus is a huge pump for the lower quarter. And then working into the glutes as well. And then, last but not least, is we have sport-specific muscle fatigue. So when thinking about, a great example I like to use is in CrossFit. After a really grip-heavy workout, we may be just specifically treating the forearm flexors, so the muscles that we're using to grip, right? In this case, we did a lot of thrusters on Sunday, so we are gonna be doing a quad recovery session for Sam today. We're just going to demonstrate bassus lateralis. When we look at e-stim parameters, so we want things to be a pump. So we need to have the intensity at a motor response. We also need it to be a non-fatiguing stimulus. So if our goal is recovery, we are thinking we want it to be non-fatiguing. So we're going to keep the frequency low. we are limiting pistoning. So we do not want to piston the tissue. Every single time we move a needle around in the muscle, we are creating a little bit more micro trauma to that tissue. And that is the opposite of what we want to do when we're thinking about facilitating recovery. So I'm going to get two needles set up in the vastus lateralis here, and we'll kind of go through the e-stim settings and, um, dive in a little bit deeper there. So for the, the needling technique, ready cleaned her skin here. We are going to be using a needle for the vastus lateralis that we feel like we have the most access to that tissue. So when thinking about choosing needle length for a larger muscle, we want to be using a longer needle where I'm going to be threading through the muscle here as I can have access to more muscle tissue. where I'd be going towards the femur. I am floating the needle in. I am not pistoning. If we get a twitch response, great. I'm not necessarily looking for a twitch response. Because we want a motor response with the e-stim parameters, we do want to be localizing our tip of the needle at a muscle spindle interaction, which is what elicits the twitch response. So what we're going to be doing instead of pistoning is a little bit of live redirecting of the needle under e-stem. We'll talk about that. So I'm just going to choose two big portions in the vastus lateralis here and thread across the tissue to have access to more. Oh, nice little twitch there. Because I did find a twitch, I'm going to leave my needle there as again, that is going to be the closest to that muscle spindle interaction where we can have better motor response. Then I'm going to choose a spot up a little bit more proximal, threading across the tissue. Perfect. Okay. So no twitch response there. Again, not necessary. We're not going to be pistoning to find that motor response.

E-STIM PARAMETERS FOR RECOVERY
So, I'm just going to be setting up a circuit here. And we are looking for, I'm gonna just pull these cords out of the way so we don't have that blocking our visual here. We are using the ES-160 today. All right, so e-stim parameters.. Low frequency, so we're thinking below 5 hertz. We want a motor response. Duration. So the longer the duration, the better. So when we're thinking about this, the research looked at 10 minutes versus 20 minutes, and they had almost double the biochemical clearance with 20 minutes compared to 10 minutes. And so we are thinking we want to set these up for longer duration, so thinking greater than 20 minutes here. We're not gonna be doing that for the podcast this morning, but we will set up that circuit and look for that motor response. So I'm gonna be increasing the intensity. Sam, let me know if it's strong, but still tolerable. Okay, we're looking for that motor response. And if we're not getting that motor response, we are going to do a little bit of live redirecting. So I have switched the, and parameters to just constant, you can do alternating frequency, but it's not necessary in the recovery session. So really whatever's the most tolerable for the patient is what we're going to want to do. So I'm increasing my intensity until we get a nice, strong muscle pump.

DRY NEEDLING FOR RECOVERY
So, this is what we're looking for when we're thinking about creating that muscle pump. Again, non-fatiguing, so we're thinking lower frequency, longer duration. Our muscles that we're choosing are either based off of following the venous system, looking at the O2 flux capacity in the muscle tissue, or sport-specific fatigue. Our mechanisms here, again, we're creating a pump. It's just a pump, it's really that simple, right? We're pumping fluid throughout the system. We're clear at a cellular level. We're clearing some of the, we're washing out the cellular debris. And then we are also facilitating vasodilation through the autonomic nervous system. If you have any more questions about this, feel free to check us out on the road. So we have a couple courses coming up on the third weekend in May. So the 17th and 18th is, you can check us out on the road. I'll be down in Virginia Beach. And then we hit, I'll be back in Florida, so maybe Florida first weekend in June and Longmont, Colorado on the 20th, the weekend of the 20th of June. So feel free to check us out on the road and have a great rest of your Thursday. See ya.

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

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Episode 1718 - 50k lessons learned 0

May 1, 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 translates lessons learned from training for a 50k trail run into strategies to use when working with older adult clients to help them become the person they want to be as they journey through life.

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.

EPISODE TRANSCRIPTION

LESSON 1: THE TRUE FINISH LINE IS AT THE END OF YOUR LIFE
Okay, so first lesson. The true finish line is at the end of our lives. The true finish line is at the end of our lives. This is a quote by Sally McRae. If you all have not heard of her, she is my absolute idol. She is a professional ultra mountain runner. She is known for her mental fortitude and crazy accomplishments throughout her career. She just did the Grand Slam of 200 mile races, which are four 200 mile races in the span of five to six months, which is absolutely insane. So she has a, her own podcast called the Choose Strong Podcast. And I started listening to her as I was starting to train. Um, when I first started trail running like a year plus ago, a little bit over a year ago, And I remember I'm running on the trail, I'm listening to her podcast, and she said that, quote, the true finish line is at the end of our lives. All of these start lines and finish lines and belt buckles and medals that we acquire, they're just adventures along the way. They're lessons learned along the way, the triumphs and the failures. What matters is the end of our lives. And it's a story that we get to tell. So I, as I was listening to this, I was thinking back to when I was younger and I ran track when I was younger. And when I was running in a race, it was first place or last place. My entire world hinged on me winning that race. If I didn't come in first place, I was gonna have a bad several days, my family was gonna have a bad several days because I was miserable. And so as I'm listening to Sally talk about this, and I'm training, I'm realizing that life is not a singular race or a singular goal to conquer, and then we're done. It's a journey. And it's not about winning, it's about becoming someone who endures. So that's my thought about this is a journey in our lives, that the end of our lives is the actual finish line. It's about, for me, becoming someone who endures. Developing the mindset and the habits and the lifestyle of someone who can go out and run 31 miles in the mountains. Okay? So when you're thinking about this with your patients, especially when we work with older adults, it's never just about their one episode of care with you. From day one, when you're sitting down and you're talking to your patient or your client, you want to be speaking to them as if this is a journey that you're going to go on together. This isn't, we're just creating goals for you to accomplish at the end of our eight week plan of care. This is about connecting with their life journey. Who do they want to become? How are you going to help them develop the habits and the lifestyles to become the person that they want to be so that the next several decades of their life are happy, purposeful years? Start that conversation early. Start talking about what's next. Again, it's not we are ending this relationship in eight weeks. What's going to be beyond that? Do you have a side gig that you do private wellness in folks' homes and you're going to then provide personal training for them? Are you going to refer them to a gym and you start that process early so you find the right fit for them so they can continue on with fitness? Start talking to your older adult clients as if this is a long-term relationship and this is a lifelong journey. Start talking to them about who is the person that they want to become and how you are going to help them get them there. Okay, that's number one.

LESSON TWO: PAIN IS MORE EASILY ENDURED WITH FRIENDS
Number two, pain is more easily endured with friends. Pain is more easily endured with friends. Team, I have never experienced pain like I have when I was out there on the trail this past weekend. There was about 5,000 feet total of elevation gain and loss. You're climbing up rock scrambles, like vertical rock scrambles, treading through water, slipping on mud, rocks and roots the whole entire time. The terrain was absolutely brutal. I've never felt this type of pain before. I mean, my ankles and my knees and my feet were just absolutely destroyed and screaming at me for a long time. I went out on that second 15.5 mile loop and I knew, I was like, this is gonna hurt the entire time. It was not my cardiovascular system holding me back. It was the pain in my joints. Every single step was grueling. And I started to think, as I'm in this much pain, I'm starting to think about our older adult clients who have aches and pains and arthritis, and I'm like, man, this may be a little bit of something that they feel on a daily basis, right? I know that this pain for me is temporary. When I finish this 31 miles, it's gonna be over, for the most part, until the DOMS sets in, which has definitely happened. But older adults, pain may be a part of their lives. Now, we know that we can get people strong and we can influence their environment and help with their diet and their stress management and their sleep. Like, we can do a lot of things that can help with pain that they feel, right? However, I don't think it's fair to come at someone with rainbows and butterflies and tell them, like, you're never gonna experience any pain. I don't think that's fair. Pain may be a very real experience for older adults, even amongst them doing all the right things and getting really strong. And we have to realize that. So this is what I want you to think about. Pain is better endured with friends. And I will tell you when I was out running and I was on that second 15.5 mile loop, just miserable and miserable amounts of pain. The one time that I wasn't feeling it as severe were the times when I was running alongside someone. When I was having a conversation with someone else on that trail who was experiencing the same thing as I was. When I was meeting people and hearing their journey of their training and why they signed up for this race, and who's waiting for them at the finish line, and what they were experiencing in that moment, and you're distracting each other, and you're learning about each other, you're making friends with strangers. I did not feel that pain as severe as when I was spending time with someone else on that trail. And I will tell you one moment in particular, I was running with this one guy pretty consistently at the last like five, six miles of the race. And I was telling him like, I ran a 20 miler and then I jumped to this 50K. So skip the marathon. And at one point, we're continuing on and he turned around and he says to me, hey, you just ran a marathon. And I was just so taken that this individual, who's trying to concentrate on his own footing and his own race, turned around to give me the benefit of, hey, you just ran a marathon. You just PR'd. And that right there, I didn't feel any pain. I was so grateful for this human. I didn't feel a darn thing. So when you are starting to work with your older adult clients, I want you as quickly as you can, starting day one, try and get them to be a part of a community. I said it before, how are we going to plant that seed early to get them to discharge to fitness, right? To go on to their second part of their journey, start getting them a part of a community as quickly as possible. The pain that many older adults experience throughout the day is because they're bored. They're bored. They're not doing anything. They're not spending time with anyone. Try and find them friends as quickly as possible, whether that is a fitness facility, a walking group, a church group. Find them community ASAP. Get them to be socially interacting with others more than just you for that one time in the week. Because their pain they're experiencing, I promise, is going to be able to be endured easier when they are spending time with others.

LESSON 3: FORWARD IS FORWARD
Okay, next one. Forward is forward. Alright? Forward is forward. I had to keep telling myself that. especially before I was heading out on that 15.5 mile loop, that second one, because there's no way I was like, I am in so much pain. There is no way I can be in this much pain for 15.5 miles, especially knowing how much climbing I was having to do for the last five and a half miles. I couldn't believe that it was possible. All right. But when I kept on going back to focusing on becoming someone who can endure, Focusing on that goal. It's not about winning this race. It's about becoming. I am focusing on becoming someone who can endure. I am having people along the trail who can distract me along the way. Even amongst insane amounts of pain, you can move forward. And I had not experienced that until this past weekend. It's incredible what the body can endure if you just focus on continuing to move forward. regardless of what that looks like. There is so much grace in forward. For me, it was, okay, running quick, like my first 15.5 miles, I was zooming, I was flying, it felt awesome. The second loop ate me alive. Running quickly became jogging, okay? Jogging slowly, my jogging slowly became hiking. all right my hiking became i am leaning up against a tree hunched over absolutely miserable and making deals with myself like julie count down from 10 and then keep moving and i out loud was counting down from 10 and then i would say go and then i would just continue moving forward it is insane how you can chip away at miles and chip away at time and chip away at pain if you just focus on forward but you give yourself grace as to what forward means so applying this to your patients especially when you are putting them through an emom or an amrap have options for them, especially those who are high achievers and they want to be able to do the level one, the highest level of the exercise you're giving them. So have options for them. So I have a fellow right now, he was just diagnosed with pulmonary fibrosis, idiopathic pulmonary fibrosis, incredibly sad diagnosis, but cardiovascularly he's very deconditioned, but also he just feels like there's an elephant on his chest that he can't get air in. And so he gets very tired very quickly when we start exercising. But I know that it's so important to build his capacity any way we can. So I will say, OK, I want you for two minutes. burpees, okay? That's the goal. When you can no longer do burpees, then I am going to have you do some jumping jacks. Take away that transitioning from up to down. When those jumping jacks become too hard, I want you to march in place. When marching in place becomes too challenging, I just want you to walk. I want you to walk down to the driveway and back up. The only thing I care about is that you continue to move forward. Give your patients options and make sure that you let them know that whatever type of forward it is or moving that it is, it has value. Continuing to move forward through discomfort, through pain, giving a lot of grace there, that's going to build a lot of confidence and mental fortitude with your patients.

LESSON 4: SOMETHING>NOTHING AND DONE>PERFECT
Okay, last one, last one. I could do this forever, but last one. We're getting close to where we're getting too long. Okay, so last one. Something over nothing and done over perfect. Something over nothing and done over perfect. So this is another quote by Sally McRae. Something that I have just had etched in my mind ever since I heard it on her podcast. Team, the consistency of chipping away at a goal every single day. and saying yes to yourself versus no is so much more important than hitting your A goal every single time that you go out to train or you go out to compete. I wrote myself a note. It's right here. I put it on my fridge so I could see it every single day. I'm going to read it to you. Hey Julie, remember last time you felt like shit before going on a run? Consider not going, but walked out the door and went for it anyway. Data shows that when that happens, you regret saying yes to yourself 0% of the time. Say yes, start moving. xoxo that's exactly what this says and i looked at it every single day every single day because no matter how bad you feel and how much you want to say no when you say yes and you do something something it doesn't have to be My goal was to do six miles, and if I don't do six miles, I'm throwing the day away. No, that could be I do two miles. That could be I stay and I do 20 minutes of strength in the garage. When you say yes, and you continue to build that consistency, you build resiliency. You are building reserve. Every single time you say yes, you are building mental fortitude. And 100%, You will feel better when you say yes. You will never feel bad for saying yes. You always feel better. So when you are working with an older adult, You're making sure that, again, you give them options. Maybe they don't do their entire HEP, and instead of them, well, I wasn't gonna do the HEP, so I just didn't do any exercise. Make sure they understand that saying yes is so important. It's the same thing. Forward is forward. Yes is yes. If they don't want to do their entire HEP, my goodness, just do five minutes of it. Five minutes. Guys, they said yes. And yes is so incredibly powerful. If we know that we wanted them to do that high intensity EMOM, we're trying to increase their aerobic capacity, but they just weren't feeling it that day, they can do yoga instead. It's still movement. We know with older adults, something is always better. than nothing. And the more you say yes, and what I did, I started to tally up the amount of times that I said yes versus no. And every single time, how did I feel afterwards? I felt so happy and proud that I said yes, and physically and mentally I felt better. Once you elicit that same feeling with your older adult clients, and maybe you write something for them too, you write them a note to put on their fridge, and they track the amount of times they said yes, it's momentum. It's going to be so much easier for them to continue to say yes every single time.

SUMMARY
All right, guys, that's it. We've been here for 20 minutes. I could talk about running and lessons learned forever, but let's recap. Number one, that true finish line is at the end of our lives. It is about the story we want to tell. It's about becoming someone who endures. becoming someone who endures. Make sure you're connecting with an older adult's life journey and who they want to become. Two, pain is more easily endured with friends. Make sure day one you are starting to figure out how to decrease social isolation and help your client find friends to work out with, to experience different sorts of pain and competition and training with. They're going to experience their pain at a lower severity, I promise. Next, forward is forward. There's so much grace. Make sure that they understand that they've got options and you are hammering in that if you can't do that level one goal, We've got options for you and as long as you're still moving, it's still forward progress. And lastly, something over nothing and done over perfect. If we're not going to reach that A goal, it doesn't matter. Just say yes to yourself consistently every single day. It's going to build resiliency and reserve and confidence moving forward and saying yes is going to become a lot easier. All right, y'all, I hope you have a wonderful rest of your Wednesday. The last thing I will leave you with are what courses we have coming up. We've got both of our online courses coming up in May on the 15th and the 16th. 15th, level one starts. 16th, level two starts. And then on the road between May and June, we are in North Dakota, Virginia, Arizona, and Texas. PT on ICE is where you find all that info. Hit us up if you want to talk about 50ks and running. I'm here for it. Have an awesome day, guys.

OUTRO
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