The #PTonICE Daily Show

Now displaying: June, 2024

Episode 1759 - The Fitness Athlete Summit: Recap 0

Jun 28, 2024

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

In today's episode of the PT on ICE Daily Show, Fitness Athlete lead faculty member Mitch Babcock recaps the annual Fitness Athlete Summit, discussing how students become leaders in loading, confident in their strength & coaching, and the importance of walking the walk.

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

MITCH BABCOCK
Good morning PT on ICE Daily Show. It is a wonderful Friday morning here in June. I hope you're doing well. Thank you for tuning in. Whether you're tuning live on Instagram, YouTube, or if you're streaming this and downloading this, after the fact. We are glad you're here and thank you so much for making PT on Ice the daily show your downloadable PT daily podcast. Today's topic is Summit Recap. So we had a Fitness Athlete Summit this past weekend here at CrossFit Fenton and I want to talk to you about some main principles so just some main themes that kind of stand out to me as faculty after observing and watching kind of the things that went down this weekend. It was a wonderful weekend and thanks to all of those that attended the course this weekend. You guys knocked it out of the park and we're going to get into that shortly. I do want to draw your attention to the fact that there are three online courses starting up in July. So if you are sitting there looking to get involved into an eight-week interactive online course, there are three that are kicking off just this first week of July. So I want to draw your attention to them before the holiday weekend kicks up and you lose track of what's starting. You've got Brick by Brick where you can work through with Alan about all the details around getting your clinic actually going. Like what are the steps involved to getting NPI number, business bank account, tax ID, all of those things that are necessary and legal to get your clinic up and running. Alan will walk you through all those steps in a brick-by-brick online course. We also have a Rehab of the Injured Runner. Jump in on that course. It's a phenomenal resource for a lot of very actionable stuff. If you are a CrossFit coach like I am, there is nothing better than being able to come to your CrossFit athletes with a lot of running related tips, and strategies towards increasing their mileage, increasing their cadence, and decreasing pain that they have with running, because we all know us CrossFitters are pretty bad runners. So that's my little shout out to the Injured Runner course. That online course kicks off in July as well. And then the last one is our Fitness Athlete Pelvic course online. Jump into that one as well for all things pelvic floor, bracing, strengthening, modifications related. That's your resource for all things pelvic. Online only, those are some eight week options for you. It was a wonderful summit. We spent all day Saturday, Sunday going through our traditional fitness athlete content. But in addition to that, we had a number of folks, we had probably 15 or 20 PTs come early and jump into a Friday afternoon class here at CrossFit Fenton. We went out to a local restaurant, kind of had some drinks and socialized a little bit Friday night. My introduction to the weekend said, we're looking to make this the most fitness heavy course, Con Ed course, you've ever went to in your life. Taking the fitness athlete course and literally ramping it up in intensity and load, and the participants answered that call all weekend long. From the first moment we broke out in back squat, we had plates on the bar, we had people getting into a heavy back squat, breaking down technique, and that theme carried on all the way through the weekend. I was stoked to see it. I love the fact that the participants leaned into the challenge that the weekend presented. And so I walk away with a couple common themes. Before I get into those, I do want to shout out our wonderful team. We had eight faculty from the Fitness Athlete Squad here this weekend, all did a phenomenal job with the lectures that they led, and it was really an honor to sit back and just kind of watch the team do their stuff. So Zach, Guillermo, Joe, Kelly, Jenna, Tucker, Alan, myself, it was a wonderful job. Team, I just want to give you guys a shout out real quick before we get into this.

LEADERS IN LOADING
The first thing that comes to mind after the weekend is the fact that these individuals, anyone that participated in the course, are now leaders in loading. in their respective communities and clinics. They're going to take all the confidence that came from the weekend, all the principles, all the learning, and they are going to be the resource in their relative clinics for helping people get stronger. And that is such an important role and a big responsibility. And you could almost see it and feel it in how attentive everyone was to the lectures and how detailed they were in the coaching and how they dove into the nuance of the barbell lifts and didn't just skim through them. You could tell that the participants at this course wanted to soak every ounce that they could from it because they knew that they were taking it back to their clinics. And maybe they had an uphill fight ahead of them. Maybe they knew that the clinicians that they're surrounded with and they're 9-5 aren't on board with deadlifts or barbells or dumbbells or heavy loading or EMOMs. And they know that when they roll back in that their sword better be sharp because they're going to be up against some resistance and kind of swimming upstream, if you will. But I appreciate the fact that they kind of knew that challenge, that they were ready for it. And I feel really confident that those folks are going to make that change. It's not an easy change. Anyone that's out there in their clinic right now listening to this being like, that was me. I was the crazy person in my clinic with the timer on the wall and the barbells banging in the clinic and everyone thought I was nuts. But hopefully you guys can share some of the stories that it works. Meaning, not only with your patients, but with your colleagues. That over time, these principles start to rub off on your colleagues that maybe were, you know, detractors at first. They weren't really on board with the mission and the vision, but they started to see your outcomes. They started to see how much fun your patients were having, and that they started to adopt those things as well. And over the series of maybe some weeks, months, or years, you now have a clinic staff that kinda operates very similarly. Everyone is now on board with the loading. Maybe it took a few in-services. If there are any tips, tricks that you guys have encountered, this would be a great podcast to comment, share, or just leave something in the comments below this of little things that have helped you and your clinic get those folks on board. You're now the leaders in loading in your respective communities. I hope you don't back off of that line. I hope, if anything, you keep pushing that line forward, saying, no, not only do we need this, we need more of it. We need heavier, more intense loading in the clinic. And if it takes me being the person to start this in my community, then I'm going to do that.

THE CONFIDENCE OF STRENGTH
That leads me on the second point that I saw over the weekend is the confidence of strength. Strength confidence, right? And that can be defined in a couple different ways. One, personally, seeing a PT relatively scared of the deadlift, relatively fearful of their low back. lean into that deadlift section from the principles and the lessons that we teach prior to to the technique breakdown to the coaching and then eventually the max out deadlift lab and watching the confidence change in just that one hour lecture is huge. Seeing that they're like, man, I didn't realize I was that strong. I didn't realize I could do that. I didn't realize my colleague could do that much weight as well. We have this newfound sense of confidence around our own strength and our own low back. But what comes secondary to that is the confidence of the strength movements themselves. I now have confidence of instructing this deadlift. I know what I'm looking for. I know what a good start position is. I know what a bad one is. I know how to cue and correct this thing. I feel much more confident with the movement itself, not just with my own strength because I feel confident with that too, but with instructing and teaching the movement. We know that physical therapists' beliefs around their low back impact the treatments that they select and the outcomes that they get with their patients. Your fearfulness of your low back strength or your back pain is wearing off on your patients in a bad way. And seeing clinicians really overcome that this weekend is one of the best parts of the entire course and not just the summit itself. But there definitely was an aura. Having the entire fitness athlete team. Having all of these participants that were really down with the mission. Really leaning into this. You could palpate the change in confidence with just that one lecture itself. It was a great moment. It was a great breakout. And I hope that that confidence that you have. After going through a course like this, where you get stronger, where you feel more confident with the strength, with the barbell movements, that you maintain that confidence by way of staying involved with the barbell, staying in the gym, continuing to practice what you preach, continuing to lean into the movements that you're not the greatest with. But get more coaching, get more refinement, and develop your skill set. Because that confidence will go a long way, not only in your personal health and development, but in your treatment, health and development, right? So it's really bifactorial, and I'm really excited to see the change in that.

THE CONFIDENCE OF COACHING
The other component, and I just have two left, the other component was watching the development of the coaching confidence, right? Seeing clinicians go from the first breakout of the weekend, telling people to activate muscles, don't do that, into the later part of day one and into day two, where you're starting to see a much more engaged, effective coaching. We come in as a profession looking to change movement with our hands or our mobilizations or our manipulations and techniques. And we leave the weekend realizing how much more effective we can be just by coaching, using our words, using tactile feedback, using tempo, using targets, using visual things. That component, that change will really carry with you in your treatments. being able to walk up to somebody and get into an effective coaching position that you can break down the static position, refine that position, break down the dynamic component of the movement, have them pause in a position where they're losing shape, correct that shape using a slow tempo to allow yourself time to make the changes you want to do. Refining your coaching ability goes so far in your your ability to refine movement in the clinic. Seeing that coaching confidence develop, seeing your ability to change movement with your words and not just your hands is really, really helpful and something that as a profession we really need to wrap our heads around more and spend more time refining. Maybe the mobilization technique doesn't need more reps. Maybe just your coaching does. Get a few more reps in there. It was a really wonderful weekend, team. From seeing the confidence of the strength movement to knowing that you guys are going back to your clinics to be the leaders of loading in your relative communities and watching how much you leaned into that coaching development side of the weekend was really, really powerful. I hope you take all of that stuff. I hope you take all the lessons, all the lectures, all the research articles. You compile that with all of your in-person experiences that you had over the weekend, watching people get after it.

WALK THE WALK
And most importantly, walking the walk, right? From Friday's optional workout that a number of clinicians jumped in on, to Saturday night's WOD at the end of day one, which you guys are accustomed to from taking ice courses. What you don't know is that we really ramped up the heat with this being the Fitness Athlete Summit. We had teams of three, we had heavy power cleans, we had bar muscle-ups, chest-to-bar pull-ups. Like we had a really spicy piece for 18 or 20 minutes there Saturday night, and all the clinicians didn't back away from the heat at all. And we even had an optional cardio piece on Sunday day two during lunch that we had more than 50% of the participants jump in on. break a sweat before we grab a little bite to eat on Sunday. Walking the walk, living this lifestyle, showing your patients in your in your relative communities that you can get strong, you can get confident with this, you can get fitter, you can get more shape and what that's going to do for your lifestyle. If all of that spurred from this weekend, it was the best weekend I could have dreamed of. In every single weekend we hit the road, we hope to do something similar. So hats off to everyone that was a participant this weekend. Hats off to the entire fitness athlete team for conveying the message loudly and with intent. I appreciate that very much. I look forward to the next Fitness Athlete Summit. We're going to do another one next year. We'll get the entire team together. I don't know where it'll be yet, and I don't know what things we'll have in store for it. But I know that we had a ton of fun this year, and there's no reason to stop that anytime soon. So be looking for the entire team to come together next year at a destination we haven't determined yet, with some coursework built into the weekend that maybe you don't find everywhere else. Be looking for that. Team, I wish you a wonderful weekend. If you are heading into a 4th of July vacation and you're stepping away from the clinic a little bit, I hope you recharge the batteries. I hope you spend time with family and friends, enjoy the moments of life, and then get back into the clinic where you make a difference. And don't forget that you do. So, with that, have a wonderful rest of your Friday and a wonderful weekend. Take care, everybody.

OUTRO
Hey, thanks for tuning in to the PT on ICE daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you’re interested in getting plugged into more ice content on a weekly basis while earning 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 1758 - Maintain your levers 0

Jun 27, 2024

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

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Brian Melrose discusses the details surrounding maintaining your secondary levers on set up for more success with cervical spine manipulation techniques.

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

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

EPISODE TRANSCRIPTION

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

BRIAN MELROSE
I'm one of the lead faculty in the spine division, teaching both cervical and lumbar courses. And I'm here and stoked to be here on a Thursday, a clinical Thursday to talk about the number one thing that I think could dramatically improve your success utilizing cervical manipulation in the clinic. And really what that boils down to is going to be maintaining your secondary levers. And so we'll get into all the details of what I mean with the verbiage there, as well as talking about a particular technique that I think this will help with. But I got to zoom out first and kind of allude to where this comes from. And to be honest, man, it's just from being out on the road for the last couple of years, teaching about 15 to 20 courses a year and getting the opportunity to work with a lot of different physical therapists, from around the country. And those folks, you know, they have a lot of different backgrounds. They have different opinions about manipulation. Some folks have been trying cervical spine manipulation for years, whereas other folks are relatively novice with things. And so I think if you can understand how to maintain your secondary levers, it's going to help everybody. If you are more of a novice practitioner or novice with utilizing cervical manipulation in the clinic, this is the one time where I'm going to plug our courses and say, if you want everything, like if you want to know how to keep things safe, if you're wondering about if the pot matters, How hard do I thrust? The answers to all of those questions will always live in our weekend course. And I truly believe that it takes a full two days of kind of immersing yourself in that space to really understand stuff. You're not going to learn cervical spine manipulation techniques well by just cruising YouTube or Instagram. If you're a novice, make it out to one of our courses sometime this year for one of those details. But if you can absorb the concept that I kind of talked through today, that is significantly gonna help your kind of hands during the weekend and therefore your success in the clinic. So listen up, tune in and see if you can grab this one. Again, I think it'll help you dramatically when you make it out to a cervical spine ice course later this year. For those of you that are more in the middle, the folks that probably did a manipulation course at some point in their career, and you use it very occasionally in the clinic, maybe once or twice, week in and week out, but you just don't feel confident with your hands. Every time you go to set up someone's neck, maybe it feels just a little bit different. If that feels like you fall in that category, then this podcast is for you. If there's one thing that I see very often on the weekends, it's folks kind of missing or losing some of their secondary levers. And if you can understand what we talk about today with a person's neck and kind of what I show with the foam roller, again, I think that will dramatically increase your success with cervical spine manipulation and therefore your outcomes in the clinic. And so to kind of dive into things, then we really have to start with describing what a secondary lever is. And so when you set up a manipulation technique, you put on your secondary levers first. That's part of your setup for the thrust or primary lever. And so secondary levers are really designed to put tension into the system. and help lock out or isolate a particular level of the spine that we are trying to, again, isolate to thrust through. And so those secondary levers take up tension and then set us up well for our primary lever, which is in the direction with which you thrust. And so the primary lever is the last lever that you put on. It's what you explore and you kind of lean in and you're eventually going to feel a barrier. you're gonna feel something crispy. And again, if you have cracked someone's neck before, you are gonna say, ooh, like there it is. Like I'm gonna come back and I'm gonna smack right through that thing. And so that's kind of the setup that we're talking about. Now let's take this a step further and go into a very specific manipulation technique so that we're all on the same page. And I want to talk today about like a mid cervical kind of cradle hold. So again contact and non contact and you're going to put your levers on first to put some tension into the neck. And so it really depends on who you learn this from. That's one factor is what secondary levers you put on first. You may also change your secondary levers, either number one, which levers you put on, and especially how much of each lever you put on based on the patient in the clinic. Like if you have someone that's very stiff and lacks side bend, you may need less of that to get their neck in a locked out position. You have somebody that has, you know, a lot of movement in their neck, you're going to need to put on a different degree of those secondary levers so that by the time you get into rotation, you say, Ooh, there it is. And I feel confident with that. And so for the mid cervical cradle hold, typically the head's on a pillow, so the patient's a little bit flexed, and then I'm gonna introduce some degree of side bend, some degree of lateral translation, and then last, start exploring rotation. And what you're hoping for on that setup is that if you put the right amount of secondary levers on board first, i.e. side bend and lateral translation, that as you begin to rotate, you're going to feel that barrier come in relatively early in rotation. You're going to feel things crisp up there. And again, you're going to have that ooh moment where you say, there it is. So I think that's the kind of setup that we're talking about, but the problem that I end up seeing all the time on the weekends is that as folks go in, they get it set up, they find that barrier the first time they say, Ooh, there it is. And then again, we can't stick at the barrier and just thrust through it. We have to back off a little bit. And there's a technique called priming where you're going to get to that barrier a couple of times before you thrust. Now the issue is, and the moment of truth that I see happen a lot on the weekends, is folks go in, they find that barrier the first time, and then they back off. And they come in, and they check that barrier again. They back off, they check it a third time, a fourth time, a fifth time, a sixth, like it keeps going. And that's again, because they're learning the technique. There's two big problems with that though. Number one is, is when you get into the clinic, think about your patient, like they're laying there, right? They're trying to trust your hands. They're trying to relax. And if you check something three, four, five, six times, they are feeling like a sitting duck. They're going to start kind of tensing up and anticipating it. And that's the last thing that we want. And so one of the jokes that I love to make is like, you get two primes. If you've got to take a third, take a third. But after that, you've got to go for it. So that's part of the problem. The other issue though is, is that each time folks tend to kind of prime or reassess that barrier, they begin to lose some of their secondary levers. What happens then is they begin to leak some of the force, or excuse me, some of the tension that they've created in the neck. And so they'll, again, side bend, side glide, they'll begin to rotate, they feel that barrier, they say, ooh, there it is. They'll back off a bit, they'll lose some of their secondary levers, and then they go back in to check with rotation again, and they have to rotate a little bit further because they lost tension in the rest of the system. And they feel that, and they go, ah, dang, it doesn't feel right. So then they want to go check it again. They check it again, they lose their levers a little bit more, and then they have to rotate a little bit further. And so by the second, third, fourth, fifth try, they've really unbuckled a lot of the tension that they put on beforehand. The thrust that they have to keep chasing the barrier, they lose confidence with their hands. And we all know that if you don't feel confident with your hands, your patient won't relax as much. And so we really have to maintain those levers as we get going. And the best way to visualize this concept is with a foam roller. So I've already posted something to the Ice Physio Instagram account to help visualize this. But I'm going to demonstrate it with a foam roller now so that you can see it. And then I'll have my wife, Ellie, step in here. We'll show it with an actual neck. So what we're looking at here is Setting things up in this position. So let's imagine this is someone's neck. There's a cervical spine, again, is oriented down towards the foot of the table. I'm going to introduce my hands here, and I'm going to begin with a little bit of side bend. And so now what I need to imagine is that I have to maintain this axis or direction of side bend in the foam roller. When I get in and do lateral translation, the foam roller needs to stay oriented in that same plane. If I unbuckle them a little bit, again, I've already lost my levers. So side bend, side glide, and then as I begin to explore rotation, I can't lose, again, the angulation of the foam roller. If I wanna keep all of the tension I've built into the neck, it needs to stay crisp, it needs to stay clean, and I need to, again, be able to set things up for the thrust technique. And so if you can visualize that with a foam roller, then it should make sense when we do it with a patient's head. So Ellie's gonna come on in here, She's gonna lay down for us. And so the same technique kind of applies, right? The pillow is introducing a little bit of flexion, just like where the foam roller was. I get my hands in here on the neck, just like this. And then I'm going to explore, again, side bend, lateral glide, and then rotation. And what I'm doing in this forehead and her chin, maintaining that orientation, then as I spin, we're going here. But I can't unbuckle some of those other levers as I re-explore that rotation. They need to be maintained so that as I get over and I thrust, I can maintain the position and maintain the tension in the system. And so I think if you can visualize this concept in terms of putting good secondary levers on first, creating a lot of tension in the system, you have to maintain that as you prep the thrust. And again, you're just not gonna get the impulse in the right area that you want. So, in conclusion, guys, whether you're novice or whether you're a little bit more advanced in trying to kind of master techniques, the whole purpose of today is to really hammer in the point that you have to maintain those secondary levers with any manipulation technique. That's what's building kind of, again, the tension in the system. And if each time you go to kind of prime the barrier, you lose some of that, you're gonna have to go further into your primary lever, in this case, rotation, to research for that barrier. It's gonna make you feel less confident, like you don't really have it.

SUMMARY
So make sure you're maintaining your secondary levers on your setups. And again, this will dramatically increase your success in the clinic, the confidence in your hands, and again, the results for your patients. Awesome. Thank you so much for having me here this morning, guys. It was great to talk about this on clinical Thursday. The last thing I want to do is just plug a couple of courses that we have coming up. Our next cervical spine courses, I'm teaching out in Kent, Washington this weekend, but we're all sold out for that. So your next chances are probably the weekend of July 13th and 14th. Jordan Berry is on his home turf out in Charlotte, North Carolina. And Miller is going to be out in Oviedo, Florida on July 20th and 21st for cervical spine. Next two lumbar courses will be in Amarillo again on that July 12th and 14th weekend. You'll be stuck with me down in Texas. And then after that, we're doing a course in San Luis Obispo out in California. Love the central coast in CA. And that will also be on July 20th and 21st. So hope to see you guys at some courses later this year. I hope you're having a great Thursday and have a great end to the week. Thanks so much.

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 1757 - The barbell is a tool, not a rule 0

Jun 26, 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 member Julie Brauer discusses how fitness equipment is not necessary for older adults to reach fitness goals, how fitness equipment is not feasible for older adults to obtain or use, and that older adults likely do not want to use this fitness equipment because they can't correlate how using it translates to functional activity

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

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

EPISODE TRANSCRIPTION

INTRODUCTION
Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the 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 sign up to receive a one month free grace period on your new Jane.

JULIE BRAUER
Good morning crew. Welcome to the PT on Ice daily show. My name is Julie. I am a member of the older adult division. Excited to be hanging out with you all this morning. Our discussion this morning I am hoping to offer you all an expanded perspective and even maybe a perspective shift when it comes to how you approach loading older adults. The shift is this. The barbell is a tool to help get our older adults brutally strong and stave off functional decline, but it is not a rule. The barbell is a tool, not a rule. So this perspective shift has occurred for me over the last nine plus years of my career, working with the sickest of the sick in the ICU, all the way to higher level athletes in a CrossFit gym. So across that entire spectrum, I've had to be incredibly creative and unique when it comes to introducing loading. I have worked with folks where loading them up is the last of their priorities. What's more important is the fact that they don't have the money to keep their lights on or they are having to use clothes to fill holes in the ceiling. I have worked with folks who have meaningful goals that have absolutely nothing to do with floating. And I have definitely had to shift my own perspective of what is success as a therapist. So let's unpack this. I've learned a lot over the past nine years of working with such a wide spectrum of folks. These are the things that I've learned. I want to share them with you. Number one, the barbell or a kettlebell or a dumbbell, insert any fitness forward tool, is not 100% necessary for older adults to reach their meaningful goals, okay? Number two, it's not feasible. The barbell and fitness forward tools, they're not feasible in many settings and in many populations that we serve. Number three, in many cases, older adults may not want anything to do with weights. Number four, final one here, is that in many cases no matter how hard we try older adults are not able to make the correlation of how lifting a weight is going to translate to their meaningful activity. So these are some themes. This is what I've learned over my nine plus years. And what I have also learned from my own experience and also being out across the country, meeting and connecting with you all, is that when we get really excited about fitness forward care, and this was me to a T, sometimes we can have blinders on and we become so laser focused on having our older adults lift weights. I mean, it makes sense. It's badass. Many times they feel like it's badass. It's sexy. It's cool. However, we can start to equate our success as a therapist with our ability to get our older adult to lift weights. And that can be a really limited perspective here. And what it can do is it can make us forget about the fact that the majority of the older adults that we're serving are not lifting barbells or kettlebells in their homes. They are lifting, pushing, pulling functional objects like laundry baskets or bags of mulch, kitty litter, dog food, pots and pans, Amazon boxes, buckets of tools. I could go on and on and on. The problem though is that many of us will develop an entire plan of care and we will never actually use these items that older adults are lifting at home. So this is where I want you to start to get a little curious and think, huh, why wouldn't I use the actual objects that my patients are using at home in my plan of care? Like that makes so much sense, right? Now, I know what you're thinking. You're thinking, well, Julie, there's so much carryover. If I can get an older adult brutally strong in their deadlift, then lifting that laundry basket is going to be successful, and it's going to be easier. And the answer is, yes, I 1000% agree with you. And that's the most beautiful thing about fitness forward tools, is that we can use them to help our older adults become brutally strong. And then the meaningful activity is easier right that deadlift we get them loaded up really heavy that laundry basket is going to feel lighter they're going to have less fear when they go to lift it their rpe is going to be a lot lower That's the beautiful thing about fitness forward tools. I think about that with my own training. So I have a bias towards a barbell. If any of you are thinking, man, this girl must hate a barbell. I love a damn barbell. I use it in my training. I'm a trail runner and I do strict strength training with a barbell to get my legs as strong as possible so that when I am running uphill or scrambling up rocks during my races, it feels a lot easier, okay? But here is where we have to really think about this. I want you to open up your mind. Here is where a perspective shift can come in. I want you guys to start thinking about this as an and, not, or scenario. So while you are working on moving your older adults towards brutally strong, building their reserve and their resiliency, I also want you guys to be thinking, only always, in tandem, use the functional objects that your folks are using at home. It's, I'm going to have Betty in the clinic today, lift a heavy barbell, and I'm going to have her lift a bag of mulch that she is wanting to lift at home. And not or, do these things in tandem. Why? Well, think about it. If we're using the objects that folks are actually using at home, let's say Betty walks into your clinic, she's scared, she's never deadlifted before, she doesn't even know what a kettlebell is, she's gonna call it a kettleball, but she sees over on a shelf that there's familiar objects that she's used at home. So subliminally, she's walking into your clinic and she's like, There's a bag of mulch in here. There's kitty litter in here. There's a bucket of tools. There's a laundry basket. Huh, I use all that stuff at home. Immediately, your environment becomes less intimidating. So imagine having those objects at your disposal when you are going to introduce the deadlift to your patient. They're familiar. Many times, they're much more approachable than a weight, especially if there's fear on board. And most of all, they are incredibly specific. We know how important task specificity is when we are teaching someone a new skill. You cannot get more specific than having your patients actually use the objects that they are lifting at home. I had a wonderful discussion with another one of our members, Trissa Hutchinson. She's on our older adult team. She's an OT. She's absolutely brilliant. She really opened my mind to this perspective as well. And she was telling me a story of how her patients, who many of them, they reside in memory care. So a lot of her folks have cognitive impairment on board. And she was telling me, Julie, it is such a high level cognitive skill to be able to correlate that kettlebell on the ground to the groceries that I have to lift from the ground. That sometimes can be too high level of a cognitive skill for many of our individuals. So she really has to put her folks in the exact scenario. She gave me a very specific example of she's working with her folks and she gives them the FES. So she's evaluating how fearful some of her folks are doing certain activities. So she does everything she can to create an obstacle course in her clinic that mimics what she is fearful of in her environment so she can build her confidence with her patient. That FES score did not go up at all. The FES scores, typically when she sees with her folks, do not improve until she puts her patient in exactly the scenario. And perhaps that means actually taking her patient outside to do a nature walk. And she actually sees herself in that scenario in the clinic because it is the exact same as what she is encountering at home. So my call to action for you all is this. I want you to think about lift with the barbell, but also lift the grocery bags. What could that look like? If you were in an outpatient clinic, I would love to hear some people start to bring in functional objects into the clinic. Many folks that we talk to across the country are telling us that they have spent so much time trying to convince their managers to put a squat rack in the clinic. Keep going after that. Keep being the squeaky wheel because it's so beneficial to have a squat rack and a barbell. However, the barrier a lot of the time, our managers are saying it's too expensive and why do we actually need that? Okay, so while you're working on that goal, what if you brought in stuff from your garage, right? Stuff that is readily available and it's not very expensive. If you're like me, I would go in my garage, my husband has a lot of stuff in there that I would want to just get rid of. Maybe I would go and try and do a little clean sweep of stuff in my garage, bring it in with some buckets, bring in some functional objects. Maybe I go and I buy a bag of mulch, right? Maybe I go and I bring in a laundry basket. Start filling your clinics with this stuff. They're readily available to most of us, and it's offering the opportunity for older adults to start lifting in a different way, a way that could be more approachable. And you could start to get further with them right out the gate.

SUMMARY
All right, y'all, that's all I have for you this morning. I love if I could hear any of you start to talk about how maybe you're starting to use some actual meaningful functional objects in the clinic. If you have any questions, comments, I'd love to talk further about this. Have a wonderful rest of your Wednesday. I will leave you with what is coming up within the older adult division. So the rest of July, is it? It's not even July yet. For the month of July, we're almost there. We have several courses, so we will be in Virginia Beach, we will be in Victor, New York, and then our whole team will be in Littleton, Colorado, for our MMOA Summit, which is gonna be awesome. And then our next L1 course, our eight-week online course, starts in August, August 14th. PTNIS.com is where you find all that info. Have an awesome rest of your day.

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

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Episode 1756 - What do we really know about strength training in pregnancy? 0

Jun 24, 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

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

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

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

EPISODE TRANSCRIPTION

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

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 within our pelvic health division. Sorry for coming on here a little bit early. We are in the throes of young kids finishing school and trying to work around new schedules. So apologies for being a little bit early. But today what I wanted to talk to you all about was what do we really know about resistance training in pregnancy. And as many of you who have kind of followed the podcast in the past know, I'm a postdoctoral research fellow at the University of Alberta looking specifically at resistance training in pregnancy, which means that a big part of my job in my postdoctoral fellowship is to be very aware of the state of the literature and then where my role is as a person trying to build a program of research to be able to add to the existing body of literature. And I'm going to start this episode talking a little bit about my story getting into this because I think that it's relevant. So my PhD research was in high load resistance training in a geriatric population. I love my older adults. You know that I'm part of the older adult division. And I had two children while I was going through my doctoral studies. I was going part time. And then I was also a national level weightlifter before I got pregnant with my daughter. So I was doing a lot of heavy resistance training during my pregnancy. And I had a committee meeting during my pregnancy talking about, you know, obviously that I was going to go off on that leave, et cetera. And one of my committee members, whose name is Stu Phillips, many of you know him from the protein metabolism and resistance training literature. He said, you know, Christina, if you think that there isn't any research in loading the older adult appropriately, wolf when it comes to what we know in pregnancy. And I thought that was super fascinating and of course being the nerdy researcher that I am, I looked into the research and I recognized that he was right. And So I kind of want to talk today about what we truly do know, what the state of the literature is, a little bit about me trying to change that, I'm going to talk a little bit about some of my research studies, and then where we can go going forward. So we know in a general population that resistance training is one of the best things that we can do for our overall health. I don't tend to try and put people into specific buckets that you have to exercise in a specific way because the best exercise is the one that you do. But in terms of longevity and maintaining independence into older age, supporting whatever exercise you like to do with resistance training is definitely a recommendation that I'm gonna make with a lot of passion. Whether you choose to prescribe to that exercise program or not, Resistance training is one of these exercise modalities that is going to allow us to have independence. It's going to stave off a lot of chronic disease and musculoskeletal injury. And we know that, you know, the best exercise program is the one that we start as early in our life as possible and go into older adulthood. I'm going to try and put on as much muscle mass as I can before the age of 40 and then hold onto it for dear life into hopefully 100. And so we have a lot of really positive evidence for resistance training in a general, like reproductive age population, but then also into older adulthood. We've talked a lot about it in the Jerry segment. But when we don't have evidence, right, around exercise, or we don't have any evidence in any type of intervention in pregnancy, we freeze, right? And I say this all the time. If we don't know, the answer is no. and when we aren't sure we freeze, which is where bed rest and pelvic rest recommendations have come in when complications can creep up in pregnancy because we don't really know what we can do, right? We're not really sure what we can do. So we want to give a recommendation that we're doing something. And so we pull people back from activities of daily living, sport, exercise and we say like, let's not do anything because you know, there's this complication happening. And where evidence is starting to show now is that many of our complications have pro-inflammatory cascades and therefore exercise might be a really important mitigating factor or modifiable influence on a person's experience of complications during pregnancy. But the baseline is that if we don't know that the answer is no. And so that knee jerk reaction has trickled into a lot of our recommendations around exercise in pregnancy and specifically around resistance training. So when we look at public perception of resistance training or exercise in pregnancy in general, it's really interesting because aerobic training is generally seen as more positive as something that you're doing to benefit the health of mom and baby. But there's a lot of fear-focused messages that are put into the resistance training space. And gosh, we've seen this all the time, right? Like we see when a person lifts a heavy deadlift and they're pregnant, like go into the comment sections and you just are gonna heave because you see everybody telling you that your baby's gonna die and that you're being reckless and all this type of thing. And so if we're going to combat these messages, and we know that the perception is generally more negative because of a lot of fear and thoughts of danger around resistance training and pregnancy, we have to one, know where the state of the research is. And then two, we have to build levels of evidence that are going to gradually gain us more confidence and being able to remove some of those fears around resistance training. I've done podcast episodes before where I talk about risk tolerance of providers to allow individuals to flex their own decision making during pregnancy and how in low to moderate intensity exercise, we tend to feel very good in that risk tolerance zone, but where we get a little squeamish is in these higher intensity zones. Part of the reason for that is the state of the literature currently. So right now I can't speak specifically to my results because I haven't published this yet, but I am working on a systematic review on resistance training during pregnancy. And we have pulled about 50 studies on resistance training during pregnancy, which sounds like a lot, which it is. And it's been a lot of work to get the systematic review under control. But what we have noticed and what I have seen over and over and over again is a couple of things about the resistance training literature. Number one is that we have very few studies that look at resistance training in isolation. And you may not think that's necessarily a bad thing, because a lot of people are exercising in multiple modalities. Think about functional fitness, they're doing aerobic training and resistance training. But when we know that there's a lot of incurred benefit of aerobic training, especially when it's dosed appropriately, there's an interference effect that we see in the literature. So what I mean by that is that we know that there is benefits of aerobic training on rates of gestational hypertension and preeclampsia. We know that individuals who respond and continue to do aerobic training have less rates of gestational diabetes. We know all of these things already. So when we put in a known benefit and then kind of add in resistance training, we can't say with confidence that resistance training reduces our risk of gestational diabetes because we know that aerobic training does and aerobic training is in that multi-component program. So it's a big issue right now that we don't have a ton of research that's on resistance training in isolation, because then we can't isolate and say resistance training benefits X, Y, Z outcome, and aerobic training, there may be overlap, and they also do X, Y, and A, B, C, but without studies done in isolation, interventional studies done in isolation, we can't really say that this is incurring some sort of benefit. The second thing about our current state of the literature is that the resistance training research is unbelievably underdosed. So I'm gonna make a comparison for you. So the evidence that we have right now around resistance training in those with congestive heart failure in their 70s and 80s is higher dosed than a lot of the resistance training literature in pregnancy. Let me say that again. A lot of our dosing for resistance training is higher in our older adults with frailty, multi-morbidity, and complexity than it is for our uncomplicated pregnancies. When I am looking at that research, that makes me sad, and it just shows how much we need to do. When there is a randomized control trial that comes out in 2024, and the aerobic dosing is 70 to 80% of heart rate reserve, which is a great intensity for the aerobic training, and the resistance training part of the exercise program is using a yellow Theraband, I see red and I start to rage. And so the dosing here is unbelievably poor, especially for somebody, right, who we are not thinking has low musculoskeletal reserve going into their pregnancy, right? In general, individuals are not having trouble with activities of daily living as soon as they find out they're pregnant. And so we are going in almost with this assumption that individuals who are pregnant cannot have higher loading on their skeleton. And we're worried about strain, but a strain is not happening on the body with a yellow TheraBand for a person who's of reproductive age who is pregnant. Like that is not an appropriate dose. And so it's concerning that there is not an appropriate dosage for our resistance training interventions, especially when it is dosed appropriately. the aerobic side. So this brings me to our next problem. is if resistance training isn't dosed appropriately, if I am getting an individual who is pregnant with no complications to do a 16-week exercise program where the max amount that they are allowed to lift is two kilos or 4.4 pounds, and I wish I was lying about that prescription, can I realistically, as a provider and as a researcher in that space, say resistance training was the part of that exercise program that incurred the positive benefit? Right, going back to my first point about how when we have multi-component programs and there's a known benefit for aerobic training, it's hard to see the additive effect of resistance training. In combination with the fact that the resistance training prescription is not sufficient, what I would deem sufficient, to drive musculoskeletal adaptation or maintenance to prevent deconditioning in a pregnant individual. That creates a problem. It creates a problem and it creates all the downstream issues that we're seeing where pregnant individuals are restricted, right? Like when our max is a yellow fare ban on a 2024 randomized control trial, that don't lift more than 20, don't lift more than 30 pounds. that's gonna hold, you know, that's not gonna get better because we don't have any evidence to back us up, right? And so this is like a call to action around how we need to change some of our thought processes around the way that we are prescribing exercise for pregnant individuals, but we also need to push back on academia and be like, hey, like, this is not okay for this to be the state of our literature because I hate that I have to say this and my postdoctoral supervisor and I were having this conversation. Do we even have enough evidence in resistance training in pregnancy to truly be able to include it in our guidelines? And the answer is we don't. Not really. We're extrapolating from our general population literature and we're saying, well, based on some of the preliminary literature we have right now, light toning exercises seem to be okay. Literally the term in a big conglomerate of our RCTs was saying that they did aerobic training and light toning for our resistance training interventions. That drives me. It drives me with just unbelievable amounts of passion about why it is so important for this clinician science bridge to happen. It is why I will not step away from literature and doing research because we just need to demand so much better. And so what does that mean going forward? we need more research in this area. And so that is where my postdoctoral work has really taken off. So when we are thinking about our literature base, when the state of the literature is a two pound dumbbell, and I'm saying, I want to do an RCT where women are deadlifting over a hundred pounds, you can imagine that that amount of gap can create issues with an IRB board or an ethics board saying, whoa, whoa, whoa, whoa, whoa. We don't want to put mom and baby at risk. here's what we need to do. And so because of that, we need to build layers of evidence. So if you guys remember from your schooling, right, we have our levels of evidence from level five, which kind of our clinical commentaries, our professionals who are doing this in practice, that when the evidence isn't there to back us up, and then we go retrospective, prospective, RCT, and then systematic reviews and meta-analyses are kind of at the top of this evidence pyramid. And so when we are trying to build an area that does not have a ton of research to back us up, we need to start building levels of evidence. And that's what I'm trying to do. And so this started with our cross-sectional survey. You've heard us talk about this on our podcast, this podcast in the past, where the first thing that we have to do is show that there are individuals who are heavy lifting during their pregnancy. And so the cross-sectional survey that was published last year was the first step in that process. say, hey, look, we put out a survey for a couple of weeks online. We got almost 700 women who had lifted heavy during their pregnancies to tell us about their experiences. Great. Look, there's this need. They are very confused about what they're allowed to do and what they're not allowed to do. Like they're getting advice, like don't lift more than 20 pounds. Two, if you were doing it before, you can continue doing it now. Just don't strain your body. And even the strain on the body is a little bit question marks because, you know, there's so much that goes into it, et cetera. Right? It creates a situation where we recognize that there is a need because there is an absence of literature and there are people who need the answers to that. The next part is that we're going to start doing retrospective data taking and so right now I have two research studies that are open for enrollment and I am going to beg all the clinicians who are listening to this if you have a person who fits these bills if you could please please please send them our studies because I hope that the first part of this podcast tells you that there is just so much we need to do. There is so much that we need to do in this area, and I need your help in order to do it. So our retrospective study is taking individuals who have given birth within the last year and tracked their exercise through a training app. So if that was Wattify, if that was an Excel spreadsheet, if that was, you know, pen and paper, whatever it may be. If you tracked your exercise during pregnancy, specifically your resistance training, and you gave birth in the last year, we want you in our research study. So what we're going to do is we're going to ask you a whole bunch of questions about your pregnancy, your labor and delivery, how you felt about it, all those types of things, and then we're going to ask you to upload your training logs. And so what we're gonna try and do is descriptively see how did people modify? Are there any issues with resistance training that are popping up as patterns that clinicians or providers or obstetricians need to be aware of? And then how can we use that information to start help counseling individuals on strength training during pregnancy? And so that's a retrospective study. We also have a prospective study that is open for analysis. This is gonna take me about three and a half years to get out, but that is okay. So we are taking individuals who are less than 20 weeks pregnant, so in that first trimester, first half of their pregnancy, and we are following them forward over time. So every trimester, we are asking individuals questions about exercise during pregnancy, and we are asking you to upload your training logs. And so what that's going to do is it's going to build on our level of evidence, right? So now we have cross-sectional snapshots in time. There are recall biases that happen with that. We have our retrospective study that because we were using the training log, that recall bias is worked around because we have evidence of what they did over time. And then the prospective study, we are getting their thoughts in real time going forward. And so now we've gone from a level five of evidence and we're going to be pushing up to level With that evidence, my next goal is something interventional. Right now, we're going to have this building of evidence that we're seeing that is going to allow me to apply for funding for a randomized control trial that looks at different dosing schemas for individuals who are deciding that they want a resistance train during their pregnancy.

SUMMARY
And so if you have any individuals or if you are listening and you are in one of these two camps, I would love for you to join our army to try and build the level of evidence on resistance training in pregnancy. It is so necessary. It is so needed. And we are going to be leading the way in our pelvic division. We are very actively involved in research. Obviously, I'm a postdoctoral research fellow, so I'm there in the weeds of it, but also our other faculty are involved in the trenches as well. And it's just so, so, so important that we do this the right way and that we gradually build a level of evidence. And I am not okay with where we are right now. We need to do better. I will be part of the trying to make this better. And I'm recruiting you all to my cause to try and help me out. So I will post these research links in the captions, or you can head over to my Instagram at drchristina underscore private, and you can hopefully sign up for some of our studies. All right, if you are wanting to hear me get all fired up about other stuff or you wanna hear some of our faculty on the road, we have two courses in July that are still open for participation if individuals wanna sign up. I am in Cincinnati, Ohio. That is a smaller course. So if you are interested, July 2021, I'm in Cincinnati, Ohio. If you are interested and you are closer to Wyoming, we have a course July 27th, 28th in Wyoming. If you cannot get on the road because of kiddos like me who is coming early because kiddos are home for the summer, we have our next online cohort starting July 6th. So we are past 90% sold out for that course. So if you are looking to get in, please don't wait because there may not be the opportunity and then you'll have to wait until the fall. All right, that's all I got. 19 minutes. I'm sorry, I just get so passionate talking about resistance training in pregnancy. I hope you all have a wonderful week, and we'll talk to you all soon.

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Episode 1754 - Incorporation: do's & don'ts 0

Jun 21, 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 importance of incorporation, the difference between various corporate structures, and secondary benefits to incorporation

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

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

EPISODE TRANSCRIPTION

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

ALAN FREDENDALL
Good morning, everybody. Welcome to the PT on ICE Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan, happy to be your host today. Currently have the pleasure of serving as our Chief Operating Officer here at ICE and a faculty member in our Practice Management and Fitness Athlete Divisions. It's Leadership Thursday. We talk all things small business ownership, practice management, tips and tricks, that sort of thing. Leadership Thursday also means it is Gut Check Thursday. So Gut Check Thursday this week comes courtesy of street parking. If you don't know street parking, It is an at-home functional fitness crossfit style program designed for people who are primarily working out in the basement, the garage, the barn, whatever. A bunch of different options, at-home programming designed to do by yourself or maybe with your spouse or your kids or something like that. So this workout was sent to me by our very own Dustin Jones, division leader over in our older adult division. 12 rounds for time, 5 double dumbbell hang power cleans right into 7 double dumbbell front squats and then drop the dumbbells and do 9 box jump overs. Recommended weights, 50's for guys in the hands, 35's for ladies. and then a 24 inch box for guys and a 20 inch box for ladies. So go there, you're trying your best to hold on to a minute per round, maybe faster if you can really cycle those dumbbells really fast and you're light on your feet and springy on that box and definitely trying to get done under the 15 minute mark. So remember, you are rewarded for participating in Gut Check Thursday. Post your time lapse on Instagram. tag us at ice physio hashtag gut check Thursday you'll be entered into a weekly drawing to win a free ice t-shirt that will mail out to you so that is gut check Thursday today we're talking about incorporation do's and don'ts so we start our brick by brick course with this topic. This is a very important topic. I believe this is a very overlooked topic. I think this is an area of practice management where we can think it really doesn't matter. We can get really sloppy with how we incorporate and our incorporation type, if we incorporate at all, and I think it's really fundamental to understand why we incorporate, how we incorporate, and one of those benefits that you may not know that will result in you hopefully paying less tax money each year as a benefit of incorporation.

WHY INCORPORATE?
Let's start with why do we incorporate? Who cares, Alan? I'm seeing patients at my CrossFit gym or I see a couple people from my run club or whatever. I see them on nights and weekends. What does it really matter? Is it worth paying the $50 to my state to form a corporation? Short answer, yes. We talk a lot in Brick by Brick that becoming a business owner, even if it's not a full-time thing, even if you never plan to grow your practice beyond yourself, the whole idea behind being a business owner is to really look at and evaluate where are those areas that have maybe even a small degree of risk but that has a really simple, easy, low cost, time and or money solution to eliminate that risk. And owning a business, running a practice is really about minimizing that risk as much as possible because why not? Why carry a bunch of risk even if it's a hundred different amounts of really small types of risk? if you don't have to. And incorporation is one of those risks. The cost of forming a corporation is something that you can do in every state on your own. You don't need to hire a lawyer. You don't need to pay $1,000 to LegalZoom. We show you in Brick by Brick that it's a form usually on your state website. It's something you can fill out yourself. It's something that might even be free, especially if you're a small business owner, you're a first-time business owner. Something that you can knock out as simple as a couple minutes. In some cases, have your incorporation documents back instantaneously. So you're thinking, in some states, five minutes and zero dollars to form a company that is going to go a long way to limit your risk. Let's talk about that risk. What is that risk? When you are running a business, if you are not incorporated in the eyes of the law, both the legal law as well as tax law, you and your company are not separate entities. You are what is considered a disregarded entity. You are somebody who has not formed a corporation. You and your company are the same person, the same entity, and that carries a lot of that risk that we were just talking about. If you were to be sued for whatever reason, your business assets can be held liable to cover whatever you might be sued for personally, and vice versa. If someone falls in your parking lot, if a robber tries to break into your clinic and falls through the window and cuts their arm on your window glass and sues you, Your personal assets can be used and seized to pay for the outcome of that lawsuit should you lose. And that is because you have not legally separated yourself, the individual American taxpayer, from your company, your business. And again, that process is very, very, very simple, often quick, often very cheap to do. And so we always, always, always encourage people Even if you are seeing one patient a week, one patient a month, you are just a side hustle, seeing patients five to 10 hours a week, even if you never plan to grow beyond yourself, you plan to just essentially be self-employed, spend the 50 bucks, spend the 100 bucks, spend the 10 minutes, spend the hour, and incorporate so that you create that legal division between yourself and your business. Your personal assets are protected when the business gets in trouble, your business assets are protected when something may happen in your personal life. The last thing you want to do is have your house seized because maybe somebody slipped on the ice in your parking lot which you have no control or responsibility over and yet here you are having your personal assets seized because you have not incorporated.

DIFFERENCES IN CORPORATE STRUCTURE
So looking at a corporation, what are the two major types that we see with physical therapists? These are going to be state dependent, but you are going to form some type of limited liability corporation. The reason, again, we do this is right in the name of those companies. We are limiting our liability. So we can either form a limited liability company, LLC, or in some states, Physical therapists may be required to form a Professional Limited Liability Corporation, PLLC, or sometimes called Professional Corporation, or PC. What are the differences? They're important and it's important to know them. I'll start with this, you should always form an LLC and not a PLLC if you do not need to form a PLLC. The major difference between these two corporation types is that in an LLC you are protected from malpractice and fraud claims against anybody else in the business including yourself as a personal practicing physical therapist working in your own business. Now in a PLLC, a professional limited liability corporation, what some states have done is said, hey, professional level folks, folks who are licensed professionals, whether they're healthcare professionals, mental health therapists, attorneys, dentists, whoever, anybody that is required to have a professional license in this state must form a professional limited liability corporation or professional corporation. Why? These states are saying, hang on a second, you should not be safe from committing male practice or fraud as an individual licensed provider, even if you are acting within the scope of a corporation. And so the difference between an LLC and a PLLC, primarily, is that you do not have built-in mail practice and fraud protection with that PLLC. At the end of the day, you have to form whatever your state requires, so if you have to form a PLLC or PC, you have to do that. But if you don't, you want to form that LLC. The second difference in a PLLC is there is a big con, and it is that everybody in the company, anybody who will ever have ownership stake in that company, has to be from the exact same profession. So for a while, ICE was a PLLC. We are now a corporation, an inc, if you will, but we were a PLLC, which means that Jeff Moore was our owner. He's a physical therapist and because he formed the PLLC and he was a physical therapist, no one else could have ownership stake in the company that wasn't also a physical therapist. So that's something to keep in mind, especially if you're going into business with a partner, that partner must be a physical therapist. If you are also a physical therapist, if you were to sell the company, you would have to sell it to another physical therapist. If you were to pass it on to your children, or your spouse, or any of those things, everybody would have to be from the same company, or you would have to dissolve and reform the company. If you're dealing at all with any sort of contract insurance or whatever, you want to avoid obviously dissolving your company, losing your business, losing your business name, losing your tax ID, all that sort of thing. So we want to avoid dissolving our company if the company is changing hands under good terms. And so that is the second con of a PLLC. But again, if you have to form it by your state law, you have to form it. So LLC versus PLLC, if you're able to, always choose LLC, but recognize you might have to choose PLLC.

TAXATION BENEFITS TO INCORPORATION
And now the final benefit, a benefit that's not talked about a lot, is one of the reasons, aside from protecting yourself from legal liability, is that there are a lot of taxation benefits to forming a corporation. This is really hard to understand, but if you have been alive for a while, you recognize that this is naturally true. America is built to service companies. There are a lot of legal benefits. There are a lot of tax benefits to owning a company. Even if you don't own a giant company like Amazon or Tesla or something like that. Even if you own your own small business and you're your own employee. there are a lot of taxation benefits to incorporating as an LLC or a PLLC. The primary benefit is that you can elect something called S-corp taxation. This is a form you fill out with the IRS, form 2553, and this is not a different type of corporation. What this is doing, back in 2016 under President Trump, a law was passed where we can elect to be taxed as an S-corporation. What does that mean? It means we are eligible for pass-through taxation. Instead of paying a 21% flat corporate tax on all of the revenue that our business makes, and then paying it to ourself, paying it to others, and having those folks pay income tax on that money, avoiding that double tax is the result of something called S-corp taxation. And so, your company does not pay tax, it does not report anything to the government, you pass through your revenue and expenses to your personal income tax. What does that do? That provides us with two main avenues for benefits. The first is it lets us enroll 20% of all of the business expenses over to our personal income tax as a deduction. Now that's pretty huge. As you're starting, you may not spend a lot in your business, but if your business grows to multiple people, you will find yourself spending tens of thousands and hundreds of thousands of dollars in expenses. What's nice is that 20% of that can get pulled through to your personal income tax as a tax deduction. And so you get to stack that on top of all the other stuff you write off. As a business owner, you have a lot more leeway now of other stuff you can write off. You can write off anything that you may have spent money on that's a reasonable business expense. And so by having a business, by being incorporated, you're able to write off a lot more things and overall pay a lot less income tax than when you were an unincorporated personal citizen just paying taxes. That is one of the primary benefits of spending the time and money to get yourself incorporated.

SUMMARY
So incorporation, do's and don'ts. Do please incorporate. If I haven't stressed it enough, it is a relatively cheap, quick process that gives you a lot of legal protection. It also gives you a lot of taxation benefits that should see your tax bill be lower once you own a business and are incorporated than before when you were not incorporated and you were just a private citizen paying taxes normally. So if you have Deeper questions about this, our Brick by Brick course starts again July 2nd. We go really deep into the weeds on topics all like this. We talk about incorporation, we talk about whether or not you should work with insurance, we talk about how to work with Medicare either in network or taking cash. and we get into the nitty gritty about a lot of business topics so that at the end of the eight weeks, you feel really good about starting your practice or at least understanding the steps you need to take to start your practice. So if you're interested, we'd love to have you. Again, the next class starts July 2nd. I hope this was helpful. Have a wonderful Thursday. Good luck with that Gut Check Thursday workout. If you're coming to Michigan this weekend for the Fitness Athlete Live Summit, we'll see you tomorrow. Have a good weekend. Bye, everybody.

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Episode 1755 - Programming for performance & profit 0

Jun 21, 2024

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete faculty member Rachel Selina discusses programming and starting to fill more of a coaching role that can be an excellent way to continue to help runners beyond formal clinical care. It can also be a fun way to diversify your revenue streams and supplement your clinic income.

Start thinking in 3 tiers for offering either endurance or strength programming (or both!)

1. Generic
2. Semi-custom
3. Fully custom/interactive

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

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

EPISODE TRANSCRIPTION

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

RACHEL SELINA
All right. Good morning, everyone. Welcome back to the PT on ICE Daily Show. My name is Rachel Selina, and I'm happy to be your host this morning. We're here for Fitness Athlete Friday. And with that, we're going to jump into the topic of programming, but not looking at it from like what the programming actually consists of. but more so kind of how do we, how do we market that programming and what is it as a service that we're actually offering? Okay. So we, we talked about this at the sampler this year, um, about starting to find ways to diversify our revenue streams. Um, mostly from the standpoint of like avoiding burnout, but also like it brings you more income, hopefully doing something that you enjoy. Doing that's kind of a change from your normal. I always think it's kind of funny. I'm definitely someone who likes diversification So I end up having like I have like six different Roles or six different jobs and so trying to explain to someone like hey, I thought you were a physical therapist It's like what I am but I also I also do this or I also do this I also offer this and to me that That helps me. I like being able to work with people in lots of different capacities. So as we're talking about our endurance athletes, we're going to look at how do we use programming, kind of both the endurance programming, like our aerobic training and strength training and offer that as a service. And one of them that we'll dive into is like, yes, it can be an additional revenue stream. But I think from a performance standpoint, it's also really helpful for our patients because if we think they're ending formal care and we can send them out and still have a way of being in contact with them, like if we have designed their next training program, right, they're done in the clinic, we're not seeing them on like a regular basis anymore, but they're following a program that we wrote, they're more likely, if something comes up like, hey, my Achilles started bothering me, instead of waiting for it to be like a big deal, Um, I think it's more front of mind if they're following something you designed for them to think like, Oh yeah, I could reach back out to Rachel. Like I could ask her about this. Um, or just being in that more constant contact, but in a non nonclinical standpoint. So I think it, it helps our patients as they're going back into their training, um, to just have that kind of touch point or remembrance, um, that we're here, um, and we can help them with that. So from a performance standpoint, they're going to, be involved with us and be in that more constant communication so things don't go unchecked for such a long time. So that I think is helpful from the performance standpoint, but then there's also lots of ways that we can offer programming and kind of our particular take on it and what good programming could look like. because we have that background, we have that knowledge instead of someone just going, not that there's, you know, not good plans on the internet, but someone just going and getting programming from a random other person or from, you know, someone who's not familiar as much with how to kind of work around injuries or prevent injuries through what our programming is doing. So if we, if we think of that, like our aerobic programming first, okay, like what's the, How many days a week are they running? Are they training for a half marathon or a marathon? I think there's really three levels of programming we can offer and I kind of think of it tiered as how much input it takes on my end. So the first tier would be I write a program and I keep it very general. Like it's not for a specific person. It's I have written a marathon training program and I have available whether it's on my website or Instagram or whatever, however you want to sell it. Like I have available a half marathon and marathon training program that anyone can just buy. Um, or maybe I offer it for free. That's an option too. Um, but someone just buys it and there's no other input from me beyond that. I wrote it. Um, and I think with that, like it's very hands off. Um, here, this is what you're getting. This is what it is. Go do it. Um, I think with that though, like we're in a good spot to be able to do that because we can design a program with all of those good like principles of progression, kind of making sure we're not progressing too much, too fast, keeping pace under control, all of that, but it's not specific, right? This is a very general. I think if you're going to, even if you offer it for free, right? You could still have on that program, right? At the header or something like that. Like you can still have your name, your clinic info, something. to that nature, where again, every time that person looks at that program, they're seeing your name, they're seeing your clinic, and just being that point where you're front of mind, right? They can't get away from you, in a good sense. So that's kind of our first tier, something very general that's just put out there, anyone can buy, there's no other input to it. If we take it a step up, okay, that next step, that next tier, I think is semi-customizable. There's now a person in front of me who has a goal. So this now is Sarah, who's going to run a half marathon. And Sarah wants to run it at whatever pace. She wants to run an eight-minute pace. I can take that program, that general program, and adapt it to what Sarah needs. So I can put specific pace goals in there. I can put… you know, Sarah works late on Tuesday, Wednesday, Thursday, so she needs shorter workouts on those days. Like I can, I can change some aspects of that program so that it is specific to the client or the patient. But then beyond that, it's not, there's not anything else beyond that. I'm not, you know, I'm not in weekly check ins or anything like that. It's here's a program that's Tailored now for you. So semi customizable I think is that mid mid range and then if we were to go one more step Okay, like someone who wants everything I think of fully custom training programs And this is where they're bringing you on a more of like a coaching role. So I've written their programming But I'm also now having regular checkpoints, right? It takes a lot more on my end because I can't just do it and be done. It requires a constant kind of back and forth and checking in on how the training is going. Are they progressing appropriately? How are they tolerating it? And making those kind of week by week changes. And this, I'll think of using this if someone has very specific goals, like it's not just here's the race and here's the pace I want. But if there's a lot of elevation involved, or altitude involved, or multiple disciplines, or just something very, very specific. Or if someone really wants that more constant touch point, this is where we'll start thinking of fully custom programming. And then in terms of, like, you're obviously going to charge different. Like I said, that first tier, if you're just putting a general program out there, you might choose to have that be a free resource for people. because you know they're going to keep seeing your name, and that might be all you get from that, which is perfect. For a semi-customizable one, I usually think of charging per the time it takes me. So if I usually have a set cash rate in my clinic for an hour, and writing a custom training plan takes me an hour and a half, I'm gonna charge an hour and a half of what my usual clinic rate is. So I'm making sure that I'm compensated for it, and it's not taking away from my other my other revenue generation. And then fully custom, I think you have a lot more flexibility here for what what you want to charge, because it's going to depend on how much of your time it's going to take. So that can be I think you can either do it on a month to month basis or think of it as like a training block, which is usually helpful with our endurance athletes because they're usually training in those blocks of like, I have four months of you know, training for this one particular event. So maybe you do a particular like four month payment for whatever you think your time will be for that, that given goal. So that's kind of our that's our aerobic training. I think we can also look at this for strength training. And in a similar sense, like I'm not going to break it down quite as much, but you can have different levels, like you can have just a general program of know two days a week of strength training that someone's going to do and they're going to do the same thing each week as kind of your lowest tier non-customized. But then you can take it up a step or and think of like I'm going to write specific workouts every week for again for Sarah. Sarah is going to get two workouts from me each week that are you know taking into account her strength level her progression and that would be a different a different cost, a different level than just that generic. Or you can also think of doing like a class. Like if you have the space to do a class, maybe you start to offer a strength training for runners class that meets either once a week or twice a week. And you have people commit to that timeframe, right? Because then you can block out that time in your schedule. You have maybe one or two hours during the week that you know are dedicated to that and getting people to sign up for that bigger block of time. But again, they're just they're all different ways to offer something that we have the skill set to do and probably do better than a number of people that are out there doing it just because we can take into account proper progression and loading principles. And if we're doing some version of the custom programming, we know how to monitor tolerance to training load and whether that adaptation is occurring how we want it to. We know how to modify Or work around injury and then if we're constantly involved with that person, right? How much more likely are they to to come to us earlier? Which is the goal like most people don't seek out care for an injury until it really stops them from running So if we can get to people earlier, right? We can hopefully keep them going just like we say we we don't want to like leave the gym when we're injured we we want to use the gym to help us with our injury and We can think of it the same way for running, like we don't want our runners to have to stop running. We want them to be able to work through that and keep running so they're not losing that capacity. And like I said, just determining your cost, like you have to decide what your time is worth and how much time each type of programming is going to take you. But I think it can be a really good way just to be able to think differently, to kind of activate a different part of our brain. Um, and it's really rewarding to be able to help someone meet their specific goal, um, and kind of see them from that whole, that whole longer term process. So just some food for thought, um, different ways you can start to diversify your income working with endurance athletes in a way that benefits you, but also really benefits your patients. Sweet. Um, we have some injured runner courses coming up. So if you are interested in our online course, that one, our next cohort starts July 9th. OK, that's our eight week online course. We meet every Tuesday. And then we have now several options coming up for Injured Runner Live. Our last two for this year will have the beginning of September in Maryland. And then we just added a beginning of November course here in Michigan in Grand Rapids. So we'd love to have you out at one of those if you're looking to dive deeper. into working with your endurance athletes. So that's all I have. I hope you have an excellent Friday. Hey, enjoy your weekend and hopefully get out there and go for a run. All right, bye everyone.

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Episode 1753 - Top tips for HIIT & medical complexity 0

Jun 19, 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 shares tips to make HIIT more objective, being diligent with monitoring vital signs, and underdosing high-intensity with medically complex patients when needed.

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

EPISODE TRANSCRIPTION

DUSTIN JONES
Alright folks, welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. My name is Dustin Jones, one of the older adult faculty within the MMOA division. Today we are talking about the top tips to apply high-intensity interval training amongst medical complexity. So I think many of us have been there, right? We're working with that individual that has a whole laundry list of different diagnoses, different medications on board, maybe in a more acute setting. And we know that high intensity interval training is helpful for people. We've seen some literature, we've read some of the research, but what does it actually mean to apply this amongst a very complex situation? All right. So we're going to cover, some key takeaways from a super helpful article that was published last year in 2023 in the Cardiopulmonary Physical Therapy Journal titled, Putting It All Together, An Evidence-Based Guide to High-Intensity Interval Exercise Prescription for Patients with Complex Comorbidities. And I really appreciated the team that wrote this article because it is difficult to navigate, right? Like, we will see some of these headlines of high-intensity interval training proven to be effective in the ICU, for example, or HIT being effective with folks that have recently suffered from a stroke. Some of these things we typically wouldn't associate high-intensity interval training with, but it's been shown to be effective. Now, when we go to apply that, it can be rather intimidating, right? I can speak to this mainly from the home health setting where The trend in home health is that people are getting discharged from more acute settings like the hospital a little too soon, right? So you have these very medically complex individuals in their home with very limited monitoring, medical support if something goes awry, and all the negative thoughts and what coulds, right? What could happen starts to creep into your head, and that can dramatically influence our intervention. Let's talk about three, I've got three main tips for y'all, things that I have learned through mainly mistakes in my career, but then also what this article talks about. One is objectify, two is monitor, three is, I'm gonna save that one for last.

BE OBJECTIVE WITH HIGH-INTENSITY TRAINING
All right, so the first one, we go to apply high intensity interval training. We need to be objective. Here's what can typically happen. You read an article, you maybe hear a PT on Ice daily show podcast, see a social media post like, all right, I'm going to use this with Betty tomorrow. All right, Betty, we're going to do high intensity interval training. And you're already working on gait training, for example. with Betty and so you're going to be like all right Betty I want you to go fast for 30 seconds and then I want you to walk slow for 30 seconds we're going to do that for a total of 10 minutes right great start I love what you're doing there you got a one-to-one work rest ratio it's already a goal that Betty has to improve her ambulation ability, maybe even distance endurance. Awesome. But what typically happens, right? She goes to do her fast walk. What does that actually look like? Is it fast? Or is it just slightly faster than her normal or a slower walking speed? All that I'm saying here is when, say ambulation, when we aren't objectifying it, when we aren't giving people a number to hit, to look to, to get that real-time feedback loop, they will often undershoot their intensity. This is where the ergometers that many of us have access to can be very, very helpful. A lot of these things are, they're collecting a lot of dust in a lot of clinics, to be honest, right? Like the new step. It's either collecting dust or we're throwing people on there for 20 minutes while you finish your notes or they take a nap, right? We got our recumbent bike. Maybe you have a rower, maybe you have an echo bike, maybe you have a ski in your clinic, but these are functionally all ergometers that are measuring work, they're measuring speed, they're measuring distance traveled. Those are objective metrics that we can use for dosage, that we can use to give people that target to try and hit to make sure you're reaching an intensity. Right, RJ, outpatient, has an Echobike. Echobike, you look at that screen, you've got calories, you've got watts, you've got your revolutions, right? You've got your distance. These are all things that we can use to set a goal to achieve appropriate intensity while we're performing our intervals. So RJ, for example, with the Echobike, it may be watts, right? You may say, pick a number of watts that you're trying to hit. during that 30-second interval and then it's going to be 30 seconds easier, 30 seconds rest for maybe like a total of 10 minutes with someone. Giving them that objective thing to look at is going to be so much more effective than just quote-unquote saying go faster, all right? NuSTEP has the same thing, right? Many of you all have already, I shouldn't say wasted the money, the NuSTEP can be helpful with certain patient populations But my gosh, the price per square foot of a NuStep is absolutely ridiculous. But if you already sunk the money and have one, freaking use it, man. That thing has all kinds of data and information that we can use to really redeem the NuStep, redeem that piece of equipment and achieve a higher intensity. All right? That's the first one. We need to objectify what that high intensity actually looks like. Use ergometers. If you don't have the ergometer, maybe use something like a percentage of a heart rate, for example, some other metrics that we can use to objectify.

MONITOR VITALS
Speaking of heart rate, number two is going to be monitor. Now, this is what really allows us to apply higher intensity intervals with medically complex individuals, is when we are monitoring Vital signs and signs or symptoms. Vital signs are absolutely huge especially in so many acute settings. Hopefully many of you all are getting them at rest initially, hopefully at least bare minimum at the initial evaluation, right? But when you're working with more acute individuals, you have these complex comorbidities. We need to be checking vitals every visit, but then when we're applying these high intensity intervals, it can be very helpful and advantageous for you to check vitals before, during exercise, and then after to gauge their response. Now I'm not saying check every single vital sign, right? But there's gonna be some pertinent ones based on who you're working with, right? So like if I have someone that is constantly cruising, you know, in the 150s over 90s blood pressure, they're pretty hypertensive. It's not managed terribly well. They sometimes have some symptoms, but a lot of times it's asymptomatic. I'm going to be checking blood pressure pretty regularly. I'll also be checking their heart rate as well. And I can do that during, and before, during, and after an interval. That's where these ergometers can be really helpful. Like a new step, for example, when I program that interval, they're working hard, but then they have that rest. That rest is when we check our vitals. I'll support their arm, get a manual blood pressure reading, and you're going to be able to gauge their response and make sure that you're in a safe zone, right? And the way we like to think about these zones is we like to think about them as traffic lights. So there's a red light in terms of things that you may see where we're going to stop exercise and a yellow light where we're going to be cautious but proceed and then green is just full send. We go into those in our Level 2 course, related to resting vitals, exercise vitals, signs and symptoms as well, related to high-intensity interval training. But for our purposes here, we want to monitor during, so you'll have a good idea of how they're responding. Another one is if someone has some type of cardiopulmonary issue, then a pulse ox can be really helpful, looking at oxygen saturation. We can see their response, make sure we're good to go, and we can adjust our dosage based on that. when we're able to monitor those vital signs it's going to give you an objective view of what's actually happening and I don't know about y'all but here's what typically happens with me is I may throw someone on a new step for example a recumbent bike and we're doing high intensity interval training and I know they've got some cardiopulmonary issues on board, some things that I'm somewhat concerned about, and I literally tell them to go hard. I may give them, you know, hit this number of watts during these hard intervals, and I literally am closing my eyes, crossing my fingers, praying to the rehabilitation gods that something bad doesn't happen. But if we're able to monitor and get that objective information, you can rest assured that you're giving that person exactly what they need, and it is safe.

UNDERDOSE THE HIGH-INTENSITY FOR MEDICALLY COMPLEX PATIENTS
Alright, so first we need to objectify it, second we need to be able to monitor it, and then third and the counterintuitive one, but it's the reality when we're going to apply high-intensity interval training amongst medical complexity, is that we need to underdose. I hate to say it y'all, but we need to underdose. Oftentimes, I'm not gonna say always, but oftentimes these folks are have a lot on board, right? And from the medical side, but then also from the psychological side, you take someone that has been given the diagnosis of heart failure and imagine what that feels like, right? You may have some perspective of what that actually means, a prognosis of that and what people can continue to do with a diagnosis like that. But there's so many individuals that will get these seven syllable medical diagnoses and they literally view it as a death sentence and they're actively falling apart right in front of your eyes. And that is not necessarily the case. There's a lot of psychological damage as well as physical damage along with these medical complexities. And it can be very advantageous when you introduce something novel and new like high intensity interval training to do it in a very approachable manner. This is where I am typically when I'm introducing I may use something like a subjective report, like an RPE, a rating of perceived exertion. That goes against the first thing I said, right? I told you you need to objectify it, but maybe initially, we want them to be a little bit more in the driver's seat and give them that RPE. You may say, I want you to go hard, I want you to go fast, I want you to go at a seven out of 10, RPE of 10 is your all-out effort, right? Initially, I think that is helpful. But we don't want to stay there because most of the time, people's true high intensity doesn't necessarily match up with their perception of high intensity. And that's where we need to be objective to calibrate that. But initially, I think under dosage, self-report can be very, very helpful. We also need to consider what these high-intensity intervals can do to people outside of our session, right? I learned this the hard way way too many times in home health, where we'd have this epic session. We'd be gone for about 20, 25 minutes, high-intensity intervals, you know, doing steps or ambulation, and then we do some transfer training. I'd take them, walk them out to their mailbox and back. They haven't seen the sunshine in weeks. Man, it was an epic session. And then I come back in a few days. What has that person done since that session? Nothing, right? They weren't able to do their laundry. They weren't able to do any tasks around their home. they were laid up because I absolutely gas them. And so we want to be able to leave gas in the tank for many of these individuals to be able to do things that are really important to them like ADLs, like IADLs, maybe a certain social function, right? And so when we start with that under dosage, you will be able to tweak and progress without impacting the rest of their life too much. which is really important. Many of you all may not have experienced that, right? I think many of you all probably did MRF, right? Memorial Day, high volume, you're working real hard for, you know, 40, 50, 60 minutes, maybe more if you're me, right? How'd you feel after that, right? Many of you all, myself included, were absolutely wiped and that's what a 10-minute session can do for some of these individuals.

SUMMARY
So, We may want to introduce it in an underdosed manner, see how they respond, make it approachable, and then gradually progress it from there. Then we start to objectify it, give them that target for, I want you to hit this many watts, for example, or this many revolutions per minute. And then we continue to monitor their vitals before, during and after those intervals, and you've got a potent cocktail that can really influence people's functional capacity, but then also the disease process that they are suffering from, and most importantly, it can be safe. All right, let me know your thoughts. Let me know any tips that you have from applying high-intensity interval training amongst medical complexity. I would love to hear from the folks in the ICU, in acute care, in skilled nursing facilities, in acute rehab, where you're dealing with a lot of medical complexity. Love to hear from you all. Drop in the chat on this Instagram video, or if you're watching on YouTube, if you're listening on the podcast, we're grateful for you listening. Hop on social media, and I'd love to hear your take as well. Hope this was helpful. I'll also put the citation for the article, the really helpful article, in the comments on Instagram as well. All right, hope you all have a lovely rest of your Wednesday. Go crush it, 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 1752 - Treating wrist pain at the shoulder 0

Jun 18, 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 addressing shoulder mobility in wrist pain patients.

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

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

EPISODE TRANSCRIPTION

CODY GINGERICH
Good morning everybody. My name is Cody Gingrich. I'm one of the lead faculty with the extremity division and I am coming with you today on a clinical Tuesday and we're going to be talking about treating wrist pain at the shoulder. All right we're going to be tackling shoulder but treating the wrist. Okay. So wrist pain going after the shoulder to deal with wrist pain. This is a big deal when we're talking specifically about, um, a fitness athletes. Okay. So The reason being, the fitness athletes, people who are lifting in the front rack position, so think our Olympic weightlifters, our crossfitters, people who are just really working a lot of front rack position or overhead movements in general, are going to really benefit from these type of things, okay? So, couple things that I wanna start with and why it is important to look at the shoulder when someone is coming in with wrist pain. In the extremity division we talk about wrist pain a lot of times and most most of the time a lot of different presentations of wrist pain are going to be due to or need more wrist extension. It is going to be a wrist extension intolerance and that is largely going to be the case when we're talking about what we are today as well. With these barbell athletes or overhead athletes that need a good amount of wrist extension to get into good front rack position, or if we were thinking about handstand walking or handstand push-ups or pressing weight overhead, we also need a good amount of wrist extension tolerance to support our body weight overhead. Okay. And a lot of times when these people can come in, we can get pigeonholed into just looking at the wrist and be like, okay, well we're lacking some wrist extension and we need to treat that and we need to calm that down. And we, we stay in our lane right there at the wrist. But what I want to talk about today specifically is going to be really addressing shoulder mobility. in order to free up some space at the wrist. So I have a couple of, uh, I have a PVC that hopefully y'all can see, and we're going to try to show you, um, why in a non-adequate shoulder mobility can end up putting way more stress at the wrist with these athletes, even if they have a pretty good amount of wrist extension. Okay. So when we're talking specifically about the front rack position, I've got a PVC pipe here. So one thing is going to be where we're starting with is going to be if we have a lack of lap mobility, a lack of lap mobility is going to not allow our elbows to come forward and up as much. Okay. And so what that leads to is that barbell then sits way more on our wrist and hand than it does on our shoulders. PVC, I got to kind of tuck my chin down and get it there. But the more that we can drive our elbows up, the more that weight then is supported by our shoulders in that good front rack position. If we don't have the ability to really turn our elbows up high and we keep them low because we don't have that mobility, then most of that weight then comes through our wrists. And even if we have good wrist mobility, that is still a ton of pressure there coming through the wrist joint. The other side of things is we also need shoulder external rotation in that front rack position to distribute the weight that's going through our wrist more evenly. So the other front rack position that I see where if we can't get our wrists and our hands out here, we end up with our wrists right over our shoulders and maybe our elbows even just outside, just like this. And what that does is it forces extension and rotation at the wrist and ends up putting a ton, a ton of stress through that radial side at the wrist. Whereas if we can then open up that shoulder external rotation, that then can distribute the weight more evenly. We can have a flat palm. and a flat wrist into extension. So the other thing when we're talking about getting overhead, I mentioned handstand walking. If we don't have adequate shoulder flexion and we are overhead, that leads us to be here and we still are trying to get our feet up and over our body to walk forward. And that then requires a significantly amount more wrist extension if we don't have all of that shoulder flexion. If we can gain more shoulder flexion then at the top we don't need to roll over our wrist extension quite as much. So a couple different ways and that could also be a lat mobility problem as well. So what I want to encourage you is we have several tests If someone comes in and they're saying they've got pain with these particular movements, right? First, make sure that they have that adequate wrist extension. And the best test we've got for that is really going to be have them place their hand on a table and then see if they can get their elbow beyond 90 degrees at the wrist. Even right at 90, they probably have enough wrist extension to be able to calm those symptoms down, even without gaining wrist extension. So you can still make gains in their pain and treat their wrist pain, even if that wrist extension is a little slower to come. It is typically easier to treat soft tissue mobility restrictions than it is joint restrictions, typically. So a lot of times in our athletes in this population, those shoulder mobility limitations are oftentimes going to be soft tissue related. So we want to then check shoulder mobility. The best test for that, to check lat mobility, is going to be the seated wall test. So if you have the person sit up against the wall, back as flat as they possibly can, PVC pipe then in their hands, palms down, and reach up can they get their knuckles to the wall? If they can, have them then turn those palms up and reach again. And if they come up short of the wall, we can be confident that there is some lap mobility restrictions on board. Okay, that is going to be a situation where treating the shoulder and the lats are going to be a really great way to address the wrist pain, because that will then allow those elbows to come up higher, take stress off of what the wrist is going to have to take on. So if we can decrease stress at the wrist by increasing shoulder mobility, we are doing a good job bumping that wrist pain forward. That's going to address both the elbows high in the front rack position and oftentimes the stacked overhead position when people are going handstand pushups, handstand walking. So we can kind of knock out two birds with one stone by really looking at the lat mobility. Secondarily, we can also look at shoulder external rotation. Okay. Now this could be a mobility issue. This could also be an external rotator strength issue. Okay. But to check the rotation can have them in supine, bring them to this position and then passively rotate and see if they have that mobility to get into that external rotation. If they don't, if they can't access that external rotation in that 90-90 position, we are going to want to start working into that external rotation. That can be with some contract relax. We can do the classic PVC stretch where we work this way and try to warm that up ahead of time before they get into that front rack position. we can also work some like band work in this position working out again contract relax or have the band pulling here stretching out some of those internal rotators and then we can go x internal rotation and then we do eccentrics into external rotation with a band moving that direction that will help to open up some of that external rotation specifically in that front rack position. Okay, so what that will do then is again in that front rack, get us from instead of this position, it will get us more that position and more evenly distribute that weight across the wrist as opposed to it digging into one side or the other.

SUMMARY
So overall, If someone comes in with wrist pain, and specifically that wrist pain is happening when they're in a front rack position, when they're putting a bunch of weight on their hands from doing handstand walking, handstand pushups, go after and look at the wrist absolutely, but absolutely don't neglect looking up the chain and looking at shoulder mobility, shoulder strength. If they don't have adequate lat mobility to get their elbows through in a front rack position or full shoulder flexion in that position, look first at the lats. See if we can't gain some shoulder mobility from that soft tissue, really be able to get in and through that elbow, take off some of the stress from the wrist. If they have a hard time getting their hands outside of their shoulders and big chest there, start looking at do they have adequate shoulder external rotation, either mobility or strength to be able to maintain that position and again, decrease the stress from the wrist. If you don't hit that and they don't have that ability, you can treat the wrist all day long, but they are going to continue to just keep pissing that off because they don't have any way to overall decrease the stress that that wrist is taking on. Once we can find that root cause of why that wrist is taking on so much weight, then we can start increasing the tolerance to that wrist extension. So we can start mobilizing there, we can start adding back like a plate carry where we're working here, we can spin that in different ways, all of that, and we can then start working at the wrist. But if we don't clear the shoulder first, you're going to be fighting a losing battle overall, because we haven't addressed why that wrist is taking on so much weight and getting irritated in the first place. Okay, so I just want to keep keep y'all's heads involved as far as don't always get tunnel vision onto one joint, right? We always want to look up the chain and seeing if there is something going on that we might be missing. That's all I got for you for today. So again, just as a quick recap, someone coming in with wrist pain, specifically our barbell athletes going overhead, we really want to clear lap mobility and external rotation mobility at the shoulder and make sure that those things are clean so that we can decrease the stress being put on the wrist. If you want to catch extremity man My last minute plans that you can make it to there. Otherwise, we will be in Kent, Washington on July 13th and 14th or Hendersonville, Tennessee on July 20th and 21st. We hope to catch you out there. We have a ton of different, all of those exercises and techniques that I just talked about are in that extremity course and we go into them in much more depth. So we'd love to catch you out on the road. All right. Hope everyone had a great day. Thanks for listening.

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 1751 - HEP for the new mom 0

Jun 17, 2024

Dr. Heather Salzer // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Heather Salzer discusses tips for designing home exercise programs for newly postpartum moms, including removing barriers to movement, being smart with the structure of the HEP, and encouraging habit stacking.

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

HEATHER SALZER
Good morning, PT on ICE Daily Show. I'm Dr. Heather Salzer and I'm here with the pelvic team at ICE. And today we are going to be talking all things home exercise plan for the new mom. I think this is an area where we can do better as clinicians. Oftentimes I hear, man, my postpartum population just really doesn't do a good job doing the exercises I give them. This is a group where they have a lot going on, right? So oftentimes we just assume, okay, well, they don't have time to add in these extra things. And that's where we're wrong. I think if we meet them where they're at and set them up for success, not only will they have small wins of being able to accomplish, that part of their rehab plan, but also we're going to see better results with our care plan from there. This is a topic that's very near and dear to my heart. In clinic, I treat about 70% pregnant and postpartum individuals, so I've had a lot of time to help these people figure out how can we best increase compliance and set them up for success with their exercises. Additionally, I am about four months postpartum with an adorable little daughter at home, but she certainly takes up a lot of my time. And so in the last few months, I've had some experience using some of these same tips and tricks that I use with my clients for myself to be able to get in some of my rehab as well. So this is a topic that's fresh on the mind for me. We're gonna divide this up into about four different sections of tips today. So we'll be talking about workout structure, removing barriers, habit stacking, and managing expectations and how you can use these areas to help set your clients up for success. Let's dive in.

WORKOUT STRUCTURE
So first of all, workout structure. I am a huge fan of using time-based workouts or home exercise plans for this group. And the reason is then they know, man, I only have five minutes, but I can sneak that in right now. And so within that, I like to keep it 10 minutes or less. And if it's somebody who's wanting more, you can give them several segments of five minute or 10 minute things, but that way you at least know like, okay, let's at least try to get these five minutes in. So what does that look like? I will use a lot of remands, so rehab every minute on the minute, and set them up with maybe three exercises, and we'll do that two times through, or three times through, and so that gives them either a six minute or nine minute workout. Another thing in this postpartum population that I'm a big fan of is the Tabata, so 20 seconds on, 10 seconds off. One specific example of something I give people a lot is some variation of that hollow hold and Superman hold. I'll set this up, what this looks like is eight rounds, so four rounds of hollow hold, four rounds of Superman hold, and we'll do that for 20 seconds on, 10 seconds off, and you can scale it up or down. So maybe that hollow hold in the beginning is just lifting one leg and focusing on kind of finding that core tension. Maybe we're progressing it all the way to a hollow rock. Similarly with the Superman, we can lift just the arms, lift just the legs, and then talk them through what are the progressions across this. And then four rounds of each, flip-flop back and forth or do all four hollow, all four Superman, and in less than four minutes, like three minutes and 50 seconds, right, they'll get a really effective both core workout and some blood flow to that posterior chain, which can be both important areas with this group. If you're like, man, I don't know, Heather, I don't know if that's really enough of a workout, I challenge you to try it today and choose a level that feels difficult for you, wherever that may be along that spectrum, I bet by the end of four minutes, you're gonna be like, oh, yeah, okay, I can see how that could work. So using those time-based intervals can be huge in this group to help set them up for success when we're thinking about workout structure.

REMOVE BARRIERS TO MOVEMENT
Second, we're gonna be worrying about removing any barriers to set them up for success for getting their workout done. A big piece of this can be equipment or space. So if all of their equipment is in their garage and they have a garage gym set up, but it's hard for them to hear their baby from the garage, they may be avoiding going in and using that space. So can they bring their dumbbells in, maybe just one set of them, program everything with one weight to start, and put them by the couch? Make that more accessible. Maybe we're using baby for weight instead. Little one doesn't want me to put her down. So instead, let's hold her. Let's see what we can do with that baby, using the baby for our weight instead. Another thing, if you're a new parent or have been around new parents at all, I'm sure you've heard the words tummy time. So I love utilizing this time that mom is going to be on the ground with her new baby as a way to get in some of our exercises as well. So we're kind of removing that barrier of like, all right, you're already going to be there. Let's set this up. So what this could look like is maybe we're working on some C-section scar tightness. So while baby's on the ground, working on baby's tummy time, mom can do the same. She can be down there doing some gentle Cobra stretching. Maybe we're taking that opportunity to slow down, take some deep breaths, get into happy baby, child's pose, do some side planks, get creative with it. What does your patient need? But tack it onto that time. And yeah, tummy time is a great opportunity to sneak that in. So really think about what's their setup at home? How can, like ask them, where do you envision yourself getting these things done? what will make space or what will make sense with your space and then work with them with that.

HABIT STACKING
Number three is going to be habit stacking. So this ties a little bit into what we were just talking about tummy time, doing their exercises while they're already doing something that they're doing that day. I first kind of heard the term habit stack from James Clear's book, Atomic Habits. And I love this concept where we take something that we are already doing across the day, and then we add our new thing that we want to do on top of that, and it's gonna help increase our ability to get that new thing done because we already have established that other habit. So in the postpartum population, there is a lot of things that happen routinely across the day, and so let's take advantage of that, right? Tummy time was one example. Another example of something that I give a lot in clinic is when we're dealing with like shoulder tension, maybe we're spending a lot of time breast bottle feeding, holding baby, coming forwards, and I want just more blood flow to kind of open things up and get them moving across the day just to get them out of that position. We always say your next posture is your best posture, right? So Can we figure out where they're spending the most of their time nursing or bottle feeding or whatever that looks like? And can we set a heavy resistance band by that? And every time they do that, which is probably gonna be every one to three hours in the beginning, that's a lot of times, can we do some banded pull-aparts just to get increased blood flow to their shoulders, neck? with that. Maybe we're not doing this in the midnight feedings. Maybe we're just encouraging like 50% of them, but that's one example of how we can get that in. Some other things that I like are adding things on with diaper changes, another thing that's going to happen routinely. If you're wanting that person to work on kind of establishing connection with pelvic floor and you think that doing some pelvic floor contraction Kegel work is appropriate, you could time that with a diaper change. So every time you change a diaper, give me 10 to 20 pelvic floor lifts. Another example I'll use is every time you make coffee or go to heat up your coffee in the microwave because it's gotten cold and you are now heating it up for the third time to hopefully drink it, can you do a set of lunges or squats in the kitchen while you're making that coffee or heating it back up? Get creative, ask your clients what are you doing across the day And if I give you this to try to do on top of it, do you think you'll have the time and space for that? Use habit stacking to your advantage. Lastly, and I think most importantly, is managing expectations. These people need wins. They need to feel successful. And they need to know that it's okay if they're not hitting this every day. So I talk a lot with these people in this group about consistency over time. That if you miss a day, if you miss a week, if life gets in the way, let's talk about what happened where we weren't able to get to it, but also let's not worry about it too much. Let's jump back on it. Because in the longterm, over the next few months, if we can be doing this a couple times a week, even for five minutes, three to four times a week, we will see change. So first of all, just setting them up for success, knowing that they do not have to be perfect with it, but then also kind of managing how fast they expect to progress with how much time they're able to put in. Because in reality, if we are doing five minutes a day, four days a week, can we expect really quick progress? Maybe not. Again, I would argue the exercise that we're getting done is always better than the one that's not happening. However, let's talk about what our realistic expectations of what we're kind of what we expect out of it based on what we're putting in. And let's really help these people have these small wins, feel confident with it. And oftentimes what's going to happen is you give them like four or five minutes of something to do. They're able to be consistent with that. They come back feeling great because they were able to do what you asked them to. And maybe they're already starting to notice a little change in their ability to contract the core again or connect with those muscles. And they're gonna come back and they'll be like, okay, I want more. How can we carve out more time? How can we make this maybe a little bit longer? Okay, now I think I'm ready to add a little bit more weight. So get that win, and then you can stack on. Always meet them where they're at. If they want more from the beginning, great, go for it, give it to them. But also, have a conversation, figure out what that looks like, and then from there, really kind of help work with them to figure out what the best plan is. Awesome.

SUMMARY
So in summary, we're thinking about our workout structure We are removing barriers to help them get it done. We're gonna give them opportunities to habit stack so that we can take advantage of the things that these moms are doing across their day already. And we're going to help them manage expectations, talking about consistency over time, and really setting them up for success. If you would like to learn more about working with this population, we would love for you to join us in one of our pelvic courses We have our next online cohort for level one starting July 8th. That's filling fast, so if you would like to get in on that, make sure you get grabbed your spot soon. And then we have two opportunities to join us on the road before long here. July 20th we will be in the Cincinnati area in Loveland, so jump on that course. And then we also have an L1 pelvic course or sorry, a live course July 27th in Laramie, Wyoming as well. So would love to see you online or on the road soon. And thank you for joining me here this morning. And I hope you have a lovely rest of your day. Happy Monday.

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Episode 1750 - Femoral neck BSI 0

Jun 14, 2024

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

In today's episode of the PT on ICE Daily Show, Endurance Athlete division leader Megan Peach discusses femoral neck bone stress injuries, including referral for diagnosis, potential treatment options, and rehabilitation & return to running.

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 Jaina.

MEGAN PEACH
This is your PT on ICE, the daily show. brought to you by the Institute of Clinical Excellence. My name is Megan Peach. I am one of the lead faculty for Rehabilitation of the Injured Runner online and live. And today I'm gonna talk to you about, no surprises here, bone stress injuries. But specifically I wanna talk to you about femoral neck bone stress injuries and what to do once you expect that your patient has a possibility of even having a femoral neck bone stress injury. because sometimes that decision on what to do might be a little daunting. And so I'm going to present this information in a bit of an algorithm format. And I'm not the biggest fan of algorithms because our patients don't often fit perfectly into the algorithm boxes that we need them to fit in to in order to progress along that algorithm route. But this one I actually think makes a lot of sense and I think it's pretty straightforward so hopefully it will be helpful for you in your clinical decision-making process. So I'm also going to make some assumptions that you have already done your subjective exam, you've already done your objective exam as well, and you are ready to make some decisions and you've decided that your patient has potentially a femoral neck bone stress injury. Now that part is really important because if you are even suspecting a femoral neck bone stress injury, then you need to consider it a femoral neck bone stress injury until it's proven otherwise. And that's important because as physios, we can't tell if that's a high risk or a low risk femoral neck bone stress injury. All we know is that there's potential there and one, they're treated differently, but two, the high risk can progress on to be a more serious injury. And so it's really important that we treat them as femoral neck bone stress injuries until that condition is proven otherwise, or it's proven as a femoral neck bone stress injury, and then we can move on in that treatment algorithm. So once you have made that decision, this person sitting in front of me is potentially a femoral neck bone stress injury or has one. The first thing we're going to do is refer them out to an orthopedist. They need additional imaging. And again, that's because we really need to determine one, if this is a femoral neck bone stress injury, and two, if this is a high risk or low risk, because again, they're treated a little bit differently. And so that referral to the ortho is going to jumpstart that part of the process where they can then get additional imaging. MRI is the gold standard to diagnose bone stress injuries. You could also refer them to their primary care provider. Their primary care provider can certainly refer them for an MRI, but ultimately they're going to go and see an orthopedist. And so it's nice to just take out that middle appointment and you can always communicate this information to their primary care provider, especially if they were the ones that referred them to you in the first place. Okay, so all of the patients are going to start out with their referral to the ortho, and then hopefully go for an MRI. Now the results of the MRI are really important because they're going to dictate at what path in this algorithm they're going to take. So I'm gonna give you three different scenarios based on the results of this initial MRI. The first scenario is that the MRI is positive for only bone marrow edema. It is a femoral neck bone stress injury, but it's only bone marrow edema. There's no fracture line. So this patient is then going to do six weeks of non-weight-bearing. Kind of a bummer, a hard conversation to have, especially if there's no distinct fracture line, but they still need six weeks of non-weight-bearing to prevent further progression of this injury. After the six weeks, whether or not they get a follow-up MRI is really dictated by that orthopedist and their experiences. Typically they don't if it is bone marrow edema only, And so at this point, they would likely begin a weight-bearing progression. And that weight-bearing progression is going to be gradual, likely over the course of a couple of weeks. After they are able to weight-bear normally, they're going to then start into a normal walking program and a formal rehabilitation program. With that being said, during that six-week period of non-weight-bearing, certainly they could do formal physiotherapy, but you could also send them home with exercises they can do on their own to prevent atrophy, to maintain the strength that they do have and the muscle mass that they do have. That, of course, is a conversation between you and the patient and the orthopedist on where they want to spend their time, potentially money, potentially number of visits for physio, because you know they're going to need them once they start that weight-bearing progression. I'm not going to talk a lot about the details of that weight-bearing progression because I want to stick to this clinical decision algorithm, but in that weight-bearing progression, it would then work itself into also a return to sport progression as well, but that's where it starts. Okay, so to summarize that first scenario, you have your patient, You have differentially diagnosed them with a potential femoral neck bone stress injury. You referred them out to an orthopedist. They had an initial MRI, which was positive for bone marrow edema. Then they did six weeks of non-weight bearing, and then they progressed into a loading program to get them to load normally and walk normally, ultimately probably run normally, and get back into the sports and the activities that they want to do. Okay, so the second scenario, we're going back to that first MRI. They come in with their results. Their results say that they now have a stress fracture, okay? And so this is a totally different scenario than the first scenario with bone marrow edema only. Now, the location of a femoral neck stress fracture is really, really important because that's going to determine whether or not this is a high-risk or a low-risk bone stress injury. So if the fracture is on the underside of the femoral neck, it is deemed a compression-type fracture, and it is going to be more low-risk. If the fracture is on the superior aspect of the femoral neck, it is deemed a tension-type injury, and that is going to heal a lot more slowly with a lot more difficulty. It is deemed a high-risk bone stress injury, and it's treated very differently from the low-risk or compression type fracture. So the MRI is going to describe the location of that fracture as well as occasionally the severity. If that person presents with a compression type fracture, so on the underside of that femur, and it is 50% or less of the width of the femoral neck, they are going to then, surprise, do six weeks of non-weight bearing, okay? And so they have a fracture line, but we're still going to treat them conservatively in this scenario. After the six weeks of non-weight bearing, typically they will have a second MRI or follow-up imaging. Occasionally that can be x-ray if they were able to visualize the fracture line on an initial x-ray. So a follow-up image, and based on the results of the follow-up image, they're going to be filtered into basically three different paths again. And so if that follow-up image says that they are making good progress and healing, so maybe we don't see a line anymore, maybe there's callus, maybe there's less bony edema, then we're going to filter them back into that progressive weight-bearing approach. And so the same thing that we use for scenario one, they're going to do a progressive loading program into full weight-bearing and then walking and then running and then return to sport, et cetera. Okay, that is if they were asymptomatic and they demonstrate healing on that follow-up image. If the follow-up image does not show any progress, it doesn't show any regression, it's just kind of stagnant, or the patient is still symptomatic, they're still having symptoms in that hip. Now, granted, they haven't been weight-bearing for six weeks. they're going to restart that six weeks weight-bearing. It is a tough, tough conversation, and nobody likes it. Not you, not the orthopedist, certainly not the patient. They're going to start that process over again, and they're gonna start back at the top of that six weeks non-weight-bearing, and then they'll likely have a repeat image at the end of that second six weeks of non-weight-bearing. I should mention here that I keep saying six weeks non-weight-bearing It's a start and I think it's important to educate our patients on that. It is just a start very often they will go into Longer durations of time non weight-bearing in order to treat this condition Okay, so the third scenario after the second image the follow-up image is that there is a regression and so this is not based on symptoms it is only based on that second image and this now shows a progression in the injury, maybe the fracture line increased, maybe the edema increased, but there's been some basically like regression in the issue. And so, or progression in the injury, however you want to take it. And so with this situation, unfortunately, they've now become a surgical candidate and they will likely stay under the care of that orthopedist. Okay. So to summarize that second scenario, They have come into your clinic, you suspect a femoral neck bone stress injury, you refer them out to an orthopedist, they come back with a positive MRI for a fracture line, but that fracture line is less than 50% of the width of the femoral neck and it is on the compression side or the underside of that femoral neck. They then do six weeks of non-weight bearing. They get a follow-up image. Based on that follow-up image, they will either continue in a progressive loading program in formal rehabilitation, repeat the six weeks non-weight bearing, and then do another follow-up image, or go on to be a surgical candidate, depending on the results of that second image. Okay, our third scenario. They come back with their first MRI, and the results show, again, a fracture line. This fracture line, though, is one of two scenarios. It is either a fracture line on the superior aspect of that femoral neck, which is a high-risk, tension-tight bone stress injury, or that fracture line is on the compression side, or the underside of that femoral neck, and it is greater than 50% of the width of that femoral neck. Either of these two situations, unfortunately, are going to necessitate, likely, a surgical intervention. So an open reduction, internal fixation, to stabilize that fracture and make sure that it doesn't progress into a more severe injury. The type of that ORIF is obviously very dependent on that surgeon as is the weight-bearing status post-operatively. So some will do non-weight-bearing for an additional six weeks, Some will do partial weight-bearing and then some will do full weight-bearing immediately after surgery. It is obviously just up to that orthopedist. And so that third scenario is quite short compared to the others. Your patient came in, you suspect ephemeral neck bone stress injury, you refer them out to the orthopedist, they come back with the MRI results with a positive for either a fracture line on the underside of that femoral neck on the compression side that is greater than 50% of the width of that femoral neck, or they have a fracture line on the tension side, the superior aspect of that femoral neck. Either of those two situations are then going to necessitate some kind of surgical fixation for that injury. Obviously, that is always a discussion between you and that patient and the orthopedist and whatever team they have around them in terms of if surgery is the appropriate intervention for them. Obviously, this is just a basic algorithm and then to help guide some of these clinical decision-making processes. Okay, so the themes in this algorithm that I want to highlight are regardless of what that initial MRI says, basically all roads lead to six weeks non-weight bearing. It's kind of an unfortunate part of this injury is that we definitely don't want this to progress from a low risk to a high risk bone stress injury. That's the worst case scenario because if we can prevent that in any way, even if it means six weeks non-weight bearing, we have to do that. So any roads, maybe with the exception of that third scenario where it just leads to surgery, all of the other paths essentially lead to that six weeks non-weight-bearing. So just know that that might be in their future. The other thing is, is that any progression that we do formally as informal rehabilitation after they've done their six weeks non-weight-bearing and they've been basically released to physiotherapy or released to progress to walking or weight-bearing, all of the progression has to be asymptomatic. Any progression that is symptomatic, creating symptoms in that hip, it must be backtracked. And so if they are initiating weight bearing and they are symptomatic, they're likely going to have to backtrack into a few weeks of non-weight bearing again. Really hard conversation again, but it's necessary in order to really prevent progression of this injury for obvious reasons. So the two themes, six weeks non-wavering and any progression must be asymptomatic.

SUMMARY
All right, that is the content I have for you today. Just want to make a couple of mentions of our upcoming Rehab of the Injured on our online course. We are currently in the middle of our, our current cohort is right in the middle of this session and All of the online cohorts this year have been on our new ICE app, which has been fantastic. It is really generating a great online community of therapists that are interested in treating endurance athletes. And so we've had some good discussions on there and it's really just fostering a great community. So if you haven't already taken Rehab of the Injured Runner online, I would definitely encourage you to do so. Our next cohort starts, I believe, in June. We will see you there. I can't wait to see you there. And have a great Friday and a great weekend.

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Episode 1749 - Technology tip Thursday 0

Jun 13, 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 5 tips to begin to get more comfortable with technology & improve your productivity

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

ALAN FREDENDALL
Good morning, P10i's Daily Show. Happy Thursday morning. Hope your day is off to a great start. My name is Alan. Happy to be your host today here on the PT on ICE Daily Show. It is Leadership Thursday. We talk all things practice management, small business, ownership, and leadership. Today we're going to be talking about a bunch of technology tips. Today is Thursday, though, which means it is Gut Check Thursday. We've been waiting to post this workout for a while. Our CEO, Jeff Moore, requested this a couple weeks ago. An interval workout every three minutes for five sets. You're gonna complete 50 double-unders, and then you're gonna hit a 400-meter run. Already, those of you that are less cardio-inclined are thinking, ooh, gonna skip that one. So our goal of that workout is obviously to get done before the three-minute mark so that we have some rest. So trying to get those double-unders ideally performed unbroken. and then completing a fast 400 meter run, trying to get done maybe between two to two and a half minutes so that we have 30 seconds to a minute of rest, and then really trying to hang on and be consistent and not let that building fatigue slow us down too much. We have a bunch of different scaling options over on our Instagram page. If you can't do double unders, if you don't have any equipment, a bunch of different options on how to modify that workout. So remember, if you participate in Gut Check Thursday, If you record a time lapse and you post it to your Instagram page and tag us, you are entered into a drawing to win a free lead from the front or be about it ice t-shirt. So don't forget, there's a little something in it for you for participating. So today, we're talking about technology tips. Now, especially for those of you that run your own practice, understanding technology is really important because it's going to let you do a lot of stuff on your own that's going to save you time, hopefully, and also save you money. In our brick by brick course we talk a lot about how important it is that we become as a profession, especially those of you who want to run your own practice and run your own business, become more comfortable with technology. The end goal of technology is that it lets us do more work in less time if we're doing it correctly and we understand the basics of technology and how that technology can help augment our back-end skills and our practice. Unfortunately, I would say as a profession, as a country, as a species, we are not very good at technology. And something to think about is that if you are 52 years of age or younger, you have theoretically had access to a computer your entire life. So very often we see folks say, Oh, I'm, I'm too old. Like I'm too old for technology. And then I find out that that person is like 42 years old and they've, they've been using a computer most of their life. And it's a lot like a car, right? You can understand how to drive a car, but not know how to fix a car, how to optimize driving your car. And it's possible for two truths to be present at the same time that you understand how to drive your car in a legal manner, in a safe manner, but also that you have no idea how your car works, how to fix it, maybe how to become a better driver, that sort of thing. And we see that same comparison with technology.

THE IMPORTANCE OF TECHNOLOGY
As practice owners, and even as clinicians, and maybe if you never have a goal of owning your own practice, we need to understand the expectations that the average consumer has around technology. 95% of Americans have high-speed internet access. That is almost everybody. 92% of Americans have a smartphone that connects to the internet, and 77% of Americans want to communicate digitally with their healthcare provider. They want to do self-service stuff, book their own appointments, pay their own bill online. They want to text instead of call or talk to you in person. They want to text or email. So understanding where we're at in 2024, we have a consumer base who has a really high expectation that not only are we going to understand technology, that we're going to be able to offer those services through our clinic. That folks can go to our website, book their appointment, text us a question about their homework, and maybe engage with us on an app. And we really, really need to become more technology forward if we're going to meet those expectations of our patients. Some folks are worried about artificial intelligence about robots. We always see these blog posts of our physical therapist going to be replaced by AI or robot. And if I've learned anything over the past 10 years or so, it's that people hate robots. We've certainly gone through our phases here at ice with chat bots and things like that. And overwhelmingly people want to talk to people So I don't think we need to be worried about being replaced as a profession. I do think you need to be worried about how somebody who understands technology better than you having an easier time running their practice with less expenses in a manner that is going to create a gap between you and them competitively. And technology can help you close that gap. So you'll find yourself working harder or paying somebody else to do this stuff for you. if you don't become more comfortable with this stuff. So today, I want to talk about five different tips that are really, I think, going to dramatically change your understanding of technology and really help dig away at that gap that you might be perceiving in productivity of are there programs, are there apps, are there software? that can help me be more organized and be more productive? The short answer is yes. So we're gonna talk about what is a computer, what are the parts of a computer that are important to understand as far as maybe purchasing a new piece of equipment, understanding how and why different pieces of software can help your practice, password keychain, things like Boomerang, which is an extension we'll talk about for your web browser, for your email, and how to do things like bookmark folders.

WORK IS ALWAYS FASTER ON A COMPUTER THAN A PHONE
So let's start with tip number one. This is tough for us to understand, especially those of you, you might be in your twenties maybe and you've had a smartphone your whole life. Computers, a laptop or desktop computer will always be faster than a cell phone. Not only will it be faster physically, what we call the hardware, it will run smoother, with the software, the pieces of technology, the graphical interface we interact with will be better, but you are able to type faster on a computer and overall be more productive on a computer than a phone. So phones are great for looking up the weather, getting directions to go to dinner, answering a short text message or something like that. But they're not great for a couple things. Number one, writing out long messages. You've all probably found yourself looking at a paper sent to you via Instagram messages or text message or something. You're thinking, gosh, not only is that going to take me forever to read, it's gonna take me forever to respond to on my phone, and you're not alone in that feeling. We've actually studied this, a really cool study, Palin and colleagues from 2019, looking at what is the speed difference between typing on your phone and typing on your computer, and finding that the slowest phone typer is only typing 13 words per minute, and the fastest computer typers are typing over 100 words per minute. that's a 615% speed difference. This paper going on to summarize that the average person is 25% slower trying to work on a phone versus a computer. So sometimes we're out and about, we don't have a computer with us, we don't have a way, even if we have our computer, to maybe get it connected to what we need to do and our phone is our only resort. But this first tip, if you have a computer near you and you're trying to do something on your phone, it's going to be a lot faster for a number of different reasons for you to just get on the computer so when in doubt switch to that computer you'll be amazed at how fast much faster you get relatively simple tasks done like answering a longer email like logging into a website or something like that so keep in mind that all pieces of technology are created first on a computer. They are optimized to work on a computer. Humans type faster on a computer. There are a number of different ways about why you'll be faster and you'll get more work done in less time if you can get on a computer versus trying to do everything on your phone. And that can be a big mindset shift for a lot of people thinking that phone is the best option or maybe the only option when they might literally have a computer within arm's reach.

UNDERSTAND YOUR HARDWARE
My second tip is understanding what is inside of your computer or phone can go a long way especially if you're making a new purchase to understand what makes a quote-unquote good versus a quote-unquote bad computer. Understanding we have four main components that matter that can change as far as hardware is concerned when you're looking at a new computer or phone. The processors or the central processing unit or CPU is one of them. The RAM, or the random access memory, is another. The video card, or what's sometimes called the graphical processing unit, or GPU. And then your hard drive, where things are actually stored. And so, understanding these components, understanding why usually more is better, is really important in having an actual computer or phone that can do the work you're asking of it. So the central processor, the processing unit of a computer, is running what's called operations per second. This is very similar to our brain. I love the comparison to our brain. The human brain is conducting one exaflop of operations per second. That's one billion billions every second. So a processor in a computer is a lot like nerve conduction velocity in your brain. Now compare that 1 billion billions to a fast modern desktop or laptop computer that's only processing about 36 billion operations per second. So 1 billion billions versus 36 billion. So human brain much faster, desktop computer not so much, but the only thing slower than a desktop or laptop computer is a phone. It's a myth that the phone in your pocket is the supercomputer that is equal to a desktop or laptop computer, and that's simply not true. Why? Size. Your laptop, your desktop can fit more stuff in it, and the stuff that it can fit is things like more processing units. So the iPhone 15 can only run 15 billion operations per second. So the average laptop or desktop computer can process two to two and a half times faster than your phone. So again, another argument to whenever possible switch from your phone to your computer. When you're shopping for a new laptop or desktop computer in 2024 we want to see 8 to 12 processing cores and we want to see each of those cores be able to process at least 3 gigahertz that's operations per second. So that is something you could find when you're looking to purchase a new computer. Often one of the first things you're shown is the brand of the processor, how many processing cores the computer has, and how fast each individual core is. Again, this is the case where more is better. The second most important hardware piece of a computer is the RAM, the random access memory. This is the thing that allows those processing cores to pull up data and begin to do operations on it. So I like the comparison to RAM is your brain's ability to multitask. It is your computer or your phone's ability to multitask. If you're somebody that keeps 700 tabs open in your web browser and you're always complaining about how slow your computer is, it stutters, it's slow, it freezes up, it locks up, it shuts down, it turns off, whatever, that is because you are asking your computer to multitask beyond its RAM's capability. Again, this is a case where more is better. More RAM, more multitask ability. In 2024, we want to see a computer have at least eight gigabytes, eight GBs of RAM or more. A really high-end desktop computer is going to have 32 to 64 gigabytes of RAM. You're going to be able to watch a TV show on one screen, process a video on the other, have a third monitor where you can still do email, and you're not going to really experience a slowdown. Vice versa, if you don't have that much RAM, you're not going to be able to multitask as much. So RAM is really important. The third component is a video card or that graphical processing unit. This is the piece of equipment that generates all those outputs from the processors and the RAMs into what you see on the screen, on your phone screen, on your laptop screen, on your computer monitors at home, on your desktop. Again, here more is better. Graphical processing units or video cards have processors and RAM built in them. Bigger is better. The more processing power your video card has, the quicker you're gonna do things like process and edit videos. So if you are someone that is doing a lot of video or audio editing, you're making content maybe for your clinic's blog or your clinic's social media, you want a computer that has a really nice video card. It's going to make it less work for your computer to do that. It's going to get it done faster. If you've ever tried to maybe render a video on an old computer, it can sometimes take hours. And during that time, it is consuming so much processing power from your computer, you often can't do much with that computer. It's slow, it freezes, whatever. You basically have to set it and leave it alone until the video is done. So if you find yourself doing a lot of video editing or you want to do a lot of video editing and you're a market for a computer, you want a really nice graphic card. And then finally, hard drives. Hard drives are not as important as they once were. We have cloud storage now. Basically, you're storing your files on somebody else's computer when you're using cloud storage. But having a solid state drive, an SSD hard drive, is really important. Hard drives used to be mechanical. They used to have gears turning. They used to have literally etching of your data ones and zeros into a physical thing inside of your hard drive. If you're old like me, you remember when your hard drive was about to fail, it started to make a lot of clicking noises, right? It was literally running out of space to write and do that physical gear turning. In today's day and age we have solid state drives. There is no physical gears present. That means that hard drives are faster, it's easier to access memory, it's easier to pull up stored files, and overall it's not, again, as big of a deal in the era of cloud storage, but having a big hard drive and making sure it's a solid state drive is going to go a long way to making sure your computer runs very fast. We're used to, and we want in this day and age, when we open up a program for it to load instantly, when we open up a website we want it to load instantly, and some of that comes from whether or not you have a solid state hard drive. So making sure you have a lot of processors, fast processors, you have a lot of RAM, you have a nice video card, and you have a big solid state hard drive are the four things you're looking for if you're going to be purchasing a new computer anytime soon. Remember, you get what you pay for. If you cheap out on this stuff, you should not be surprised that you have a device that is slow, that freezes a lot, that has a lot of problems. My last three tips here are all software-based. So tips one and two were hardware-based. Tips three to five are software-based.

PASSWORD KEYCHAINS
The first thing is to get a password keychain. What is this? It is usually a program or a web browser extension that remembers your passwords. So when you go to log into a website, it automatically remembers your username and your password, and your job is now just to remember one password to log into that program or keychain. It's a very secure way to remember a lot of passwords. I see people every day forgetting their password and spending time trying to reset their password, calling customer support, whatever, and otherwise spending a lot of time remembering passwords. The research would support that that is true. Research would say the average person spends 12 to 15 minutes a day or about 12 hours a year just trying to reset, remember, or obtain via phone a new password for a forgotten password. So if you know that's you, look out for your future self and your time and get a password keychain. I use a Chrome extension, a Google Chrome extension called LastPass where I just need one password. I can log into it from any computer or web browser that I have access to and it remembers all of my passwords. It generates random, secure passwords for any new account I create and remembers it for me, and I just need to log in with that one password that I remember. I no longer know almost all of my passwords anymore. They are randomly generated, they are secure, and they are automatically filled in for me when I go to log into stuff. So, a password keychain can make it so you get hacked less often, you are spending less time trying to figure out or remember a password, and again, overall improve your productivity, and your internet security.

BOOMERANG FOR GMAIL
Tip number four, an email extension, again for Google Chrome, called Boomerang. If you find yourself overwhelmed by email, if you know you see emails and you think, gosh, I need to respond to that, but I don't have time, and if you are someone who finds yourself very often forgetting to get back to those emails, then an extension like Boomerang is great for you. You can tell Boomerang to send an email back to you with a bunch of preset settings. Send this back to me an hour. Send this back to me in a day, a week, a month. Send this back to me on a specific date and time that I tell you. Send this back to me every day until I get a reply. So even if you're waiting on somebody else to reply to you, you can use Boomerang to keep track of your email. Boomerang also has a great feature where you can pause your inbox. So if you're somebody, you go out of town, you go on vacation, you go on maternity leave, whatever. and you don't have the self-control to not look at and answer your email, Boomerang can become your self-control. So you can pause your inbox, people who email you will just get a message that says, hey, this inbox is turned off, come back later. And so that can be a great way, instead of just maybe a vacation message, where you let people know you're not in the office, but you're still receiving their emails, if you know you can't stop yourself, use the pause inbox feature on Boomerang.

BOOKMARK FOLDERS
And the last tip here is stay organized with websites you need to access very often. You can create bookmarks both on your phone and on your computer. And on your computer, in your browser, if you use a browser like Google Chrome, you can actually create folders on that bookmark bar. have a folder for everything related to your clinic. You can have a folder for everything related to your personal taxes, to whatever you want. And now as you save and bookmark links, you can organize them by those folders and keep track and organized track of a lot of different websites that you might frequently visit in a very organized and logical fashion and whatever makes sense to you of how to organize and name those. So you can have Hundreds and hundreds of websites organized in a drop down folder by folder by folder across that bookmark bar on your computer. On your phone, you can bookmark anything you want directly to your phone's home screen. So a lot like apps that you use frequently, if there are websites you find yourself using often, bookmark those, create a shortcut, put it on your home screen so that you can just tap it and go right to that website that you need to visit very often.

SUMMARY
So, five tips. Thinking about hardware style, hardware importance, that you will always get done stuff faster when you use a computer versus a phone. A lot of that has to do with the hardware in a computer. A computer is always going to be faster. we're looking to make sure we have a lot of processing or cpu cores we're looking to make sure we have a lot of ram or ram that we have a big solid state hard drive and that we have a nice modern video card if we're going to be using our computer particularly if we're going to be doing a lot of multitasking we're going to be trying to answer email, and watch a meeting, and do notes, or we're doing maybe video editing, we're producing and cutting videos, maybe for social media, we want all four of those things on board. Software-wise, save yourself time, look out for your future self, get a password keychain like LastPass, get Boomerang for your Gmail inbox so you no longer lose emails, and you keep your emails more organized, you respond to your emails in a more timely fashion, and then keep yourself organized with websites that you visit frequently either using bookmark folders on your website browser on your computer or by bookmarking those websites and putting them on your phone's home screen. So I hope this was helpful if you're learning looking to learn more tips about how to be more efficient with business, with running your practice. Our next cohort of Brick by Brick starts Monday, July 2nd. The course is already over half full, so we hope to see you there. I hope this was helpful. We'll see you next time. Have a good Thursday, have a good weekend. Bye, everybody.

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Episode 1748 - All the grief you cannot see 0

Jun 12, 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 as she discusses experiencing loss, processing grief, and its impact on being a geriatric clinician.

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

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 within our geriatric division and today I want to talk a little bit about grief. This is kind of a personal conversation, but it's also one that I think is really important when we are working with older adults. So personally, I've kind of been speaking a little bit on my social media. I lost somebody very close to me very recently. So I lost my godmother. She was my aunt. She was in my top 10 list of favorite people and she was somebody who had battled cancer a long time ago. They found out a couple of weeks ago that she had a metastasis in her brain and her first radiation she didn't do very well and she passed away like very very suddenly. And to say that this rocked me, like, I don't know if I'm going to keep it together on this podcast. I'm going to try. But to say that this rocked me was like an understatement of the world. And it was devastating. I'm still not OK. And it made me think a lot about grief. So I am 34 years old. And over the last two and a half years, I have lost three people that are really close to me. I lost an uncle that was my dad's best friend, my aunt who was my mom's best friend, which means that they were around us all the time, and I lost my grandmother who I was really close to. And as I was reflecting on this most recent loss, which my aunt was probably the closest person that I have ever lost, I reflected a lot on the process of grief and I thought a lot about how my older adults must feel. And so it reminded me of a conversation that I had with my grandmother. So my grandmother passed away just shy, a month shy of her 98th birthday. She lived a very long life. Her husband was alive until he was 93. And she was just this incredible role model of successful aging. somebody who was able to keep cognitive capacities, physical capacities in the realm of what she wanted for a very long time. And I was having a heart-to-heart with her one time, and I'm sure many of you have had similar conversations with loved ones that have lived a long life. And I said, you know, Grandma, I want to be like you and live to 100, because at that time I was certain she was going to be a centurion. And she turned to me and she said, you don't really want to live to 100. And I asked her why, and she's like, because everybody around you is dead. And to be somebody at, I'm 34 years old, to have had this feeling of accumulated loss, I'm only starting to potentially scratch the surface of what she could possibly mean and what all of our or so many of our older adults may be experiencing in their life. And so while I feel the acute sting of losing somebody really close to me, what I'm also like really recognizing is that there's also a accumulation effect that weighs heavily on my heart around having multiple people that I've been really close to that have passed away. And if I am feeling that at 34, I can only imagine how many of my older adults are feeling when it comes to, you know, they've lost parents, all parents, both parents, their in-laws' parents. They may have lost siblings or, God forbid, kids. Like there's friends and family, like you know, there's jokes around how our older adults are one of their social calls is going to funerals because they experience loss around them so frequently. And I never truly appreciated, I think, how much of a toll that would take on an individual's soul and their experience in some of their zest for life until I felt like some of the accumulated effects over a relatively short amount of time of experiencing a significant amount of loss. what this got me to think about is the way that we interact with grief with our older adults. And when we, really as a culture, how we interact with grief. And so I had one of our TAs, Rachel Moore, she's one of our lead faculty for Pelvic. We were having conversations about this and she said, you know, it's so interesting because everything else just keeps going and you feel like you're stuck in this loop of, oh my gosh, this person has left. And it's true, right? We are with individuals in that short amount of time where we're doing funeral preparations and all those types of things, but that grief weighs heavily on a person's soul and on a person's mind. And we don't really teach individuals how to deal with grief. And when it comes to older adults, we oftentimes think that this is such a normal part of the aging process that I don't think we ever truly hold space for individuals when they are dealing with grief. And so when I was reading a book called Breaking the Age Code, this really came front of mind. So we talk at an MMOA about the psychosocial considerations of working with older adults, about how it can be so great for us to put a heavy deadlift in their hand or get them getting up off the floor for the first time in a decade. And all of those things are really wonderful. But if there are other buckets that are just leaking because they do not have the financial resources, the mental resources, or the skills in order to help with these big buckets that are truly just hemorrhaging, then we're not really gonna give them the best type of care. And when I was reading a book called Breaking the Age Code, it really came front of mind for me about this. where when we look at mental health disorders, and not to say that grief is not a very healthy expression of sadness, but Becca Levy, who wrote The Code Breaking the Age Code, she's the one that we talk about with all of our ageism literature. She wrote a section in this book, her book on mental health, and she talks a lot about how the knee-jerk reaction with our older adults is to give them anxiolytics and antidepressants, without truly leaning into grief and leaning into talk therapies and conservative cognitive behavioral therapies that can just be so, so beneficial when we're working with our older adults. And she described some literature where she actually said, you know, many of our older adults may do even better with talk therapies than some of our younger individuals do because they're creating that connection so intensely. are craving those skill sets that they need in order to make it through their day because their grief is so heavy and your grief doesn't just last for two weeks. And so I was reading, kind of thinking about all this and the weight of grief and the thoughts around grief and how this relates to our older adults and how personally this is relating to me. I started reading a book called The Collected Regrets of Clover and there was a couple of things that they really talked about that I think is helpful for the way that I'm approaching now or thinking about approaching conversations with some of my older adults that I am working with who are experiencing loss or who have disclosed to me that they have lost a lot of people that are close to them. This book is it's fiction. It is so beautiful. It talks about a woman who is a death doula who basically comes and supports individuals through the end of their life. Similar to how a postpartum doula would help a new baby come into the world or a pregnancy postpartum doula, a death doula helps people end their life and end their life on their terms. And they talk about how when we're thinking about grief, First, it's this large weight that is on their frame. And as time passes, that big backpack turns into a purse. And what she's saying is that your grief is always carried with you, but the weight of it becomes easier to carry with time. It never goes away, but we start to be able to function in some ways with it. And I think that's really such a powerful thing to speak to. And when we are working with our older adults, they may be holding a lot of purses. They may be carrying a lot of bags of loss in the non-literal sense that can create this expression of apathy or a lack of engagement, which can sometimes create this space where it may be hard for individuals to engage with us in rehab. sometimes being able to dig deep into some of those considerations and create resources for them can be one of the best things that we can do. And so in this book, she had this quote and I read it on my Instagram a couple of weeks ago, but I'm going to read it to you now. And then we're going to finish off this podcast with a couple of things that I'm thinking about as a geriatric clinician to recognize that there is a lot of grief with our people that we are working with that we cannot see that are influencing who they are and how they show up in the world. And so in this book, this was literally the fifth page in. So if you're a fiction reader, this is such a beautiful book, but they said the most important thing is never to look away from someone's pain, not just the physical pain of their body shutting down, which we see all the time in rehab, right? But the emotional pain of watching their life end while knowing they could have lived it better. Giving someone the chance to be seen at their most vulnerable is much more healing than any words. And it was my honor to do that, to look them in the eye and acknowledge their hurt, to let it exist undiluted, even when the sadness was overwhelming. And so to put this into the context of rehab, I think there's a couple of things that I can think of as a clinician. And the first is that physical vulnerability and emotional grief, they are challenging to navigate. And we want to recognize that not only are we working with individuals who have low physical reserve, but there is an emotional piece of recognizing the loss of physical capacities and the emotional load of the loss of people that love them and they loved. as they get older. So my dad is 67. He has lost his mom, his brother, his best friend, and another friend from school in the last two years. And he's like, this might be it for me. All these people that I planned my retirement with are no longer with me. And I don't want to go to the golf courses anymore. I don't want to engage in physical activity because the people that I wanted to engage in physical activity with are no longer there. diving deep into some of those conversations, we say at MMOA to get truly curious, but not only physically curious about the things that drive individuals, but emotionally curious about maybe some of the things that are holding them back. And I think that can be a really, really wonderful way to get into some of the barriers and recognize that it's a little bit more complicated than them just not wanting to engage in doing squats with us, right? And so that's kind of number one. Number two is it's heavy for us to be able to listen to things that are really sad, but we can have a very big role in trying to mend and heal some individuals who do not have somebody to talk to. We have a loneliness epidemic in our older adult spaces, really all over our generations, but that is compounded, that loneliness is compounded when the people that you are not lonely with have passed away. And so recognizing trying to create resources, whether that is resources within the community like seniors associations or gyms where individuals can connect and have new kinships, especially in the face of loss when they are ready to. is one way for us to create resources and networks. But additionally, having a person that you can refer that is a psychologist, a talk therapist, a psychiatrist too, but where the knee-jerk reaction isn't just prescribing medications. And I am not anti-medication, do not mishear me, but I think that the addition of, you know, our conservative side, we talk about how we are not anti-surgery, we are conservative management forward. Why are we not applying this same mindset when we are working with our older adults who are dealing with really heavy emotions and maybe have never been taught how to deal with grief? I am a parent who is trying to not hide, but make appropriate the work that, you know, of grief and grief processing with my five-year-old. And I am acutely aware of trying to teach her skills to manage sad emotions. But so many of our older adults don't, they don't have those skills. And so it's important for us to recognize some of those resources. And so where I'm going to challenge you all today is one, to lean into these conversations if you have them with some of your older adults. But two, is to do a quick Google search to see if you can find a talk therapist in your area that you could have in your referral network when these conversations do come up. And inevitably, if you're working in geriatrics, the concept of grief and loss will come up. I recognize that in the United States and in Canada, one of the hardest things is finding someone who's in network or taking Medicare and finding somebody who doesn't have a super long wait list. I totally recognize that. It may require a little bit of digging deeper and that can oftentimes be one of the biggest barriers for individuals seeking care through talk therapy and why our primary care physicians are leaning into med management. But sometimes, you know, the best thing we can do is try and find some providers, find individuals who work with older adults on the regular, and try and create those bridges and those connections when appropriate. All right, I hope you found that helpful. I kept it together pretty good, I think, considering all things considered. If you are looking to get into some of our older adult live courses for the summer, we have a couple of opportunities coming up. Our last opportunity in June is in Charlotte, North Carolina with Julie. That is June 22nd and 23rd. In July, we have three courses going. We have Virginia Beach, July 13th, 14th. Jeff Musgrave is up in Victor, New York, July 20th and 21st. And if you truly want the full experience of all of our MMOA faculty and staff, we have our MMOA Summit where Dustin and I are going to be teaching the course, but all of our teaching assistants and other lead faculty are going to be there. That is going to be in Littleton, Colorado, July 27th, 28th. That is going to be a super fun time if you are interested in hanging out with all of us and geeking out about older adult care, like that is the time to take MMOA Live. So if you have any other thoughts, questions, concerns, let me know. If you want to share some of your grief journey, I am all ears because It has been quite the couple weeks that I know that I'm just at the front end of this journey and I'm not gonna shy away from it. And it's definitely given me some new perspective as a geriatric clinician. Even when I thought I kind of had done my research and I've been in a lot of experiences talking about grief, it is so different when you're experiencing it yourself. All right, hope you all have a wonderful week. Signing off now, 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 1747 - Expectation and tissue healing 0

Jun 11, 2024

Dr. Justin Dunaway // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Management & Pain Division lead faculty Justin Dunaway discusses new research regarding patient expectation & tissue healing.

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 Total Spine Thrust Manipulation or Persistent Pain Management 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.

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.

JUSTIN DUNAWAY
All right. Good morning, YouTube. Good morning, Instagram. Looks like the cameras are looking good. Okay, here we go, team. Welcome to PT on Ice, Clinical Tuesday. I am Justin Dunaway, lead faculty with Institute of Clinical Excellence. I teach in our Total Spine Thrust Manipulation courses and our eight-week Persistent Pain Comprehensive Management courses, which the newest cohort began this week. Still plenty of time to jump in if you're interested. Just coming back from a weekend in Bozeman, Montana, teaching Total Thrust at Excel PT with Jason London. Big shout out and thank you to that group for bringing me out. If you've never been to Bozeman, it's an absolutely beautiful town, totally worth your time to get out there and see it. All right, today's topic, expectation and tissue healing. This is an absolutely fascinating, fascinating study that came out in December of last year. I'd been on a bit of a hiatus from PT on ice, and when this study came out, I was super excited for the opportunity to jump back on the stage, and I knew that the first topic had to be talking about this stuff. So, I'm a bit of a nerd in the beliefs and expectations space. I think there's so much really cool evidence, some really cool, really intricate, fascinating studies that have been done. And we know that the way patients believe about their body, about tissue damage, what they know and understand about pain, and the expectations that can come from that can change pain, pain perception, motion, pain pressure threshold, all of that stuff. We know that patients' beliefs around interventions, they believe that this intervention can be helpful or harmful, they expect this intervention to help or hurt, will absolutely change their outcomes with that intervention. We have seen research that shows us that patients' beliefs aside, provider beliefs, If I believe in the intervention I'm about to give a patient, versus if I don't, that will change the outcomes of that intervention as well. We know that beliefs and expectations around exercise, when all things are held constant, when everything about the patients are held constant, when everything about exercise is held constant, we just look at beliefs, we know that beliefs around exercise as it relates to my job, how physical my job is. If I believe that my job is physical enough that it counts as exercise, it can actually have positive effects on blood pressure, resting heart rate, body composition, and weight. We know that when I think about my beliefs around exercise, it relates to my peers. All things being held equal, if I believe I exercise less than my peers, it actually has a negative effect longevity some really interesting cool research from Ellen Langer a handful of years ago but she took older adults put them in this this five-day retreat where where they set up the whole building to be like from 1952, all the shows for a certain month that year, all the pictures and the furniture and the magazines and news articles. And they were only allowed to talk about stuff from that year for five days. And then they had massive changes in all kinds of physiologic stuff. They had massive changes on disability and like six minute walk tests and things like that. And what's fascinating is they took a picture pre and post this five-day retreat and then had independent reviewers look at these pictures. And the independent reviewers rated the five-day post pictures as years younger than what they looked like when they went into the trial. So just incredible, fascinating stuff in the world of how powerful the mind-body connection is. Now there's this interesting new line of research that I just kinda stumbled on recently where the expectation variable that they start to play with is perceived time passage. So time is held constant, but in very creative ways they get patients to believe that more or less time has passed. One really interesting trial is they give subjects, they feed subjects, they measure blood glucose, they hold time constant, And then in some sessions, they make the subjects believe that more time has passed. Some subjects believe that less time has passed. And what you find is that blood glucose levels track better with perceived time passage than actual time passage. Another interesting trial is they took humans and they short sleep them, give them six hours of sleep and measure a bunch of cognitive tasks. And obviously you do worse when you're six hours asleep on cognitive tasks. But then in the second piece of that, they give you six hours of sleep but they make you believe that you got eight hours of sleep and a good night's sleep. And then that mitigates that and they actually do significantly better on those tasks. So that's kind of everything leading up to this point, but this study, and there's so much more, it's such a really cool body of literature in this space, but the study I want to talk about here came out in Nature, super well-respected journal, in December of last year, and it's called Physical Healing as a Function of Perceived Time, from Peter Engel and Ellen Langer. This is going to sound kind of nerdy because it is, but if researchers had baseball cards, I would have an Ellen Langer rookie card framed in my office. Her body of literature in this space over the last, since like 1970 to now, is just absolutely incredible and has really paved the way for everything about beliefs and expectations. So here's the premise of this study. And this study was mind-blowing. What they did is they brought subjects in. And subjects, they had three sessions. Each session was an hour long. Sat the subject down, put a cup on their forearm, just like a standard biofascial decompression therapy cup, put the cup on, gave it five pumps, left it on there pretty tight for 30 seconds, popped the cup off, took a picture immediately, and then had a timer on the wall for 28 minutes. At the end of the 28 minutes, took a second picture. And then during those 28 minutes, they had the subject, specific time intervals, rate their healing. Asked them a handful of questions, but this is basically about how much do you think it's healed, how red is it, how swollen is it, is it painful, blah, blah, blah. And then at the end of the 28 minutes, then they had just a random, unrelated task to kind of fill the rest of the hour. Like they watched TV and rated commercials and played a video game or things like that. So then the trial itself looked like this. When you came in, you were randomized into one of three scenarios. Scenario one, everything I just said, there's a 28-minute timer on the wall, pre and post, and they do the things. Scenario two, they come in, and there is a 14-minute timer on the wall. Now, they're in the room for 28 minutes, but the timer is altered, so it ticks down a bit slower. So even though I'm in here for 28 minutes, I believe I'm only in here for 14 minutes. Scenario three, timer on the wall. The timer is set for 56 minutes. Again, it's only 28 minutes long. It just ticks significantly faster. So at the end of that 28 minutes, I believe that I've spent 56 minutes in the room waiting by healing. Okay, so that's how the trial's set up. Really interesting way that they controlled for this, and they controlled for kind of the after-minute variables. I won't dive into that. But the outcomes, the outcomes are where it really gets neat. So the first piece of this outcome is not gonna be mind-blowing. The patients, or the subjects, when you've looked at their self-report of healing, what they believe happened is they looked at their arm each time, When they were in the 56-minute trial, when the timer ticks 56 minutes, even though it was only 28, they believed that more healing had taken place than when they were in the 28-minute room, and more healing took place in the 28-minute room than in the 14-minute room. I thought I was in the room longer. I feel like more healing occurred. Cool, but that's not mind-blowing. The mind-blowing piece is this. Those pre and post pictures, they sent those off to independent reviewers that didn't know anything about the trial. They just said, hey, take a look at these pairing of pictures and tell us which ones healed more, which ones kind of healed, which ones didn't heal nearly as much. And without a doubt, when looking at the pictures, the pictures that came from the 56-minute room, showed more healing than the pictures that came from the 28-minute rooms, and those showed more healing than the pictures that came from the 14-minute rooms. And again, remember that they were all 28 minutes. Every picture was taken pre and post 28 minutes. The only difference was how much time I perceived had passed. That is fascinating. What the conclusion of the trial was is basically that tissue healing Isn't just a function of time passage tissue healing time. That's still important, but that's not the only piece tissue healing is at least in part a function of Perceived time passage, but it's not really perceived time passage, right? It's it's me believing that more time had passed Really put me in a space where I believe that more healing has occurred and when I believed more healing occurred. I It did. Even though that was such a short trial, even though it was so acute, just believing in that space that my body was healing faster, it did. Now, this has massive implications in my head, from acute injuries through through tissue healing from surgeries. It doesn't matter if we're treating a patient that's got persistent 10-year centrally dominant pain, if I just rolled my ankle, if I was just in a car accident, if I just had an ACL reconstruction or anything along those lines. If tissue healing and tissue health is a piece of the puzzle, then my beliefs around my capacity for my tissues to heal or how quickly they're healing or what's going on in my body since that injury, that is gonna have a direct implication and direct effect on how quickly and how healthy those tissues can heal. I think that's the direction that this line of research is going. So what do we do with this information? What I'm not suggesting is that we start messing with the clocks in our clinic and bring people in for a 30 minute session, but make them feel like it was an hour or things like that. Although that's kind of interesting, right? And I think Dr. Langer, if you're listening, I think a really cool trial would be to take a whole bunch of humans Relatively untrained, you put them on a bike three times a week for the next six weeks at 30 minutes RPE of six, and a third of them believe they're on the bike for 15 minutes, a third believe they're on the bike for 30, a third believe they're on the bike for an hour, and I bet what you find is that the hour group outperforms everybody else. It's pretty fascinating, but… What I think that this means for us from a clinical perspective is that when we think about like patient education, we think about beliefs and expectations and things like that, we tend to focus on, importantly, but we tend to focus on teaching patients about pain. We tend to focus on trying to test, retest so they can show immediate improvements in the clinic. We try to get patients to kind of believe in the interventions that we're doing. But there's a space in the education, there's a space in whatever the patient's mindfulness practice is, there's a space in trying to get patients to really think about their tissue healing, thinking about their rate of tissue healing, thinking about the health of the stuff inside their body, and shifting that in a very positive direction. Because what Ellen showed us is that that is going to affect tissue healing. So at the end of the day, this is just another really cool facet of information in this mind-body connection space. And from a treatment perspective, we need to not just be thinking about having really good clinical reasoning, really good skills, and being able to really match the right intervention with the right hypothesis, with the right patient, things like that. But we've got to be thinking about the context in which our treatments occur. We've got to think a lot about where the patient's beliefs and expectations are about themselves, about their body, and the interactions they're having outside the clinic. The more work we can do to get the patient's mindset in a space that's positive, that's healthy, that is pro-healing, whether it's understanding pain, whether it's believing in the treatments we're about to do, whether it's really just understanding that they have a very, very powerful capacity for their tissues to heal and heal well and heal quickly. Those are the things that are really gonna drive outcomes forward. And I think that the novel piece of this study is that it's more than just about physiology, it's more than just about pain and pain perception. Now the belief piece also will actually affect, speed up, slow down the rate at which our tissues heal. Alright team, so again, absolutely mind-blowing study. Another really great piece of information, this mind-body connection. And thank you all for hanging out for the last 12 minutes. It was awesome to be back on the stage, chatting with you all. Hope to do it again very soon. Have an awesome day in the clinic.

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Episode 1746 - Pelvic workshop excellence 0

Jun 10, 2024

Dr. Shaelyn Sharbutt // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Shaelyn Sharbutt makes her debut on the podcast, discussing how to execute a successful pelvic workshop geared toward coaches.

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

SHAELYN SHARBUTT
What is up? Good morning and welcome to the PT on Ice daily show. My name is Dr. Shae Sharbutt and I am on faculty for the pelvic division here at ICE. Today we're going to talk a little bit about doing a workshop for local fitness professionals and coaches based around pelvic floor issues. So this is really important because so many of those people's clients will either put their memberships on pause or stop working out completely during this new phase of life. They're trying to navigate it. Maybe it's their first time being pregnant or their first time being postpartum. and they might not have a pelvic floor specialist friend or a good provider telling them that it's okay to do these things. They might have a really good relationship with their coaches and so this is going to be the first person they talk to about these things.

CONTACTING THE GYM & PLANNING THE WORKSHOP
So typically whenever I first start talking to a gym, I will contact the gym directly, either their gym manager or their gym owner or their head coach about the interest that they might have in a workshop like this. We can DM, we can email, and you might even have a close enough relationship to text these people, but it's really best if you can get a meeting face-to-face and build that relationship. This not only gets that gym owner or that head coach super excited about what you're going to tell them, but it also lets them see the value that you're going to bring the other coaches and their members. So whenever you go to have this sit-down conversation, it's best to be prepared. I always have a PowerPoint or a presentation to give to these coaches when I do these, and I'll bring that along to that meeting with that gym owner or head coach to kind of show them what to expect from this workshop. It helps them feel a little better prepared, know what kind of equipment I'll need before I teach their coaches, and how much space I'm going to take up. It's then important to make sure that they understand that it needs to be during a time when we don't have open gym going on and we don't have class times going on. Maybe see what time of the gym is the least busy and they can block off a schedule and say, hey guys, we're trying to get our coaches the best education we can. Please don't come to the gym from this time to this time this Sunday. Have them kind of plan that ahead for their members. And that way the coaches can focus everything on what you're saying and what you're teaching them. And then they're not distracted by gym members working out or maybe wanting to cue somebody's lift in a corner or what have you.

KNOW THE GYM'S PAIN POINTS
So whenever you're creating content for this workshop, you really need to think about what these people do. Are you going to a CrossFit gym? Are you working with contact sport athletes like in a martial arts gym or a jiu-jitsu gym? Is there going to be running involved? Are there gymnastics movements being educated? Are there heavy barbells that people are getting under. You really need to understand what these people are doing day in and day out to be able to educate their coaches on progressions and regressions. So this should really be a community that you're involved in and that you understand what they're doing and those coaches are going to respect you even more if you're involved. So from there, we want three main things for our pelvic floor workshops for these coaches.

GIVE SOME PELVIC BACKGROUND
The first thing is a little bit of background. Most people don't even know that they have a pelvic floor, let alone that they can struggle with issues with this area of their body. So give these coaches a little bit of background. Educate them on these muscles. It doesn't have to be a full-blown anatomy lecture. Nobody wants to sit through that except maybe a nerdy PT student. But make sure that you give them a little bit of background. Maybe you show them a couple photos of what the pelvic floor muscles look like. Maybe you whip out a model. But if you can relate that back to something they're familiar with, like hip structure, hip and glute muscles, core canister, maybe some abdominal muscles, that'll kind of relate it back to things that they cue day in and day out and are way more familiar with. From there you want to give a background also on symptoms that they might have their clients complaining about in the gym. So a lot of CrossFit coaches are going to understand that there are women who leak with double unders and running and lifting, but maybe educate them on some abdominal pain, maybe educate them heaviness in that vaginal region. Really make sure that they understand that these symptoms are not the same for everybody and that points of performance are most important and we'll get to that here in a second. But giving that background and giving some symptoms to look out for can be really helpful.

GIVE GOOD DEMONSTRATIONS
Part two of the pelvic floor workshop, you want to make sure that you give good demonstrations. So let's say for example, I'm in a CrossFit space and we're talking about pull-up regressions and progressions throughout pregnancy and postpartum. If I'm talking about a banded pull-up, I'm going to take out my band and I'm going to show them different variations of a banded pull-up. I'm going to show them what I like even more, a toe spot pull-up or a low bar pull-up. we're going to go over points of performance, we're going to talk about engaging the lats, we're going to talk about holding that nice hollow body position, and cues that we might give someone who has a baby in their belly, such as hug baby or pull baby close to your spine, and then have the coaches practice that with each other. So, demonstrations are super important. Have them watch you set it up. And from there, you want to have a discussion and get their minds thinking about when they would use these different variations. So, if we're going to stick on this pull-up progression example, let's say that we're talking about a workout being done in class FRAN. That's a great, easy example. So for those of you that don't know, FRAN is a 21-15-9 of thrusters and pull-ups. Let's say I give them an example like someone is five months pregnant. It's their first pregnancy. They're having some uncomfortable stretching on the abdominal region. They don't like it. They are really good at kipping at baseline, but doing that large kip is really bothering them. What kind of scale would you give them? Question these coaches, ask them these questions and get their brains thinking and have them think through some different variations that they would use. It's also important to teach these coaches and have them think about timeline. So you don't want the time domain for this pregnant or postpartum athlete to be vastly different than everybody else in class. So if she can't do strict pull-ups or it would take her forever to do strict pull-ups and this Fran workout is taking people in class five minutes or less, what variation could we give her? What rep scheme could we give her to give her the similar stimulus to the rest of class and make her feel involved? So having the coaches build this discussion with each other and get out of their comfort zone from their typical scaling options can be super fun and helpful. Also lets it be a little bit more active. From there, I typically get a million more questions about specific movements. So, be prepared to answer questions about rowing. Be prepared to answer questions about going upside down. Maybe they'll ask you about bench press. Not only laying on their back, but getting up from that bench press and not being uncomfortable. They're always going to ask about core exercises. So have things ready, have examples ready to go for more demonstrations, but really make it a discussion and that'll be a lot more fun and involved of a seminar. So, that's part two we covered. Part one being give a little bit of background. Part two being some good demonstrations and examples of class workouts.

GET COACHES ACTIVE & INVOLVED
Part three that you want to make sure you get is the coaches doing these things. Get them involved. Get them moving. We already talked about it a little bit with pull-ups But if we're talking impact progressions make every coach in there get their plate out and they're gonna do toe taps with you Make sure they're coaching each other through different breathing techniques under load and then from there on We're always talking about hashtag be about it here at ICE. Get a group workout going. Have everyone have to choose a variation that they normally wouldn't do, a scaled option that they normally wouldn't do. Some of our coaches are games athletes and they're fantastic coaches and they're fantastic athletes, but they've never had to do a toe spot pull up in their life. Have them practice toe spot pull-ups in a workout. It is hard. Have them practice that form. Have other coaches pick them apart, just like they would any of their other clients. That can be a super fun way for them to practice their coaching skills, but also feel what it's supposed to feel like. And then they can imagine, man, if I had a big old belly with a baby in it, how hard would this movement be? So that can be super fun as well. So lastly, you want to make sure that you feel comfortable being the subject matter expert. Don't be ashamed to refer to yourself as the expert in your field. You want to make sure these coaches have someone to ask, someone to talk to. someone to send their clients to that they don't feel comfortable modifying their workouts or they have more questions that are just out of their scope. It's okay to be the subject matter expert. It's okay to know what you're doing. I think sometimes we apologize for that and we just need to be confident and know that we're the person that they should refer to. We are the fitness forward professional and we are in it with them. We understand what these mamas want to do. So make sure you're cool with being the referral source for these coaches.

SUMMARY
Guys, thanks for listening. Our next cohort for level one, if you want to learn more from your pelvic crew, that is in July, and then that's selling out really fast. Make sure you also get signed up for level two if you've already done a level one. We're wrapping up a level one right now, so you know those people are going to hop on that level two as soon as they're done. They're all fired up. And then lastly, We have a live course in Cincy, Ohio. Get signed up for that as well. We love the live course. We go over in detail a lot of the variations of progressions and regressions I just discussed. So if you're not comfortable with that, sign up for that Cincy course. We can't wait to see you there. And if you need even more info, get on our pelvic newsletter. It is a blast and it is best practice. So that's sent out every month. We will talk to you guys soon.

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Episode 1745 - The role of the deltoid in functional fitness 0

Jun 7, 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 anatomical & clinical considerations of the deltoid muscle in functional fitness, as well as the best ways to begin to train the deltoid in the gym.

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 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.

ALAN FREDENDALL
Good morning, PTonICE Daily Show. Happy Friday morning. I hope your morning is off to a great start. My name is Alan, happy to be your host today here on the PT on ICE Daily Show. It is Fitness Athlete Friday. We talk all things CrossFit, powerlifting, Olympic weightlifting, endurance athletes. For that patient, athlete or client of yours that is recreationally active, Fridays are all about topics for that person. We are finishing out deltoid week here at ICE, so we're talking all things shoulder, in particular the deltoid muscle, exercises for the deltoid, manual therapy for the deltoid, so go back if you haven't been listening the rest of this week to all the episodes from all the other faculty, Monday, Tuesday, Wednesday, Thursday, dry needling techniques, cupping techniques, exercises, modifications, importance of deltoid exercises for pregnant and postpartum moms, we've got it all. Plus, we have a whole bunch of great content on our Instagram page as well, related to the deltoid and all of those topics. Today on Fitness Athlete Friday, we're going to tackle the deltoid from its role in functional fitness. So in particular, we're going to be talking about vertical pressing. So we're going to talk about anatomical considerations of the deltoid as it relates to lifting weights overhead. We're going to talk about clinical considerations of why do we care about someone's deltoid when they come in for physical therapy treatment. And then we're going to finish talking about how we think you should actually train the deltoid with these patients and athletes in the clinic.

THE DELTOID: ANATOMICAL CONSIDERATIONS
So a brief anatomy overview to start. What are our considerations for the anatomy of the deltoid? We need to understand and recognize the deltoid muscle is large, it is designed, it is built for blunt force trauma. If we come away from social media and computers, and the past 2000 plus years of human progress, and we go back to ancient man and even before we became humans and we were walking around on all fours, understanding the role of deltoid, but as we're crawling around on all fours, we have hip extension from our hip, we have glutes and quads as our primary lower extremity muscles, and in the upper body, we are pulling ourselves along the ground. We are designed for vertical pulling in particular, We all understand the importance of the lat. There's probably not a single person, if you walked into a room and recommended that the average person could benefit from doing some strict pull-ups, there's probably nobody that would voice opposition or concerns. But yet, when we start to talk about vertical pressing, all of a sudden, the conversation changes. Whoa, don't lift your arm overhead. That's dangerous. We've heard things, and I've heard things, like even when I was in school, that the shoulder is so mobile, it's just really not optimal to lift your arm overhead. Which, if we go back to our history and our evolution, doesn't really seem practical. And I think it's a fundamental misunderstanding. of how the deltoid functions and its role in providing that stability to the shoulder joint. So being quadruped, now bipedal organisms, now standing up resisting gravity, great at vertical pulling, not great at vertical pressing, especially when we don't do it. Why? The shoulder is inherently mobile, it is inherently unstable. It does not have a lot of bony support. The deltoid is the primary muscle that gives us that stability. throughout the whole range of motion of the shoulder. The deltoid is primarily responsible for flexion and abduction. It is the prime mover of shoulder elevation. And in particular, as we begin to approach 90 degrees of flexion and abduction and move up towards 120 degrees and beyond, the deltoid really becomes the only mover. A lot of the other smaller muscles, upper traps, rotator cuff muscles, whatever, really fall off and the deltoid stands alone as moving things overhead. And so we see that that does not happen. That does not happen in a lot of people. We already know most people are sedentary. They're not lifting weight overhead, pushing or pulling. But for those folks that are, we need to get them doing probably more vertical pressing to train that deltoid to really understand and respect the anatomy that we need to have a really strong deltoid if we really want to have a strong and stable shoulder. Really great evidence on the importance of the deltoid as the prime mover of the shoulder. An article back from 2021, the Journal of Elbow and Shoulder Surgery, Hecker and colleagues, Really cool study. They took people, they gave them an axillary nerve block on one side, and then they gave them nothing on the other side. And they tested maximal isometric strength. And what they wanted to find out is how much strength comes from each of the shoulder muscles, at what degree of shoulder flexion, shoulder abduction, internal or external rotation, adduction and abduction. And what they found is when they blocked the axillary nerve, and they tested isometric strength, instantly with the arm still at rest, moving into flexion, the shoulder strength was reduced to 76%. In flexion and in abduction, it was reduced to 64%. And now again, as we elevate that shoulder further up towards 90 to 120 degrees, the strength fall off was even more significant. Flexion now at only 25% strength, and abduction at 30 strength. So the deltoid is involved in the entire range of motion of primarily flexion and abduction. But in particular, as we get up towards 90, and as we start to bring our arm all the way overhead, it is primarily deltoid, which means we need to be training the full range of motion, and we need to be training more pressing patterns, and not so much laying on our back or laying on our stomach and doing prone rotator cuff work, trap work, whatever. That stuff is great early on in therapy, but if we really want to get the deltoid strong, we need to move it through the range of motion that it controls, which is all of it, and in particular, all the way up and overhead.

THE DELTOID: CLINICAL CONSIDERATIONS
So discussing clinical considerations, who might we see with a deltoid problem? How could we pick up that somebody might need to get stronger deltoids? I would argue just like with glutes or quads, it's every human being, right? There's no one that is checking the box on strong enough muscles. I don't think you'll find a single elite athlete who thinks, I don't need to train anymore. I've made it. They're probably always aware of their weaknesses and things they need to train. and I would argue vertical pressing, training the deltoid is true for every single person. But we do see these presentations come in. where we start to think, hmm, what I'm seeing, I think I'm treating the symptom of a bigger problem. So when the deltoid isn't doing its job, that's when the other smaller muscles of the shoulder complex take over. That's when we have people with upper trap stiffness or upper trap pain or headaches or posterior cuff pain or issues up in their neck, trouble with rotation, side bending, whatever. those smaller muscles that can act to elevate the shoulder are taking over because the deltoid isn't pulling its weight. The long-term solution isn't to only train those muscles, it's to train those muscles if it makes the person feel better, but again, get back to training the deltoid. So when we see those patients come in the clinic, oh, my traps, my traps, my traps, my traps, my neck is stiff, I've got a headache, and we start to dig into the subjective, what have you been doing? Oh, we've been doing a handstand push-up cycle at my gym. Oh, we've been doing a split jerk cycle, a clean and jerk cycle, a snatch cycle, whatever. you start to hear that this person has increased their volume and overhead lifting and they're complaining of all of these secondary symptoms of upper trap, neck, headache, whatever. When I hear that, I'm thinking this person, this person, yes, needs my help. reducing pain, restoring range of motion, but I'm also thinking, I need to get this person on a vertical pressing program. Especially a functional fitness athlete, I need to be getting them doing strict press, I need to be getting them doing handstand pushups, strict handstand pushups, whatever they can tolerate, wherever they're at in their fitness journey, maybe it's handstand pushup, eccentrics, whatever, but I'm thinking, we need to start integrating some vertical pressing in this person's program, because yes, while we're treating their symptoms short term, the way they're presenting tells me they would benefit a lot from stronger shoulders. These symptoms are probably going to be less likely to show up in the future if we do that. And so as we're reducing the symptoms, resolving the symptoms in the local tissue, we then need to evaluate if the deltoid needs strengthening. A lot of folks ask, how strong should your shoulders be? We have a lot of really great evidence on bodyweight normalized exercise in the lower extremity. We know the stronger your squat gets relative to your bodyweight, the less likely you are to develop lower extremity injuries. So the stronger a 1x bodyweight back squat, a double bodyweight back squat, stronger, stronger, stronger, less, less, less injury. We don't have a lot of that research in the upper extremities, but I would say that a strong person should be able to press 50-100% of their bodyweight overhead. Now that's going to depend on a lot of things. Training age, right? Somebody that just started lifting overhead six months ago is probably a very long time, like years or decades away from achieving a bodyweight strict press. Somebody that has been training a lot and is close is obviously going to get there a lot closer. But we don't necessarily need to get there with a strict press. Somebody that can push press their body weight, somebody that can jerk their body weight, somebody that can show me a strict handstand push up, that person really tells me that they have really strong shoulders. Arm length plays a big role here. Those of you with longer arms, I know you're listening right now, nodding your head. I'm five foot seven. I have these little T-Rex arms. I don't have a lot of range of motion before my arms are locked out overhead. Someone built like me. isn't actually going to have a stronger press, a stronger handstand push up capacity than someone that is six foot six and their fingertips touch the middle of their fibula, right? So consider that as well. Don't hold people's feet to the fire on that too much. But no, we want to see people getting a strong press, we want to see them move towards a 50% bodyweight press, and then continue to train that as much as possible. We have a number of different tools we can use as well to look for asymmetries in the clinic. I love to just stick with a dumbbell strip press in the front rack. Hey, let's try a five to eight rep max. Let's see if we have an asymmetry. If somebody can't tolerate that due to pain, I love to go to a landmine press and try to find a five to eight rep max there, and then try to see if I can observe any asymmetry. And then we know if we talked here on the past on the Daily Show, to clear up asymmetries, we need to be training the weaker side three to four times the volume. So that person needs to be doing maybe four to five sets of pressing work for every set that the strong side does. So that's always a consideration as well. When we look at ratios in the upper body, we need to understand the upper body is or at least should be a little bit weaker compared to our lower body. Humans are primarily legs. We do have those people out there. You probably all have a friend that has a 400 pound bench press and a 200 pound back squat. They're just built. They're built different, right? They love upper body, skip leg day a lot. But in general, our legs should be stronger than our upper body. How strong? About 40-60, maybe 30-70 at the most. But when you start to get to a ratio of 80% of my strength is in my legs and 20% is in my upper body, we really get into an issue where now our lower body can generate more power than our upper body strength can handle. And so we have some really cool research, Matt Sura and colleagues, 2023 Journal of Science and Medicine and Sport followed swimmers and asked that question in their research. Hey, is there a ratio where lower body strength leads to upper body injury? And the answer seems to be yes, which is really interesting research. So this study followed 48 competitive swimmers across six months. At the start of the study, these swimmers had no pain. Across the six months of training, 20 swimmers developed pain and the researchers testing baselines and reassessments throughout the study wanted to pick up on how can we determine who's most likely to develop a shoulder injury across a season of competitive swimming. And so finding that folks who developed a stiffer shoulder across those six months, worse posterior deltoid range of motion, And those folks who had higher ratios of lower extremity strength to upper extremity strength went on to develop pain. Their legs were able to generate so much power in the water that their shoulders were too weak to keep up. And over time, we're assuming and carrying forward that that led to overtraining essentially of the upper body. We can see that in the gym, with movements like push press or push jerk, we know the legs provide the majority of the motion and the power for those movements. And if our shoulders are not strong enough, yes, our legs can help us get that weight overhead. But if we're doing that a lot, and our shoulders are just not inherently stable, because we have a weak deltoid, then we can run into trouble where the ratio becomes so skewed that it can now be harmful. So I like to think of this is the legs begin to write checks that the shoulders can't cash, right, the shoulder is not moving through the full range of motion. And now those other muscles have to take over because that ratio is so skewed. And that's who shows up in your clinic door, right? I have stiff traps, I have a headache, I can't turn my head, I did a bunch of push jerk, I did a bunch of kipping handstand push ups, whatever, we need to treat that person's symptoms, we need to get their shoulders stronger, we need to control that ratio a little bit better.

THE DELTOID: TRAINING
So as we finish up here, how do we do that? How do we train the deltoid? A lot of people think they're training the deltoid, they think they're training shoulders, but they're not really doing it effectively, which is why they don't see a lot of results in whatever their goal might be for the shoulder, even if it's just to not have shoulder pain during exercise. And so we see a lot of what we might call bro shoulder press, right people sitting or standing in the gym. That arm is cocked out to 90 degrees of abduction and then they're kind of just pumping that weight up and down overhead, right? They're in a neutral grip. They're in a small amount of abduction They are technically in no flexion in a small amount of external rotation so in that movement that kind of seated or standing dumbbell press where the weight is just floating out in space is EMG studies would say that person is primarily training the triceps. If you ask that person in the moment, where do you feel this, they would probably tell you their triceps. And so getting people to understand what does deltoid training look like. is very important because some folks may think they're doing it, they may think they're doing a lot of it, and they're not. They're probably training triceps, they're probably primarily overloading a different muscle, which is just exacerbating the whole problem. They're probably allowing a dip in their legs in the strict press. So again, the legs are primarily generating the momentum for the movement. And they're probably just not performing full range of motion. And again, The deltoid is on the whole range of motion, especially at and above 120 degrees. So we need to be training full range of motion if we want a really strong, robust deltoid. Most people skip deltoid training completely, which is another factor, right? Coming into the gym and doing five by five strict press is not fun. It's not sexy. It's not as cool as ring muscle ups or a heavy deadlift or a heavy power clean or something like that, or even just doing push press or push jerk. It's more momentum. It feels cooler. You can lift more weight. And so strict press often gets left behind, which is the thing that some athletes and patients need to be training the most. Other athletes might be thinking, hey, I bench press a lot, I have strong shoulders, but when we look at studies of what muscles are active at what degrees of incline in a bench press, we see that we have to elevate that bench to almost 60 degrees just to begin to get a little bit of anterior delt work. And that we have to incline it to 90 degrees, which is, you know what, no longer a bench press, you are sitting upright, to begin to target the lateral and posterior heads of the deltoid. We had a cool study from Rodriguez, Redallo, and colleagues in the Journal of Environmental Research and Public Health in 2020 that looked specifically at that and said, hey, primarily in the bench press, even at an incline, you are still primarily targeting the pec muscles. Yes, at 60 degrees of incline, you begin to get more anterior delt, but bench press is for the chest, which some of you are saying, Alan, I knew that already before I listened to this podcast, but others out there might be thinking, hey, I thought that was also getting my delts. It's not. So we need to recognize that we cannot bench press our way to stronger deltoids. That will certainly get you a stronger chest, better push-up capacity and ability, but it will not do anything to really train your deltoids, and if that's a weakness area for you, help shore up that weakness. And so we need to get folks training shoulder flexion and shoulder abduction through the fullest range of motion possible, training them together. Yes, barbell strict press, alternating dumbbell press, standing, sitting, Z press, whatever. And in really, really being sticklers for people that they work the full range of motion. If you're going to use dumbbells, they need to start in the front rack position where the head of the dumbbell is on the shoulder, and you are pressing through 180 and 180 degrees of shoulder flexion and abduction. and you're not hanging out here and just giving it that little tricep hump that people like to do. Train the full range of motion. For those folks who are needing or wanting to do handstand pushups, handstand pushups are also a great way to train the vertical pressing pattern. If folks already have strict handstand pushup capacity, working at it as accessory work is great. Adding things like plates for a deficit will challenge bigger ranges of motion that will develop and continue to progress in a linear fashion vertical pressing, and deltoid strength. If they can't do strict, but they can kip, we can have them kick up to the wall, lower themselves through that range of motion, and do a handstand pushup negative. That is a great shoulder strengthener. I have a lot of athletes do that for accessory work. Even athletes that have strict handstand pushups and have good strict handstand pushup capacity, working that time under tension, especially if they can tolerate a deficit, is gonna make really robust shoulders, a really strong, healthy shoulder, And because they're training a deficit so often, when a workout shows up with regular handstand pushups or regular strict handstand pushups, those athletes fly through those workouts because their capacity has increased so much. At all costs with those folks, we want them to avoid kipping unless they're doing an eccentric, because again, that's the same as if they were standing up and doing a push press or a push jerk. We want to avoid having the legs help us train the shoulders. When we need to get strong shoulders, we should be training the shoulders. Folks can benefit a lot from complexes, things like doing a bunch of strict press followed by push press or push jerk. That is a great way to train the deltoid under fatigue, which relates a lot, especially to those athletes who are going to be using a lot of vertical pressing under cardiovascular fatigue. So one of my favorite ways to do that is 3 sets of 3 strict press, add some weight, 3 sets of 3 push press, add some weight, 3 sets of 3 push jerk. Starting fresh, working the deltoid, sets of 3, very heavy load, getting stronger. is the deltoid fatigues, using the legs a little bit to help it out with the push press, and as it gets really tired, using the legs even more in our push jerk. You'll find if you do a big complex like that, that your shoulders are tired, your shoulders are sore the next couple days, and that is really a unique feeling to have soreness in the deltoid that a lot of people don't experience because they're primarily not training the deltoid, or other muscles are taking over for them because their deltoid is so weak. For accessory work, the EMG exercise with the largest deltoid activation is a prone Y with the arm unsupported, moving in and out of 120 degrees of flexion abduction with the hand wound up and as much external rotation as possible. So that's from Mike Reinhold and colleagues, they have a bunch of research on EMG activation in the shoulder muscles. That's where the delt works the most out of a number of different exercises. So after training is done, after we've got our strict press or handstand push ups in, we can go to that prone Y do some burnout sets, something like that, and really begin to overload the deltoid in a way that facilitates a lot of strength.

SUMMARY
So the deltoid, largest or should be largest, strongest muscle in the shoulder built for work, built to move the shoulder through the whole range of motion, but only if we train it. Otherwise, those smaller muscles are going to take over. The shoulder is inherently unstable, that full 180 degrees of freedom. It doesn't have bony approximations that give it support as much as the hip or other joints, which means we need strong muscles, in particular, a strong deltoid to act as the stabilizers for us. In the clinic, we're primarily treating the aftermath of what happens to people when their shoulders are not as strong as other parts of their body, their legs, their traps, their posterior cuff, whatever. We need to clear up those local symptoms and then get that person on some sort of deltoid strengthening program so that the deltoid begins to do the work. Most folks will find that their capacity in the gym, in their fitness, often increases with overhead lifting, and they have less symptoms, less stiff traps, stiff neck, headaches, so on and so forth. A lot of folks have no issue doing vertical pulling. They might be doing vertical pulling multiple times per week, really training the lats, pull-downs, pull-ups, chin-ups, muscle-ups, whatever, but often they are avoiding vertical pressing, or they're using a variation of a vertical press where their legs help them a lot when they should be focusing on strict movements. Strict movements like strict press, strict handstand push-ups, and training the full range of motion. Remind these folks they are welcome to do as much bench press as they like, but you cannot bench press your way to a stronger deltoid. And when in doubt, again, keep it strict. So I hope this was helpful. I hope you have a wonderful Friday, a great weekend. If you want to join us online, our next cohort of fitness athlete level one online starts August 2nd. Fitness athlete level two online starts September 2nd. And then a couple chances to catch us out on the road. Zach Long will be teaching this weekend in Raleigh, North Carolina. And then in two weeks, we have the fitness athlete summit here in Fenton, Michigan at CrossFit Fenton. We'll have all four lead faculty from the division here, as well as our four teaching assistants, so our full staff will be on hand for that course. That's gonna be a lot of fun, so we hope to see you in two weeks here in Fenton. Have a great Friday, have a great weekend, bye everybody.

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Episode 1744 - Myofascial decompression for the deltoid 0

Jun 6, 2024

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

In today's episode of the PT on ICE Daily Show, Extremity Division leader Lindsey Hughey discusses when, why, and how to perform cupping to the deltoid muscle.

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.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account.

LINDSEY HUGHEY
Good morning, PT on Ice Daily Show. How is it going? Welcome to Technique Thursday. My name is Dr. Lindsay Hughey. I am division lead of extremity management along with Dr. Mark Gallant, and I am here to talk to you about a deltoid myofascial decompression technique. So in honor of deltoid week, I want to share just a common technique we'll use. First, I will kind of give a little context of why we would use this technique, and then I'm literally going to show you how we'll do cup placement, and then how we'll follow that up with active movement. So we do passive, and then we actually do a little neuroreeducation to that area.

WHY CUP THE DELTOID?
So why we might choose this technique is someone that literally has pain with palpation at that deltoid, baby with abduction, they have a painful arc, and or when you manually muscle test into abduction and or flexion, they have some pain symptoms. So this would lead us to want to do this treatment. In our extremity management course, we usually call this the weak shoulder bucket. A lot of these folks fall under that umbrella. So I actually have an assistant with me today. So Paul is going to come and sit, and I'm actually going to have him sit like this. I usually have the patient either lay in supine, side lying, or prone to do this technique. But for ease of you all to view the deltoid, I want to have him sit, and then we'll have him lay on his side. So we want so just to orient us to the deltoid and I'm going to move this camera just a little bit right so the deltoid actually gets its name because it looks like an upside down delta so if these points all the way down to that deltoid tuberosity by the way to dive deep into the anatomy of the deltoid check out Clinical Tuesday with Ellison Melrose because we are doing all things deltoid this week. And she did a fabulous episode on not only the anatomy, but the function. So take a look at that. But here we're going to target, we want to target the anterior, the medial, and that posterior region. So some people think of this as like clavicle, acromion, or spinal. So what we're going to do is attach our cups to each of those regions and then all the way to that deltoid tuberosity. So I'm going to grab my gadgets. So practical things we need are some kind of lubricant. I'm going to use Free Up today, but it doesn't really matter, kind of your favorite lotion oil that'll help this stick. So I'm going to put a little lotion anterior, medial, and then that posterior, right? Because we have three main parts here. And then we'll go down to this deltoid tuberosity area. So I'm going to use these nice curved cups. These are actually the newest cups from our colleague and friend, Cup Therapy. So Chris DiPrato just came out with these and his team, and they are awesome for suction. We really, by the way, love myofascial decompression because it's really the only thing we have that really offloads tissue versus like our dry needling, our exercise, our massage, our wonderful treatment adjuncts. but they're compressive in nature. So sometimes this decompressive technique is just a novel stimulus to help that muscle relax and move better and activate better.

CUPPING THE DELTOID
So I'm going to start with that middle portion and I want For muscle, we usually want about 300 to 600 millimeters of mercury or pressure taken off. And there are gauges that pumps that actually show you that pressure. This is just a standard pump today, but just to keep that knowledge in your back pocket. And then we're going to go posteriorly. So again, I want to make sure lotion is there. I'm going to attach here. How are we doing, Paul? Such a good patient. Such a good model. And then we're going to go anterior. So I'll just kind of shift my body so that you all can see that. Again, we're pumping up. We try to get enough besides that 300 to 600 millimeters or mercury, but enough that they don't pop off. And if this do pop off during this demo, we'll just reattach. And then finally, down here, a little bit more lotion. And then we'll pump. We're getting a little slidey there, doing OK. Sometimes you're doing OK. Sometimes hair gets us, and we might. User error is always fun, too, when your hands are sliding. I'm just going to change this out. Here we go. That one, we needed to go, I think, a little bit smaller. That one was a little too big for the surface. That's why there's different size cups. OK. To visualize, we have anterior, medial, posterior, so we're hitting all parts of that deltoid. And then we're trying to sink into that deltoid tuberosity. For our treatment, I'm going to have Paul lay in sideline, so that shoulder is up. First part of this, and I'll just adjust the Instagram camera a little bit, is we're going to do some passive movement. So we're never just having the patient sit with the cups and doing nothing. It's very rare that we would just let this be a static treatment. So I'm going to take Paul's arm, and then I'm going to move him into all the motions that the deltoid produced. So that anterior is more flexion, internal rotation, abduction for that medial and then posterior contributes to extension and external rotation. So I'm gonna move in and out of all those positions. So I'll demo just a couple of those and then the next part is let's let the patient own this movement with some neural re-education. So then Paul will do those movements and I'll show you our favorite sideline trio for that. So I'm going to flex him and I'm moving my body with this. And then I might mess with a little bit of internal external rotation. And when you're up close to the cups, what you see is some pumping on off of that tissue. And I'll do just a couple more of these. And then I can even abduct. A little bit for Paul on off, and I would spend like a minute or so kind of going off on off and deflection, internal external rotation. I might even go into a little bit of extension. And then I want him to do some of these movements. So I'm going to go from behind to direct Paul and get out of your way. But one of our favorite things for the weak shoulder and to really light up that deltoid and even the cuff, because we know they work together in upward elevation, is we're going to do external rotation. Elbow straight, do flexion, come down, and then go to 90 and do horizontal abduction. So we're hitting all parts of that deltoid and the cuff with this movement. And we'll have Paul do a few of these reps unloaded, but then I'm going to give him a change plate, and I'm actually going to have him load this up. And probably the hardest part is just remembering all the movements. It doesn't quite matter what order you do it in, but what matters is kind of targeting all the different areas of that beautiful deltoid muscle. So go back to external rotation, and this is just like a real patient, right? There's going to be some error in each movement. Again, it doesn't matter necessarily the order. And then horizontal abduction. To make it a little harder, we're going to go ahead and give him a weight. So he's going to go ahead externally rotate. I'll just guide him through those first reps, elbow straight, go ahead and flex. Meanwhile, the pods are still attached, offloading that tissue. He'll come back to 90 and then horizontally AB duct, right? And then we'd give him a sweet spot. You can go ahead and relax. A sweet spot, what we call an extremity management, the rehab dose because we are targeting local tissue. So our rehab dose is anywhere from 8 to 20 reps, 3 to 4 sets, and we're taking a rest break of about 60 to 90 seconds. And our intensity varies from 30% to 80% depending on tissue irritability. But we've done this out.

SUMMARY
So some key things, we apply the cups, right? But then we actually move the human passively. Then we have them actively do the thing, neuroreeducation. And then finally, we take the cups off. And what we would do is reassess one of those things that blipped an exam, whether it was palpation, whether it was that presence of a painful arc, and or our manual muscle testing to see, did NPRS change with our palpation? Did painful arc, was quality of movement improved, and or NPRS, less pain associated with that elevation? The other thing, one little other pearl I want to share with the cups. So we remove the cups and then we'll massage that area a little bit. But what's neat is you can even take some pressure off. I'm taking this last cup off, but I can reduce the pressure a tiny bit and I can end with like a sliding technique where there's a little bit of offloading still present, but we're sliding along that tissue. for overall treatment dur be more than like 3 to 5 technique. And what's neat asterix very quickly. And pain. The motor bands tha immediately are a little and then they're able to elevate their arm better. And so this quick and efficient technique is one that I would really encourage you to use with your folks that have any deltoid and or cuff issues. You've heard me throw out some terms today regarding weak shoulder, the rehab dose, and the sideline trio. These are all terms that are really common to our extremity management course. So if you haven't taken it yet, Mark and Cody and I and our team to see you on the road an offerings. If you check u dot com in the summer. So in Salt Lake City with Ja and 14th will be in Kent, Washington again. And then July 20th, 21st will be in Hendersonville. So Cody will be there. That is bound to be a blast with that Hendersonville crew. And then it keeps on coming. We have another course in July, Bend, Oregon. So a lot of West Coast opportunities. So my West Coasters join me. I will be doing all those West Coast courses. And then we have more offerings in August. So you can't miss us. Thank you for joining me on Technique Thursday to learn a little bit more about the deltoid. And thanks to Paul, my patient who always looks like he's sleeping, but he's actually awake and with it. I hope you all have a beautiful day. Take care.

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Episode 1743 - Permission to succeed 0

Jun 5, 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 three tips to give older adults permission to succeed in physical therapy: acknowledge their concerns, craft experiences that ensure success, and focus on belief change.

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

JEFF MUSGRAVE
Welcome to the PT on ICE daily show. I'm going to be your host, Dr. Jeff Musgrave. This podcast is brought to you by the Institute of Clinical Excellence. It is Wednesday, so it is all things older adults. So excited to be here with you today. So even if you're not treating primarily older adults, I think you're gonna find a lot of value in today's topic. So today's topic, we're gonna be discussing permission to succeed. So this is very common in the older adult space, but you're gonna see this in lots of different populations that you're gonna be treating. where because of the interactions that older adults or any of your patients on your caseload have had, they've got a very negative outlook on their ability to recover, their ability to return to the things that they love. I've seen this across acute care all the way into the fitness realm. and especially people when they first come to us in the fitness realm for training as older adults in stronger life, they will need some encouragement. They will need some reframing of what is possible and reframing of how they see themselves. So I believe that you will not get the person physically if you do not first get them mentally. You have got to build that confidence in between their ears. They've got to see and understand a path forward before you're going to get the body on board. So I would love to share with you today some tips to make that just a little bit easier. I think a quote that really sets the stage for this discussion is from Dr. Justin Dunaway. We love to quote him in the older adult division and one of our favorite quotes of his is, beliefs and expectations are the foundation upon which outcomes are built. Beliefs and expectations are the outcome are the foundation upon outcomes are built. So we really have to believe that it's possible. We've got to know our patient's beliefs and we've got to set the stage for them to be successful. So, because our older adults have heard, you've got the worst case of, insert diagnosis, bone on bone, you've got degenerative disc disease, they've heard all these nocebos or noxious language that strikes fear in the hearts of our patients. Whether they're older adults or not, you're going to see this in younger populations too, but we see it a ton in our older adult population. So I've got three tips for you today to try to help move patients towards a mindset that's going to allow you to be successful.

ACKNOWLEDGE CONCERNS
So the first one is acknowledge. You need to acknowledge their concerns. Our older adults come with some baggage typically. They've lived more years, more decades, they've had more injuries, and oftentimes they've been told more negative things than our younger patients. They've been told You can't get better, or you'll never do X, Y, or Z again. Jog, run, swim, lift heavy things, insert the favorite activity that they love that is part of the reason they're living their life. This happens all the time, unfortunately. So, we need to hear those concerns. If it looks like we're running into a barrier where they think they can't do what your job is to help them do, we've got to ask some clarifying questions. We need this information anyway. Why do you think it's not possible for you to fully recover from this back injury? Is it a bad experience with physical therapy? Is it negative expectations that have been set from another provider? Is it an experience a friend or loved one had? And then you get the opportunity to find out what was their bout of care like? What type of treatment intervention were they getting? Was it even appropriate? Was it the right movement? Was it at the right intensity? Was it across the right duration? Was there such a huge disconnect between what they actually wanted to do and what they were being asked to do? that they didn't see the connection, they never did their home exercise program. There is so much we need to know about why they have the negative outlook that they have. And then you get the opportunity after hearing everything, because if you cut them short in this phase, you will not get them. If you don't hear all their concerns and why, you can't give them the information they need to help them bridge that gap from I can't get better to oh, maybe I can get better. You don't have to completely change their mindset in one or two visits. Unlikely you'll be able to do that anyway. What you need to do is inspire some curiosity. You need them to be curious about the possibility of getting better. If you can get them from, I don't think it's possible, to now I'm curious, you've cracked the door open and created just a little bit of hope. you may be wildly successful with this patient. So, once you've heard everything, you get the opportunity to share some success stories. And you can say, man, I hear you. I know you've been told by this provider, and I can understand based on what you've seen, based on your imaging, based on your past experience, why you would be concerned that maybe you can't overcome this. but I've seen people in your condition with this diagnosis at your age, maybe even older, maybe even less healthy than you, get over this. It's gonna take time, it's gonna take hard work and consistency, but man, how would your life be different? If you could bridge the gap to a full recovery, what would you do differently? How much better would your life be? Let's just be curious. We've got time together. Let's do this thing. So I would call that step one. Acknowledge their concerns, ask clarifying questions, share success stories. have to do that first. Let them get it all out. You want to know every objection they have so that you can tell them why they don't need to be concerned about that.

CRAFT EXPERIENCES THAT ENSURE SUCCESS
The second piece, your job is to craft. Your job is to craft experiences that ensure success. There are two ways that we commonly do this with older adults that I assure you work with younger adults as well. The first one is make it laughably easy. In the older adult division, we call this intentional underdosage. This could be because someone is fearful, This could be because someone just has very low confidence. This could be because they're in unfamiliar setting or they've never done any weight training before. You're getting to set the stage for them. And you can do that by building successful reps. You want to make it so easy there's no way they can fail. Ramp it up a little bit. Let them be successful. Oh man, that's awesome. You're stronger than I thought you were. Ramp it up a little more. Ramp it up a little more. But what you don't want to do here is get greedy. If you get greedy as a clinician, I've done this several times, where you're like, man, I think they can actually deadlift 100 pounds, let's see if we can knock that off the list on day one deadlifting. And then they get scared, they get fatigued, or maybe you just misjudged it, and they can't lift that up, and now you've ended on an unsuccessful rep. You've shot yourself in the foot. So when you make it laughably easy, you intentionally underdose, make it easier than what you know they can do, you want to stop short of their maximal capacity. typically on that first visit, unless you're calculating an estimated one rep max, which is a whole nother topic. If you're already familiar with estimated one rep max testing, that is not the same as intentional underdosage. We're talking day one, building confidence, okay? So that's how we're going to, that's the first way we can craft an experience to ensure success is to intentionally underdose. The second thing that we're gonna do is test retest. We're going to show them that we can be successful. We're going to identify the asterisk sign, the comparable sign, whatever you want to call it. Doesn't matter. Especially when the primary concern is pain. Often with older adults it's function, but sometimes it's still pain. So I don't know, you know, the reason I'm here is because I can't get my arm up into the top cabinets anymore. I get shoulder pain. I get stuck. It hurts. Your job as a clinician, after you do your assessment, you figure out their range of motion, their strength, you've done a solid subjective, you ruled everything out, you've got a pretty good idea of what's going on, you're gonna give them some treatment, and then you're gonna retest, right? You need to make it very clear, you need very accurate measurements, and you need to tell the patient, here's where you got to. Man, that was about here, wasn't it? and make it really clear to them. You want them to remember that first measurement because what you're going to do is you're going to make them better. You're going to use your voodoo, right? You're going to throw your darts. You're going to do some manual therapy. You're going to do some exercise. You're going to put all those components of a solid treatment together and then at the end, you're going to knock their socks off, right? They thought that their shoulder could never get better. They've already been to PT several different times or it's been 10 years since this has been going on and you're going to show them. You're going to crack the door open on a successful recovery, just enough to at least make them curious. Test, retest. So when you craft that experience, you've got two solid options here. You can Intentionally underdose, if you're looking at a strength or a functional goal, or you're gonna use test, retest. Make it very clear, be very accurate on both measurements. Make it super clear, make sure it's your asterisk sign. You're gonna show them success. You're gonna give them the experience of being successful when they walked in the door and thought they could not be successful.

FOCUS ON BELIEF CHANGE
And then the third thing, once you've done that, you've still got work to do. You've got to focus them. You're going to have to focus them. You're going to have to refocus them throughout the entire bout of care. These beliefs go deep. They've been going on for a long time. You're going to have to chip away at those across the entire bout of care from the first interaction to the last one. Okay, especially if these beliefs have been long standing. So once you, the bedrock of changing their beliefs is giving them a successful rep and then reminding them of that success. You would think it would be obvious. There are so many client interactions where I did not do a good job of sharing. Remember, here's where we started. You can only slide your hands down to your knees when you came in and you had searing pain down your leg. And then they're at mid-shin, or maybe almost they're touching their ankles in the first visit. When that is their comparable sign, they're like, oh no, I moved that much. like you absolutely did not, but I did not make it clear enough what was going on at the beginning to show you how you progressed. So you need to make that painfully clear. After that, you need to remind them of their progress. Each visit, remember where you started. Remember where you started. The first day you walked in, you thought that it was going to be impossible to lift up this 10-pound weight from an elevated surface. You looked at that weight. You stared at it. You looked at me. You looked back at the weight. You were like, this is not happening. And then what happened? You walked up, you moved that thing. You got several reps. We even got up to 15 pounds that first time. You didn't think you could do 10. You thought that was out of reach. Now you're lifting 30 pounds. 30 pounds. You have had a 300% increase in your functional ability. Incredible. Now you're doing it off the floor. Think about how that opens up your life. How many things in your life weigh 20 to 30 pounds? Now you're doing it for reps. Think about all the things you can do now that you could not then. And the reality is, our patients aren't gonna have this nice, linear progression. So the third step on focus is going to be to share with them, these are a couple of my favorites I like to use, is progress is non-linear. We like to think it's just going to go up and up and up and every visit is going to be a smashing success. It's going to be the most you've ever done. It's going to be incredible. But that is not the case. We know that it's more like a good stock in the stock market. A really solid stock has got down days. and your patients are going to have down days. Medically, especially with older adults, they tend to be more medically complex. If you've got a progressive neurological condition, you've got someone with MS, and they're going through an exacerbation, there may be two weeks where there's flatline progress or reduction, but if it's still above where they started, you need to highlight that. Yeah, but we're not where we started, and we know this is going to end. And then we're going to start climbing again. And when we back up and look at this picture, it's going to be off the charts. When we back up, we've still got a solid line going up that day. So the other quote is, every day is not going to be your best day. Come in and give me what you got. That gives our patients permission to do what they can. And sometimes that is enough to crack the door open on a really solid recovery. I love this quote. Now, I'll share it with you. It comes from a spiritual realm, so I'll share that and then I'll give you the bit for it. So, a man with an experience of God is never at the mercy of a man with an argument. A man with an experience in God is never at the mercy of a man with an argument. So, if we reframe this around our patient's beliefs and expectations, their argument of I can't get better, we're gonna chip away at that by producing these successful experiences, building on success. We're gonna chip away at those beliefs. It's like, man, I know you thought you couldn't do it, but you've already done it. You're already someone you didn't think you were.

SUMMARY
And that's what I've got for you, team. So three steps to give your patients permission to succeed. One, acknowledge their concern. You've got to listen well, ask clarifying questions, know all the barriers that are in your way, and you're going to push those out of the way with success, stories of sharing how you're going to be different. Second thing is you're going to craft successful scenarios. You're going to ensure success, whether it's an intentional underdosage or test-retest. You're going to show them what they didn't think could be done. You're going to do it. Not you, they're going to do it. They're going to be the ones that are going to show themselves. those experiences, and then you're going to focus them on that success. You're going to focus on the long game, how their life's going to be different. You're going to be highlighting how those little incremental changes are going to change their life. And over time, you're going to change their beliefs, their expectations about themselves, and you will change the way they age. You will change their life if you can do those things. Team, if you've got other strategies, if you found any of these things helpful or you've got other strategies you want to share, I'd love for you to drop that in the comments. If you're watching this on Instagram. If you want to learn more about what we're doing in the older adult division, our next cohort of level one is going to start August 14th. Level two, the last cohort completely sold out. So just so that's on your radar. It doesn't come around as often, but that next cohort is going to be October 17th. I'm going to be in Houston, Texas this weekend. We still got some seats. If you're in the area, you don't want to miss it. It's going to be an absolute blast. Then the 22nd of June, we're going to be Charlotte, North Carolina. Then I'll be back in Victor, New York on July 20th. And team, after that, we're going to have an MMOA Summit the following weekend. So that's going to be 727 Denver, Colorado, MMOA Summit. Almost all the faculty is going to descend on Denver, Colorado, and bring you the goods. Team, I hope you have a wonderful Wednesday. We 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 1742 - The deltoid: form, function, and clinical application 0

Jun 4, 2024

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

In today's episode of the PT on ICE Daily Show, Dry Needling faculty member Ellison Melrose discusses the form & function of the deltoid muscle, as well as clinical applications for dry needling to the deltoid for different patient populations.

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

ELLISON MELROSE
Good morning, PT on Ice daily show. We are live on YouTube and on Instagram. My name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of Ice. I'm super excited to be here for deltoid week. So I kind of compare this to like the sharp week from childhood, right? So this is the most exciting week of the year for us. Um, we are here to talk all things about the deltoids. So we came off of yesterday. Jess, um, started talking to us about the importance of deltoid strength during motherhood and how we can maybe implement some deltoid strengthening in some um, early postpartum period, right? Using more of like a hypertrophy style training versus, you know, diving right into things like CrossFit right away. So that was really awesome. Um, I'm here to tell you guys today about the form function and some clinical applications of deltoid strength. So let's dive right in. Um, if you have been to an upper quarter course with either myself or Paul, we spend a few minutes just on the deltoid side, just talking about how cool the deltoid is.

THE DELTOID: FORM
So let's start with form, right? So if we look at the deltoid, there is no other muscle in our body that is shaped like the deltoid. Some may compare it to the glute, the glute max of the lower quarter width, you know, how it kind of spans that, that joint and has multiple origins to the single point insertion, um, similar to the glute max. But if you actually look at the deltoid, the origin is almost a full circle, right? So it's about 300 degrees of, um, contact with our, lateral third of the spine of the scapula, the lateral border of the acromion, and the lateral third of the clavicle. So it's about 300 degrees to a single point insertion at the deltoid tubercle. Right? That's like really, really cool. There's no other muscle in our body that does this. This allows us to move in multiple planes of motion. And we'll talk about the function in a little bit more depth later. But just by looking at it. There's nothing else like that we have in our body. Next, we have its innervation, which is also fairly unique, right? So the axillary nerve, its number one job, let's see, its number one job is to provide a motor response to the deltoids. I'm having a little bit of issues on Instagram, We'll come back, we'll just keep it going here on YouTube. So, its main motor branch is to the deltoid. It does innervate teres minor, but I would argue that's probably the smallest muscle we have in our shoulder girdle. And likely the most important part of the axillary nerve is its motor contribution to the deltoid. So if we did not have an axillary nerve, what would that look like in the shoulder girdle, right? That would look like a significant sulcus. So we would not be able to use any of the other muscles in the shoulder girdle without the axillary nerve. Next, we have different regions of the deltoid. So we have the deltoid can be separated into three primary regions, right? We have anterior deltoid, we have middle deltoid, we have posterior deltoid. Well, in 2010, what they found, there was a study that looked at those compartments and what they found was there's actually a further fascially subdivided region in both the anterior and the posterior delt. So each of the anterior deltoid and the posterior delt, each of those have three separate fascially subdivided regions. Really cool. What they also, another study looked at was the EMG activation throughout the deltoid. And what they found was there's at least six differentiations with EMG activities. So we have those fascially subdivided regions can be turned on and turned off, maybe independent of each other, which allows us to maybe think about the function of the deltoid a little bit differently. Right? So our form, we have a very unique origin and insertion. We have a very unique innervation with only a single nerve. And that's main job of that nerve is to innervate the deltoid. Our brain perceives that muscle as really important when things, when we have one nerve and its main job is to just provide motor function to that muscle. So it's super important. We also have the form as the we can divide it further from those original three divisions that we kind of think about back in PT school to seven different subdivisions that we may be able to activate, turn on and turn off independent of each other.

THE DELTOID: FUNCTION
So let's dive into the function, right? There are four main functions of the deltoid. The first is it's a mover, right? And that's what we think about when we think about the deltoid. We think that it moves into flexion, abduction, extension, internal rotation, external rotation, right? It's a mover in our primary planes of motion. It can also fine tune movements, right? So now that we know that like the deltoid has all of those subdivisions and we can maybe recruit those independent of each other, we can fine tune specific movements. It acts as a synergist with other primary movers in different planes. For example, the posterior deltoid is a great synergist with infraspinatus. We're thinking about, you know, end range external rotation or external rotation in that abducted position. The deltoid may be able to help or maintain that movement pattern and act as a synergist with the infraspinatus. Really cool stuff. So it's a mover. It's also a stabilizer. So I mentioned earlier that if we had an axillary nerve lesion, that would look like a detrimental sulcus sign to the glenohumeral joint, right? So the deltoid, when we think back to PT school, we were like, I at least put a lot of emphasis on the bicep tendon, you know, maintaining its humeral head placement, the rotator cuff, fine-tuning those movements so that it stays in that ball, the humeral head stays in the glenoid fossa appropriately. But if you took away the bicep tendon, right? People do that all the time. We have biceps tenodesis. We still have a functioning shoulder, right? If you took away the rotator cuff, we see that a lot. People have full thickness tears of specific rotator cuff muscles, and they still have function of their shoulder. If you took away the deltoid, you would not, right? you would not have the ability to use the rotator cuff, to use the bicep tendon, to do their primary movements. So it is a stabilizer to the glenohumeral joint. It almost provides an accessory like suction to that labrum to help maintain that humerus in the glenoid fossa. It also provides stability to other joints in that area. So if we think about where it crosses, it spans the AC joint. There's only one other muscle in our body that spans the AC joint, and that's the upper trap. So when we think about if we have damage to the AC joint or our passive structures have maybe been or have been impaired, we have an active stabilizer in the deltoid and the upper trap that cross that AC joint. So again, deltoid strength may be able to help maintain that stability in the AC joint when some of those passive structures have been lost. So it's a mover, it's a stabilizer. Next, it's a cushion. So we don't really think about this often when we think about muscles, but muscles cushion the bones, right? So they cushion the bones, they protect some higher, more sensitized structures in the region. And in this region, in the axillary region, we have brachial plexus and all of its branches exiting the axilla. So we have some very important neurovascular structures close by. So what could be very detrimental to those tissues would be a proximal humeral head fracture. So what the deltoid can do is it can cushion or kind of dampen the blow to a blunt trauma to that bone, which may help reduce the impact, and reduce the likelihood of a proximal humeral head fracture. So really cool stuff. So we're thinking maybe patient populations, that would be beneficial for. And we'll talk about that in a second. So it's a mover. It's a stabilizer. It's a cushion. Last but not least, it's a pump. A lot of what we do in physical therapy, we're just pumping fluid. Our goal is to reduce chemical irritation in that tissue. if we have pain, for instance, right? So we need muscles that help facilitate hemodynamics. When we look at the upper quarter, one of the best muscles to do that is the deltoid, not only by its pure mass, but its capillary density. So it has a higher density of capillaries, which helps with it both, you know, the hemodynamics and the perfusion in that area, but also its proximity to the lymphatic axillary watershed. and just the venous structures, right? So if we think about our venous return coming up into the axilla, all of those things are very important. And when we look at research that was surrounding lymphedema and edema reduction in the upper quarter, what they found was that the deltoid plays a key role in edema evacuation from that upper quarter. So function, right? We have, it's a mover. Not only is it a gross mover, but it's a fine tuner. It's a stabilizer. We would have no upper quarter function without the deltoid. It is a cushion. So it can provide some cushioning for any trauma that occurs in that upper quarter, which is going to protect some of those more sensitized structures we have in this area. And it's a pump. We're pumping fluid, right? So it can help with edema reduction, any sort of acute injury in the distal extremity, not only thinking lymphedema, but also thinking like acute injury. Maybe we don't want to target those tissues. Speaking specifically from a needler, maybe we don't want to needle the tissue that's the issue because it's in an acute inflammatory stage. We want to think proximally. What can we do proximally? we can needle and stem the deltoid, which may help with that fluid dynamics.

THE DELTOID: CLINICAL APPLICATION
Lastly, I want to talk about three different patient populations that may be beneficial to think about improving the robustness of the deltoid. I'd argue that every single patient population could benefit from a more robust deltoid. But when you look at the research, First, let's talk about operations. So shoulder surgeries. When you look at the research, the deltoid, the strength and mass of the deltoid is one of the number one predictors of a positive outcome from both rotator cuff surgery and something like a reverse total shoulder. So no matter what the surgery, what they're finding is that if you have a stronger deltoid going into it, you have better outcomes coming out of it. Right. So say we had a patient who, you know, they've come, they've been seeing us for a few months, conservative methods of rotator cuff for rotator cuff tissue healing. Right. And they're like, you know what? I'm still in pain. I think I'm going to get the surgery. And you're like, great. Let's keep hammering that deltoid. Right. You have six weeks until surgery. Six weeks is a great time for some progressive overload, some hypertrophy and strength building to that deltoid. It's only going to set you up for more success post-op. So I believe Paul will be putting out some research for that or a post about post-operative implications with deltoid strength today. So look for that on Instagram. Next, we have our hypermobile shoulders. So when we think about shoulder instability, may have had some recurrent subluxations or have had trauma to this area where some of those passive structures have been stretched or maybe aren't doing the job that they were meant to do, right? When we think about the detrimental effect of not having a deltoid, not having the ability to maintain that humeral head in the glenoid fossa or at the glenoid fossa, like how detrimental that can be to upper quarter function. We know that strengthening the deltoid, or we should know, we should implicate that the strengthening of the deltoid would significantly improve their tolerance to loading that shoulder girdle, right? So we kind of, you know, you think about, we're always hammering people with rotator cuff exercises. And sometimes I think we forget about the big guy of the deltoid. because we don't necessarily contribute that to maintaining that glenohumeral joint support, right? So we're thinking pre and post-op, we're thinking shoulder instability, and last but not least, we're thinking our older adult population. So this is going to kind of follow into tomorrow, where we'll have the older adult division diving into the importance of deltoid strength in that older adult population. But let's speak a little bit to the research. So as we all age, we know that we have some sarcopenia that typically occurs, right? So we have a little bit of change in our muscle mass. And when we look at independence in the older adult population, one of the things that helps folks maintain their independence is being able to lift things overhead, right? Their overhead capacity. So deltoid not only does that movement, but as we age, what we find is we have a shift in fiber type or maybe mass. And we'll talk about that gender specifically. So males, as they age, they don't necessarily see significant atrophy in the number of fibers or the overall size of the deltoid. But what they do see is they see this shift from type 2 fibers to type 1 fibers. So we have atrophy of type 2 fibers and more preferential activation of type 1 fibers, which is going to limit their power producing ability in the upper quarter. Females, it's a little bit different. We don't see that shift in fiber type, but what we do see is we see general atrophy, right? So we see loss of muscle mass in the deltoid, which is significantly going to impair their independence with that overhead movement. Don't want to steal too much of that for tomorrow, but three main patient populations that may benefit from a more robust deltoid, pre and post-op, hypermobile or instability, and then the older adult population.

SUMMARY
So today we kind of dove into all things form, function, and clinical application of the deltoid. Hopefully we can get this post up onto Instagram so our folks over on Instagram can also enjoy today's content. So for those that are looking to learn a little bit more about the deltoid, head on over to our Instagram. This whole week we're going to be posting different things of how to load the deltoid. Paul will be posting some different ways of how to needle the deltoid to access both the anterior and the posterior shoulder in different positions. So head on over to Instagram and check out those posts this week. If you're looking to join us on the road, Paul and I will both be Doing a lower quarter course at the end of this year, we have a few upper quarter courses remaining this year, where you can learn how to, you know, needle the upper quarter and particularly the deltoid. So hop on to PT on ice. Yeah, ptonice.com to check out some of those courses coming up this fall, and I hope to see you on the road. Have a great Tuesday.

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

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Episode 1741 - Deltoid week: pelvic floor edition 0

Jun 3, 2024

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

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member Jess Gingerich discusses the role of the deltoid and upper extremity strength in pregnant & postpartum moms.

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

JESSICA GINGERICH
Good morning, PT on ICE daily show. My name is Dr. Jessica Gingrich and I am here to kick off deltoid week. So if you are wondering what that is, the faculty have come together and we are going to take this week and we are going to talk about the deltoid. This is gonna be a really fun week. We are going to learn just how to assess it better, how to use better pain management strategies, and really ultimately how to load the deltoid better and just treat shoulder pain differently. Now, we are coming hot off of semifinals over in Knoxville. We had wonderful, also Monday, here's my dog again, if you can hear. Olive with the trash guy We are coming hot off of semifinals where we watched Tia Claire to me dominate That was really cool You know, there are other athletes out there Haley Adams. I'm wearing her shirt today I mean coming back and just in just doing such a phenomenal job, but Tia crushed it and that was really cool to see her coming back postpartum So we're going to take today and we're going to talk about the deltoid and the pelvic floor. I know you guys are probably like, I'm sorry, what? How are you going to put that together? And you know, I a little bit thought that as well because we're not going to palpate the deltoid and then bring on pelvic floor symptoms likely. So the deltoid, we know abducts the arm. It's going to flex and internally rotate with those anterior fibers and it's going to externally rotate and extend with the posterior fibers. We want to make sure that we can take this muscle and maximize it for motherhood. So we are going to further break down the pelvic space with the deltoid, and we are going to bring this into the pregnant and postpartum space. Motherhood is a journey. I'm not yet a mother, but I treat moms every single day, and I see the different pieces that they have to do, the challenges that come with it. We have new tasks, right? Like tasks that look different than when we were before a mom. Getting back to exercise, a lot of the times is a massive goal of a lot of people. We're starting to see pregnant and postpartum people just infiltrate exercise, like the exercise space. And that's so fun to watch. So we are gonna first break down and talk about pregnancy.

PREGNANCY: A PERFECT TIME TO BUILD STRENGTH
So pregnancy is a wonderful time to build strength. A lot of times we have moms who don't feel great all the time, especially further into their pregnancy, getting their heart rates up. In doing these metabolic conditioning pieces, going on long runs, they don't necessarily feel great all the time. Some moms do. But we can take that time and we can bodybuild. and we can hit a strength piece and then we can sit down and rest for three minutes and maybe that rest for three minutes is also the same time as giving our baby some attention. So things that we can do in the pregnant time is work on things like push-ups, bench, elevate the bench if you have to, go down to your knees for your push-up, elevate the push-up. overhead press, variations of overhead press, whether we're doing a push jerk, a strict press, a Z press, a bent over row, hitting those posterior delts, and then even doing things like a front rack hold or a front rack carry. These movements are going to mimic a lot of the movements that they're going to have to do postpartum or they may already be doing if they have another kiddo at home. So in pregnancy, focus on setting the foundation for upper extremity strength. Breastfeeding, bottle feeding takes up so much time. Sometimes that time is valued and sometimes it's not and that's okay. Sometimes that's very frustrating. Let's prepare mom so when she's breastfeeding or bottle feeding every two to three hours that she doesn't come in and she's like oh my neck and my back hurt because we're building that strength. So now we're going to switch and go into the postpartum space. The postpartum, we have this with a zero to two weeks is our healing timeframe, right? We aren't doing a push jerk at 70%. So maybe we're doing things like stretching the posterior delt with a sleeper stretch. loading the delts with banded I's T's and Y's, stretching the anterior delts and the pecs with a doorway stretch, and then doing some banded pull aparts. And maybe we can incorporate that after every feed, or maybe if that's too much, can we do it at least once a day to help utilize these muscles to decrease back pain and decrease neck pain? So, we're gonna dive further into this week with other divisions, so extremity, dry needling, where they're gonna talk about pain management strategies. So using dry needling techniques, soft tissue, cupping, joint manipulation, and other loading strategies to help load the deltoid, make the deltoid feel really good, and incorporate this into your moms, into your pregnant women. help them. You look at them as a whole body, not just pelvic floor because that's rarely what it is. So, if you are thinking about taking pelvic courses, head over to PTOnIce.com. We've got our live course, our L1 online course, and then we've actually recently added a third L2 at the end of the year due to high demand. So if that is something that you are or that is on your list, head on over and check it out and we will see you at 9am tomorrow.

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